Debriefing is a concept that has been around in the area of trauma for a long time. In the lay person's mind, it has come to mean any type of intervention following a traumatic even. It is however, a very precise method of intervention. There is also the belief that if one does not receive debriefing after a trauma, they will not recover; this too is not true. Critical Incident Stress Debriefing (CISD) is a term that has been around since 1983 when it was introduced by its developer Jeff Mitchell. It was developed with the purpose of preventing PTSD by intervening with trauma victims shortly after the traumatic, or "critical", incident with a specific type of debriefing, to prevent the later insert of PTSD symptoms. The model was originally used in the military setting but later found much popularity in the hospital, police and EMS areas. As originally set out, CISD consists of 7 distinct stages to aid stress management. These stages are progressed though within 24-72 hours of the critical incident in a group format (i.e. all the trauma victims), and the group leader is responsible for the pace at which the stages are moved through, and the session should last anywhere between 90 minutes to 3 hours.
CISD was immediately adopted as a debriefing model as it was simple to follow and the implementation could easily be taught to the average person. However, over the years, there has been a constant debate regarding the efficacy of CISD and numerous studies have been conducted on its effects. Some people will remain on the side of CISD and say that it certainly has a place and serves a distinct purpose, while others adamantly say that CISD has absolutely no positive effects and that in some cases has actually proven to be harmful.
On the side of those supporting CISD, including its founder, are the fairly obvious reasons for their viewpoint. They believe that CISD works on the concept of early intervention by which the victims can express their feelings before the onset of serious symptoms. They also believe that it is important for the victim to be able to speak about their pent-up emotions and the horror they may be feeling, and while doing so are able to reconstruct the experience while talking it through with their fellow victims. Thirdly, they believe that CISD helps to show the victims that there is, or will be, an end to their struggles with the help of the strictly set out stages of CISD. Fourthly, they believe that the group setting, in itself, serves a large purpose by providing a sense of cohesion and a support group. Lastly they believe that by seeing people interact in a group setting, the leaders are able to pick out those who are more severely affected by the critical incident for possible further treatment. There have been studies conducted where victims of a traumatic event who received CISD reported less symptoms of PTSD than their counterparts who experienced the same trauma and didn't receive CISD.
However, on the other hand completely, there are many people who do not share the above view. They strongly believe that CISD is totally ineffective and that in some cases can actually cause harm. The people supporting this view-point use the following to back their reasoning: CISD rushes in when the victim has just experienced a trauma and expects them to relive and talk about it in a group. The problems with this are that that may not be the victim's main need at the time. Their primary concerns could simply be how they are going to get home, how to cancel their credit cards or how to get hold of a family member, for example. Secondly, many people have an avoidance method of coping and by avoiding the reliving of the trauma, they are actually helping themselves to recover, at least at the time. By forcing them to change this coping mechanism, one is damaging or hindering their recovery. Thirdly the counsellor could be pathologizing normal reactions to trauma and making them seem un-normal and irregular, when they aren't at all. Those against CISD also believe that by reliving the trauma, the victim could be re-traumatized, depending on their coping skills. They also argue that the group setting may not suit everyone who has been traumatized, and that one debriefing session cannot possibly be enough to solve anything. There were also studies done to try and disprove the efficacy of CISD and they found that those who received CISD were either no better off than those who didn't, or were in fact, in some cases, worse off than those who didn't. Some research has actually shown that those who did receive the CISD were more likely to develop symptoms of PTSD at a later stage.
Over the years, CISD has in fact been discredited by most research done on its efficacy. It has been shown to be of no use at all and in some cases to be harmful to the recipient. It has also been shown that debriefing may not be necessary at all; the majority of those who have experienced a trauma, will recover without any type of intervention. So what are the alternatives? Watchful Waiting was a technique that developed following CISD and called for passively waiting until the victim shows signs of PTSD before intervening. Is this possibly doing too little though? The research for supportive counseling has also shown little support for the continued use of counseling.
With all this research considered and the arguments that have continued for years, why are trauma workers still being trained to implement CISD? Does this not cross the ethical border of "do no harm"?
http://www.nspb.net/index.php/nspb/article/view/33/30
http://www.heathsommer.com/13.html
http://fsomle.com/2011/08/12/critical-incident-stress-debriefing-cisd-should-it-be-used-as-an-intervention-strategy/
http://www.houd.info/CISD.pdf
Saturday, 25 February 2012
Friday, 24 February 2012
Child Neglect: Why the voice against it is silenced by society?
One of the grievances facing our society today, which is often ignored and swept under the carpet, is the issue of child neglect. Since the outcome of this issue is never addressed, our society is unaware of how neglect traumatises and psychologically damages a child. The most disturbing aspect concerning child neglect is the manner in which society has become desensitised to this issue and subsequently ignores it in our communities. These cases frequently go unreported and even when they are reported, are often ignored until a tragedy occurs, like the death or serious injury of the unsupervised child.
The Child Abuse Prevention and Treatment Act (CAPTA) defines child abuse and neglect as any amount of serious harm or maltreatment which results in death, serious physical or emotional harm, and including an act, or failure to act, which presents an imminent risk to a child under the age of 18 (www.yesican.org/defined). In this definition it is clear that child neglect is therefore abuse. Yet society fails to recognise child neglect as a similar serious offence such as physical and sexual abuse. Before we go further, it is essential to evaluate the definition of child neglect. According to C.H Kempe, child neglect is the failure of parents to provide for a child’s basic needs in safeguarding the health, safety and well being of the child. It includes nutritional neglect, educational neglect, and failure to provide medical care or to protect a child from physical, emotional and social danger (Horbert & Frankel 2005).
Society at large is unaware that at most times, the trauma related to child neglect has a far more wide-reaching consequence than that of sexual or physical abuse. Neglect can be extensively destructive to the child; impairing the child’s physical, psychological, intellectual, social, behavioural and emotional development (Lindon, 2003). Studies have indicated that “the number of cases of neglect per year is approximately twice the number of physical abuse and approximately four times the number of sexual abuse” (Giardinoa, 2007).
Neglect is not easy to detect because it tends to exist below the surface of a family system. In most cases it is established gradually over an extensive period of time which makes it difficult to identify (Lindon, 2003). The reasons behind child neglect are often not easy to trace and may differ due to varying factors concerning the nature of the neglect. Sadly, one common factor is that some parents may be replicating a distorted parenting style learned from their own parents (Giardinoa, 2007). Therefore parents are unable to differentiate between raising the child and abusing the child, which then develops into a vicious cycle. The question we need to grapple with is how do we break this vicious cycle from continuously sabotaging innocent children?
It’s a heartbreaking reality that thousands of children are subjected to neglect; this has been such a huge problem in South Africa. The government has implemented the Children Act, which contains guiding principles for parents to comply with to ensure that the child’s best interests and well-being are regulated. Act No 18 of 2006 states that a person with specific parental responsibilities and rights are obliged to provide the needed care and protection for the child. Act No. 38 of 2005 stated that if a child is not provided with the minimum standard of care to meet their basic needs, the child must be removed to a place of safety (Government Gazette, 2006). Yet our society often fails to follow up on this procedure, which raises more concerns regarding our fight against child neglect.
Another factor we need to bear in mind when dealing with child neglect are the most extreme cases of emotional and psychological neglect. Severe neglect of a child is one form of trauma that will most certainly have a long-term impact on a child well into adulthood. In fact, ongoing trauma caused by neglect may cause a child to suffer from depression, insomnia, promiscuity, brain alterations, suicide and extreme anger and eventually suffer from Post Traumatic Stress Disorder (PTSD). Today there is growing evidence that verifies that PTSD can be a result of the accumulation of such childhood traumas. In some cases trauma does not show up until much later in life or until it is triggered by certain circumstances (www.casapalmera.com).
Severe forms of neglect mostly occur in families with a lack of resources. If parents can't look after their children, who will? How can we raise awareness to address these matters? Can the child rely on society in order for their needs to be met? These are the questions we need to grapple with. Child neglect needs to have a voice in order to raise awareness. Most of us know morally that child neglect is wrong, yet we witness it daily in our schools, in the streets and in communities. Unfortunately nothing is still being done to reduce this injustice in our society. Awareness, both at social level and at an individual level, is of paramount importance to bring a voice to the voiceless.
References
Casa Palmera (2011).Neglect, Abuse and Other Forms of Childhood Trauma.
Giardinoa A, (2007). Helping Children Affected by Abuse. St Louis. G.W. Medical Publishing, Inc.
Government Gazette,(19 June 2006), Act No. 38,2005& Act No. 18,2006. Children’s Act.
Horbert, C & Frankel, J (2005). Good Practice in Child Protection.( 2nd Ed) United kingdom. Stanley Thorns (Publishers) Ltd.
Lindon J, (2003). Child Protection. (2nd Ed) London, Hodder& Stoughton publishing.
Friday, 10 February 2012
Are the kids ok? Are school-based trauma interventions the answer?
Much of our knowledge about post traumatic stress disorder (PTSD) is based on adult studies. It is however clear from new scientific disciplines that our findings based on adult research studies are not always relevant to children and adolescents. It is therefore not uncommon that mental health professionals have different perspectives on child and adolescent trauma, especially with regards to the effects of trauma and the type of interventions that are most effective in reducing negative outcomes. The impact of trauma, especially repeated exposure, is often widespread and persistent. It impacts on a child’s physical health as well as his cognitive and psychosocial functioning. Although the exact number of children affected by trauma is difficult to determine, research studies confirmed that a significant number of children are exposed to highly challenging and dramatic life events. A ten year longitudinal study of 1,420 children and adolescents in the United States
Exposure to a single traumatic event is described as “Simple Trauma” whereas repeated exposure to traumatic events refers to “Complex Trauma”. Although simple trauma can cause impaired functioning, it presents less risk to the adolescent than complex trauma. Complex trauma in adolescents often occurs in cases of abuse and neglect but can also occur in the witnessing of domestic violence, war or natural disasters (US Regional Research Institute for Human Services, 2007). Traumatic events also include sexual abuse, physical abuse, community and school violence, medical trauma, motor vehicle accidents, suicide and other traumatic losses.
How adolescents cope with these traumatic events depend on their level of development, age and environmental support. A key issue in providing this support and preventing psychosocial problems related to trauma, is early identification of traumatised teens and the implementation of an effective treatment approach. Most children and adolescents develop short-term distress after a traumatic event while most return to their prior level of functioning over time. It is however youth who have been exposed to complex trauma, with a past history of anxiety problems or whom have experienced family adversity that is at a higher risk of showing symptoms of PTSD. Their recovery can also be impeded by individual and family factors which make social, community and governmental support networks critical for recovery. It is within this support network that the importance of school intervention programmes stand out.
In South-Africa the high poverty and unemployment rates coupled by cumbersome crime and domestic violence statistics, exclaims the need for professional intervention. Unfortunately in the US alone, less than 16% of adolescents with general mental health problems have sought mental health services because of their problems (Helland & Mathiesen, 2009; Rones & Hoagwood, 2000). On a positive note, schools may be one of the most resourceful arenas in providing supportive interventions for adolescents dealing with trauma. Not only are schools easily accessible to all children but it is also a familiar setting that can sufficiently provide a safe and supportive environment for the treatment of trauma symptoms.
A recently published review on school-based intervention programmes have identified cognitive behavioural therapy as the most common treatment approach to reduce serious trauma reactions, such as PTSD , anxiety and behavioural problems in treating children and adolescents ( Rolfsnes and Idsoe, 2011). They also found empirical verification for Cognitive behavioural interventions for Trauma in Schools (CBTIS) and Trauma Focused Cognitive Behavioural Therapy (TF CBT) as effective interventions for reducing PTSD symptoms of learners.
Traumatic stress is one of our country’s most important public health challenges due to its high prevalence and widespread impact. Evidently school professionals play an important role in facilitating the recovery of children and adolescents when traumatic events occur. Beside cognitive behavioural interventions there are also multiple opportunities within the school environment for counsellors or trained professionals to implement prevention-based practises to address these needs. The early identification of learners who are at risk for traumatic stress or of those who have already experienced a single traumatic event needs to be the primary level of intervention. When schools commit to the universal screening of all their students it can provide a crucial way to prevent psychopathology and deficits in school functioning as a result of trauma exposure.
Can we assume the kids are ok? In a high risk country like South-Africa where the exposure to traumatic stress is almost a given it will take professional intervention to ensure that at risk youth do not develop full blown PTSD. Schools offer professionals that opportunity. Its familiarity and easy access provide adolescents with the safe and secure environment where they can begin to review their trauma. When school professionals, teachers and families work in tandem they often provide the best help for children and adolescents who shows symptoms of, or are at risk for, traumatic stress.
Sunday, 5 February 2012
Thinking about the 99.
We’ve all had moments of looking at the people around us and wishing we had a little more of what they have. Our car, TV and laptop somehow morph into symbols of poverty when compared to the fancier car, flatter TV and state of the art laptop of our wealthier neighbour. The theory of relative deprivation says that we compare ourselves and our lives to that of our reference group (our peers, neighbours and colleagues) and that if we see them as having what we do not have, but which we feel we deserve, we feel deprived and hard done by (Sociology in the news 2008).
Another theory to be considered here is that of coherent arbitrariness, which, in it’s simplest form is a theory of relativity holding that people are good at ranking values on their own scale, but not good at placing their scale in an absolute context (Poundstone 2011). This theory suggests that the value we give certain objects is determined, to a large extent, on the ‘anchor’ or benchmark that is presented to us.
Apply this to the dilemma of middleclass feelings of relative deprivation, and a red flag pops up! We don’t know how wealthy or un-wealthy we are, how privileged or underprivileged, until we compare ourselves to another group; until we put ourselves on a scale of sorts. The higher our anchor is, the higher the bar of comparison is. And in the instance of those Joneses (who are so hard to keep up with!), the poorer we feel in comparison!
Globalization simply exacerbates the situation, as our reference group, or, anchor, is no longer just our neighbours and colleagues, but, thanks to the internet and TV, a supersized reference group made up of the Kardashians, Beckhams and the like!
Let’s get down to some absolutes. In 2008, South Africa scored 0.666 on the gini coefficient, meaning that the level of inequality is unacceptable (The Presidency, 2009). The OECD published an article highlighting the fact that in that same year, South Africa’s wealthiest 10% earned 58.07% of the national income, while 80% of the population earned 25.35% of the national income (Suddenwalk, 2011).
While many may feel relatively ‘poor’, there is a massive chunk of the South African population that is absolutely poorer and less well off. This brings us to the controversial issue currently filling up newspapers (and Wall Street!) – the 99%, the 1% and social justice. Call it responsibility, obligation, generosity or necessity, it is imperative to reach out to those South Africans with the most wealth and skill and somehow foster in them an interest in the poor.
Perhaps an incentive is needed. And perhaps, said incentive could be increased happiness! If we change our anchor or reference group from the super wealthy to the super poor, our feelings of being hard done by may well decrease, resulting in greater happiness and contentment.
Theorists of coherent arbitrariness found that anchors that people had really engaged with were the most effective (Poundstone 2011). We see a similar thing when someone diagnosed with cancer, for example, for the first time begins to support cancer associations. An ‘out there’ problem has suddenly hit home. In other words, changing the anchor from prosperity to poverty may have more sustainable and groundbreaking effect if the wealthy are interacting and engaging with those less well off. And what if, just maybe, engagement fosters distribution? As the anchor changes, people may even be motivated to give or redistribute their wealth (financial, skills or knowledge) in various ways.
This is a controversial idea, and may well be seen as pure selfishness - is it acceptable to help others so that we feel better about ourselves? However, in a country with inequality as great as ours, is this a valid argument? Perhaps any means should be pursued if it will help to close the gap between white collar and blue (or no collar at all!)? Especially if it generates ideas and gets lawyers, accountants, teachers and the like engaging with the underprivileged in a way that counteracts our anchor of wealth and prosperity, and gives us an anchor that is closer to the experience of the 99%.
On the other hand, a less sceptical lens could see this suggestion as an expression of ubuntu – sharing (finances, skill and knowledge) with the less fortunate as an outworking of our understanding that we are all connected by our shared humanity. This view also acknowledges the mutual learning that takes place in any interaction, and thus, that ‘the poor’ have much that they, in turn, can share with and teach ‘the rich’.
Reference list
Poundstone, W. 2011. Priceless. Oneworld Publications, Oxford.
The Paradox of Happiness, Sociology in the News. 2008. http://www.correntewire.com/sociology_in_the_news_the_paradox_of_happiness
Accessed on 31 January 2012.
The Presidency, Republic of South Africa, Development indicators 2009. http://www.thepresidency.gov.za/learning/me/indicators/2009/indicators.pdf Accessed on 2 February 2012.
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