Rethinking Trauma Talk

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Sadly, it has become a well-practiced ritual.

When a student opens fire at a school, when a teenager drowns on a Scout trip, even when something unprecedented like the 9/11 attacks kills a YMCA coach, one adult response is almost always the same: Rush in counselors for the kids.

Teams from the National Association of School Psychologists have the drill down so well that they’ve arrived at shooting sites 12 hours after a request from the U.S. Office of Safe and Drug-Free Schools. In addition, over the past three years that office has dispensed about $11 million to schools for locally based counseling and other services in the wake of such traumatic events.

But as government agencies, schools and some youth-serving organizations almost reflexively offer crisis-response counselors to help youth, a growing body of research has raised a fundamental question: Does it help?

Perhaps most noteworthy was an analysis of recent research – published in 2002 in Great Britain’s premier medical journal, The Lancet – which said crisis intervention teams do little or no good in reducing symptoms of Post-Traumatic Stress Disorder (PTSD). The Dutch authors, who examined seven studies, said the interventions could actually harm the emotional healing process.

And a study published in November by Psychological Science in the Public Interest concludes, “Although psychological debriefing is widely used throughout the world to prevent PTSD, there is no convincing evidence that it does so.”

Try telling that to Scott Poland. The director of psychological services at the Cypress-Fairbanks school district in Houston led crisis teams that flew into Paducah, Ky., and Jonesboro, Ark., after shootings by youths in 1997 and 1998 left a total of eight people dead and 15 wounded. For him, the debate over the value of crisis response is answered by the calls and letters he’s received from youths months and even years afterward.

“They tell me, ‘That session helped so much. It changed everything. We knew we were not alone,’ ” says Poland, who is on the advisory board of the National Organization for Victim Assistance.

Psychological Battles

Psychological debriefing, as it is now generally known, can be traced at least to World War I, when commanders met with their men after major battles to debrief them, says the recent study in Psychological Science. “The objective was to boost morale by having combatants share stories about what had happened,” the authors write. Decades later the practice evolved to help people routinely involved in traumatic events through their jobs, such as firefighters and police officers. More recently, debriefing spread to “primary victims” – survivors exposed to trauma, usually violence wreaked by people (shootings and accidents) or nature (storms).

The widespread use of debriefing-like counseling for youth took hold with the rash of school shootings in the 1990s. Initially, that help typically involved sending in counselors, social workers or psychologists from around the country, such as those from the school psychologists’ association, to provide short-term help. Over the past few years the federal government has been putting more focus on providing funds to the affected school districts to pay for psychologists and other locally based services.

Also, the U.S. Substance Abuse and Mental Health Services Administration maintains a $30 million network of grants and contracts “to provide services nationally to providers who assist children experiencing post-traumatic stress disorder.”

Nonprofit youth-serving agencies practice more of a “sometimes” approach to post-traumatic counseling, and are less likely than schools to send designated “crisis response teams” to debrief the kids in groups. The youth agencies usually don’t have psychologists at the ready as schools districts typically do, and the traumatic incidents are more likely to be accidents or to occur away from the agency’s facilities, rather than murderous rampages on site.

For instance, Boy Scout leaders brought in grief counselors after a 16-year-old drowned last July in a lake at Sand Hill Scout Reservation near St. Petersburg, Fla. The Boy Scouts of America (BSA) does not provide a crisis response team for such incidents, says Brandi Mantz, associate director of marketing and communications for the BSA. When tragedy befalls a Scout or a leader, she says, “Our recommendation is that they [the local councils] have individuals available,” such as psychiatrists, clergy and adults known to the youths.

Right after the 9/11 attacks, the YMCA of Greater New York provided counselors (from both inside and outside the agency) and trained its staff members to work with youth in groups and individually at all 19 of its branches, says Shelly Wimpfheimer, vice president of Youth and Family Programs. Youth in several of the branches knew people who died in the attacks (including YMCA members), and 5-year-olds at one branch suffered the loss of a volunteer coach. The coping activities, which varied by age, included art, role-playing and group discussions.

Such intervention is intuitively appealing. But recent studies have questioned the value of the “wide net” approach of crisis response teams, while holding out hope for more focused counseling.

The Research

“Many times I think our objective is to do something because we feel threatened, and we feel compelled to do something,” says Richard Gist, the principal assistant to the director at the Kansas City, Mo., fire department, who has studied the efficacy of mental health crisis interventions for more than 10 years. When his first study indicated that such interventions played no significant role in preventing subsequent post-traumatic stress, “we sat on these findings for four years” before going public, says Gist, who is also an associate professor of psychology at the University of Missouri-Kansas City. “We figured it must be an anomaly.”

Today, those findings have been replicated in studies across the globe.

Gist wrote an accompanying editorial for the Lancet report, in which he said that when trauma victims go through “psychological debriefing,” it may interfere with their natural assimilation to a tragedy and prevent them from getting immediate help from a more traditional support system: their family and friends.

For Gist, such intervention is “no better than doing nothing, and it may make it worse.” And, he says, “there is no evidence that it is any more beneficial to young people than it is with adults.”

In a similar vein, the World Health Organization recommends against single-session psychological debriefings “that push persons to share their personal experiences beyond what they would naturally share.”

Does packaging a single-session debriefing into an array of other interventions make much difference?

“This is roughly equivalent to adding a hint of mint flavoring to the same old dentifrice and labeling it, ‘New and Improved,’ ” Gist says. “It just doesn’t fly.”

William Modzeleski is not so sure. The associate deputy undersecretary at the Department of Education’s Office of Safe and Drug-Free Schools does not believe those studies can be applied to school shootings, because of the nature of the circumstances and the victims involved.

“There really hasn’t been any research in the U.S. that has taken a look at what is the most effective way to respond in the aftermath of a shooting that has occurred in a school,” he says.

Besides, he says, “research tells some of the story, but it doesn’t tell all of the story. One thing we clearly know from all these disasters is: There are kids that are hurting, there are faculty who are hurting and there are parents who are hurting. Without some help, teaching and learning can’t take place.”

Based on what he hears from school districts, “I do believe they [crisis response teams] are helpful,” Modzeleski says. So does Larry J. Macaluso, superintendent of the Red Lion, Pa., school district, which had a deadly shooting last spring.

“Whether it has long-term value or not, perhaps that may be questioned,” Macaluso says. But “the need for it at the time is critical, even if it is just to get the people through the short-term trauma.

“Then, of course, if you drop it from there, you won’t have problems resolved.”

Everyone appears to agree that long-term counseling tailored to the needs of individuals who indicate they need it is beneficial. That is why the drug-free schools office now provides grants for both short- and long-term psychological services. (See sidebar.)
Making matters murkier is a 2001 consensus report, “Mental Health and Mass Violence,” from which both sides of the debate have found support for their positions.

The report is based on a workshop organized by the National Institute of Mental Health, which brought together 58 disaster mental health experts from around the world in 2001 to try to reach a consensus on early psychological interventions.

The group agreed that the medical literature indicates that “early, brief, and focused” interventions within four weeks of a traumatic event “can reduce distress in bereaved spouses, parents and children.”

But it also said that psychological debriefings – in this case, one-on-one sessions in which people recall an event and the emotions it evoked – “do not consistently reduce risks of later post-traumatic stress disorder or related adjustment difficulties.”

The conclusion: “Precise recommendations as to when follow-up should occur are impossible owing to the number of significant variables involved.” The group suggested a national research initiative to assess the effectiveness of early psychological intervention – all of which leaves those on the front lines with few certain answers.

The Teams

Unexpected tragedies leave no time for a grant application process. That’s why the Department of Education routinely taps the National Association of School Psychologists and the National Organization for Victim Assistance (NOVA) to go to a scene and provide immediate help.

NOVA says its typical team is led by a mental health professional with a doctoral degree and includes mental health specialists, victim advocates, public safety officials and clergy. All have had a minimum of 40 hours of training. (NOVA offers a three-day certification training program, at a cost of $400, for those who want to volunteer to be crisis response team members in their communities.)

Once on site, the team helps local authorities identify those who are most at risk of experiencing the effects of trauma, leads initial group sessions and trains local providers for longer-term services.

Cheryl Tyiska, NOVA’s director of victim services, is aware of the mixed reviews on crisis response teams. She thinks part of the problem is that the teams were oversold early on and promoted as a means to prevent or minimize Post Traumatic Stress Disorder, which she says “was not correct.”

NOVA uses what Tyiska describes as “a low-key approach,” conversing with people at a shelter about how they’re feeling, while handing them a cup of coffee.

“We’re not trying to fix them. We’re not trying to take the pain away, or do any kind of diagnosis,” she says.

It’s more of an educational approach: “We’ll tell them, ‘If you find you can’t sleep, don’t be too alarmed, because it’s not that unusual. But if it goes on too long, you might want to consider seeing someone,’ ” Tyiska says.

“Our experience is that most of the people feel they’ve been very useful,” she says of the conversations.

Although NOVA offers its services for free, its 2001 tax returns show it received more than $2.5 million in gifts, grants and contributions, including a $1.4 million federal earmark for crisis response. Deputy Director John Stein says that “95 percent of our revenue is training income, membership dues and donations.”

As for the school psychologists, Assistant Executive Director Ted Feinberg says the Education Department covers the counselors’ lodging and meal expenses, but does not pay for their time. (The association does get some funding from the department, he says.)

“I have heard discussions that people are concerned that there are groups out there that are making money off of other communities’ misery,” Feinberg says. “But if they’re out there, I’m not aware of them.”

“For those of us who have a passion for this,” he says, “there is a feeling of ‘there but by the grace of God go all of us.’ … I also want to model for my child that ‘volunteer’ is not a cliché.”

He’s puzzled by the dispute about the effectiveness of crisis response teams. “It seems to me to be a no-brainer, that if you let people talk about it, they have less difficulty dealing with very difficult situations,” he says.

Time Heals

For now, the effectiveness of crisis response may come down to individual success stories, based on an array of variables that may make any structured group approach impractical.

At the YMCA in New York, the meetings with staff and youth soon after 9/11 were followed by offers of individual help with clinicians. “I worked really hard at not cramming this down people’s throats,” Wimpfheimer says. “We didn’t have a heavy use of counselors. The idea was to let the kids know something was available.”

In the end, there may be no better healer than time.

In May 1988, a rural community south of Louisville suffered a heartbreaking tragedy – the death of 27 people, mostly teenagers, when a drunk driver going the wrong way on an interstate highway near Carrollton, Ky., hit a school bus returning from a church outing to an amusement park.

Kay Sharon, spokeswoman for the Hardin County School District, which the students attended, says there was a huge outpouring of offers to come and help. “I remember at one point, it was like, ‘What are we going to do with all these people?’ ” she says.

NOVA was among those providing services, and the school district received a grant to bring in a special therapist for two years.
“For the first five years, we had a memorial service every year,” Sharon says. Then life began to nudge everyone along. Last spring, Sharon says, the 15th anniversary of that calamitous event passed without ceremony or commemoration.


Ted Feinberg, Assistant Executive Director
National Association of School Psychologists
Suite 402
4340 East West Highway
Bethesda, MD 20814
(301) 657-0270

Richard Gist
Principal Assistant to the Director
Kansas City Fire Department
22nd Floor, City Hall
414 E. 12th St.
Kansas City, MO 64106
(816) 513-1700

National Crisis Response Team
National Organization for Victim Assistance
1730 Park Road NW
Washington, DC 20010
(202) 232-6682

Scott Poland
Director of Psychological Services
Cypress-Fairbanks Independent School District
10300 Jones Road
Houston, TX 77065
(713) 460-7825

“Does Early Psychological Intervention Promote Recovery From Posttraumatic Stress?”
Psychological Science in the Public Interest, November 2003
The American Psychological Society
Suite 1100
1010 Vermont Ave. NW
Washington, DC 20005
(202) 783-2077,
click on journal name.

“Single session debriefing after psychological trauma: a meta-analysis”
The Lancet, September 2002
360 Park Ave. South
New York, NY 10010-1710
(212) 633 3810,
search for first four words of headline.

Feds Provide Money, Locals Provide Service

To see how the federal strategy for helping youths after school shootings has changed, consider the federal responses in El Cajon, Calif., and Red Lion, Pa.

After an 18-year-old student in El Cajon’s Granite Hills High School opened fire in March 2001, wounding five, the U.S. Department of Education’s Office of Safe and Drug-Free Schools immediately called Ted Feinberg. Within 12 hours, Feinberg, assistant executive director of the National Association of School Psychologists, had a team of counselors on campus.

When a student shot to death his principal, then himself, at the Red Lion Area Junior High School last April, no team of psychologists came parachuting in from out of town. What came instead was $50,000 from the drug-free schools office, which the district used to bring in local psychologists and to help shape crisis counseling for individual youths. The district has applied for a $250,000 grant from the same office for long-term help.

Since 2001 the office has awarded at least 21 such grants totaling more than $10.7 million, as part of a strategy in which the federal government asks local officials what they need and tries to find them the money to do it.

The shift in focus comes from lessons learned in responding to a string of shootings in the late 1990s. Consider Columbine.
Feinberg was among those first called to Littleton, Colo., immediately after two Columbine High School students opened fire in the school in 1999, killing 12 youths and a teacher before turning their guns on themselves.

“The first question they [school officials] asked us was, ‘We have 5,000 volunteers offering to come and help. What should we do?’ ” Feinberg recalls. “We counseled them that they neither needed, nor could handle, 5,000 strangers in their city.”

School officials were quickly overwhelmed by the need to help students and their families, and turned to the local Jefferson Center for Mental Health. During the first year after the shooting, the nonprofit center provided various forms of support, therapy and crisis counseling to more than 700 people in some months. The total cost that first year, according to the center, was $967,047. The second year was only slightly less expensive.

“We were assured that dollars would be coming” to help, says Jo Anne Doherty, vice president of clinical services at the center. “But it turned out we were not eligible for federal disaster dollars.”

Eventually, she said, the Healing Fund, through United Way, gave $386,000, while the state disaster fund contributed $125,000, a federal crime victims’ fund pitched in $244,000, individuals gave $40,000 and staff donated $278,000 worth of time.
But “the need was long-term,” Doherty says, with persons receiving services not even peaking until close to 18 months after the incident. The center is still trying to raise at least $400,000 more for ongoing costs from the shootings and their fallout.

Such needs and costs are why Congress authorized the drug-free schools office to spend up to $10 million a year on Project Serv (School Emergency Response to Violence), through which Red Lion received its money. The program provides quick $50,000 six-month grants, and 18-month grants of up to $300,000 for longer-term services.

At Red Lion, District Superintendent Larry J. Macaluso says the initial grant was used, among other things, to pay for the services of 20 psychologists provided by Pennsylvania’s school system, as well as services from local mental health agencies. Macaluso consulted by phone with psychologists who’ve responded to other school shootings.

Because school was closed for a few days after the shooting, the psychologists used a local church to conduct assessments of youths’ needs, and to begin providing both group and individual counseling. When school reopened, the psychologists visited every classroom “to discuss the incident with a teacher and share with the students that they were going to be in the building within the next several weeks to respond to students’ need,” Macaluso says.

He says he plans to use the larger, long-term grant to help pay for a counselor and psychologist who serve the junior high school and a high school attended by some of the students who were at the junior high last spring, as well as for a school resource officer.

The drug-free schools office gives local authorities wide latitude in how to use the money; the goal is to “restore a sense of safety and security.” For example, in the midst of random sniper attacks in the Washington, D.C., area last fall that included the shooting of a teen at a middle school, the office provided $600,000 in Serv grants to local jurisdictions.

Maryland set up a public education campaign on stress management and coping skills for children and adolescents. Virginia organized a general community outreach that included group crisis counseling. Washington set up mental health programs in 22 schools, along with classroom presentations on staying safe and coping with anxiety.

Federal officials also appear to be moving toward a more pre-emptive approach to crisis response.

The U.S. Substance Abuse and Mental Health Services Administration maintains a $30 million network of grants and contracts “to provide services nationally to providers who assist children experiencing post-traumatic stress disorder,” including a $3 million grant to the University of California at Los Angeles to establish a National Center for Child Traumatic Stress.

(Both the available and awarded grants can be found on Click on “Grant Opportunities.”)

The awards include $4.8 million for 12 grants to fund the creation of new community treatment and services centers “to improve treatment and services for all children and adolescents in the United States who have experienced traumatic events or witnessed such events.”