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Best Practices in Mental Health Emergency Recovery in Schools Jackie Kibler, Ph.D. Department of Psychology, University of Montana

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Presentation on theme: "Best Practices in Mental Health Emergency Recovery in Schools Jackie Kibler, Ph.D. Department of Psychology, University of Montana"— Presentation transcript:

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 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 Decrease the need for response Plan for a rapid, coordinated, effective response Execute the plan Restore the learning environment; Monitor and assist the healing

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, 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.


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 Student Supervision Public Information Officer Liaison Officer Safety Officer Site/facility Security Transportation Psychological First Aid Team Leader Operations Section Chief Facility and Materials Documentation/Recorder Planning Section Chief Food Services Staffing Communications Logistics Section Chief Personnel Insurance Claims Finance & Admin S. Chief Incident Commander Health Services Group Supervisor Student Reunification Group Supervisor Medical Triage Team Leader Note – vertical reporting lines below Section Chiefs only for space saving illustration, Supervisors report directly to Chiefs, Team leaders to supervisors etc,.

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 R ESPONDING TO T RAUMATIC S TRESS 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 Developed to work with inner-city children who experience trauma symptoms from exposure to violence. Cognitive Behavioral Intervention for Trauma in Schools (CBITS) Lisa Jaycox, Ph.D (2004)

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 Screening Clinical Interview Pre-group Assessment* CBITS Group (10 weeks) Self-assessments* Post-group Assessment* * Allow tracking of outcomes. Group not needed Group not appropriate Refer out

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 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? Core Action 1: Contact and Engagement

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 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 Core Action 5: Practical Assistance

37 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 Core Action 6: Connecting with Social Supports

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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