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

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 product’s 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 MEDICAL SERVICES
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
Public Information Officer
Liaison 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 it’s 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
Let’s shift gears. . .
Responding to Traumatic Stress

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 can’t happen to me. (My parents won’t 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 31

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, don’t 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 33

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 34

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 35

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
It’s early morning, December 18.
School has just begun for the day.
A full school bus is late arriving due to ice on the roads. 40

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. 41

42. Discussion Questions
What are the first five steps you would take to activate the school’s 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? 42