1. 1 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

2. 2 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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4. 4 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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8. 8 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..?

9. 9 What is societal Resilience Societal resilience is the ability of society to adapt positively to adversity and keep society functional, supportive and open.

10. 10 What are the challenges for society after massive trauma? Survival mode (focus on short term immediate solutions) Patterns of Traumatic Bonding Coping with feelings of helplessness Isolation of victim groups Sensation seeking disregulation

11. 11 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

12. 12 2. Patterns of Traumatic Bonding Strong bonding in peak periods (in-group) Wild growth of volunteer organizations, often competing fiercely. Neglect (and often isolation) of groups that are seen as “guilty”, or as “not coping”. Strong rejection of out-group

13. 13 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

14. 14 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.

15. 15 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

16. 16 3. Feelings of helplessness Multi-layered traumatic memories are based in personal, familial, cultural experiences

17. 17 4. Isolation of victim groups Estrangement between victims and non-victims is a two-way process Victims feels alone: “No one under-stands me” 2. Need for recognition (narcissistic phase) Society creates special status for victims

18. 18 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

19. 19 5. Sensation seeking Keeping up alertness Addiction to alertness (adrenaline) Risk-taking behavior

20. 20 6. Disregulation Exhaustion Disregulation of anger Perception of time Memory for immediate past

22. Early detection ?

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

24. 22 Third Generation Trauma Services First Generation = Trauma – Pathology - Treatment Second Generation = Prevention Programs

26. Immediate Intervention

27. Detection of disorders

28. Treatment

30. 25 Direct care for children:Community and Clinical Intervention Model Ecological – systemic intervention Community intervention Screening process Therapeutic intervention Parent Groups Care givers Groups First Phase 4 treatment modules Second Phase Assistance on the individual and community level

31. 26 Capacity building for trauma care:Community and Clinical Intervention Model Ecological – systemic intervention Community intervention Screening process Therapeutic intervention Therapists training Interviewers training Group facilitator training “How do we cope? Community Resilience” Increasing capacity Identifying toddlers and parents in distress Empowerment and assistance on the individual and community level

32. 27 Integrative intervention for protecting children:Community and Clinical Intervention Model Ecological – systemic intervention Screening process Therapeutic intervention Community intervention Parent Groups Care givers Groups Therapists training First Phase Interviewers training 4 treatment modules Group facilitator training Second Phase “How do we cope? Community Resilience” Treatment Identifying toddlers and parents in distress Empowerment and assistance on the individual and community level

33. 28 Continuum of Services Pre-event Long- term Immediate Care Community Event Target group Content Agency

35. Workshop for school staff

36. Parent meeting

37. Information and consent regarding screening

38. Screening - administration of self report questionnaires by teachers and research assistants in the classroom

39. Classroom debriefing with teacher and research assistant

40. Feedback of results to school counselors

41. Counselor interview to validate screening results

42. Meeting with parents and identified child for decision making and referral to school or community based services

43. Start a whole school resiliency program

46. Psycho education

47. Learning to Play Again

48. Identify Coping Resources

50. 33 Conclusions When trauma is a massive presence in society, we need to think systemically and get away from our “one-on-one” orientation to therapy. Active screening and outreach to children at risk are highly effective for all ages The big challenge for the science of traumatology is to see if “resilience” can be built or strengthened.

51. 34 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

52. 35 So what am I saying? We need to open our minds to broader concepts than PTSD. There are natural tendencies of society that counteract the planning of services in the midst of ongoing trauma 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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54. 37 For more information: www.traumaweb.org Thank you !!