NASPs Effective Interventions for PTSD

Coping After a Crisis

In the wake of a crisis almost everyone is
hurt and confused, but some are at risk of
developing long-term consequences. Quick,
effective intervention can help alleviate
these people’s pain.

BY STEPHEN E. BROCK AND KATHY COWAN

JANUARY 2 0 0 4 9
Until recently severe trauma
reactions were most commonly
associated with veterans
or survivors of major catastrophes,
not the young people filling
our nation’s schools. Generally,
when a student or a staff member
coped with the psychological aftermath
of a tragedy, they did so without
the involvement—or responsibility—
of school personnel. But
educators have come to recognize
that schools play a critical role in
any crisis response and care system
serving children and youth. This is
true whether dealing with an act of
violence on campus, an accident
involving a serious injury or loss of
life, a natural disaster, or terrorism.
For the most part, schools have
done an admirable job of improving
crisis support in terms of planning,
prevention, and ensuring physical
safety during and immediately after
an event. An essential part of this
effort, however, is the ability to recognize
and respond to the mental
health effects of a crisis—including
such serious disorders as posttraumatic
stress disorder (PTSD).
Although principals are primarily
concerned with understanding and
meeting the needs of students, they
also must pay attention to the
potential effect of a crisis on staff
members, particularly those who are
serving as crisis caregivers for their
students.
Range of Reactions
Anyone, regardless of psychological
strength, can be initially affected by
exposure to an event that causes
fear, helplessness, or horror.
Symptoms can be emotional, physical,
cognitive, and social and interpersonal
and vary significantly in
severity and duration. Strong reactions,
such as anxiety or anger, can
be normal and usually are not debilitating.
With time, most people are
able to recover from the psychological
effects of a traumatic experience.
According to the National Institutes
of Mental Health (2002), a “sensible
working principle” in the immediate
aftermath of a traumatic event “is to
expect normal recovery.”
A minority of children and
adults, however, will develop longterm
difficulties that can significantly
impair their daily functioning. Some
will be at risk of developing PTSD,
the most common and devastating
of the clinical anxiety disorders
that are triggered by psychological
trauma. The exact size of this
minority will depend on the type
and severity of the event because
some events—especially acts of
human violence—are more traumatic
than others. Although only a
trained mental health professional
can diagnose and treat PTSD, educators
can help minimize potentially
serious consequences of the
disorder by recognizing warning
signs, identifying high-risk students,
and providing appropriate
interventions and referrals.
What Is PTSD?
PTSD is a characteristic set of
symptoms resulting from “exposure”
to a “traumatic stressor” (American
Psychological Association, 2000).
The kinds of stressors most likely to
result in PTSD include death, serious
injury/harm, and other threats
to physical integrity. Exposure is
defined as directly experiencing or
witnessing a traumatic event or
learning about an event being
experienced by a family member,
close friend, or another loved one.
Coping After a Crisis
BY STEPHEN E. BROCK AND KATHY COWAN
In the wake of a crisis almost everyone is
hurt and confused, but some are at risk of
developing long-term consequences. Quick,
effective intervention can help alleviate
these people’s pain.
Stephen E. Brock is a nationally certified school psychologist and school psychology
trainer at California State University–Sacramento. Kathy Cowan is director of
communications for the National Association of School Psychologists (NASP). This
article was written in cooperation with NASP.
COUNSELING 101
STOCK PHOTO IMAGE
C O U N S E L I N G 1 0 1
10 P R I N C I PA L L EADERSHIP
This explains why a number of
people developed PTSD after
September 11 although they were
not directly affected by the attacks:
They knew someone close who had
died or they “experienced” the catastrophe
on television.
The general symptom categories
of PTSD are persistent reexperiencing
of the traumatic stressor, persistent
avoidance of reminders of the
traumatic event, emotional numbing,
and persistent symptoms of
increased arousal. PTSD is different
from a more “typical” traumatic
event response (i.e., a normal
response to abnormal circumstances)
by the duration and intensity of the
symptoms. They must last for at
least one month and cause significant
disruption to the individual’s
daily life. For example, following a
school-related traumatic event a student
or a staff member may be
unable to return to the building.
Different Ages, Different
Symptoms
PTSD symptoms of adolescents
closely resemble those of adults.
Teenagers with PTSD may become
more aggressive, start fights, or
behave irrationally. They may have
trouble sleeping, participating in
class, and completing assignments
or lose interest in cocurricular activities
and friends. They are also at
increased risk of substance and
alcohol abuse, reckless behavior,
and suicide.
Younger middle school students
and children may display a different
pattern of symptoms. Specifically,
their anxieties can be more generalized
than those of older individuals
whose symptoms are much more
clearly linked to the traumatic event.
For example, they may display generalized
fear of strangers; separation
anxiety; and sleeping difficulties,
including frightening dreams that
do not necessarily reflect the stressor.
They may engage in repetitive
play or representations in art or
writing that reflect the trauma. They
may also be more disruptive in class,
express the belief that they will not
live to adulthood, believe that certain
omens foretell traumatic events,
and exhibit such physical symptoms
as headaches and stomachaches.
How Common Is PTSD?
The lifetime prevalence of PTSD
among adults is slightly less than
8% and among children and adolescents
slightly more than 10%.
Females are two times more likely
than males to develop the disorder.
The rate of PTSD after any specific
event varies greatly depending on its
type and intensity. Sudden, humancaused
disasters involving assault,
injury, physical threats, or fatalities
can be particularly traumatic, as are
unusually intense and long-lasting
experiences. In addition, PTSD
seems more likely to develop in
young people if the perpetrator of a
violent act is a trusted adult. It is
important to keep in mind, however,
that virtually any traumatic experience
has the potential to cause
PTSD among some victims, given
the right set of circumstances and
the particular vulnerabilities of the
individuals involved.
Risk Factors
Usually exposure to a traumatic
event is not sufficient in itself to
generate PTSD in most people.
Certain factors put specific individuals
at greater risk for developing
the disorder. A fatal school bus accident
may not cause PTSD in most
of the students involved but might
trigger it in the student whose father
recently died in a car crash. Being
aware of the more powerful predictors
of PTSD can help school personnel
and parents identify students
who are potentially more vulnerable.
Physical and emotional proximity
to the traumatic event. The closer
people are to a traumatic event,
the greater the likelihood that they
will develop PTSD. Proximity
includes both direct personal exposure
to the event (physical proximity)
and relationships with crisis victims
(emotional proximity), particularly
when the victim is killed. Not
surprisingly, crisis victims, especially
those who were physically injured,
are at greatest risk.
Subjective perceptions of the
traumatic event. The individual’s
subjective impression of the traumatic
event can be more important than
the event itself. Simply put, those
who develop PTSD perceive traumatic
events as extremely threatening.
Those who do not view an
event as threatening (no matter how
horrific others may judge it to be)
are unlikely to develop PTSD. This
is why the demeanor of teachers and
other staff members is important
during and after a crisis. The reactions
of trusted adults can help shape
students’ subjective perceptions of a
traumatic experience, particularly for
middle level students.
Family and social factors.
Students who no longer live with a
nuclear family member, are exposed
to family violence, have a family his-
School counselors
are staunch
student advocates
who work closely
with teachers and
administrators to
ensure students’
welfare and
protect their rights.
JANUARY 2 0 0 4 11
tory of mental illness, or live with
caregivers who have PTSD are more
likely to develop PTSD themselves.
In addition, the absence of close
peer friendships, access to positive
adult models outside of the family,
or connections to prosocial organizations
or institutions (such as
schools) increases vulnerability.
Mental health and trauma
history. A preexisting mental illness
influences the development of
PTSD. Students who had mental
health problems (such as depression
or bipolar disorders) before experiencing
the trauma are more likely to
develop PTSD than those with good
baseline mental health. Individuals
who previously experienced psychological
trauma also are more likely
to develop (or reexperience) PTSD.
What Are the Warning Signs of
PTSD?
Immediately after a traumatic event,
it may be difficult to identify those
who will develop PTSD because
symptoms can mirror many normal
reactions (e.g., anger, difficulty concentrating,
and nightmares) that will
dissipate on their own. Distinguishing
the difference requires training; any
concern about a student should be
referred to a mental health professional.
However, initial reactions to
the event are important indicators of
whether someone may develop
PTSD.
The initial response of individuals
who develop PTSD usually involves
“intense fear,” “helplessness,” or
“horror.” Not only does a severe
immediate response (e.g., panic) act
as a powerful warning sign, but it
also influences the individual’s ability
to cope with the experience independently
and adaptively. Educators
should note these immediate
responses in students and consider
them when determining who
requires crisis intervention assistance
and support. The presence of any
persistent PTSD symptom in the
PSYCHOLOGY 101 CASE STUDY
Assessing the Risk for PTSD
A local gang, in response to the beating of a fellow gang member by a student at
your high school, has come on campus. A fight breaks out in the student parking lot
between the gang and the student’s friends. A 15-year-old gang member is hospitalized
with a stab wound, and one of your students is killed by a gunshot wound to
the head. A teacher was in the immediate area and tried to intervene; she was
hospitalized with a serious stab wounds but is expected to live.
How Traumatic Is the Crisis Event?
The situation described in this case study is obviously extreme and very rare, but it
illustrates many of the principles of assessing the risk for PTSD. This event involves
violence that has resulted in death and injury and likely generated feelings of intense
fear, helplessness, and horror within the school community. This is the type of event
that is likely to be highly traumatic and generate symptoms of PTSD among survivors,
witnesses, and friends of the victims. This situation would probably require
comprehensive crisis intervention from the school, which may include crisis intervention
team members who are not typically a part of the school staff. The fact that a
teacher was injured may significantly affect school staff members and increase the
need for outside assistance.
Who Is At Risk?
Students who were involved in the fight (especially those who were injured or who
felt that they were threatened), those who were close friends of the student who was
killed, and other staff members and students who were especially close to the
injured teacher are at the greatest risk for developing PTSD symptoms. These individuals
were physically or emotionally proximal to the traumatic event. In particular,
any student or staff member who displays significant crisis reactions (e.g., who panicked
during or immediately after the fight) or are socially isolated (e.g., who viewed
the deceased student as their one and only friend or who do not have a supportive
family) are at particular risk.
To a lesser degree, the students and staff members who knew but were not
especially close to the fight victims are also at risk. Attention should also be directed
to students and staff members who have personal histories that include witnessing
or experiencing assaultive violence (especially those with a prior history of
PTSD) or experiencing any other mental disorder.
Students and staff members who are at low risk for developing PTSD would
include those who did not see the fight or its aftermath, did not have any relationship
with victims, did not ever feel that they were in danger, and do not display any
crisis reactions.
How Should the School Respond?
The school needs to classify students and staff members according to risk factors
and levels and carefully monitor their status. Psychological first aid should be
offered to anyone who requests it, but special attention should be directed to those
who were physically and emotionally close to the crisis. The school needs to be prepared
to refer any student or staff member whose symptoms do not remit within a
few weeks to a mental health professional who has expertise in dealing with traumatic
stress. In addition, the school should be prepared to make such a referral of
anyone who reports that they subjectively feel that they are having difficulty coping
with the traumatic event.
Although it is important for the school to identify those who are at high risk for a
traumatic stress reaction to provide them with immediate assistance, it is also important
to identify those who are at low risk and to give them the opportunity to cope
with the crisis. Doing so may help to generate feelings of empowerment and the
belief that they are able to manage stressful events. Providing crisis intervention
assistance to those who truly don’t need crisis team support may unintentionally
send the message that the event was more threatening then it actually was or that
the student is not a capable problem solver.
12 P R I N C I PA L L EADERSHIP
aftermath of a traumatic event is
also reason for concern and should
trigger careful monitoring of affected
students. Among those symptoms
that appear to be most worrisome
are those that reflect an
unusually high level of alertness
(e.g., being easily startled).
How Can Schools Help?
PTSD is a very serious mental
disturbance that cannot be taken
lightly. Effective treatment typically
requires the assistance of a clinical
psychologist or psychiatrist who has
specific training dealing with trauma
victims. The most important role
that principals can play is to ensure
that their staff members are able to
recognize risk factors and warning
signs of PTSD and know how to
make appropriate referrals. Although
usually not trained to treat PTSD,
most school-based mental health
professionals (e.g., school counselors
and school psychologists) can provide
the staff development training
needed to ensure that school personnel
can recognize PTSD symptoms
and provide appropriate screening of
students who might need referral to
expert providers in the community.
Other recommendations include the
following:
Address the needs of any student
who exhibits signs of distress.
Being part of a caring support network
is one of the most important
ways to protect people against serious
trauma reactions. Educators
should respond to students who
appear in distress, even if they do
not have risk factors for PTSD.
Reaching out reinforces that adults
care and enables staff members to
build students’ natural resiliency as
well as identify those students who
need further monitoring or referral
to a mental health professional.
Establish a crisis intervention
team. These teams are designed to
help students and personnel cope
with psychologically traumatic
events and to identify those who
need professional mental health
assistance (e.g., those with PTSD).
Team members, including some
mental health personnel, may need
additional training in crisis response.
It also may be necessary to identify
trained personnel in the district or
coordinate training and staff
resources with other schools or
neighboring districts.
Develop a protocol for the school
crisis intervention response. Such
PREVENTING PTSD IN CRISIS CAREGIVERS
School personnel who provide crisis care to students may be at increased risk of developing PTSD
if they also are affected by the event or have personal risk factors. Offering the following advice
can help principals ensure that staff members receive adequate support:
• Don’t underestimate the effect of providing crisis care.
• Understand the nature of the crisis and the students who need care.
• Know your limitations and what you can feel reasonably comfortable handling in a crisis.
• Be aware of your history of personal loss or trauma.
• Be willing to decline an assignment or seek help from someone more experienced.
• Ask family members and friends to help with regular chores if your crisis responsibilities demand extra
time.
• Maintain a healthy diet and water intake.
• Get plenty of sleep, preferably without the use of sleep aids or alcohol.
• Take periodic breaks while in the midst of a crisis response; go for a walk or call a friend.
• Connect with trusted friends or family members who can help counter negative feelings.
• Take time to process daily events with team members or colleagues.
• Find an acceptable outlet—for example, exercise, a favorite hobby, sports, music, art, or movies.
• Avoid excessive news coverage.
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JANUARY 2 0 0 4 13
a protocol should identify specific
individuals to fill specific crisisintervention
roles. Among these
roles is a mental health officer, who
is responsible for establishing referral
mechanisms and monitoring crisis
reactions among students and staff
members. The protocol should
include a school policy regarding
access to onsite psychological firstaid
assistance either by community
mental health professionals or
trained school personnel.
Learn which students may be
at increased risk for developing
PTSD. Provide parents with information
about the risk factors and
symptoms of PTSD. Encourage
them to tell their child’s teacher,
school psychologist, or counselor if
their child has experienced a previous
traumatic event or personal loss,
has a mental health problem, or is
exhibiting warning signs. Ideally,
parents should know to share this
information under any circumstances,
but they should be reminded
immediately following a crisis
event involving members of the
school community.
Encourage students to seek
help. Although individuals cannot
self-diagnose PTSD, students can
recognize when they or a friend
are experiencing problematic
symptoms. Schools need to reinforce
that students should tell a
trusted adult any time their feelings
or thoughts interfere with their normal
routine. Student self-reporting
can augment, but not replace, adult
observation of students affected by a
traumatic event.
Pay attention to the needs of
staff members. Depending on the
event, staff members may be at risk
of PTSD. They may be affected personally
or have individual risk factors.
They may be at additional risk
if they are acting as crisis caregivers
to students. Supporting the emotional
needs of students over
an extended period of time is draining,
particularly for teachers and
support personnel who must remain
“in control” day in and day out.
Principals should allow staff members
time to take care of their own
needs. The school psychologist can
help support individual staff members
and facilitate group discussions.
Ensure that a range of schooland
community-based interventions
are available for students
and staff members. For the minority
of individuals who need professional
mental health assistance, it is
important that the school identifies
who in the local mental health community
has expertise in working
with trauma victims. In particular, it
will be important to know who has
training in a form of psychotherapy
known as cognitive-behavioral treatment.
This form of therapy has documented
effectiveness in helping
individuals to recover from PTSD.
The school psychologist or social
worker is generally an ideal resource
for appropriate community referrals.
PL
References
❏ American Psychiatric Association.
(2000). Diagnostic and statistical manual
of mental disorders (4th ed.). Washington,
DC: Author.
❏ Brock, S. E., Lazarus, P. J., &
Jimerson, S. R. (2002). Best practices in
school crisis prevention and intervention.
Bethesda, MD: National Association of
School Psychologists. Related document
can be found at www.nasponline.org
/NEAT /trauma.html
❏ National Institute of Mental Health.
(2002). Mental health and mass violence:
Evidence-based early psychological intervention
for victims/survivors of mass violence.
A workshop to reach consensus on
best practice [NIH Pub. No. 02-5138].
Washington, DC: U.S. Government
Printing Office. Retrieved July 25, 2003
from www.nimh.nih.gov/research
/massviolence.pdf
SYMPTOMS
Persistent reexperiencing of the traumatic stressor: Reoccurring intrusive and distressing thoughts,
images, or feelings associated with the event; reoccurring and upsetting dreams about the trauma.
Persistent avoidance of reminders of the event: Deliberate efforts to avoid thoughts, feelings,
discussions, activities, places, or people that are associated with the traumatic event; inability to
remember elements of the event.
Emotional numbing: Reduced interest in important and previously enjoyed activities; feeling all alone or
detached from others and unable to react emotionally; feeling as if there is no future.
Persistent symptoms of increased arousal: Difficulty falling or staying asleep; unusually alert and
easily startled; difficulty concentrating; increased irritability and anger.