Appendix C

"One Pager" Handouts for Group Crisis Intervention Sessions

A Brief Explanation of

The National Crisis Response Team

A Project of The National Organization for Victim Assistance

Founded in 1975, the National Organization for Victim Assistance (NOVA) is a private, non-profit, umbrella organization working on behalf of victims of crime and of other crises. NOVA is guided by four purposes: to serve as the national advocate in support of victim rights and services; to provide direct services to victims and survivors; to help state and local victim assistance programs expand and improve their services; and to be of service to its members. The National Crisis Response Team (CRT) is part of NOVA's Division of Victim Services.

As with individuals, whole communities suffer trauma in the aftermath of disasters or especially gruesome crimes. The community may experience a sort of paralysis immediately following the incident. Almost everyone is in shock, yet each individual is soon likely to react with a different set of emotions, which may include sadness, anger, fear, helplessness or euphoria.

The caregivers in the community, though wanting to help in the crisis, may themselves be affected by a sense of shock. They may also be unsure of what to do, since few are trained in using their helping skills in catastrophic situations. Organizing a plan of action may be difficult in the confusion of the moment.

For all these reasons, it often helps to have outsiders come for a short period of time to offer information and suggestions on how to mobilize a program of responding to the community's distress. That is the mission of the CRT _ to serve as consultants to the leaders and caregivers of a community in severe distress.

A CRT consists of service professionals from all over the country, typically including mental health specialists, victim advocates, public safety professionals, and members of the clergy, among others. The team for each disaster is formed in consideration of that particular community's demographics. All team members are volunteers with only their travel and lodging expenses covered by the local community or from donations to NOVA. NOVA will send a crisis response team to any community in crisis within twenty-four hours of a request.

There are three primary tasks the team performs:

• helping local decision-makers identify all the groups at risk of experiencing trauma;

• training the local caregivers who are to reach out to those groups after the CRT has departed; and

• leading one or more group crisis intervention sessions (also known as "debriefings") to show how those private sessions can help victims start to cope with their distress.

For more information on NOVA's National Crisis Response Team, or to find out how to develop a local community-based crisis response team, please call NOVA's 24-hour number: (202) 232-6682. Victims wanting assistance may call (800) 879-6682 at any time for information and emotional support.

Stress and Trauma

Your Day-to-Day Life

Individuals exist in a normal state of "equilibrium" or balance.

That emotional balance involves everyday stress, both positive and negative _ like being late to work, getting a promotion, having a flat tire, getting ready for a date, or putting the children to bed.

Occasionally, stress will be severe enough to move an individual out of his or her normal state of equilibrium, and into a state of depression or anxiety, as examples.

But most people most of the time stay in a familiar range of equilibrium.

When Trauma Occurs

Trauma throws people so far out of their range of equilibrium that it is difficult for them to restore a sense of balance in life.

Trauma may be precipitated by stress: "acute" or "chronic."

1. Acute stress is usually caused by a sudden, arbitrary, often random event.

2. Chronic stress is one that occurs over and over again _ each time pushing the individual toward the edge of his state of equilibrium, or beyond.

Most trauma comes from acute, unexpected stressors such as violent crime, natural disasters, accidents or acts of war.

1. Some trauma is caused by quite predictable (but hated) stressors such as the chronic abuse of a child, spouse or elder abuse.

2. "Developmental crises" come from transitions in life, such as adolescence, marriage, parenthood and retirement

3. Though similar to acute stress, chronic and developmental crises have significant differences not covered in this review.

The Crisis Reaction

The normal human response to trauma follows a similar pattern called the crisis reaction. It occurs in all of us.

Physical Response

The physical response to trauma is based on our animal instincts. It includes:

1. Physical shock, disorientation, immobilization and numbness: "Frozen Fright."

2. "Fight-or-Flight" reaction (when the body begins to mobilize):

• Adrenaline begins to pump through the body.

• The body may relieve itself of excess materials by urinating, regurgitating or defecating.

• Physical senses _ one or more may become more acute while others "shut down."

• The heart rate increases and one may hyperventilate, sweat, etc.

3. Exhaustion: physical arousal associated with fight-or-flight cannot be prolonged indefinitely. Eventually, it will result in exhaustion.

Emotional Reaction

Our emotional reactions are heightened by our physical responses.

1. Stage one: shock, disbelief, denial

2. Stage two: cataclysm of emotions _ anger/rage, fear/terror, sorrow/grief,

confusion/frustration, self-blame/guilt

3. Stage three: reconstruction of equilibrium — emotional roller-coaster that

eventually becomes balanced, but never goes back to what it was before the

crisis _ a new sense of equilibrium will be developed.

Trauma and Loss

Trauma is accompanied by a multitude of losses:

1. Loss of control over one's life

2. Loss of faith in one's God or other people

3. Loss of a sense of fairness or justice

4. Loss of personally-significant property, self or loved ones

5. Loss of a sense of immortality and invulnerability

6. Loss of future

Because of the losses, trauma response involves grief and bereavement. One can grieve over the loss of loved things as well as loved people.

Trauma and Regression

Trauma is often accompanied by regression _ mentally and physically.

1. Individuals may do things that seem childish later. Examples include:

• Singing nursery rhymes

• Assuming a fetal position or crawling instead of walking

• Calling a law enforcement officer or other authority figure "mommy" or "daddy" _ or at least thinking of them that way

2. Individuals may feel childish. Examples include:

• Feeling "little"

• Wanting "mommy" or "daddy" to come and take care of you

• Feeling "weak"

• Feeling like you did when you were a child and something went terribly wrong.

Recovery From Immediate Trauma

Many people live through a trauma and are able to reconstruct their lives without outside help.

Most people find some type of benign outside intervention useful in dealing with trauma.

Recovery from immediate trauma is often affected by:

1. Severity of crisis reaction

2. Ability to understand what happened

3. Stability of victim's/survivor's equilibrium after event

4. Supportive environment

5. Validation of experience

Recovery issues for survivors include:

1. Getting control of the event in the victim's/survivor's mind

2. Working out an understanding of the event and, as needed, a redefinition of values

3. Re-establishing a new equilibrium/life

4. Re-establishing trust

5. Re-establishing a future

6. Re-establishing meaning

Long-Term Crisis Reactions

Not all victims/survivors suffer from long-term stress reactions.

Many victims continue to re-experience crisis reactions over long periods of time.

Such crisis reactions are normally in response to "trigger events" that remind the victim of the trauma. They can bring back the intense emotion that occurred with the original trauma.

"Trigger events" will vary with different victims/survivors, but may include:

• Identification of the assailant in, say, a police lineup

• Sensing (seeing, hearing, touching, smelling, tasting) something similar to something that one was acutely aware of during the trauma

• "Anniversaries" of the event

• The proximity of holidays or significant "life events"

• Hearings, trials, appeals or other critical phases of the criminal justice process

• News reports about a similar event

Long-term stress or crisis reactions may be made better or worse by the actions of others. When such reactions are sensed to be negative (whether or not they were intentional), the actions of others are called the "second assault" and the feelings are often described as a "second injury." Sources of the second assault may include:

• the criminal justice system

• the media

• family, friends, acquaintances

• hospital and emergency room personnel

• health and mental health professionals

• social service workers

• victim service workers

• schools, teachers, educators

• victim compensation system

• clergy

The intensity of long-term stress reactions usually decreases over time, as does the frequency of the re-experienced crisis. However, the effects of a catastrophic trauma cannot be "cured."

Even survivors of trauma who reconstruct new lives and who have achieved a degree of normality and happiness in their lives _ and who can honestly say they prefer the new, "sadder-but-wiser" person they have become _ will find that new life events will trigger the memories and reactions to the trauma in the future.

Long-Term Traumatic Stress Reaction

When someone survives a catastrophe, they often experience stress reactions for years.

Long-term stress reactions are natural responses of people who have survived a traumatic event.

Long-term stress reactions are most often a result of imprinted sensory perceptions and reactions in the brain and body.

Long-term stress reactions are not always pathological nor do they necessarily require intensive mental health interventions.

The most common types of long-term stress reactions include:

A. Post-traumatic Character Changes

B. Post-Traumatic Stress Reactions

C. Post-Traumatic Stress Disorder (PTSD)

a. Re-experiencing the event both psychologically and with physiological reactivity.

• Intrusive thoughts

• Nightmares and distressing dreams

• Flashbacks

b. Numbing, avoidance, and isolation

• avoidance of thoughts or activities that remind one of the event

• avoidance of previous habits or pleasurable activities that the individual

engaged in before the event

• estrangement and isolation

• reduced affect or feelings of "emotional anesthesia"

• partial amnesia

• a sense of foreshortened future

c. Behavioral arousal

• inability to concentrate

• insomnia or interrupted sleep patterns

• flashes of anger or irritability

• startle reactions or hyperalertness

Duration of symptoms last for one or more months

The trauma reactions and symptoms impair functioning.

D. Acute Stress Disorder (ASD)

E. Adjustment Disorder

F. Complex PTSD or Diagnosis of Extreme Stress Not Otherwise Specified (DESNOS)

Symptoms may occur in persons who have survived complex, prolonged or repeated traumas during which they have been subjected to coercive control. Such control may be imposed through violence or threat of violence, control of bodily functions, capricious enforcement of petty rules, intermittent

rewards, isolation, degradation, or enforced participation in the violence.

G. Depression

H. Simple Phobias

I. Panic Disorder

J. Anxiety Disorder

It is not important to know all the symptoms for the stress reactions mentioned above. If you become concerned about your reactions or how long they last, it is useful to talk to a mental health professional who is a specialist in working with people who have experienced traumatic events.

Long-Term Crisis Reactions

Long-term crisis reactions are described more fully in another of NOVA's one-page fact sheets.

A simpler way to view long-term stress reactions is to think of them as crisis reactions that repeat themselves, in large part due to trigger events that remind the victim/survivor of the trauma.

Long-term stress or crisis reactions may be exacerbated or mitigated by the actions of others. When such reactions are exacerbated, the actions of others are called the second assault and the feelings are often described as a second injury.

Long-term crisis reactions tend to become less frequent and less severe as time passes, but in some victims, due to the severity of the trauma, they may last a lifetime.

Children's Reaction to Trauma

I. Caveats about Children

A. Regression

B. Double Loss

C. Live in Present

D. Growth

E. Change

II. Developmental Stages of the Child

A. Age: Birth - 2 Years

1. Language capability: pre-verbal.

2. Communication mode: physical activity.

3. Thought processes: distinguishes self from others and other things.

4. Growth emphasis: sensory perception and response.

5. Primary need: physical human contact for reassurance.

6. Primary relationship: with caretaker(s).

B. 2 Years - 6 Years: Pre-School

1. Language capability: development of language/verbal expression.

2. Communication mode: expression of feelings primarily through play, but

communication of needs often through words.

3. Thought processes:

• pre-conceptual thinking but engages in primitive problem-solving.

• active imagination but grounded in reality _ fantasies are about things

similar to those they have experienced.

• minimal concept of time and space.

• inability to concentrate on any one thing for more than a few minutes.

4. Growth emphasis: physical independence; dressing, feeding, and washing self.

5. Primary need: need for nurturing.

• "who will take care of me?"

• wants structure and security.

6. Primary relationship: with family.

C. 6 Years - 10 Years: School Age

1. Language capability: language well developed.

2. Communication mode: still uses play for primary expression but supplements

play with emotive language.

3. Thought processes:

• uses problem-solving techniques but also trial and error approach to problems.

• understands time and space concepts.

• strong orientation to the present but has some sense of future and past.

• makes choices.

4. Growth emphasis: toward independence in establishing new relationships;

exploring new environments.

5. Primary need: trust.

6. Primary relationship: still family but movement toward establishing strong peer


D. 10 Years - 12 Years: girls' pre-adolescence

12 Years - 14 Years: boys' pre-adolescence

1. Language capability: language may be more advanced than concepts.

2. Communication mode: "acting out" is common form of expression; poetry developing.

3. Thought processes:

• prone to extreme feelings and idealized emotions or life styles.

• judgmental about the world and self.

• thoughts become integrated with feelings and engender beliefs, biases, and prejudices.

4. Growth emphasis:

• towards emotional independence: involves swings back and forth from childlike

states to imitations of adult life.

• growth of sexuality and concern with sexual identities.

• emotional turmoil heightened by physical changes.

5. Primary need: support and self-esteem.

6. Primary relationship: back and forth from family to peers.

E. 12/14 Years - Adult

1. Language capability: uses and creates language to express self.

2. Communication modes: Drama and physical activity is preferred recreation since it provides a socially accepted way of acting out feelings; poetry still intense.

3. Thought processes:

• understands "cause and effect."

• can consider possibilities and explore options without experiencing them.

• judgmental about everything _ sees things in black and white.

• can conceive of future activities but does not think of future in

terms of self _ the Peter Pan dream.

• prone to taking irresponsible risks and failing to think through the

consequences of actions.

• reflection on symbols and possibilities.

• decentering.

• development of critical faculties.

• emotional turmoil may include periods of depression and euphoria.

4. Growth emphasis: independence from adult world _ particular target of conflict is usually parents.

• ego-orientation and self-centeredness.

• feels strong need for privacy and secrecy.

• body and sexual image is highly important.

• sense of immortality.

• creation of dance, style, world.

5. Primary need: stability, limits and security.

6. Primary relationship: with peers.

III. Child Reactions To Trauma

A. Overview: Children's reaction to a trauma will involve not only the impact of the catastrophe on their lives (what they saw, heard, felt, smelled and so on) but a sense of crisis over their parents' reactions. The presence or absence of parents and terror over a frightening situation _ one that has rendered the children's parents helpless _ all contribute to children's distress.

"A central theme that emerges from exploration of children's responses to disaster situations is that, in a way that is not generally appreciated, they, too, experience fear of death and

destruction... Particularly influential in the young child's experience are the presence or absence of his parents and the terror of overwhelming physical forces that seem to render the `all

powerful' adult parents frightened and powerless."

B. Birth - 2 Years

1. High anxiety levels manifested in crying, biting, throwing objects, thumb sucking, and agitated behavior.

2. While it is unlikely that the child will retain a strong mental memory of the trauma, the child may retain a physical memory.

C. 2 Years - 6 Years: pre-school

1. Children may not have the same level of denial as do adults so they take in the

catastrophe more swiftly.

2. Engage in reenactments and play about the traumatic event _ sometimes to the

distress of parents or adults.

3. Anxious attachment behaviors are exhibited toward caretakers _ may include

physically holding on to adults; not wanting to sleep alone; wanting to be held.

4. May become mute, withdrawn and still.

5. Manifest a short "sadness span" but repeat sadness periods over and over.

6. Regress in physical independence _ may refuse to dress, feed, or wash self; may forget toilet training; may wet bed.

7. Sleep disturbances, particularly nightmares are common.

8. Any change in daily routines may be seen as threatening.

9. Does not understand death (no one does) and its permanency _ reaction to death may include anger and a feeling of rejection.

D. 6 Years - 10 Years: School age

1. Play continues to be the primary method of expression. Often art, drawing, dance or music may be integrated in the play.

2. The sense of loss and injury may intrude on the concentration of the child in school.

3. Radical changes in behavior may result _ the normally quiet child becoming active and noisy; the normally active child becoming lethargic.

4. May fantasize about event with "savior" ending.

5. Withdrawal of trust from adults.

6. May become tentative in growth towards independence.

7. Internal body dysfunctions are normal _ headaches, stomach aches, dizziness.

8. May have increasing difficulty in controlling their own behaviors.

9. May regress to previous development stages.

E. 10 Years - 12 Years: girls' pre-adolescence

12 Years - 14 Years: boys' pre-adolescence

1. Become more childlike in attitude.

2. May be very angry at unfairness of the disaster.

3. May manifest euphoria and excitement at survival.

4. See symbolic meaning to pre-disaster events as omens and assign symbolic

reasons to post-disaster survival.

5. Often suppress thoughts and feelings to avoid confronting the disaster.

6. May be judgmental about their own behavior.

7. May have a sense of foreshortened future.

8. May have a sense of meaninglessness or purposelessness of existence.

9. Psychosomatic illnesses may manifest themselves.

F. 12/14 Years - 18 Years

1. Adolescents most resemble adult post-traumatic stress reactions.

2. May feel anger, shame, betrayal and act out their frustration through rebellious acts in school.

3. May opt to move into adult world as soon as possible _ to get away from the sense of disaster and to establish control over their environment.

4. Judgmental about their own behavior and the behavior of others.

5. Their survival may contribute to the sense of immortality.

6. They are often suspicious and guarded in their reaction to others in the aftermath.

7. Eating and sleeping disorders are common.

8. Depression and anomie may plague the adolescent.

9. May lose impulse control and become a threat to other family members and him/herself.

10. Alcohol and drug abuse may be a problem as a result of the perceived meaninglessness of the world.

11. Fear that the disaster or tragedy will repeat itself adds to the sense of a foreshortened future.

l2. May have psychosomatic illnesses.

Some Coping Strategies for Children

A. Rebuild and reaffirm attachments and relationships. Love and care in the family is a primary need. Extra time should be spent with children to let them know that someone will take care of them and, if parents are survivors, that their parents have reassumed their former role as protector and nurturer is important. Physical closeness is needed.

B. It is important to talk to children about the tragedy _ to address the irrationality and suddenness of disaster. Children need to be allowed to ventilate their feelings, as do adults, and they have a similar need to have those feelings validated. Reenactments and play about the catastrophe should be encouraged. It may be useful to provide them with special time to paint, draw, or write about the event. Adults or older children may help pre-school children reenact the event since pre-school children may not be able to imagine alternative "endings" to the disaster and hence may feel particularly helpless.

C. Parents should be prepared to tolerate regressive behaviors and accept the manifestation of aggression and anger especially in the early phases after the tragedy.

D. Parents should be prepared for children to talk sporadically about the event _ spending small segments of time concentrating on particular aspects of the tragedy.

E. Children want as much factual information as possible and should be allowed to discuss their own theories about what happened in order for them to begin to master the trauma or to reassert control over their environment.

F. Since children are often reluctant to initiate conversations about trauma, it may be helpful to ask them what they think other children felt or thought about the event.

G. Reaffirming the future and talking in "hopeful" terms about future events can help a child rebuild trust and faith in his own future and the world. Often, parental despair interferes with a child's ability to recover.

H. Issues of death should be addressed concretely.

© 1987, 1994, 1998 by the National Organization for Victim Assistance, Washington, D.C.

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