COUNSELING 101 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 STOCK PHOTO IMAGE

ntil recently severe trauma Although principals are primarily term difficulties that can significantly reactions were most com- concerned with understanding and impair their daily functioning. Some Umonly associated with veter- meeting the needs of students, they will be at risk of developing PTSD, ans or survivors of major catastro- also must pay attention to the the most common and devastating phes, not the young people filling potential effect of a crisis on staff of the clinical anxiety disorders our nation’s schools. Generally, members, particularly those who are that are triggered by psychological when a student or a staff member serving as crisis caregivers for their trauma. The exact size of this coped with the psychological after- students. minority will depend on the type math of a tragedy, they did so with- and severity of the event because out the involvement—or responsi- Range of Reactions some events—especially acts of bility—of school personnel. But Anyone, regardless of psychological human violence—are more trau- educators have come to recognize strength, can be initially affected by matic than others. Although only a that schools play a critical role in exposure to an event that causes trained mental health professional any crisis response and care system fear, helplessness, or horror. can diagnose and treat PTSD, edu- serving children and youth. This is Symptoms can be emotional, physi- cators can help minimize potential- true whether dealing with an act of cal, cognitive, and social and inter- ly serious consequences of the violence on campus, an accident personal and vary significantly in disorder by recognizing warning involving a serious injury or loss of severity and duration. Strong reac- signs, identifying high-risk stu- life, a natural disaster, or terrorism. tions, such as anxiety or anger, can dents, and providing appropriate For the most part, schools have be normal and usually are not debil- interventions and referrals. done an admirable job of improving itating. With time, most people are crisis support in terms of planning, able to recover from the psychologi- What Is PTSD? prevention, and ensuring physical cal effects of a traumatic experience. PTSD is a characteristic set of safety during and immediately after According to the National Institutes symptoms resulting from “exposure” an event. An essential part of this of Mental Health (2002), a “sensible to a “traumatic stressor” (American effort, however, is the ability to rec- working principle” in the immediate Psychological Association, 2000). ognize and respond to the mental aftermath of a traumatic event “is to The kinds of stressors most likely to health effects of a crisis—including expect normal recovery.” result in PTSD include death, seri- such serious disorders as posttrau- A minority of children and ous injury/harm, and other threats matic stress disorder (PTSD). adults, however, will develop long- to physical integrity. Exposure is defined as directly experiencing or Stephen E. Brock is a nationally certified school psychologist and school psychology witnessing a traumatic event or trainer at California State University–Sacramento. Kathy Cowan is director of learning about an event being communications for the National Association of School Psychologists (NASP). This experienced by a family member, article was written in cooperation with NASP. close friend, or another loved one.

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This explains why a number of play or representations in art or the particular vulnerabilities of the people developed PTSD after writing that reflect the trauma. They individuals involved. September 11 although they were may also be more disruptive in class, not directly affected by the attacks: express the belief that they will not Risk Factors They knew someone close who had live to adulthood, believe that cer- Usually exposure to a traumatic died or they “experienced” the catas- tain omens foretell traumatic events, event is not sufficient in itself to trophe on television. and exhibit such physical symptoms generate PTSD in most people. The general symptom categories as headaches and stomachaches. Certain factors put specific individ- of PTSD are persistent reexperienc- uals at greater risk for developing ing of the traumatic stressor, persist- How Common Is PTSD? the disorder. A fatal school bus acci- ent avoidance of reminders of the The lifetime prevalence of PTSD dent may not cause PTSD in most traumatic event, emotional numb- among adults is slightly less than of the students involved but might ing, and persistent symptoms of 8% and among children and adoles- trigger it in the student whose father increased arousal. PTSD is different cents slightly more than 10%. recently died in a car crash. Being from a more “typical” traumatic Females are two times more likely aware of the more powerful predic- event response (i.e., a normal tors of PTSD can help school per- response to abnormal circumstances) sonnel and parents identify students by the duration and intensity of the School counselors who are potentially more vulnerable. symptoms. They must last for at Physical and emotional proximi- least one month and cause signifi- are staunch ty to the traumatic event. The clos- cant disruption to the individual’s er people are to a traumatic event, daily life. For example, following a student advocates the greater the likelihood that they school-related traumatic event a stu- will develop PTSD. Proximity dent or a staff member may be who work closely includes both direct personal expo- unable to return to the building. sure to the event (physical proximi- with teachers and ty) and relationships with crisis vic- Different Ages, Different tims (emotional proximity), particu- Symptoms administrators to larly when the victim is killed. Not PTSD symptoms of adolescents ensure students’ surprisingly, crisis victims, especially closely resemble those of adults. those who were physically injured, Teenagers with PTSD may become welfare and are at greatest risk. more aggressive, start fights, or Subjective perceptions of the behave irrationally. They may have protect their rights. traumatic event. The individual’s trouble sleeping, participating in subjective impression of the traumat- class, and completing assignments ic event can be more important than or lose interest in cocurricular activ- the event itself. Simply put, those ities and friends. They are also at than males to develop the disorder. who develop PTSD perceive trau- increased risk of substance and The rate of PTSD after any specific matic events as extremely threaten- alcohol abuse, reckless behavior, event varies greatly depending on its ing. Those who do not view an and suicide. type and intensity. Sudden, human- event as threatening (no matter how Younger middle school students caused disasters involving assault, horrific others may judge it to be) and children may display a different injury, physical threats, or fatalities are unlikely to develop PTSD. This pattern of symptoms. Specifically, can be particularly traumatic, as are is why the demeanor of teachers and their anxieties can be more general- unusually intense and long-lasting other staff members is important ized than those of older individuals experiences. In addition, PTSD during and after a crisis. The reac- whose symptoms are much more seems more likely to develop in tions of trusted adults can help shape clearly linked to the traumatic event. young people if the perpetrator of a students’ subjective perceptions of a For example, they may display gen- violent act is a trusted adult. It is traumatic experience, particularly for eralized fear of strangers; separation important to keep in mind, howev- middle level students. anxiety; and sleeping difficulties, er, that virtually any traumatic expe- Family and social factors. including frightening dreams that rience has the potential to cause Students who no longer live with a do not necessarily reflect the stres- PTSD among some victims, given nuclear family member, are exposed sor. They may engage in repetitive the right set of circumstances and to family violence, have a family his-

10 P RINCIPAL L EADERSHIP PSYCHOLOGY 101 CASE STUDY tory of mental illness, or live with caregivers who have PTSD are more Assessing the Risk for PTSD likely to develop PTSD themselves. A local gang, in response to the beating of a fellow gang member by a student at In addition, the absence of close your high school, has come on campus. A fight breaks out in the student parking lot peer friendships, access to positive between the gang and the student’s friends. A 15-year-old gang member is hospital- adult models outside of the family, ized 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 or connections to prosocial organi- hospitalized with a serious stab wounds but is expected to live. zations or institutions (such as schools) increases vulnerability. How Traumatic Is the Crisis Event? Mental health and trauma The situation described in this case study is obviously extreme and very rare, but it history. A preexisting mental illness 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 influences the development of fear, helplessness, and horror within the school community. This is the type of event PTSD. Students who had mental that is likely to be highly traumatic and generate symptoms of PTSD among sur- health problems (such as depression vivors, witnesses, and friends of the victims. This situation would probably require or bipolar disorders) before experi- comprehensive crisis intervention from the school, which may include crisis interven- encing the trauma are more likely to tion team members who are not typically a part of the school staff. The fact that a develop PTSD than those with good teacher was injured may significantly affect school staff members and increase the baseline mental health. Individuals need for outside assistance. who previously experienced psycho- Who Is At Risk? logical trauma also are more likely Students who were involved in the fight (especially those who were injured or who to develop (or reexperience) PTSD. 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 What Are the Warning Signs of injured teacher are at the greatest risk for developing PTSD symptoms. These indi- PTSD? viduals were physically or emotionally proximal to the traumatic event. In particular, Immediately after a traumatic event, any student or staff member who displays significant crisis reactions (e.g., who pan- it may be difficult to identify those icked 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 who will develop PTSD because family) are at particular risk. symptoms can mirror many normal To a lesser degree, the students and staff members who knew but were not reactions (e.g., anger, difficulty con- especially close to the fight victims are also at risk. Attention should also be direct- centrating, and nightmares) that will ed to students and staff members who have personal histories that include witness- dissipate on their own. Distinguishing ing or experiencing assaultive violence (especially those with a prior history of the difference requires training; any PTSD) or experiencing any other mental disorder. concern about a student should be Students and staff members who are at low risk for developing PTSD would referred to a mental health profes- include those who did not see the fight or its aftermath, did not have any relation- ship with victims, did not ever feel that they were in danger, and do not display any sional. However, initial reactions to crisis reactions. the event are important indicators of whether someone may develop How Should the School Respond? PTSD. The school needs to classify students and staff members according to risk factors The initial response of individuals and levels and carefully monitor their status. Psychological first aid should be who develop PTSD usually involves 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 pre- “intense fear,” “helplessness,” or pared to refer any student or staff member whose symptoms do not remit within a “horror.” Not only does a severe few weeks to a mental health professional who has expertise in dealing with trau- immediate response (e.g., panic) act matic stress. In addition, the school should be prepared to make such a referral of as a powerful warning sign, but it anyone who reports that they subjectively feel that they are having difficulty coping also influences the individual’s abili- with the traumatic event. ty to cope with the experience inde- Although it is important for the school to identify those who are at high risk for a pendently and adaptively. Educators traumatic stress reaction to provide them with immediate assistance, it is also impor- should note these immediate tant to identify those who are at low risk and to give them the opportunity to cope responses in students and consider 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 them when determining who assistance to those who truly don’t need crisis team support may unintentionally requires crisis intervention assistance send the message that the event was more threatening then it actually was or that and support. The presence of any the student is not a capable problem solver. persistent PTSD symptom in the

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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.

aftermath of a traumatic event is usually not trained to treat PTSD, care and enables staff members to also reason for concern and should most school-based mental health build students’ natural resiliency as trigger careful monitoring of affect- professionals (e.g., school counselors well as identify those students who ed students. Among those symp- and school psychologists) can pro- need further monitoring or referral toms that appear to be most worri- vide the staff development training to a mental health professional. some are those that reflect an needed to ensure that school person- Establish a crisis intervention unusually high level of alertness nel can recognize PTSD symptoms team. These teams are designed to (e.g., being easily startled). and provide appropriate screening of help students and personnel cope students who might need referral to with psychologically traumatic How Can Schools Help? expert providers in the community. events and to identify those who PTSD is a very serious mental Other recommendations include the need professional mental health disturbance that cannot be taken following: assistance (e.g., those with PTSD). lightly. Effective treatment typically Address the needs of any student Team members, including some requires the assistance of a clinical who exhibits signs of distress. mental health personnel, may need psychologist or psychiatrist who has Being part of a caring support net- additional training in crisis response. specific training dealing with trauma work is one of the most important It also may be necessary to identify victims. The most important role ways to protect people against seri- trained personnel in the district or that principals can play is to ensure ous trauma reactions. Educators coordinate training and staff that their staff members are able to should respond to students who resources with other schools or recognize risk factors and warning appear in distress, even if they do neighboring districts. signs of PTSD and know how to not have risk factors for PTSD. Develop a protocol for the school make appropriate referrals. Although Reaching out reinforces that adults crisis intervention response. Such

12 P RINCIPAL L EADERSHIP 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. a protocol should identify specific are experiencing problematic who in the local mental health com- individuals to fill specific crisis- symptoms. Schools need to rein- munity has expertise in working intervention roles. Among these force that students should tell a with trauma victims. In particular, it roles is a mental health officer, who trusted adult any time their feelings will be important to know who has is responsible for establishing referral or thoughts interfere with their nor- training in a form of psychotherapy mechanisms and monitoring crisis mal routine. Student self-reporting known as cognitive-behavioral treat- reactions among students and staff can augment, but not replace, adult ment. This form of therapy has doc- members. The protocol should observation of students affected by a umented effectiveness in helping include a school policy regarding traumatic event. individuals to recover from PTSD. access to onsite psychological first- Pay attention to the needs of The school psychologist or social aid assistance either by community staff members. Depending on the worker is generally an ideal resource mental health professionals or event, staff members may be at risk for appropriate community referrals. trained school personnel. of PTSD. They may be affected per- PL Learn which students may be sonally or have individual risk fac- at increased risk for developing tors. They may be at additional risk References PTSD. Provide parents with infor- if they are acting as crisis caregivers ❏ American Psychiatric Association. mation about the risk factors and to students. Supporting the emo- (2000). Diagnostic and statistical manual symptoms of PTSD. Encourage tional needs of students over of mental disorders (4th ed.). Washington, them to tell their child’s teacher, an extended period of time is drain- DC: Author. ❏ school psychologist, or counselor if ing, particularly for teachers and Brock, S. E., Lazarus, P. J., & their child has experienced a previ- support personnel who must remain Jimerson, S. R. (2002). Best practices in ous traumatic event or personal loss, “in control” day in and day out. school crisis prevention and intervention. Bethesda, MD: National Association of has a mental health problem, or is Principals should allow staff mem- School Psychologists. Related document exhibiting warning signs. Ideally, bers time to take care of their own can be found at www.nasponline.org parents should know to share this needs. The school psychologist can /NEAT /trauma.html information under any circum- help support individual staff mem- ❏ National Institute of Mental Health. stances, but they should be remind- bers and facilitate group discussions. (2002). Mental health and mass violence: ed immediately following a crisis Ensure that a range of school- Evidence-based early psychological inter- event involving members of the and community-based interven- vention for victims/survivors of mass vio- school community. tions are available for students lence. A workshop to reach consensus on Encourage students to seek and staff members. For the minori- best practice [NIH Pub. No. 02-5138]. help. Although individuals cannot ty of individuals who need profes- Washington, DC: U.S. Government self-diagnose PTSD, students can sional mental health assistance, it is Printing Office. Retrieved July 25, 2003 recognize when they or a friend important that the school identifies from www.nimh.nih.gov/research /massviolence.pdf JANUARY 2004 13