This Web site is a component of the SAMHSA Health Information Network
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This Web site is a component of the SAMHSA Health Information Network. |
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A Guide for Intermediate and Long-term Mental Health Services
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| Preparatory | Immediate | Intermediate | Long-Term | |
| Time Frame | Before any violence occurs | From day violence occurs until 60 days afterward | From 61st day through one year anniversary | After one year anniversary |
| Infrastructure | Establish school crisis response and recovery teams and protocols; establish and/or maintain partnerships in community | Establish and maintain three working groups | Continue community and provider working groups | Groups gradually phase into community relationships |
| Assessment | Assess current mental health needs and develop appropriate capacity to meet those needs; address range of mental health needs into the Safe School Plan | Triage, with focus on at-risk groups | Provide screening, outreach services and follow-up of students at high risk for PTSD, depression and anxiety disorders | Re-assessment, with focus on delayed reactions and continued outreach to students who continue to be symptomatic, with special attention to anniversary and other emotionally significant events |
| Focus for Services | Range of intervention services from public mental health education to prevention, early intervention and tertiary services | Provide a sense of support and emotional safety; utilize a public health approach | Support recovery; focus on building strengths, assets and coping skills; provide treatment without stigma for those with ongoing needs | Return to normalcy; continued support, assistance and treatment for those with ongoing needs |
The preparatory phase is not truly a phase of crisis recovery, but an ongoing state. It is of crucial importance that schools and communities have an infrastructure of strong relationships already in place, so that when working groups need to be formed, and different groups have to work together for the recovery of the entire community, the transition is as smooth as possible. Several expert reviewers of this document have emphasized this point.
"The shock, trauma and complexity of our societies don't permit the establishment of working alliances within 60 days. This was the most significant limiting factor in mobilizing an effective response in New York…schools and communities (must) know that collaborative relationships need to be forged, meetings held, and procedures developed well before an event occurs and the immediate phase begins."
-Dr. Pamela Cantor, Children's Mental Health Alliance, New York
"It has been my experience that people typically fall back on the most familiar, over-learned, conceptual framework at times of stress and ambiguity. After 9/11, for example, most educators were primarily concerned with getting the educational process back on track, preferring to focus only on preset roles/structures, and freely admitting that they felt too overwhelmed to enter the unfamiliar territory of mental health. Safety officers tightened safety enforcement and did not feel able to address the mental health repercussions of either the disaster or their response to the disaster. Because of this completely human response to crises, it is necessary to build the mental health response system and the network of relationships that support it before any crisis occurs."
-Dr. Mary Courtney, New York University
The Immediate Services Phase focuses on re-establishing the social and emotional equilibrium of the school environment, encouraging students to return to school, providing a nurturing and supportive environment that emphasizes inclusiveness, and reaching out to students and staff who may feel isolated and alone. After incidents of disaster or mass violence, school-age youth are most likely of any age group to show severe impairment, suffering from social, psychological, and health-related problems. Psychological first aid is an appropriate intervention, acknowledging fears and concerns and focused on developing coping strategies.
The need for active outreach services is crucial. For personal reasons or because of the pre-existing or resultant school climate, students and teachers may not want to identify themselves as experiencing difficulties. Too often, the physical, cognitive, social, emotional and behavioral changes that occur are hidden or denied for fear that one will be seen as "crazy" or "weak".
Changes in the environment help students and staff feel safe and convey the message that safety and security at school is not "business as usual". These changes may include additional school resource officers, increased numbers of helping adults on campus, guarded gates and limited entry. What is most important is that students and staff feel cared for and are reassured that they are not alone. For example, the Thurston High School cafeteria became a traumatic reminder to students of the site two students were killed and 25 students and one police officer were wounded by Kip Kinkel on May 20, 1998. When school resumed, students were too distressed to enter the building for meals and assemblies until the administrator changed its appearance with a different color of paint, new tables and chairs.
The community at large can offer support in various ways. After tragic violent events at some schools, the community showed its concern through special lunches provided by faith-based and community organizations, assembly addresses by city leadership or community "heroes" such as the first responders (law enforcement, emergency personnel) or visits by local sports figures.
"It is essential that the planned mental health intervention be more inclusive than restrictive and that includes the essential, but time-consuming, outreach process."
-Dr. Mary Courtney, New York University
The community at large can offer support in various ways. After tragic violent events at some schools, the community showed its concern through special lunches provided by faith-based and community organizations, assembly addresses by city leadership or community "heroes" such as the first responders (law enforcement, emergency personnel) or visits by local sports figures.
The primary method of assessment at this stage is gathering information about student and staff exposure to the violent incident. Exposure to violence as an eyewitness to death or injury or close relationship to victims increases the risk of psychological trauma. Level of exposure is important information that may be helpful in assisting children and adults who have long-term mental health needs.
Organizing services involves bringing together all of the stakeholders and the providers and establishing a means by which regular communication can occur. Planning during the immediate service phase may be turbulent and intense, but structure and a clear process will evolve from open communication and a focus on restoring the emotional well-being of the school family. Consultation and support from outside the school or community can help to inform the school and community leaders of what is "normal," what can be expected, and what tasks would be sequentially sound.
Organizing services in the immediate services phase also involves planning for intermediate and long-term services. The first 60 days may seem interminable, but, as reactions subside and media attention fades, longer-term needs will become more evident. If crisis response services and a recovery infrastructure have been established, the transition to intermediate and long-term services will be paved with stronger professional bonds and working relationships forged by the crisis.
A frequently used model of assessment is illustrated in the following diagrams:
In the immediate aftermath of an act of violence, using a triage method of risk screening and exposure to violence (a process for determining who will be treated first in an emergency), can assist in the identification of individuals at risk for psychological trauma. These include:
a. Risk factors by exposure/contact (in order of greatest risk):
b. Other risk factors:
Already at-risk students, such as those in special education or foster care, may be more likely than other students to suffer psychological trauma after school-related violence. They may need more assistance than other students, and those who conduct triage assessments should be aware of this fact.
Other "at-risk" behaviors and reactions:
-Dr. Bruce Young, National Center for PTSD
- Marked acute stress reactions: Extreme anxiety (fear, panic, worry)
- Dissociative symptoms (experiencing the world as dreamlike, detachment, derealization, depersonalization)
- Uncontrollable intense grief
- Marked sleep difficulties or loss of appetite
- Extreme cognitive impairment (confusion, poor concentration and decision-making, marked intrusive thoughts)
- Marked somatic complaints
After most incidents of mass violence or disaster, the reactions of psychological trauma and stress subside. During the immediate response phase, a great number of students and staff or community members may be highly distressed, but over a period of six to eight weeks, smaller numbers of individuals continue to be reactive.
After incidents such as school shootings, a clinical screening at the beginning of the intermediate services phase can be helpful in assessing the recovery needs of students and staff. Without this measure, there are some guidelines for identifying individuals who may need intermediate and long-term assistance.
Some studies of disasters and mass violence suggest that children, as a significant segment of the population, are at highest risk for psychological trauma, behavioral changes and impairment. These findings support the conclusion that attention must continue to be paid to the stress levels of youth and adults in communities long after the disaster has passed.
Key protective factors that mitigate trauma after critical incidents:
-Phil Woodall, Principal, OrangeGrove Middle School, Tucson, AZ, based on Peter Bensen's "40 Developmental Assets"
- Set and communicate high expectations
- Provide opportunities for meaningful participation
- Increase pro-social bonding
- Set clear, consistent boundaries
- Teach "life skills"
- Provide caring and support
Children's, adolescents' and adults' risk for impairment is likely to increase along with a number of factors found present after a manmade or natural disaster:
Outreach efforts for intensive services should focus on areas of the communities where at-risk individuals and families are likely to live and congregate. One of the institutions most frequented by families, especially mothers with children, is the school. Other institutions include churches, synagogues and other faith-based organizations, physician's offices, heath and mental health clinics, police and fire stations.
While disasters that engender severe, lasting and pervasive psychological effects are rare, some studies have found that the effects on children and adults are greatest when at least two of the following factors are present:
The latter two factors characterize school-related violence of a criminal nature, and in some incidents, such as the shootings at Columbine High School and Thurston High School, there is significant damage to areas of the school that serve as daily gathering places for students.
The increased risk and vulnerability of youth to developing clinical disorders as a result of such "high impact" violence and the widespread (schoolwide) traumatic effects highlight the need for professional mental health services for these youth through the long-term phase.
The seamless transition from the immediate crisis response to effective long-term mental health recovery of students and staff depends upon the development of joint mental health services within the school and the community. In large scale incidents of school-related violence, such as the tragic shootings at Columbine High School in Littleton, Colorado, and Thurston High School in Springfield, Oregon, both public and private non-profit community mental health agencies played significant roles in providing services on campus and in community clinics for those individuals who continued to experience trauma-related symptoms after the immediate services period.
Information and emotional and tangible support are important to the mental health recovery of victims/survivors. Teachers, administrators, family, clergy, and other previously known community supports provide important protection against adversity. Unfortunately, these same protective resources can themselves be victims of disaster and violence and sometimes suffer from the same ill effects. In addition, in events of mass violence such as school shootings, it has not been established that these resources are powerful enough to overcome the considerable effects of profound trauma.
"In addition to referring students who may benefit from direct involvement with health professionals, the classroom teacher is in the position to contribute or complement student recovery following traumatic events at school. The impact of the event is likely to "play out" in the classroom and these behaviors are sometimes best acknowledged and dealt with in the context of the event as they occur in class. For example, a number of students may be anxious and in turn, become less cooperative or take less active involvement in classroom discussions. There may be angry outbursts or questions about safety, etc. In each case, teachers should have guidelines on how to respond correspondingly in the context of how the event is influencing student/classroom behavior."
-Dr. Bruce Young, National Center for PTSD
There is some indication from the comments of students after school shootings that long-term services (beyond the first anniversary period) on school campuses can serve as a traumatic reminder of the event, which prolongs and re-opens their distress when they are attempting to resume classes. This would suggest that long-term mental health services for students, staff and family members are best provided in community settings away from the school. The expert panel of the Project SERV focus group, however, found that when services were off-campus, many people found it difficult to avail themselves of those services.
This is an important decision that the Community Advisory Working Group and the Mental Health Provider Working Group should make with care. There is a balance between those students and staff who are anxious to normalize the climate of the school and the recognition that mental health recovery services are needed by some individuals far beyond the one-year anniversary. How these services are organized, located and made known and available to students and staff is crucial to the long-term recovery of the school family.
In both the intermediate and long-term phases of recovery, schools should not abandon their routines and social activities because these keep students, teachers and parents informed about the needs of the school family. The routine and activities provide natural places where experiences can be shared and preserves the sense of belonging and solidarity that is so needed after an act of school-related violence.
School tradition can be enhanced with the formation of a few new groups and new social activities in which students can brainstorm about various themes for rebuilding the school community. Like the Community Advisory Working Group, a Student Advisory Group, linked to student government, can help to identify and discuss school problems, and work constructively toward a specific goal or task that is achievable within the school year. Community groups can contribute a great deal to this effort, by mentoring and supporting students who are attempting to find longer-term community solutions to the current and pre-existing problems of violence that have so greatly affected their school. The involvement of law enforcement, emergency service personnel, faith-based organizations, community service organizations, and others during the long-term phase of recovery helps to rebuild a higher level of safety, community and individual wellbeing.
Promising Intermediate and Long-Term Interventions for Traumatized Students
Although the importance of delivering appropriate and effective mental health services on school campuses is emphasized by experts, further research is needed to understand which interventions are effective and how they might need to be modified for delivery in schools. Students may develop a variety of mental health problems following a school-related violent event, with two of the most common problems being post-traumatic stress disorder (PTSD) and depression.
Treatment recommendations from practice guidelines for childhood PTSD, based mainly on clinical consensus and empirical evidence from adult studies, state that treatment for children with PTSD should consist of four components: direct exploration of the trauma, stress management techniques, cognitive reframing techniques and inclusion of parents in treatment. Cognitive behavioral therapy (CBT), which includes the first three of these components, has been the most widely supported in controlled outcome studies of adults and children who have been exposed to trauma. Such therapies have been shown to be effective for children with a history of sexual abuse and single incident trauma and more recently for children with exposure to community violence. CBT can also be effective in treating symptoms of depression, and has been shown to have good short and long-term effects in randomized controlled trials. CBT has also been found to be an acceptable form of therapy in diverse populations. Reasons given for the acceptability of this form of treatment have been the immediacy of "answers" in response to mental health distress and the fairly quick resolution of the distress.
In addition, for disadvantaged minority populations, treatment often needs to be coupled with case management, referrals, and translation services. As part of the treatment for children who have been exposed to violence, psychoeducation with parents about the child's trauma symptoms is recommended during treatment to monitor the child's symptoms and after treatment has been completed for continued effect.
"Systems of education and mental health are joining toward the development of a full continuum of mental health promotion and intervention programs for youth in both special and regular education. We use the term 'expanded school mental health' (ESMH) to describe these programs which are well established in many communities and growing in others…The ideal is that these ESMH staff are integrated into the school, viewed as equal players on the school team, not as 'outsiders.'
-Dr. Mark Weist, University of Maryland
In delivering this type of intervention for traumatized students on school campuses, the program needs to be designed in the context of the school ecology. One school program for students exposed to community violence, including school-related violence, was shown to be effective in improving symptoms of PTSD and depression. Part of this program's success has been in its use of a collaborative research model that incorporated an academic-community partnership in the development, evaluation, and implementation phases of the program. Thus a guideline-based CBT program for traumatized students was coupled with the knowledge and experience of educators and school clinicians in designing a program that was acceptable to the school community and feasible in the school setting.
More research is needed to determine what specific interventions are best after a school-related violent event, but until such research is available, CBT and supporting services, implemented through school-community partnership, seems the most promising alternative.
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