1. © Raija-Leena Punamäki 2007 Consultation Workshop, Ramalla 6- 9.12.2004 Raija-Leena Punamäki Mental health development in Gaza Intervention and prevention Youth as a special target

2. © Raija-Leena Punamäki 2007 Research on Resilience Question to be answered: What are the characteristics of those persons who have managed well in spite of the traumas and stresses they have experienced? Methods: Epidemiological research, prospective studies Types of stresses: –war –single trauma (crises, catastrophes) –child abuse (physical, psychological )

3. © Raija-Leena Punamäki 2007 Population Traumatic event During stress After stress Before stress Vulnerability and risk factors Protective and modifying factors Why do children differ in their reaction to stress ? High symptom group Low symptom group From birth Later reactions

4. © Raija-Leena Punamäki 2007 Individual Resilience Factors: constitutional robustness social skills, easy temperament autonomy, internal locus of control coping, feeling of self worth cognitive capacity sense of coherence creativity (symbolization) hobbies, special interests

5. © Raija-Leena Punamäki 2007 Resilience Factors in Family good child - parent interaction patterns in early childhood/infancy clearer family structures, rules, rituals at least one resilient parent parents who allow others to help common values between parents and children/youths strong family ties high socio-economic status low expressed emotion required helpfulness

6. © Raija-Leena Punamäki 2007 Resilience Factors in Child’s Network at least one significant other person during childhood feeling of group identity, belonging common shared values between child and society society-structures that support the child’s coping strategies

7. © Raija-Leena Punamäki 2007 Relationship between Trauma and Resilience Perspectives

8. © Raija-Leena Punamäki 2007 Rutter (1998) 1. Level of risk 2. Sensitivity to risk 3. Reduction of negative impact 4. Reduction of negative chain reactions 5. Fostering positive chain reactions 6. Opening new opportunities 7. Neutralizing experiences 8. Processing the experiences

9. © Raija-Leena Punamäki 2007 Mental health problems (MHP) & communal responses in military violence Acute symptoms of depression, aggression, PTSD & dissociation Children at risk: wounded, homeless, poor, low threshold temperement, earlier trauma, accumulated family problems, constitutional A) INTERVENTION MHP Symptom-focused treatment B) PREVENTION MHP Resíliency groups Psychoeducational Family involvement Children & families exposed to trauma with no special vulnerability PROMOTION MH Promotion of healthy conditions: Schoool, healthcare, participation National politics, strategies

10. © Raija-Leena Punamäki 2007 Intervention in war zones A. Symptom management-groups –evrybody exposed to same event B. Resilience-building -groups –Resilience > affected but not broken –mixed /at risk /activity-oriented groups C. Therapy –groups & individual –selected according to problem/diagnosis –problem-focused, process-oriented, fantasy-work, symbolic play, –psychoeducative, problem and coping-focused

11. © Raija-Leena Punamäki 2007 Differences A vs B vs C A Symptom management & ’debriefing –deals with information, understanding –procedes pre-designed order, strong guiding –addresses painful memories, symptoms and coping B Resilience-building -groups –deals with fantasy - ( or documentary if chosen by child) –encourage initiative from members in planning –adresses resources –addresses problems directly only by members initiative C Therapy –groups & individual –addresses problems and resources –processoriented, -not pre-designed

12. © Raija-Leena Punamäki 2007 Developmental aspect in war trauma There are not ’war children’: (a) personality (b) age make traumatic experience unique Developmental age (stage) provides both protective self-healing processes and vulnerabilities Cognitive development: memory, attribution, explanations, causality Communication of feelings and expriences developes

13. © Raija-Leena Punamäki 2007 Trauma & Child development

14. © Raija-Leena Punamäki 2007 Developmental Salient Tasks Impact of Stage trauma

15. © Raija-Leena Punamäki 2007 What one should learn –the uniqueness of a person the most hurting/ provoking experiences the collection of fears before /after the ideas of solution the fantasies of danger, revenge and help the dreams of future the picture of self and others the early important memories The savior, protector, safe place

16. © Raija-Leena Punamäki 2007 Problems among children in war > methods Night-mares –drama- let other child continue story- let dreamer end story Sense of time –drawings - good and bad memories - future, (dramatize future) Loss –make a picture, unfullfilled sentences, read alod, send a letter Sharing coping – strategies - Picture test, story telling (helper, danger, end) dream work