Group Crisis Intervention Techniques
Group crisis intervention builds upon the lessons of individual crisis intervention while opening avenues for building stronger communities and increasing the depth of understanding in human tragedies. While the focus of such group work is often portrayed as simply the overwhelming emotions of trauma and helping survivors gain cognitive control and understanding of what happened, group sessions should always include not only listening to reactions and allowing participants to tell their stories but assisting them in facing their futures. Reestablishing human connections and affirming hope is critical. It is useful for the crisis responder to remember the words of Helen Keller:
The marvelous richness of human experience would lose something of rewarding joy if there were no limitations to overcome. The hilltop hour would not be half so wonderful if there were no dark valleys to traverse.
II. Goals of Group Work
A. Guiding the release of emotional steam after the pressure-cooker of trauma.
B. Addressing great numbers of individuals after a community tragedy.
C. Peer group validations of individual reactions enhance the effectiveness of the validations provided by crisis intervenors.
D. Group work helps establish social support; rebuild a sense of community bonds; and repair the social fabric rent by the disaster.
E. Education of community members about trauma and its aftermath.
F. Affirmation or reaffirmation of hope in the future.
III. Scope and Nature of Group Crisis Intervention Services
NOVA has adopted the term "group crisis intervention" rather than using the term "group debriefing" because there is a growing reluctance to refer to "debriefings" in a community crisis response effort for several reasons. First, the term is often confused with what is known in military and law enforcement populations as "logistical debriefings" which are used to obtain from participants details of an operation. Second, for many community members, "debriefing" sometimes carries with it mental health connotations that may inhibit participation. Third, even among crisis responders, there is often debate over what the "debriefing" process implies. And finally, it is often used carelessly to describe social exchanges that have little value in addressing trauma or crisis.
B. NOVA's protocol
Group crisis intervention is useful both as an immediate response to acute crisis and as a way to continue to integrate the trauma into community life. NOVA's protocol for group crisis intervention relies upon a chronological approach for addressing the crisis event. Group participants are asked to remember what happened at the time of the trauma, what has happened in the aftermath, and what they expect to happen in the future. If the trauma is particularly intense, it may be useful to pace the group session to avoid initial feelings of being overwhelmed again. To avoid premature exploration of trauma material, group facilitators may want to start group sessions with the question, "What was life like before the event happened?" While facilitating this review, the group leader constantly seeks to ensure the group's sense of safety and security, to provide opportunity for ventilation and validation, and to help participants predict and prepare for problems in the future.
C. Critical Incident Stress Debriefing (CiSD) protocol
CISD uses a similar process to that used by NOVA but most people using CISD models address trauma by guiding groups through the following phases:
The facts of the incident,
What participants think about the incident,
How participants reacted to the incident,
What stress symptoms have been experienced,
Education about the incident and subsequent stress, and
A conclusion and preparation for the group to go back to their lives.
IV. Description of NOVA Protocols
If a catastrophe such as a serial murder or massive bombing takes place, it is likely that many victims and survivors may not have a great deal of time to focus on group work. Intermittent sessions may be better than one lengthy group session. However, in some cases, a horrific crime can occur in a matter of minutes and community members may find time to participate in comprehensive group sessions. If a catastrophe is a no-low-point tragedy or lasts over an extended period of time, there may be a need for repetitive interventions. When there is no opportunity for repetition, the sessions may be focused on somewhat different issues than those used in immediate post-trauma situations. Because of these variables, several types of group crisis intervention protocols have been developed. This chapter will first review the basic NOVA protocol used in the immediate aftermath of sudden, immediate, low-point tragedies and then when and how NOVA employs modifications of this protocol.
A. Group crisis intervention _ basic protocol
Group crisis interventions often take place at or near the site of the community trauma coincident with the first days or week of the trauma event. The technique allows the facilitators to address thoroughly all of the elements of crisis intervention; to educate participants on the common pattern of crisis reactions and what long-term stress reactions are to be expected; and to help participants consider coping responses. The group sessions usually last between 1½ hours and 3 hours. All victim and survivor populations can benefit from participation. NOVA conducts sessions for both homogenous groups, such as school personnel, firefighters, or survivors of those who have died in the tragedy, and heterogenous groups for any victims, survivors, caregivers, or community members who want to attend. Although groups of 20-25 participants are ideal, group sessions have been conducted with as few as five people and as many as 600 people. In extremely large groups, not all members can participate verbally, but most benefit from listening to those who choose to participate, hearing the commonalities in stories and reactions, and observing the process itself.
2. Timing of Sessions
a. Try to arrange sessions so that they do not conflict with events such as funerals, memorials and the like.
b. Night sessions are generally better for community-wide group meetings. Day sessions are generally better for school personnel, children, and employees.
3. CRT group sessions are usually no more than two hours in length. The following estimates of how that time might be spent will vary based on group participation but are included as a guide for crisis responders.
a. 1½ hours of group work.
10 minutes: introductions by facilitator focused on providing guidelines for discussion and establishing parameters of safety and security for participants.
35 minutes: questions designed to help review immediate physical sensory perceptions and emotional reactions of shock and disbelief and to give an opportunity for ventilation and validation of these reactions.
25 minutes: questions designed to help review reactions reflecting emotional turmoil, including fear, anger, frustration, shame, guilt or grief, and to provide an opportunity for ventilation and validation.
10 minutes: questions designed to elicit participant expectations for future coping strategies and to help predict and prepare group members for what may happen over the next few weeks, months or year.
10 minutes: summary by facilitator of what has been said in order to review validation and emphasize preparation for the future, and conclude the session.
b. Post-group session.
Allow 15 to 30 minutes for distributing handouts, answering individual questions, talking to individuals, and saying good-bye to individual participants.
The following logistical guidelines are listed in order to describe ideal situations, but crisis responders should be aware that in many disasters, group sessions will be conducted under onerous conditions.
a. The room should be accessible and comfortable for group members.
b. Mental health and other caregivers intersperce themselves among the participants. NOVA conducts most sessions with two intervenors but encourages local caregivers to participate in order to assist individuals who may need to take a "time out" during the session and to identify the caregivers to participants if they need additional assistance or referrals in the future.
c. Sessions should be conducted with the participants in a horseshoe or circle configuration where possible.
d. Flipcharts are used to record reactions of participants if possible and with permission of participants. Flipcharts will be destroyed after the session unless the participants want to keep them.
e. Sessions are conducted by a pair of intervenors.
f. Handouts are provided but should not be distributed until the end of the session.
g. Make sure tissue is easily accessible.
h. Make sure water is available.
i. Let people know where the nearest toilet facilities are located.
j. Let people know where they can smoke.
5. Group Intervention Team Roles
a. Group facilitator (one person should be "in charge").
The group facilitator is the only team member who talks during the group session. Facilitators are responsible for introducing the session, stating the guidelines, asking the questions, providing validation, assisting group members in validating each other, summarizing the session, and concluding it. If possible, the facilitator should be seated with the group either at the open-end of the horseshoe or in the circle.
Begins with "I am sorry it happened" to you.
Introduces self and other team members.
Introduces NOVA, gives NOVA references, if needed, describes NOVA's role in the community and the team's voluntary involvement.
Introduces local caregivers who are present.
Gives permission to the group to say what they want and to come and go as they please. Reminds them that if they leave, someone will follow them out to see if they are alright. Emphasizes that while they are not confined to the room, it would be helpful if they would return after taking a break.
Defines ground rules for session.
Facilitates the session.
Summarizes and concludes the session.
b. Supporting team member _ "The Scribe".
This person is not a facilitator, but he or she is an active member of the group crisis intervention team. NOVA has designated this member as "the scribe" because of his or her role in taking notes during the session. However the scribe does far more than simply taking notes. The scribe should stand while taking notes and be as unobtrusive as possible. The scribe:
Provides emotional and practical support to the facilitator, if needed. For example, a facilitator may begin to cough and need water _ the scribe would make sure that water was available.
Assists with individuals who may go into crisis within the group by distributing tissue, providing physical comfort, or helping them leave the room. (If local caregivers are assisting, they would take on this role as described below.)
Records notes on a flipchart of participant crisis reactions.
Takes over the group if the leader cannot continue. For example, if the facilitator becomes ill _ the scribe would provide immediate assistance and perhaps relieve the facilitator for the rest of the session.
Contributes only when called upon by the facilitator. For example, the facilitator may know that the scribe has particular expertise in helping elderly people cope with disaster and may ask the scribe to address a question on this subject during the prediction and preparation stage of the session.
c. Other crisis intervention team members (optional).
Local caregivers, when available, should be prepared to assist with individuals in crisis.
Other CRT team members, if available, should be prepared to assist with individuals in crisis.
Other CRT team members, if available, should be prepared to replace the scribe if the scribe must replace the facilitator.
6. Ground rules for group session are established.
a. Confidentiality of communication.
NOVA team members are expected to assure the group that all discussions in the group will be confidential. This does not mean that issues raised in the group cannot be talked about outside the group but rather that no story or concern will be attributed to any specific group member or described in a manner that can be used to identify that group member. NOVA team members cannot guarantee that all group members will abide by such promises of confidentiality but they can encourage the group to make a sign of assent to confidentiality to help underscore the importance of it. The facilitator should indicate that participants will not be allowed to take notes or to record the session.
b. Agenda for session.
The session is designed to help the group define the crisis reaction, provide some crisis intervention, and to predict and prepare the group for possible future events
In describing the agenda, the facilitator indicates that the group will talk about:
_ How the participants reacted or are
_ How their family or loved ones reacted or are reacting.
_ Expectations for the future.
c. Permission should be given to participants to express any thoughts or reactions they might have, but the facilitator should make it clear that no physical violence or verbal abuse will be allowed.
d. Ask that individuals identify themselves when they talk, if they are willing to do so. However, assure them that they may participate anonymously if they prefer.
f. Remind them that this session is not designed to be a critique of what happened but a review of reactions.
7. Session Procedure
a. After the introductions and orientation, the facilitator should:
Ask participants to tell about their experience during the event.
_ Where were they when it happened?
_ Who were they with?
_ What did they see, hear, smell, taste, or touch at the time?
_ What did they do? How did they react at the time?
Wait patiently through silences.
These questions are asked as a group to prompt participants to remember and to think about their initial reactions. They are not individual questions for which the facilitator awaits a response. After the questions are reviewed, the facilitator may ask if any participant would like to volunteer to tell what he or she remembered. At times, there may be an initial silent period. The facilitator should simply allow the silence to take place until a volunteer begins to talk. After one person participates, in most cases, others will follow rapidly. If that does not happen, the facilitator may repeat the series of questions again.
Respond to each participant by thanking him or her for telling about his or her experience.
Listen and validate any statements that fit within the crisis reaction framework.
Underscore similarities between participant responses.
b. After the first series of questions, the facilitator should:
Ask participants to describe what has happened to them in the aftermath of the event.
_ Since the time of the disaster, what are some of the memories that stand out in your mind?
_ What has happened in the last 48 hours? What do you remember seeing or hearing during that time?
_ How have you reacted?
Listen, respond, validate.
c. After the second series of questions, the facilitator should:
Ask participants to think about what has happened; to think about what will happen in the next few days or weeks; and consider what possible reactions they might have to those issues.
_ After all that you have been through, what do you think will happen at your job in the next few days or weeks?
_ Do you think that your family has been or will continue to be affected?
_ Do you have any practical concerns about what will happen next?
Ask participants about how they think they will deal with problems or issues that they have raised?
_ In many cases, they will have developed coping strategies in the past that they will refer to.
_ In some cases, they will seek information about how to deal with specific problems.
As they identify coping techniques, reinforce positive methods and suggest alternatives to negative methods.
Answer questions about problems, if possible, and tell them about written information that is available.
Suggest referrals if they are available.
Avoid making promises that cannot be kept.
d. After each set of questions has been addressed, and reactions or issues explored, the facilitator should move to summarizing what has been said during the session.
The scribe stops making notes on the flipchart.
The facilitator stands to review the notes and uses them to identify:
_ descriptions of acute sensory perceptions.
_ descriptions of shock and disbelief.
_ descriptions of emotional turmoil.
_ concerns about the future.
_ coping strategies that might be used to address such concerns.
The facilitator indicates that the descriptions of reactions are all reflective of crisis or trauma reactions.
The facilitator talks about expectations for the future that were mentioned but adds others not addressed that may arise.
The facilitator reassures participants of useful coping strategies.
e. The facilitator closes the session by sitting down again with the group, and then:
Thanks the group for participating in the session.
Repeats "I am sorry that this tragedy happened to you.
Gives participants a safety net for the future:
_ a plan for future group meetings.
_ a contact with community caregivers.
_ NOVA's telephone number and other resources.
_ If needed, ideas for a rumor control mechanism through which the community can get accurate and prompt information in the future.
Indicates that the session is over but that the facilitator and scribe will remain in the room for a few minutes if anyone has additional questions or concerns.
8. Session Process
a. Be prepared for emotional reactions and behavioral symptoms of trauma as manifested by the following:
Fear, anger, confusion, shame, guilt, or grief. All six responses may emerge during group sessions, but occasionally only one is predominant.
Inability to articulate reactions. Participants are trying to sort through their reactions and organize them into a story, but often that process is sporadic and words cannot be found to describe what they have experienced.
Physical agitation. Participants may find it difficult to sit or stand still for discussion. They may need opportunities to get up, move around, smoke cigarettes, or drink water. They may also fidget, bite fingernails, laugh or cry at seemingly odd moments.
Speech agitation. Sometimes participants find themselves stuttering, talking very rapidly, or being choked up when trying to say something. Facilitators should use patience and silence to allow participants to gather their thoughts or words.
b. Provide emotional support and understanding.
Project competence, calmness, authority, and encouragement.
Maintain a non-judgmental attitude about situations and responses.
Promote physical comfort.
Establish rapport through active listening, eye contact, and empathic responses.
If children were involved in the trauma or the event, allow them to attend sessions with their parents.
Listen and validate.
9. Special Issues
a. Dealing with anger: anger at you or anger at each other.
It is not unusual for participants to direct anger at the facilitator or at other people in the group. This is particularly true if the session takes place a number of days after the tragedy. Participants consolidate their anger and outrage at the event and channel it towards others. Remind participants that violence is unacceptable but that anger is not uncommon. Facilitators are often perceived as "safe" persons to express frustration towards, and should be prepared to listen to all concerns. It can be useful to apologize for any things that participants think have been done wrong and to try to explain how such things might have happened.
b. Dealing with grief: extent or hierarchy of grief.
Sometimes participants start to compare notes on their feelings of grief in a manner that suggests that certain group members have a right to feel greater sorrow than others. The facilitator should try to encourage the group to recognize that many are grieving and that everyone should have a chance to define their own grief. If sadness becomes overwhelming in the group, it is sometimes helpful to encourage the group to remember positive experiences with the persons for whom they are grieving. This, at times, can lead to laughter instead of tears.
c. Dealing with practical issues: financial, criminal justice, and the facts surrounding the event.
The facilitator should address any practical issues that are raised in the group succinctly with whatever information he or she has available. If nothing is known about the issues, the facilitator should simply say something like, "I don't know, but I will try to find out. Please feel free to get in touch with me at NOVA (or a local number) tomorrow."
d. Dealing with multiple traumas.
If participants raise other tragedies that they have been reminded of due to the current disaster, allow them briefly to tell about those tragedies. If they need to discuss those previous events in more detail, refer those participants to crisis intervenors in the room or make time to talk with them after the group session. Refocus the group on the event at hand.
e. Dealing with issues of God or the world beyond.
Be accepting of all beliefs. Sometimes facilitators can be accepting, but other group members ridicule beliefs. Encourage the group to recognize that faith isn't scientific. Everyone has their own concept of values and the cosmic universe. Two issues are common.
Many people believe in an afterlife. There may be differing concepts regarding heaven or the spirit world, but the concept of life beyond death is not unusual. In some cases, survivors believe that their loved ones contacted them as they died through supernatural means. In some cases, victims believe that they had a message from God that saved them from death. The facilitator may want to allow the group to explore such experiences while confirming that each person searches for meaning in their own way.
At times, the experience of the group process may be powerful enough that someone may be moved to offer a group prayer. Prayer can be an inhibitor to the group process. It also is difficult to ascertain whether everyone in a group will feel comfortable in prayer. It is advisable to suggest that a prayer might be appropriate for those who wish to participate after the group session is concluded.
f. Behavioral problems: silence, monopolization, hysterical behavior.
Silence is golden. Accept silences as moments when groups are thinking and processing their reactions.
If a participant tries to monopolize group conversations, use judgement to discern whether the rest of the group is interested in what the participant is saying. If they are not, suggest that the participant talk to someone after the meeting or take a break to talk to another crisis responder. In most cases, facilitators can find something in what the participant is describing to link his or her reactions to others in the group. Facilitators may say something like, "Is it okay if I stop you there, because you have just talked about being frightened and I heard someone else say he was frightened. I wonder if anyone else here might have been frightened?"
If participants become out of control or hysterical during a group session, the Scribe or another crisis responder should offer to talk to them outside. If they resist leaving the group, allow the group to help reassure them that their story is heard and their reactions are reasonable.
g. Use of humor in group crisis intervention.
Facilitators should let the group lead the way in using humor. Facilitators should not try to be humorous. The only time when facilitators should intervene in the use of humor is when it is used maliciously against another group member or an absent person who the group knows. Facilitators should try to defuse reactions that have precipitated cynical or sarcastic remarks and focus on the group process as a way of exploring reactions.
B. Group defusing protocol
Group defusings usually are conducted at or near the site of the community trauma coincident with the first days or week of the crime. They are purposely short in length, lasting between 30 and 45 minutes. Often the primary target populations for such defusings are emergency workers who face competing demands on their time, but short defusing sessions can be helpful to others as well. Because of the time limit involved in defusings, they do not address all elements of crisis intervention. Their focus is on immediate issues of safety and security, flash-points of trauma reactions, and thoughts on how to continue to live through immediate re-exposure to the crime scene or its aftermath. It is usually recommended that participants in defusing sessions also participate in follow-up group crisis intervention sessions.
2. Timing of group defusings.
a. Defusing are usually done immediately after shift rotations.
b. They last for no longer than 30 to 45 minutes.
c. The following is an example of the timing of various segments of a 45 minute defusing.
3 minutes: introduction and orientation emphasizing safety and security issues for the group.
10 minutes: ventilation and validation of immediate reactions to announcement of disaster.
20 minutes: ventilation and validation of flashpoints and reactions to them.
7 minutes: prediction and preparation for continuing work at the trauma event.
5 minutes: summary and conclusion.
3. Questions used during defusings.
a. Ventilation of immediate reactions.
Where were you when you first learned of the disaster?
What do you remember seeing, hearing, smelling, touching, tasting?
What did you do?
b. Ventilation of flashpoints.
Many people who do emergency work find that there is a specific incident during their immediate response that sticks in their minds or troubles them. Can you think of any such incidence that has occurred during your work over the last shift (or use relevant time frame such as 8, 12 or 24 hours)?
Do you have any thoughts or reactions about that incident now?
c. Prediction and preparation.
As you go back to work, do you think that incident will continue to trouble you?
Are there things you can do or think that can help you to cope with such thoughts or reactions?
4. Key issues for facilitators.
a. Validation of reactions.
b. Reassurance of workers' competence.
c. Education on coping strategies.
d. Reassurance of continuing support for workers.
C. Extended trauma protocol
In prolonged disaster situations when the crisis intervenors arrive in the middle of an extended trauma event _ such as war (in the former Yugoslavia, for example), disease (the impact of HIV/AIDS in some communities), a natural disaster with thousands of deaths and massive destruction requiring months or years of cleanup and rebuilding (The Great Hanshin earthquake in Kobe, Japan), long-term or ongoing intense criminal activity such as unsolved serial murders (Gainesville, Florida, coed murders) _ the questions used to elicit the crisis reactions, and to prepare to cope with a radically changed future, will be different from standard ones. This is particularly true when there is no opportunity for crisis responders to provide repetitive group interventions and there are no local caregivers prepared to continue repetitive interventions.
2. Timing of the extended trauma protocol.
a. These group interventions may take place at any time during the trauma event, but usually occur some weeks or months after the event affected the session's participants.
b. Because such interventions often are used when it is expected that these sessions may be the first or only ones made available to survivors, the sessions last for as long as it takes for everyone who wants to have an opportunity for active participation.
c. The minimum time for such a protocol is usually 3 to 4 hours.
d. The following is an example of how a 4 hour session might be paced.
10 minutes: introduction and orientation addressing safety and security issues.
35 minutes: review of memories of pre-disaster life in order to provide a temporal anchor with life before the event.
1 hour: ventilation and validation of reactions to the most significant event that precipitated victim or survivor involvement in the disaster.
1 hour: ventilation and validation of significant incidents and reactions to them that have occurred since the survivor became involved.
30 minutes: prediction and preparation for future stresses and review of coping strategies.
30 minutes: generation of dreams and hope.
15 minutes: summary and conclusion.
3. Sample questions for facilitating the sessions.
a. Establishing a temporal anchor.
Can you remember and describe what life was like before this catastrophe started?
Are there events from that time that stand out in your memory as particularly happy or good?
b. Reactions to event that precipitated participation in the disaster.
What event made you realize that you or your family were a part of this ongoing tragic situation?
Can you describe where you were when it happened, who you were with, what you remember seeing or hearing at the time, and how you reacted?
c. Reactions to ongoing incidents and events.
Since the disaster began, can you describe some of the most significant illustrations of its impact on your life? Where you were when they happened, and what you remember doing in response to them?
Can you describe any other incidents or events that affected you or your family and how your family or you have reacted?
d. Identification of future stresses and possible coping strategies.
What are some of the problems you expect to face as this disaster continues?
Are there ways in which you or others can prepare to deal with such problems?
e. Establishment of a framework for hope.
What kind of life do you expect when the immediate impact of this disaster begins to subside?
What kind of life do you dream of for you or your family when this disaster is over?
Are there specific steps that can be taken now to begin to prepare for a better life in the future?
4. Key issues for facilitators.
a. Establishment of temporal anchor.
b. Validation of reactions.
c. Reassurance to participants that people care about their plight.
d. Education on coping strategies, problem-solving, and resources.
e. Affirmation of spiritual beliefs.
f. Affirmation of hope.
D. Repetitive group intervention protocol
The process of repetitive group crisis intervention sessions is employed when a community perceives itself as being under siege as a result of numerous different disasters have taken place in the same community in a relatively short time period, or when there is a high level of ongoing criminal behavior that has caused community members to live in fear and feel helpless, or as a supplement to one-on-one crisis counseling. At times it is used after a crisis response team has done an initial group session and local caregivers plan ongoing group sessions until the state of siege seems to subside or is terminated. At other times, local crisis response teams can initiate the process through an initial session and follow-up sessions. It is particularly useful in crime situations when an offender is not yet identified or apprehended because it can help community members cope with ongoing feelings of fear and dread. It can also be helpful when communities are awaiting delayed identification of victims who have died or information after abductions.
All the elements of the crisis reaction and long-term stress reactions are covered in the first session with a particular emphasis on safety and security concerns. In follow-up sessions, the focus is on one or two dominant crisis reactions each time, as the participants identify them. Since the disaster(s) or crime(s) continue, the participants describe high significance incidents that have occurred during the ongoing experience. Short-term coping strategies are reviewed.
2. Timing of repetitive sessions
a. The process is predicated on the fact that a number of group sessions will be held. These may be set up in advance on a regular schedule _ weekly or bi-weekly. The length of the first session which is used to orient group participants to the goals of the sessions and to plan the logistics of future sessions runs 1½ to 3 hours. Succeeding sessions are usually shorter and last from 1 to 2 hours.
b. The following are examples of the pacing of the protocols for both the initial session and the follow-up sessions
Repetitive group debriefing protocol _ 3 hours (First Session)
30 minutes: introduction and orientation and establishment of safety and security. This segment is longer than in other protocol because time should be taken to explain the repetitive group process and to establish group-developed rules for participation and involvement. The group may want to set guidelines for attendance and develop their own procedures for assuring confidentiality.
30 minutes: ventilation and validation of initial reactions to the beginning of the trauma event.
1½ hours: ventilation and validation of current and ongoing crisis and long-term trauma reactions.
45 minutes: prediction and preparation for continuing trauma incidents and coping strategies.
15 minutes: summary and conclusion.
Repetitive group debriefing protocol _ 1½ hours (Follow-up Sessions)
10 minutes: introduction and updates. Often in repetitive group sessions, a small amount of time needs to be allotted to ensure that all group members are aware of any updates in the progress of the disaster or the criminal case. Review of safety and security guidelines.
30 minutes: ventilation and validation of ongoing crisis and trauma reactions to incidents that have occurred since the last time the group met.
20 minutes: ventilation and validation on a priority crisis reaction identified by group such as fear or anger.
20 minutes: prediction and preparation for new issues associated with the trauma and reminder of useful coping strategies.
10 minutes: summary and conclusion.
3. Sample questions for repetitive group sessions
a. Initial session: same questions as used in basic group protocol.
b. Follow-up sessions
Ongoing crisis and trauma reactions to incidents that have occurred since the last time the group met.
_ Can you describe any incidents or events relating to this disaster that have happened since we last met and which have particularly troubled you?
_ Can you explain what you saw or heard and how you reacted?
Priority crisis reaction identified by group such as fear, anger, confusion, or grief.
_ Can anyone describe what they think is the most serious disaster-related reaction in this community today?
_ Can you explain why you think this is the most serious reaction and tell me what, if anything, has caused it?
_ Can you tell me how this reaction is being expressed by you or others?
Addressing new issues associated with the trauma and reminder of useful coping strategies.
_ What do you expect to happen between now and when we meet again that may cause additional problems or reactions in the community?
_ How do you think the community will react?
_ Are there things that you or others might do to address those problems and reactions before they happen?
4. Issues for facilitators.
a. Providing information updating disaster progress.
b. Validation of reactions.
c. Generating group cohesion around relevant reactions or issues.
d. Education on coping strategies, problem-solving, and resources.
e. Affirming group and community peer support for addressing problems.
E. Retrospective group crisis intervention protocol
The concept of retrospective group intervention developed due to several factors. First, many communities that survive a violent criminal attack face ongoing traumatic events connected to the crime similar to those faced by individual crime victims. Such events include the response of the criminal justice system, media scrutiny of the community or replays of the event itself, the "anniversary" of the event, the deaths of key players in the event, or the occurrence of a similar event in the same or another community. These separable events often cause the community to relive the original trauma, creating a need for some community members to process the crisis reactions once again. Second, because knowledge of the impact of crisis and appropriate responses has only recently been developed, some communities bear the scars of disasters or crimes committed in the past and request assistance now to address the old pain. Third, some communities do not request immediate assistance but realize six months or a year later that assistance might have been useful.
Retrospective group crisis intervention usually takes place in the community where the crime occurs, although if the community has been destroyed or was transitory in nature, it can take place elsewhere. It may occur months after the trauma but also can take place years later. Because of the nature of the extended memories that are elicited, the session may be extended over a number of hours. With a very small group, it may take only 2-3 hours to process the issues, but on occasion, the session could last 5-8 hours. The target population for such interventions are community members experiencing current distress attributable to the trauma. Since the trauma event happened in the recent or distant past, it is useful to ask group members to close their eyes and think about the event for up to one minute prior to discussion. While they are doing this, the facilitator can ask them the first series of questions. When the minute is over, they open their eyes and the facilitator again asks the first series of questions.
2. Timing of group sessions
a. In most cases, safety and security are no longer issues so the group focuses on ventilation, validation, and integration of the trauma ex-perience. The crisis reaction, long-term stress reactions, and community-oriented coping strategies are addressed as well as concerns about inter-generational transfer of trauma. It is likely that survivors will respond to facil-itated questions about the tragedy by telling their stories from beginning to end, without need for prompts. In most cases, they will have begun to extrapolate the story framework, or completed it, as a part of their unconscious or conscious integration of the story into their lives. Most sessions last between 3 to 4 hours; however, some sessions have lasted as long as a day, with a break for lunch.
b. Suggestions for pacing a retrospective group session (3 hours)
15 minutes: introduction, orientation and establishment of safety and security.
1 minute of focus on the trauma event while participants close their eyes.
1¾ hours: review of memories of the impact of the disaster; ventilation and validation of common reactions.
30 minutes: reflection on how the disaster affected community and individual lives over time and assessment of positive changes.
20 minutes: prediction and preparation for helping the next generation cope with the aftermath of the disaster in question or with future disasters.
10 minutes: summary and conclusion.
3. Sample questions for retrospective group work
a. Review of memories of the disaster. Facilitator suggests all participants focus on the memory of the event and asks the following.
Where were you when the disaster happened?
Who were you with?
What do you remember seeing, hearing, smelling, touching, tasting?
What did you do or how did you react?
[Note: these questions normally result in each participant telling the story of the beginning of the disaster as well as key events in the aftermath and their reactions throughout both periods.]
b. Reflection on how the disaster affected community and individual lives over time.
In retrospect, how do you think the disaster affected or changed you, your family's or the community's life?
Do you think there were negative changes?
Do you think there were positive changes as a result of the disaster?
c. Helping the next generation cope with future disasters.
If you or others learned lessons from the disaster, what do you think are the most important lessons that you could tell your children or grandchildren?
Can you identify practical lessons, lessons that affect coping strategies, and lessons that reflect hope?
4. Issues for facilitators
a. Validation of reactions.
b. Education about crisis and trauma reactions and coping strategies.
c. Reassurance of individual and community competency in the face of disaster.
d. Reaffirmation of community and spiritual connections.
e. Education and preparation for the next generation.
F. Specialty group techniques
1. General thoughts
All of the above group crisis intervention techniques can be modified to address unique population groups. Groups for children utilize art and play as methods of ventilation and validation. Elderly group sessions may incorporate special visual or auditory aids, and may integrate long-term memories into the interpretation of current trauma. Non-English speaking groups may require facilitation through translators or creative nonverbal expression. Coping strategies and interpretation of crisis reactions should take into account differences in cultural backgrounds.
2. Homogeneity or heterogeneity in group work
For many years victim assistance professionals have conducted peer groups for survivors and victims with an emphasis on bringing survivors or victims together who have suffered similar crimes or disasters. Examples of peer group counseling have been found in support groups organized by Parents of Murdered Children, Mothers Against Drunk Driving, rape crisis centers, and domestic violence programs. While it may be that crisis response group work is most effective when done initially in homogeneous groups of victims, survivors or emergency responders, there is growing evidence that over time integrating groups with different types of victims, survivors of different types of disasters, and different age groups of victims or survivors may have particular advantages.
"I'm challenging the notion of homogeneity [in groups]," says Hadar Lubin [a psychiatrist with Yale Psychiatric Institute]. [He] works with women assembled into small, heterogeneous therapy groups in which, for example, someone trying to recover from domestic abuse may be sitting next to the traumatized witnesses to a deadly fire or a shooting. For 16 weeks of collective psychotherapy, the women work with their disparate experiences, and although many professionals would hold that such differences might prevent, rather than facilitate, recovery, Lubin says "patients report that they're feeling better. Their morale is up, they're more hopeful, and their esteem has increased. In such a short time, it's not our goal to cure their trauma or make them forget it. Rather, we want to provide these women with the tools they need to deal with the effects of trauma in their lives. We can't answer the existential questions, but we can do something to help them tolerate having the questions."
V. Helpful Hints for Caregivers
A. Hints for the Scribe1
1. Record precise language used by participants. Do not paraphrase.
2. Denote in the record when there is a change in speaker: the use of bullets, different colored markers, arrows or such can help make that denotation.
3. Underline words or phrases that stand out as illustrations of crisis reactions, long-term stress symptoms, effective coping strategies, spiritual issues.
4. Record at least one comment from every group member who participates.
5. Record at least one phrase that can help identify the participant who is speaking: "my father died in the crash," "walking nearby when the building blew up," "eating lasagna when the shots rang."
6. Write legibly and spell accurately.
7. Record words and phrases _ not complete sentences.
8. Record selectively; do not try to record whole stories.
9. Stand to the side of the flipchart so participants can see their words recorded.
10. Do not react to the stories or the description of reactions.
11. Watch the facilitator for signs of distress or physical needs.
12. If you must leave the room to care for a distressed participant, draw a double line underneath the last comment that was written so that, if you return and continue writing, this break is clearly illustrated for the facilitator.
B. Hints for the Facilitator
1. Make sure you have the factual details of the disaster as accurately as possible. Know the names of relevant locations, the names of victims who have died, and any notable leaders in the community. Know when the disaster happened and how many people are dead and injured.
2. Prepare for any unique issues with which a particular group may be concerned due to the nature of the disaster or its aftermath. For example, after a fire-related disaster, many participants may be distressed about viewing or knowing about burned victims or survivors. After a disaster involving drowning victims, participants may be overwhelmed by seeing bloated and distorted bodies.
3. Do not emote in response to what is said. Show sympathy and concern through body language or validation of reactions.
4. Remain and act calm and assured.
5. Establish eye contact with the speaker and hold that eye contact throughout his or her story.
6. When asking questions of the group, look at as many group members as possible. If one or two members are conspicuously silent, be sure to include them in your eye contact.
7. Do not be afraid of silence.
8. Respond to individuals in the group when they tell their story by saying "I'm sorry."
9. Do not argue with participants whose version of the story differs from the facts as you know them.
10. Be prepared to answer factual questions concisely.
11. Do not elaborate on extraneous details.
12. Do not probe for further explanations or descriptions of participants' stories, but if they describe a part of the event without indicating reactions, ask them if they had any reactions at the time that they are willing to tell the group.
13. Validate key reactions verbally if the participant gives you the opportunity. Seek validation from other group members by asking questions such as: "Did anyone else have a similar experience?" "Joe talked about being angry and Mary just said she found herself screaming at a police officer who wasn't doing anything. Mary, were you angry when you were screaming?" If the participant does not give anyone an opportunity to validate verbally, nod affirmatively in response to key reactions.
14. Practice validating responses with a variety of words. Sample responses are:
"I can't imagine how upset you must have been."
"Anger is not uncommon. Some people even talk of being outraged or furious when they are so distressed."
"Fear is not unusual. Many people are terrorized when they think their lives or someone they love is threatened."
"Everyday life is shattered by senseless murder."
"I'm not sure anyone can fully understand how much agony this disaster has caused you and your family."
"Pain is a common bond in disaster, but its experience can't really be shared."
"It can be terribly frustrating not to know what happened."
"It must be very difficult to believe yourself to be to blame for this tragedy. It's not unusual for us to think back on ways that we could have avoided a disaster, but you are not responsible for the behavior of a murderer."
"Some people are ashamed and humiliated when they are helpless to prevent or respond to tragedy. But tragedy often makes people helpless and you didn't have any control over what happened."
"Disasters like this don't make sense."
"It is difficult to comprehend anything as terrible as what happened to you."
"Sometimes it's hard to put words to an awful event. Tears can serve as a useful alternative."
"Take your time, it's all right to cry after someone you love has been killed."
"It's not unusual to feel like a little child or baby when something this awful overwhelms you."
"It's very difficult to think you will ever feel good again when such a bad thing has happened to you."
15. Do not tell the group of your own experiences or those of others in this or other disasters to validate their own stories. Their experience is unique.
16. Sometimes a quotation or line of poetry can serve to offer validation or a helpful response. Examples:
You have to live through a time when everything hurts.
_ Stephen Spender
In our sleep, pain which cannot forget falls drop by drop upon the heart until, in our own despair, against our will, comes wisdom through the awful grace of God.
17. Keep track of time so that you can end on time.
18. Try to remember at least four or five names of the participants if the group members choose to identify themselves, and use those names in response or in the summary of the session.
19. Tie all comments back to the crisis reaction or long-term stress reactions.
20. Summarize the session with reference to the scribe's notes, but retain the crisis reaction as a framework for the summary. In the summary, you should not necessarily follow the order of the speakers; rather draw the crisis reaction out of the notes in the order of your training and your handouts.
21. Remember to predict important events that will be facing the community in the summary of future concerns. Inform them of any problem issues that may arise and make concrete suggestions for sources of further information if such referrals are available.
22. Underscore positive suggestions or thoughts that some participants might have raised during the segments focused on the future.
23. Thank the group members for participating in the session _ include all group members in the thanks, those who told about their experiences and those who listened to others.
24. Distribute handouts to the group members as they leave the session.
25. Give them NOVA's telephone number along with a local referral if available for further information.
Facilitators and participants in group crisis intervention sessions can learn much from the philosophies behind traditional Indian teachings of group and community life and communication.
Traditional teachings seem to carry a suggestion that people will always have different perceptions of what has taken place between them. The issue, then, is not so much the search for "truth" but the search for _ and the honouring of _ the different perspectives we all maintain. Truth, within this understanding, has to do with the truth about each person's reaction to and sense of involvement with the events in question, for that is what is truly real to them. And if that is so, then justice processes [and perhaps crisis intervention] must somehow deal with and validate their reality while also giving them the chance to understand how others see things
Speaking in that way constantly declares an understanding that part of the richness of life rests in the fact that all human beings are likely to respond in unique and interesting ways to the same events, things and people.
_ Rupert Ross, Dance with Ghosts
© 1987, 1994, 1998 by the National Organization for Victim Assistance, Washington, D.C.