Community Stress Prevention Volume 5 PDF

COMMUNITY
STRESS PREVENTION
VOLUME 5
EDITORS
OFRA AYALON - MOOLI LAHAD - ALAN COHEN
This edition was published with the help of UJIA Canada

© 2003 All rights reserved
The Community Stress Prevention Centre
Tel Hai Academic College
Kiryat Shmona ISRAEL
Printed in Israel
ISBN 965-90536-0-6
This volume is dedicated to Moshik Lev, CSPC team member and lifelong educator.
1941-2002. A considerate, warm-hearted, well-esteemed man, devoted to his family
and friends and to his students in his capacity as youth group leader, teacher,
counsellor and head of Emek Hahula upper school. Moshik was a bridge builder, both
within his kibbutz, Gonen and the Upper Galilee region, always with creative ideas
and graceful solutions.
Contents
Introduction
About the authors

page
Chapter 1 The need for ER protocol in the treatment of public
manifesting ASR symptoms following disaster.
Mooli Lahad & Ruvie Rogel 1
Chapter 2 After the Bomb in Omagh, Northern Ireland.
Elizabeth Capewell 20
Chapter 3 Six Part Story Making in the Assessment of Personality

Disorder: History, Practice and Research.
Kim Dent-Brown 43
Chapter 4 The Crucial Cs for Encouraging Communication:
Some Tools for Building Resilience.
Ilse Scarpatetti 61
Chapter 5 Israeli and Palestinian Teachers Learn about Children
and Trauma: Security, Connection, Meaning.
Alan Flashman 69
Chapter 6 COPE CARDS for Trauma and Healing.

Ofra Ayalon 82
Chapter 7 The Media and the Understanding of the

Trauma Vortex at the Political Level
Gina Ross 95
Chapter 8 The Development of Debriefing in Israel.

Mooli Lahad & Alan Cohen 117
Chapter 9 The HANDS Project: Helpers Assisting Natural Disaster
Survivors
Ofra Ayalon, (in collaboration with Alan Cohen, Mooli Lahad,
Shulamit Niv, Yehuda Shacham) 127
INTRODUCTION
ii
COMMUNITY STRESS PREVENTION 5
Community Stress Prevention Volume 5
Introduction
Writing this introduction shortly after another suicide bomber has claimed 17
victims, this time in Haifa, and at the beginning of the war in Iraq, we see that we are
still in the midst of a long and ongoing struggle for survival, physical as well as
mental. This volume, however, intends to continue the ideas of previous Community
Stress Prevention volumes by looking at what is helping, what is working even in the
face of terrible adversity, how are individuals and communities coping after disasters.
CSPC director Prof. Mooli Lahad and team member Ruvie Rogel chart the
development of a standard procedure for hospital emergency rooms following a
large-scale incident. The large numbers of people suffering from shock and resultant
pressure on the ERs necessitates a comprehensive outlook to population management
which is only now in the process of development.
We then turn to Northern Ireland, a long-time source of conflict but with rays of hope
that occasionally break through. CCME (Centre for Crisis Management and
Education) director Elizabeth Capewell’s account of the rehabilitation of the Omagh
community as the result of intervention, following a devastating terrorist bomb
attack, gives us an insight into all the factors that need to be taken into consideration
in such a complex operation. She makes use of Prof. Lahad’s BASIC Ph model first
described in CSP 2, as well as her own CCME intervention models.
The next chapter, also contributed by a British author, Kim Dent-Brown of Hull
University, makes an in-depth investigation of the assessment of personality disorder,
using Six-piece storymaking (6 PSM) based on the BASIC Ph model. This is the first
attempt to establish the psychometric reliability and validity of this method.
Chapter four is contributed by Swiss clinical psychologist, Ilse Scarpatetti – an expert
on Adlerian psychology, on communication in times of emergencies. She focuses on
psychological tools for use in everyday practice with clear implications for the
situation in areas of conflict, specifically the Middle East.
Psychiatrist Dr. Alan Flashman records one of the rare meeting points between Israeli
and Palestinian teachers since the beginning of this conflict. He describes some
therapeutic methods, aimed to help Israeli and Palestinian teachers to deal with the
traumas faced by their pupils. Dr. Flashman considers the implications of turning the
“other” into “demons” and suggests methods and tools to counteract this process.
One of these methods involves the use of “therapeutic cards”. Dr. Ofra Ayalon,
director of NORD C.O.P.E. Centre, brings into light the innovative tool of
“therapeutic cards” that she has developed over many years of experience with
creative methods for coping with adversities.
How we view the Israeli-Palestinian conflict is one of the central features of Gina
Ross’s article. Gina Ross is the founder and chair of the International Trauma
Healing Institute in the United States and the co-founder of the Israeli Trauma Center
in Jerusalem. She explores the role of the media in the healing of trauma as well as
iii
INTRODUCTION
the role of trauma in conflicts between nations. One of her major aims is to create
guidelines on how to reduce the traumatic effects of tragic events and contribute to a
better coping rather than amplifying trauma.
Chapter eight contributed by two of the editors, Mooli Lahad and Alan Cohen and it
presents the material that we have to date on the CIPR (Critical Incident Processing
and Recovery model) developed by Prof. Lahad and Stephen Galliano from ICAS in
England. The accumulated experience of debriefing meetings and follow-up with
victims of the various terror incidents in Israel has given us the opportunity to
examine closely this controversial subject.
The final chapter by Dr. Ofra Ayalon was written in collaboration with CSPC team
members Alan Cohen, Prof. Mooli Lahad, Dr. Shulamit Niv and Dr. Yehuda
Shacham, and reflects also the work of our colleagues from Turkey Leyla Navaro,
Neylan Özdemir and Nevin Dölek. This chapter reports on the joint H.A.N.D.S
project, a long-term psycho-social training intervention, that was carried out by the
CSPC as a response to the major earthquake in north-eastern Turkey in 1999. This
project, that continued for over a year, was documented in a film that can be obtained
on our site: www.icspc.org.
It is our hope that this edition marks the end of the conflict and the beginning of the
long rehabilitation for all concerned in this troubled region – and worldwide.
iv
About the Authors
Dr. Ofra Ayalon

Dr. Ofra Ayalon is an Israeli psychologist, family therapist and traumatologist,
author and trainer throughout the world in the field of trauma and coping with
terrorism. She was a senior lecturer for 35 years at the University of Haifa, and
currently is the director of Nord COPE Center, and senior consultant at the
Community Stress Prevention Center in Kiryat Shmona - Tel Hai College, Israel. She
has conducted extensive, longitudinal research on the impact of domestic violence,
trauma, stress, major disasters, war terrorism, and bereavement on children and their
families. In the wake of 9/11 attacks on America she has widely consulted on dealing
with trauma in organizations, schools and clinics in USA. She has published
extensively on the impact of domestic violence, trauma, stress, major disasters, war,
terrorism, and bereavement on children. She devised a comprehensive method for
crisis intervention programmes widely used to enhance coping skills for survivors
and rescue workers during and after major disasters.
[email protected]
Elizabeth Capewell M.A.

Elizabeth Capewell is the director of an independent company, the Centre for Crisis
Management and Education CCME) founded in 1990. She is currently completing
her doctorate at Bath University in Action Research in Developing Major Disaster
Management practice. CCME has the organisational, professional and personal
credibility of working with schools after catastrophic events, having researched good
practice at the Community Stress Prevention Centre in Israel, in California and
Australasia. Ms. Capewell has worked with Kendall Johnson, PhD of Los Angeles in
developing School Crisis management in New York City School Board in 1992 and
with Dr Ofra Ayalon in Croatia, Finland and the UK. As an Education Officer, she
responded to the massacre at Hungerford in England in 1987. Since then she has been
involved in 8 major UK disasters such as the Hillsborough football stadium disaster
the IRA bombing of the Docklands, Manchester and Omagh, the 1988 Lockerbie
plane bomb disaster, the Dunblane school shootings of 1996, London train crashes.
She also led the CCME response to the Bahrain air crash in 2000 and many traumas
involving schools and youth organisations at home and abroad. CCME has also
undertaken over 50 trauma response programmes for a company employing young
people of diverse ethnicity.
[email protected]
Alan Cohen M.Sc.

Alan Cohen earned his second degree in Applied Psychology and is the research
coordinator with CSPC since 1985. His special interests are in stress and trauma
treatment and biofeedback. He is an EMDR facilitator. Together with Prof. Lahad
and Dr. Ayalon he is a co-editor of the Community Stress Prevention Series (1-5) and
author of a number of articles on stress treatment.
[email protected]
v
INTRODUCTION
Kim Dent-Brown M.A.

Kim Dent-Brown trained in the UK as an Occupational Therapist and subsequently
as a Dramatherapist. He has used 6-Part Storymaking since the early 1990s in the
mental health services of the National Health Service (NHS) in Hull, north-east
England. In 1997 he joined a specialist psychotherapy team working with personality
disorders, using 6PSM as an assessment tool. In 1999 he spent a month in Israel with
the developers of 6PSM at CSPC, having won a travelling Fellowship from the
Winston Churchill Memorial Trust to do so. In 2001 he won a Research Training
Fellowship from the NHS to enable him to engage in full time PhD research into
6PSM at University of Hull. Kim is chair of the research sub-committee of the
British Association of Dramatherapists and is keen to promote the establishment of a
solid empirical evidence base for the practice of dramatherapy.
[email protected]
Alan Flashman M.D.

Dr. Flashman came to live in Israel from U.S.A. in 1983. He is a Board Certified
Pediatrician, General Psychiatrist, Child & Adolescent Psychiatrist (USA). Dr.
Flashman is a member of Faculty, Program for Integrative Psychotherapy, Magid
Institute, Hebrew University of Jerusalem (Family therapy) and Central School for
Community Workers, Tel-Aviv (Therapeutic communication with children and
adolescents who witnessed family violence). He is a Learning Companion and Group
Facilitator, Middle East Children's Association. Private Practice, Beer-Sheba.
Editor, Therapeutic Communication with Children (Hebrew), Jerusalem, 2002.
[email protected]
Prof. Mooli Lahad

Prof. Lahad is a specialist in educational psychologist, medical psychology,
bibliotherapist and dramatherapist. Founder of the CSPC in 1981. He is a world-
renowned expert in intervention and treatment of stress and emergencies with
children, adults, communities and organisations. Winner of the Israel Psychological
Association. Elena Bonner Prize for outstanding field work in preparation for stress
and emergencies. Director of the educational psychology services of Kiryat Shmona
between 1984-88 Head of the Haifa University bibliotherapy course 1986-89. Prof.
Lahad is the current head of the dramatherapy course at Tel Hai College and irects an
international dramatherapy programme in Britain, Denmark, Greece and Cyprus. He
is the author of 16 books and many articles on coping with stress and crisis.
[email protected]
Dr. Shulamit Niv

Shulamit Niv is an educational psychologist, school counsellor and stress treatment
expert. She is also a Certified Family Therapist and coordinator of projects with
communities coping with ongoing stress countrywide for the CSPC.
[email protected]
Ruvie Rogel M.Sc.

Ruvie Rogel has a BA. in Psychology, M.Sc. in Human Resources Management and
vi
Training and currently completing his PhD in Educational Management, researching

the effects of an ongoing uncertainty on a municipal education system. He has held
a variety of positions on both individual and community levels: Director of municipal
education department in Katzrin, Director of the Mitzpe Ramon Arts Colony
boarding school and has worked with mentally handicapped children and adults in
Jerusalem and Washington DC.
[email protected]
Gina Ross MFCC

Gina Ross, is the founder and chair of the International Trauma-Healing Institute in
the United States and the co-founder of the Israeli Trauma Center in Jerusalem. She
specializes in trauma and cross-cultural therapy. She is certified in Somatic
Experiencing (SE), Eye Movement Desensitization and Reprocessing (EMDR),
Thought Field Therapy (TFT), and Traumatic Incident Reduction (TIR). She was the
founder and chair for seven years of the Cross-Cultural Committee under the Los
Angeles, California, Association of Marriage, Family, and Child Therapists (MFCT)
and serves a multi-cultural clientele in seven languages, from over 50 countries in her
cross-cultural practice.
Ms. Ross is a faculty member and international teacher/trainer for the Foundation for
Human Enrichment; she has presented at international conferences as well as
appearing on radio and television. An expert on the impact of trauma in individuals,
communities, groups, and nations, Ross sees a major role for the media. Currently
she is working with Israeli and Palestinian societies and particularly the media, to
bring understanding of the role of trauma and the political trauma vortex in Middle
Eastern politics and has written her first book: Beyond the Trauma Vortex: The
Media’s Role in Healing, Fear, Terror and Violence.
[email protected]
Ilse Scarpatetti, Lic. Phil;

Ilse Scarpatetti graduated in psychology from Zurich university. She did her
postgraduate training as a psychotherapist at the Alfred Adler Institute in Zurich and
is also a certified therapist for Guided Affective Imagery (Leuner) and teacher for
Autogenic Training (I.H. Schultz). She has also trained in EMDR, progressive
muscle relaxation and hypnosis. She went through the specialisation program of the
Federation of Swiss Psychologists in victim assistance and trauma therapy and has
special interest in emergency psychology. Mrs. Scarpatetti has been involved in the
psychological response to several bank robberies and recently the parliament
shooting in the Swiss canton of Zug. She is also a mediator and has published various
books and articles integrating law and psychology.
[email protected]
Dr. Yehuda Shacham

Yehuda Shacham is an educational psychologist and school counsellor. He is also
aCertified Family Therapist, medical psychologist and expert in stress treatment.
Since 1992 he has been Deputy Director of the CSPC
[email protected]
vii
The need for ER protocol in the treatment of public manifesting
ASR symptoms following disaster.
Mooli Lahad, Ruvie Rogel
In recent years the amount of acute stress response (ASR) clients coming to General
Hospital Emergency Rooms (ER) following critical incidents has risen steadily.
Whereas until the mid-80s the prediction was that the ratio between the physically
injured and those with emotional reactions individual would be 1:3 respectively, the
reality of the past 28 months in Israel since October 2000 and reports from NY
following the 9/11 WTC attack is that the ratio has risen to 1:10 and in some cases
1:12.
The amount of emotional reactions, some of which are accompanied by minor
wounds too, puts almost impossible pressure on ER personnel making it very
difficult to operate an ER due to this sudden influx of patients. There is therefore a
need to develop a solution for at least three issues. The first need is for an
organisational solution as to where to address the needs of these tens of people; the
second is, what is the best procedure of admission and the third, the need for a
treatment protocol.
In the latest publication of "Mental Health and Mass Violence" published by the US
Department of Health and Human Services, US Department of Defense, US
Department of Veterans Affairs, US Department of Justice and the American Red
Cross (Nov 2001) the intention was to reach a consensus on the best practices to
work with victims and survivors of mass violence (ASR), based on the research
evidence. However, one must admit that out of 77 research papers reviewed by this
committee only eight could be considered ASR, only five of these concerned ER
psychological intervention and one was on medicinal treatment.
The ER studies, (Bunn & Clarke 1979; Gidron et al 2001; Stevens & Adshead 1996;
Eid, Johnsen & Weisaeth 2001; Shalev et al. 1998) showed the benefits of the
intervention as well as the medical study of Gelpin et al (1996). Three had found
negative or no significant outcome. Four were done with military personnel or rescue
forces and none with children.
It is clear then that even the best practice can not be based on seven studies and that
without thorough assessment of what is done with the ASR victims upon admission
and over the first 24 hours, we will not be able to give a consensus of best practice.
We therefore conducted an extensive survey of 9 ERs in general hospitals in Israel
which treated thousands of ASR clients over the past 28 months (since the outbreak
of the 2nd uprising starting on 29th September 2000, “Intifada El Aksa"). The in-depth
interview was carried out with at least the senior psychiatrist of that hospital and the
chief social worker, usually the two disciplines that handle the ASR clients. We used
a structured interview asking the senior psychiatrist and head social worker to
describe to us a flow chart of admission of ASR clients and the kind of treatment
they receive.
ER Protocol with ASR Symptoms
This article will address the problem of ER treatment of ASR clients, it will define
ASR, and will review some of the main recommended treatments found in the
literature. The findings of our survey will be followed by recommendations on
admitting, accommodating and treating ASR clients in ER.
ERs and psychiatric patients *
* Unfortunately the ASR patients are classified under "psychiatry" when arriving at
general hospitals
The problem of handling emotionally affected patients admitted to a general hospital
ER is known in peaceful times. It is becoming even more problematic when the ER is
flooded by tens of ASR clients. As Awad (2002) puts it in the editorial column of the
April edition of the Bulletin of the Canadian Psychiatric association:
Immediate intervention and emergency room psychiatric assessments take place in a
state of turmoil. Emergency rooms in general hospitals are crowded much of the time
and ambulances are frequently redirected in most of the major cities, as a result of
congestion in emergency rooms. (We use the term immediate intervention referring
to the aftermath of a terror incident (Noy, 2002) rather than crisis intervention which
is more widely used in a developmental context.)
In such difficult situations, patients with psychiatric problems are
often treated as “not a priority” and sometimes as “nuisances”.
They are kept for hours, hanging around the reception area
corridors or in a poorly suited physical setting. Apart from the
obvious pressures and congestion in many emergency rooms,
negative attitudes from emergency room staff frequently prevail
towards psychiatric patients (Awad 2002).
A US National report by the American Hospital Association,
states that the number of ER visits increased by 15 percent
between 1990 and 1999.
Many emergency rooms lack appropriate facilities for the assessment or containment
of disturbed behaviour. If admissions are not warranted or beds are not available, this
position can be problematic. It may take hours to find a bed in another facility, access
to a “safe house” or even a referral to an urgent clinic for assessment and follow-up
the next day. In essence, immediate intervention and psychiatric assessments in the
emergency rooms are an aggravation for our patients and their families, and a
frustrating chore for the psychiatrists and mental health teams (ibid.).
Taking this into account the next part of this article deals with the questions: What do
we do with the people who arrive in large numbers? Should they just be given a
listening ear, a "TLC" treatment? Medication? Or is there an understanding of the
ASR syndrome that leads to any recommended protocol?
What is ASR?
ASR is a transient disorder of significant severity which develops in an individual
without any other apparent mental disorder in response to exceptional physical and/or
2
mental stress and which usually subsides within hours or days. The stressor may be
an overwhelming traumatic experience involving serious threat to the security or
physical integrity of the individual or of a loved person(s)
The symptoms usually appear within minutes of the impact of the stressful stimulus
or event, and disappear within 2-3 days (often within hours). Partial or complete
amnesia for the episode may be present.
There must be an immediate and clear temporal connection between the impact of an
exceptional stressor and the onset of symptoms; onset is usually within a few
minutes, if not immediate. In addition, the symptoms:
(a) show a mixed and usually changing picture; in addition to the initial
state of "daze", depression, anxiety, anger, despair, overactivity, and withdrawal
may all be seen, but no one type of symptom predominates for long;
(b) resolve rapidly (within a few hours at the most) in those cases where
removal from the stressful environment is possible; in cases where the stress
continues or cannot by its nature be reversed, the symptoms usually begin to
diminish after 24-48 hours and are usually minimal after about 3 days. (The ICD-
10 Classification of Mental and Behavioural Disorders is copyright of the World
Health Organisation 1992).
If the recovery from ASR is within three days to week, then why should we be so
concerned about it?
Acute Stress Disorder as a Predictor of Posttraumatic Stress Symptoms
Classen et al (1998) studied the effect of being "just" a bystander exposed to shooting
of office mates. They found that 33% of the employees met criteria for the diagnosis
of acute stress disorder. Acute stress symptoms were found to be an excellent
predictor of the subjects' posttraumatic stress symptoms 7-10 months after the
traumatic event. They concluded that these results suggest not only that being a
bystander to violence is highly stressful in the short run, but that acute stress
reactions to such an event further predict later posttraumatic stress symptoms.
Birmes et al (2001) studied peritraumatic dissociation, acute stress, and early
posttraumatic stress disorder in victims of general crime. A total of 48 subjects
completed the protocol: 21 (43.8%) were men, and most subjects were married (n =
30, 62.5%). All were victims of violent assault: 21 (43.8%) were shot, stabbed,
mugged, held up, or threatened with a weapon; and 27 (56.3%) were physically
attacked or badly beaten up. All were admitted to an emergency department, and 9
(18.8%) were hospitalised in surgical units. This study is useful in that it is the only
one of general crime victims in which peritraumatic dissociation was measured
within 24 hours of the assault and its implication that ASR clients may develop
PTSD. They conclude that high levels of peritraumatic dissociation and acute stress
following violent assault are risk factors for early PTSD. Identifying acute re-
experiencing can help the clinician identify subjects at highest risk.
3
Thus it is obvious that treating ASR clients in ERs is crucial. Do we have factors that
influence who is most likely to experience serious and lasting psychological distress
as a result of a disaster?
Norris & Byrne and Diaz & Kaniasty list the following to be the pre-disaster factors
influencing the development of PTSD:
Gender influenced postdisaster outcomes in 45 studies, as follows:
In 42 of 45 studies (93%), women or girls were affected more adversely by
disasters than were men or boys. The effects occurred across a broad range of
outcomes, but the strongest effects were for PTSD, for which women's rates often
exceeded men's by a ratio of 2:1.The effects of gender were greatest within
samples from traditional cultures and in the context of severe exposure.
Age and Experience influenced disaster victims' outcomes in 17 samples, as follows:
• A consistent pattern was not apparent within the findings from the
three child and adolescent samples.
• Middle-aged adults were most adversely affected in every American
sample where they were differentiated from older and younger adults.
Some research suggests that middle-aged adults are most at risk
because they have greater stress and burdens before the disaster
strikes and they assume even greater obligations afterwards.
• Professionalism and training increase the resilience of recovery
workers, although past trauma per se does not.
• Culture and Ethnicity shaped the outcomes of disaster victims in 14
studies, as follows:
• studies showed that the effects of the disaster were greater in
developing countries than in the United States.
• Among adults, results for ethnicity were quite consistent. In 100%
of the five samples, majority groups fared better than ethnic minority
groups.
• culturally specific attitudes and beliefs that may prevent
individuals from seeking help.
Socioeconomic Status (SES). In ten (91%) studies, lower SES was consistently
associated with greater post-disaster distress. The effect of SES has been found to
grow stronger as the severity of exposure increases.
Family Factors influenced outcomes in 19 samples, as follows:
• Married status was a risk factor for women
• Being a parent also added to the stress of disaster recovery, mothers
were especially at risk for substantial distress.
4
• Children were highly sensitive to post-disaster distress and conflict in

the family. When measured, parental psychopathology was typically the
best predictor of child psychopathology
• The effectiveness of interventions for children may be limited if the
family is not considered as a whole.
• Pre-disaster Functioning and Personality influenced outcomes in 22
samples, as follows:
• Regardless of the data collection method, pre-disaster symptoms were
almost always among the best predictors (if not the best predictor) of
post-disaster symptoms.
• Persons with pre-disaster psychiatric histories were disproportionately
likely to develop disaster-specific PTSD and to be diagnosed with some
type of post-disaster disorder.
• "Hardiness" decreases the likelihood of post-disaster distress.
Within-disaster Factors
The presence of all of the following during a disaster has been found, at least in some
studies, to predict adverse outcomes among survivors: Bereavement during the
disaster, Injury to oneself or a family member, Life threat, panic or similar emotions
during the disaster, Horror, Separation from family (especially among young people)
Extensive loss of property, relocation or displacement.
As the number of these stressors increased, the likelihood of psychological
impairment increased.
Post-disaster Factors
• Stability versus change in psychological symptoms was largely
explained by stability versus change in stress and resources.
• Attention needs to be paid to stress levels in stricken communities long
after the disaster has passed.
What sort of treatment is suggested?
The treatment of the public following a terror incident can be compared to that of
soldiers in battle conditions. The principles of PIE (Proximity – to ensure attachment
to the unit, Immediacy – to prevent the onset of post-traumatic reactions and
Expectations – a clear message that he will return to full functioning and will assume
routines and responsibilities) are relevant for civilians as well.
On an individual level ER provides the closest possible and most immediate
treatment. Here too, the emphasis should be on functioning rather than pathology. It
is this message at the very early stages which can determine the continuation of the
symptoms or their disappearance and return to functioning. On a community level,
maintaining community services and keeping the schools running as much as is
5
possible will make sure that people are expected to continue with their day to day life
as much as is possible.
However, considering that we are talking about civilians and not soldiers, is
treatment of ASR a choice? Some might argue that it is not. Foa says "People should
be encouraged to use natural supports and to talk with those they are comfortable
with — friends, family, co-workers — at their own pace". She even suggests that "we
do not recommend intervention in this initial aftermath period". Is the answer
therefore to the masses arriving at the ERs: "Go home, you will be better off without
us, relax, talk, forget about it and only if you feel awful then come back"? Of course
not. Even Foa does not suggest this. In the guidelines for mental health professionals'
response to the recent tragic events in the US (post September 11 2001) she wrote:
If someone wants to speak with a professional in this immediate aftermath period, a
helpful response will be to:
i) Listen actively and supportively, but do not probe for details and
emotional responses. Let the person say what they feel comfortable
saying without pushing for more.
ii) Validate and normal natural recovery.
iii) If people do present to clinics or counsellors requesting help,
single-session contact should be avoided. In these instances people
should be scheduled for 2-3 more visits over 2-6 weeks time.
iv) Traumatic experiences may stir up memories and/or exacerbate
symptoms related to previous traumatic events. Thus some people will
feel like this is "opening old wounds". These symptoms should also be
normalised and are likely to abate with time. It may be helpful to ask
people what strategies they have successfully used in the past to deal
with this, and to encourage them to continue to use them.
CSPC protocol that will be described later deals with the translation of these
principles or general guidelines into practice.
Pharmacological treatment for acute traumatic stress reactions (within one
month of the trauma) is generally reserved for individuals who already have received
individual or group debriefing and/or brief crisis-oriented psychotherapy. If these
approaches are ineffective, clinicians should consider pharmacotherapy.
Furthermore, there are no FDA approved medications for acute stress reactions and
the only FDA approved medication for PTSD is sertraline. Prior to receiving
medication, the trauma survivor should have a thorough psychiatric and medical
examination. Ongoing medical conditions, psychiatric diagnoses, current
medications, and possible drug allergies should be assessed. In addition, clinicians
should ask questions regarding alcohol, marijuana, and other drugs since these
substances may interact with prescribed medications and may complicate an
individual’s psychological and physiological response to the trauma. The acute use
of medications may be necessary when the survivor is dangerous, extremely agitated,
or psychotic. In such circumstances, the individual should be taken to an emergency
6
room. In the emergency room, short-acting benzodiazepines (e.g. lorazepam) or high

potency neuroleptics (e.g. haldol) with minimal sedative, anticholinergic, and
orthostatic side effects may prove effective. Atypical neuroleptics (e.g. risperidone),
at relatively low doses, may also be useful in treating impulsive aggression.
After a disaster, some survivors experience extreme and persistent arousal in the
form of anxiety, panic, hyper-vigilance, irritability, and insomnia. Empirical
research has shown that hyper-arousal during the first few weeks following trauma is
a risk factor for the development of PTSD. Techniques to reduce arousal include
relaxation and breathing exercises, utilising social supports, psychotherapy, and
pharmacotherapy. Pharmacological agents for the treatment of trauma-related
arousal include benzodiazepines and antiadrenergic agents such as clonidine,
guanfacine and propranolol. Recent trauma survivors may also suffer from
debilitating symptoms of depression. Since all three symptom clusters of PTSD
respond to selective serotonin reuptake inhibitors (SSRIs), and because depressive
symptoms originating soon after trauma may predict PTSD, it is recommended that
SSRIs be considered for persistent posttraumatic depression. In addition, SSRIs may
be useful for controlling anxiety and irritability. It is important to note that
traumatised women, compared to men, may be particularly responsive to the
beneficial effects of SSRIs. (National Center for PTSD Fact Sheet)
Why should primary health care providers be knowledgeable about traumatic
stress?
Having knowledge about traumatic stress is important because Trauma often
leads to PTSD and other impairment. PTSD often presents to primary care
providers, but goes unrecognised
• In the private sector, nearly half of all visits instigated by a mental-
health disorder are to a medical clinic or provider. Of those visits,
90% are to primary care providers.
• Despite its prevalence, PTSD is likely to remain unrecognized and
untreated in primary care patients. Few medical clinics
systematically identify trauma survivors who have related mental-
health problems.
• Failure to identify and treat PTSD has adverse effects on the patient’s
physical and mental health. Traumatic stress is associated with increased
health complaints, health services utilization, morbidity, and mortality.
Untreated PTSD can impair recovery from medical conditions.
The primary care practitioner is likely to see an increase in traumatized
individuals after a disaster or national terrorist event. Many of these patients
will present with physical rather than mental or emotional symptoms.
Therefore it is recommended that primary care providers educate themselves
about the effects of trauma and routinely screen individuals for trauma after
major disasters (Prins et al, 1999).
7
Preliminary Summary and Conclusions

So far we reviewed some of the most "burning" issues of ASR conceptualisation and
controversy around its treatment. However we feel that if ASR patients are
"flooding" the ERs following critical incidents, non-treatment of ASR syndrome as
much as inappropriate treatment may result in PTSD. As there are guidelines to
assessment and treatment of ASR, primary care givers can identify and help ASR
patients.
Therefore it is a worthwhile professional effort to build a shared minimum protocol
of ASR treatment in ERs.
The ER Survey
The aims of this survey were threefold:
1. To screen ERs where hundreds of ASR victims were admitted and
treated in the past 28 months, hoping to learn about the procedures of
handling and/or treatment of these clients.
2. To look for common procedures across institutes.
3. To obtain organisational recommendations and a minimum
treatment protocol for handling ASR clients.
The survey was initiated by the Community Stress Prevention Centre (CSPC), in
collaboration with the hospitals. It was conducted in nine hospitals, using a structured
interview covering the process in which ASR clients are treated from the moment of
arrival to the time of discharge from the hospital and follow up. It is important to
mention the level of cooperation we found among the interviewees, the senior
psychiatrist of that hospital and the chief social worker. They all showed enthusiastic
and full co-operation and a strong will and commitment to develop a model and a
method for the treatment of ASR clients in emergency rooms.
The following are the main findings:
Alerting the psychosocial team
There are variations in staff emergency-call systems i.e.; outside the psycho-social
hospital team, who else will be called to ER and how? Some hospitals call both
psychiatrists and social-workers. In some places, co-operation between the
psychiatric departments (PD), and the social services (SS) is not yet fully organised
and so sometimes both are called upon and at other times just one of the professions
Staff positions and placement
Staff positions and placement – usually staff positions are pre-determined or there is
a clear knowledge as to who is the authority to place workers at their positions.
Psychiatric hospitals backup system
Psychiatric hospitals backup system was designated few months after the outbreak of
the Intifada in October 2000. This back up system provides psychiatrists and mental
health teams for the general hospitals without psychiatric departments. Most
hospitals report that the system is generally working satisfactorily but there is a
8
further need for training in collaborative work so that the local and the backup teams
will use the same terminology and methods.
The hospitals' information centres
The hospitals' information centres work more or less uniformly, mainly operated by
social workers. The structure and organisation is quite clear and so is their method of
operation. In some places a psychiatrist or a member of the mental health team joins
the SS staff in screening ASR symptoms of severe nature and or support waiting
family members or the mildly injured until admission to ER or to the ASR treatment
area. At times the psychiatric department will join upon being called.
Examination and initial diagnosis procedures
Examination and initial diagnosis procedures – upon admission every ASR client
first undergoes a physical examination by a senior physician, usually a surgeon. That
means that according to the "triage" procedure these clients will wait quite a while
before they will be seen or referred to the ASR site. There is no agreement as to who
makes the psychological- psychiatric diagnosis. In some places police investigations
take priority over psychiatry.
ASR assessment and records
ASR assessment and records. There is no clear indication to the number of ASR
admissions as all "mild or minor injuries" are recorded as such with no specific
indication to the fact that these patients manifested ASR symptoms. However, there
is a unanimous feeling that the numbers of ASR clients are increasing with the
continuation of terror incidents.
ASR site
ASR site - are not a clear issue and there are a number of variations. At some places a
site exists and operates automatically. At other places it is a professional and /or
administrative decision. In some hospitals, the criterion to open a site is the number
of patients, despite the fact that ASR patients usually arrive in at least two waves:
immediately after the incident and few hours later.
Usually patients do not receive any explanation when being referred to the ASR site
as to why they are sent there and what will be done with them. Location of the sites
also varies. Sometimes it is within the ER area, at other places it is outside the ER
and even within considerable walking distance.
Diagnosis and treatment at the ASR
There is no uniformity or agreed protocol of assessment between hospitals, no
consensus about who is doing the patient evaluation, treatment approach- individual
or group, use of medications and inclination towards hospitalisation. Most places do
not tend towards hospitalisation and medications. When a need for hospitalisation is
evident – the patients would not be admitted to the psychiatric department. Preferably
they would stay in ER. Hearing tests and eye examinations are sometimes held at the
site or on referral back to the ER.
9
In-patient treatment and follow up

In-patient treatment and follow up is conducted in some places during stay in
hospitals, in others the inclination is not to hospitalise at all.
Discharge
Discharge in most cases is through ER, however discharge does not always include a
mental health professional nor, as stated before, is an ASR assessment registered in
the discharge form. Thus GPs are not able to follow up on ASR patients on emotional
or behavioural issues as these were not indicated at discharge.
Follow up after discharge
Follow up after discharge varies. In general no structured follow up is done however
there are some variations here. When staff at the ASR site decide that a patient
needs special attention this patient is called for additional treatment. In some cases
patients come back on their own initiative. The three hospitals with trauma units are
more inclined towards inviting patients with severe symptoms for follow up
treatment, the other hospitals sometimes refer the ASR patients to community mental
health clinics and have no follow up programs and records. The children’s hospital in
Hadassa-Ein Karem, Jerusalem keeps a documented follow up of hospitalised
children. Some places hold follow-up groups for patients with severe
symptomatology, but there is no clarity as to the nature and focus of those groups.
Treatment of second wave of ASR
For the treatment of second wave of ASR patients that usually arrive at the ERs,
some hours or a day after the traumatic event is over, there is no special place for
their admission or treatment.
Treatment of accompanied families
Treatment of accompanied families – despite the lack of a uniform attitude towards
families, most places tend to allow a family member to participate in the process.
Usually, attitudes to family members do not vary with physical injuries and ASR
patients. Families waiting at the information centre or "holding" areas are supported
by SS staff.
Outside agencies
Social security services are contacted within 24 hours as a regular procedure, as they
are obliged by law to follow every injured person after "an act of hostility".
Media coverage in ERs - there are variations and at times conflicting attitudes
amongst hospitals as to permitting media access and the range of coverage. All
hospitals are aware of the media role as a PR instrument, thus allow them in to
advance hospital PR. Some places insist on patients' consent, others, in a few
instances tend to allow media coverage as a therapeutic instrument, as a "recall
procedure".
Other organisations - police and army units are usually apparent at the ER. They are
there for intelligence and information gathering, an activity that sometimes interferes
10
with the psycho-social interview. In some incidents different voluntary organisations,

embassies, political organisations and a host of other organisations are present at the
ER adding to the chaos and a further source of burden on staff.
Contact with local authorities
An important task of the psychosocial team is to connect victims with their relatives
and to make sure that social continuity is functioning. This is not always possible,
although in the main cities there are representatives of the local municipality working
with the psychosocial team in the ER to help ASR patients connect with their next of
kin and to make sure that upon discharge they are not left alone.
Helping the staff
Helping the staff - usually there is some consideration of help for staff members,
however there are no set rules or a protocol. In some places staff are debriefed, at
others it is a process of evaluation and conclusions, and at certain hospitals it is a
multi faceted process. There is a very big gap between the level of burn-out and
fatigue of certain teams, and the amount of help given to them. Medical staff in
general are reluctant to get help, however more and more paramedical (nurses,
support staff etc.) indicated a need for such attention.
The paradox of Trauma Centres.
Complex injuries are referred to the specialist hospitals which are university or large
regional medical centres . It is the smaller local general hospitals that usually receive
the Trauma (ASR) patients as they are diagnosed as "minor injuries". However, these
hospitals have a very small psychiatric unit and usually no psychologists. As a result
the trauma centres get less opportunity to work and study the phenomena of ASR and
are therefore less experienced with it and they will receive the patients only as ASD
or more often as PTSD.
Areas of specific needs
The interviewees mentioned two places in the hospital apart from the ASR site where
they feel there is a need for special attention. The unidentified persons site and the
mortuary. In these two places psychosocial team assist the families and individual
next of kin who wait to discover the fate of their loved ones.
The issue of mixed teams of Jewish and Arab staff members was mentioned both as a
source of intra-staff concern, with a few of the victims (the majority of them were
Jews) being aggressive toward the non-Jewish staff.
ASR Protocol
On the whole there was not a clear protocol, that means:
• to whom it should be administered
• how long should an ASR patient stay in hospital
• what is the minimum intervention needed
• is it an individually based or is it a group oriented
• can a member of family be present
11
• what procedures should it include: EMDR, PD (CISD),

Relaxation, CBT, Breathing exercises, Psycho education,
Information, hand-outs, telephone call.
• How one does "resourcing".
Even the psychiatric assessment is not always very clear. In most places there is
some kind of procedure, what is apparent is that most cannot support it with research
based validity.
Recommendations
We will deal with recommendations in three parts:
• Administration & logistics
• Best practice based on 22 years of CSPC experience and
published research
• Further steps
Administration & logistics
In view of the predicted influx of ASR patients to ERs there is a definite need to
allocate a specific site for ASR patients and their next of kin. The long wait of ASR
patients in the general ER is adding pressure to the ER staff and resources, not to
mention the exposure of ASR patients to the sights and sounds of the ER which may
affect their mental well being.
• The ASR site should be opened as soon as the hospital receives an alert of a
disaster. The site should be staffed with a skeleton staff to address the first
wave. The ASR site director should then decide on reducing or extending the
staff according to information from the ER and taking into account the
expected second wave of ASR patients.
• The ASR site should include individual treatment positions (both chairs and
beds) and group site/s for group work. Food, beverage and medical first aid
should be available at the ASR site.
• Accompanying family members should have a reception area with food and
beverages. If admitted in with their next of kin they should be supported too.
• Whenever possible the holding of ASR patients with hearing complaints
should be examined in the ASR site or in the general auditory ward (not in
the ER).
• Whenever possible the ophthalmic check shouldn't be done in the ER,
however as ophthalmic complaints may be indications of severe symptoms
they should be given priority. Closing of the ASR site should consider
various factors and the decision should be based on these considerations.
• A specific diagnostic item should be in the admission and discharge forms
indicating that the person was treated / diagnosed as an ASR patient. This is
important both for follow up and statistical reasons and to enable the GP that
12
receives the ASR patient to be sensitive to signs and symptoms before the
patient's condition deteriorates.
Suggested protocol for ASR patients.
Evidence based early psychological intervention. (Table adapted from the
"Mental Health and Mass Violence" NIMH publication no. 02-5138 Sept. 02)
Study Study Interval Conditions Results
Group between
Trauma &
Assessment
Bunn & Individual Counselling 13 M 17 F ages 16-68 Content analysis
Clarke trauma. sessions and 1. 20 mins. of verbal sample
1979 Next of kin assessment "supportive, emphatic" before and after.
of injured at ER counselling in quiet room Pre-Post decrease in
or ill adjacent to ER
level of anxiety
persons participants encouraged
to express feelings and (measured through
admitted to
concerns re: crisis. content analysis
ER
Information about injury scales) of
or illness and its intervention group
prognosis was provided as for the control
2. 20 mins. alone in group.
quiet room adjacent to
ER
Gidron, Individual Treatment 9M 8F assigned to Fewer participants in
Gal, trauma within 48 either: 1- 2 telephone MSI than control
Freedman, adult MVA hrs. of ER sessions of memory group met criteria for
Twiser, survivors visit structuring intervention PTSD and greater
(MSI) modelled on
Lauden, CBT.
reduction in PTSD
Snir & found in the MSI as
Benjamin 2- 3 telephone sessions compared to
2001 of supportive listening supportive
sessions at consecutive counselling at 3-4
days within 48 hrs. of
month follow-up.
discharge from ER
Hobbs & Individual Session in 44M 19F All subjects show
Adshead trauma ER within reduction in SEQ, BDI,
one session IES scores by 3 months
1996 MVA 24 hrs of
"standardised post trauma. Only those
survivors, medical
interview" counselled with high entry on BDI
dog bite, treatment SEQ scores had
group.
assault by significantly better
stranger Untreated group outcome at 3 months in
the counselled group
vs. control.
13
Carlier Collective As soon as 46 M voluntary 8 months later no

Lumbets trauma – possible policemen in study difference in PTSD
Von Police (not symptoms 18
59 officers who were
Uchelen officers specified) months debriefed
not debriefed for
& following show "disaster
“operational reasons”.
Gersons the El Al related hyper
Intervention CISD no
1998 aircrash in arousal symptoms
indication as to how
Holland
many
Carlier Individual Debriefing 86 Police staff given Post PD more re-
Voetman M/F police 24 hours 1 3 individual PD experiencing PTSD
& officers and 3 symptoms among PD
82 no PD
Gersons months 6 months later, no
2000 post significance among
trauma groups. High level of
satisfaction with PD
not correlated with
positive outcome
Eid, Collective 1 day post 9ML group PD, stress Additional group
Johnson trauma : accident management & PD reported fewer
& military operational PTSD (PTSS-10) 2
Weisaeth personnel debriefing. weeks later. No
2001 (MP) fire- difference on IES or
9FF stress
fighters GHQ-30
management &
(FF) to car
operational
accident in
debriefing
tunnel
Hobbs Individual 24-48 hrs. 54 received 1hr. PD had worse

Mayou trauma MVA individual session PD outcome on 2 BSI
Harrison adults M&F (review of the scales no difference
& PD treatment traumatic experience, on IES / neither
and no
Worlock treatment /
emotional expression, groups did not show
1996 control promotion of cognitive significant reduction
processing. (limited in any symptoms
structure)
Shalev Collective HGD 39M in 6 small Pre-post debriefing
Peri trauma 39 within 48- groups , 2.5 hrs. scores showed that
Rogel- Israeli 72 hrs. historical group HGD was correlated
Fuchs soldiers after debriefing (HGD) with self report
Ursano (M) exposure based on Marshall's reduction in anxiety
& exposed to model. (STAI) improvement
Marlowe combat in self-efficacy (self-
1998 C)
14
CSPC Immediate ASR Intervention Protocol.

Psychological first aid is brief, attuned to the severity of the crisis and the
immediate needs of the survivors. Although it is clear that PFA will differ according
to circumstances some prominent elements, which have been found helpful, emerge.
The most universal are:
Adult leadership, which is also adult modelling for children of all ages:
• Reuniting members of family;
• Clear directions of “what to do, where to go etc.”;
• Verifying information;
• Helping children understand what has happened as the crisis unfolds or
after it has ended;
• Providing a clear sense of the future, even at the very place where they are;
• Physiological relaxation and tension reduction (only in a safe location).
Contrary to the usual expectation that children are needy and passive at this phase, it
has been found that children gain control by having an active role and that enhances
their resourcefulness (Ayalon, 1983). Adults can help children build group support,
allow for and accept a variety of emotional expressions, and engage children in step-
by-step problem solving and planning for the next move.
Early Crisis Intervention (ECI)
Broad spectrums of brief therapeutic methods are often used with affected
individuals, families and groups in this phase. This is the time for an ad hoc
screening (triage) for children who may be in a high-risk situation, as a result of the
enormity of their loss, their age, their previous vulnerability and other factors. It is
fair to say that early immediate intervention was believed for a long time to be geared
to reduction or even elimination of PTSD. In recent years we have come to
understand that this aim is both impossible and even counterproductive. With
growing evidence that the very severe and chronic PTSD patients are not just
manifesting “normal reaction to an abnormal situation” and that there are
predisposition factors to their problem, the aim today is to focus on reducing acute
symptoms (Acute Stress Disorder ASD or Acute Stress Response ASR) and help
those affected on a moderate level to rebuild the life which was disrupted by the
traumatic events and return to daily functioning as soon as possible.
One of the leading assumptions is that at the root of a major crisis lies the crucial
element of disruption in the perception of meaningful continuities, namely:
functional continuity (how to maintain routine), historical continuity (what is my
identity now? Who am I?), interpersonal continuity (how to patch up a broken
social network), narrative continuity (how to bridge the gap in my broken life-
story), spiritual (how to deal with a world which is no longer good, safe or
predictable) (Omer & Alon, 1994, Lahad 2001).
15
Thus the three general aims of ECI are:

1. To enhance and broaden natural resilience and teach new coping skills.
2. To work through the perceptions and responses to the disaster so
that the event may be integrated into the fabric of life and
remembered without re-awakening traumatic reactions (similar to
working through loss and bereavement, Parkes, 1998).
3. To find new ways to bridge the disrupted continuities.
This process is much more extensive and therapeutic than psychological first aid, it
requires more time and a higher level of therapist training than is required by PFA .
Among the most frequent methods and strategies used in ECI are: conducting
mourning and memorial rituals, promoting positive affirmations of resilience;
enhancing and accepting verbal and non-verbal expression of the full range of
emotional responses; sharing personal perceptions and experiences; working through
dreams and nightmares, reprocessing traumatic reactions by a variety of techniques
such as EMDR, NLP and de-freezing the somatic trauma by body awareness,
expression and regaining body-mind control.
ER ASR Protocol
In over 20 years of direct work with victims of terrorists attack along the Northern
border of Israel and our vast international experience in disasters (Northern Ireland,
Former Yugoslavia, Earthquake aftermath in Turkey & Greece, victims of torture in
Norway and Sweden to name just a few) we have been asked time and again to
respond on the spot with psychological first aid.
The need to develop an immediate intervention protocol to deal with the ASR (Acute
Stress Response) of the civilian population along the northern border between Israel
and Lebanon was imminent and the lack of such protocol was evident.
Thus, over the years, based on "trial and error", reading the relevant data and
obtaining first hand training from world-renowned experts, a structured protocol was
developed and refined according to practice and international research.
The Protocol
The CSPC protocol combines the following elements
Screening and assessment of ASR
Screening and swift assessment of coping resources- according to our Integrative
Model of Coping and resiliency – BASIC Ph
For the individual
The use of our modified "triage" model of continuities and re-organising continuities
to screen between those at risk and those in danger of deterioration.
Using Milton Erikson’s “Pacing and Leading” method for the dissociative/detached
patients.
Use of relaxation both action (Jacobson method) and Focusing (Gendlin)
In special cases: EMDR; TIR; EFT.
16
For groups
CIPR- our revised and controlled method of debriefing called “Critical Incident
Processing and Recovery”, NEVER before 72 hours. We have had success with a
version of Mitchell's Diffusion in the immediate stage (Lahad & Cohen, see this
volume). Noy (2001) recommends Marshall’s version of debriefing used by
commanders with their soldiers after an incident. Here the emphasis is on what
happened and although emotions and thoughts experienced during the incident may
arise, they are not actively solicited.
The use of Non-verbal Expressive Methods - Conclusions
Despite an international effort to agree on "best practice protocol" very little has been
done so far to study the ASR in the immediate post critical incident phase where
hundreds are arriving at the ERs. The few studies that exist were all made on adults,
based on very small samples and it seems as if they were made on an "opportunity-
basis" that is reacting to the situation rather than planning in advance.
It is clear from our survey that a structured and well-controlled study of ASR
treatment in ERs is needed, as there are differences that may result in negative
outcome.
Whenever there is a protocol, it is based on experience and "what looks likely to give
good results". It is therefore our recommendation that an international task group will
design a research studying existing protocols and validating effective methods in
order to have an agreed " minimum–protocol" for individuals (adults and children)
for groups (families and other groups) taking into consideration ethnic differences
and developmental needs.
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19
After the Bomb in Omagh, Northern Ireland
Creating Systems for Healthy Coping in Schools and the Community
Elizabeth Capewell
The Omagh bomb – The Incident

Omagh in County Tyrone is a small market town in Northern Ireland serving a
regional population of some 200,000. Saturday 15th August 1998 was a fine
summer’s day and the town was crowded with people shopping for the new school
term and waiting for the Carnival procession. A coded warning from the Real IRA, a
dissident republican group against the Peace agreement, saying that a bomb had
been placed near the Courthouse caused police to direct people to Market Street at
the other end of the main street.
Circles of vulnerability
This is a region of close community and family bonds. Thus, the majority of the
population over a very large area were caught up in the anxiety of waiting to hear if
friends and relatives were safe. A significant number of people were away on holiday
at the time, unable to check on family members or offer help to others. Victims did
not just come from Omagh town. Many were from villages around Omagh and from
elsewhere in the Province. The dead and injured included a school group from
Buncrana, Co. Donegal in the Irish Republic and their guests from Madrid. This
bomb was indiscriminately destructive affecting Catholics, Protestants, a Mormon,
Northern and Southern Irish and tourists. The toll included 10 children, 6 teenagers
and unborn twins. Unusually for Northern Irish atrocities where 90% of fatalities are
male (Smyth 1998), 18 (60%) of the Omagh dead were female. Over 400 people
were injured, about 50 seriously and many had traumatic amputations. Over 2000
contacts were made to GP surgeries in the few weeks after the bomb. McKittrick,
(1999) in his detailed account of the incident concludes ‘The death toll was
extraordinarily high and extraordinarily comprehensive’.
Emergency rescue and response:
The immediate recovery and rescue of so many dead and injured continued the
trauma and confusion. It was followed by the long and complex process of locating
the injured in hospitals across the Province and of identifying bomb blasted bodies.
The local Leisure Centre became the reception centre for relatives and a morgue was
set up in the Army barracks. This went on non-stop until the Sunday night. Funerals
were held in the following week and a Memorial Service was conducted in the town
centre on the following Saturday afternoon.
For many victims, the suffering has continued because of compensation issues, long-
term disability and disquiet over the handling of the criminal investigation by the
Police and politically sensitive legal proceedings which have not brought any sense
of justice.
The psycho-political background of the “troubles” in North Ireland
Ireland has a long history of civil unrest, going back many centuries. Its roots and
early development are extremely complex but over the years the political differences
have become aligned to religious differences. In 1921, six counties were separated
from the newly formed Irish Free State, and remained part of the United Kingdom as
Northern Ireland, with its own Government.
1969 saw the start of the Civil Rights movement which aimed to restore equal civil
rights for Catholics. Since then, the Troubles, as they are euphemistically called,
have claimed 3,600 lives, injured and maimed 40,000 people in a population of only
1.5 million. Many commercial and private buildings have been destroyed. Fear is a
constant fact of life – fear of the enemy within ones own family or community and
fear from the ‘other side’. One’s name and speech can identify one’s community.
Fear is also a constant companion for many people we met in Buncrana, a seaside
town not far from the Border – fear of crossing into the North and fear of IRA
activists in their own community. Secrecy and mistrust have become a way of life.
Though largely unreported beyond the Province, community violence continues to
the present and in February, 2003, a bomb exploded in Enniskillen, just south of
Omagh and scene of a fatal bomb attack in 1987.
Many people in the North will claim they have not been affected by ‘the Troubles’.
Yet this is the only place in the UK where police stations look like fortresses, armed
patrols are found and restrictions placed at certain times on movement. The Troubles
have undoubtedly affected the social and economic fabric of life and researchers
point to high levels of mental health problems. (Smyth, 1989) It is probable that
people have become habituated to the condition of unrest, (anyone under 30 has
known nothing else), and denial has been a major method of coping Bolton, 1999).
In my work with teachers in Derry, teachers denied they were affected by the
Troubles but when asked whether the Peace had made any difference, the list of
differences was long.
The Local Context
Omagh is a community whose citizens are hard-working, God fearing people
espousing high moral principles and with a high level of educational achievement.
The town is relatively wealthy compared with other parts of the Province, with good
quality housing. The proportion of Catholics and Protestants are fairly equal and
there are not the physical signs of division such as flags and painted kerb-stones
found in Belfast and other towns. Clergy of different denominations regularly meet
and relationships between Catholics and Protestants were regarded as amicable.
The politeness of the people is refreshing, yet this politeness may be a mask, and a
necessary coping device, hiding underlying conflicts (Bolton, 1999). While informal
activities such as the use of shops and some leisure facilities are integrated and inter-
community links are fostered, formal arrangements still tend to be segregated.
Different parts of the town are identified as predominantly Catholic or Protestant
areas and intermarriage can cause problems. In England, I met a Protestant woman
from Omagh married to a Catholic who had not dared go back home for 12 years
because her mother feared the reactions of neighbours. Though there is one
Integrated School, children tend to be educated by schools within their own religion
and the Health Centre has a GP from each tradition.
21
After the bomb in Omagh
Social problems may also be an expression of the stresses of life in the area. It has
the dubious distinction of the highest completed youth suicide rate in Europe,
according to local youth workers and alcohol and drug abuse and domestic violence
are also high. Motor vehicle accidents also claim a high number of young people. In
fact more people have been killed on the roads in the Province than by the Troubles.
A few months before the bomb, the town was shocked by the brutal torture and
murder of a pregnant teenage girl involving two local school children as accomplices.
There were two more murders in the months following the bomb. Time and time
again, we found that scratching the surface of the mask revealed multiple trauma.
The immediate response to the bomb and its significance
The immediate rescue was undertaken by members of the public then emergency and
medical services. After this was completed, the Regional Director of Community
Care, David Bolton, began the work of organising immediate humanitarian support to
those directly affected. The Director had been involved in the response to the 1987
Enniskillen bomb in the neighbouring County and had extended his knowledge of
disaster response in England. He put his experience into practice and ensured that
steps were taken to reduce the stresses arising from the identification of bodies and to
provide as human an atmosphere as possible.
An Emergency Co-ordination Centre was quickly set up in the town to offer a drop-
in information and support centre staffed by experienced volunteers and social
workers from across the Province.
This was the first time in Northern Ireland that a major disaster response could be
put openly into operation. After the Enniskillen bomb, the political situation and the
overt sectarian nature of the attack made this impossible and the response had to be
undertaken in a quiet, ad hoc manner. Because the Omagh bomb felt like an attack on
a democratic Peace Agreement involving all sides, there was public recognition of
the need to respond openly to the trauma (the Bloomfield, and Social Service
Inspectorate reports of 1998)
Using outside consultants – overcoming resistance
The Chief Executive of the district’s Education authority had the vision to accept
external help. We were aware when accepting the contract that there would be many
of his colleagues who would not share his vision. We therefore had to proceed
carefully, ‘securing our tent pegs’ in as many places as possible and watching for
‘minefields’ and barriers to work out how best they could be negotiated.
In common with other practitioners we had previously observed how a local
community pulls together very tightly after a disaster, minimising existing
differences and focusing totally on survival (Raphael, 1986). Where the disaster
renders everyone and every system vulnerable, the need to regain feelings of control
is high. Local professionals may fear that organisational and professional
inadequacies and personal vulnerabilities might be exposed. In this environment,
there will always be a section of any community or organisation that copes by denial,
for example by retreating into ‘normal business’ with the result that anger and other
feelings are projected on to outsiders.
22
Accusations about ‘experts parachuting in’, demanding high fees and leaving quickly
have to be understood and borne as part of the territory of external consultancy. From
my experiences of being an internal professional in the Hungerford disaster and from
my research with others, I also know that ‘insiders’ can also experience the same
feelings of being ‘outsiders’ with all its dangers. The issues are in fact more about the
unequal power relationships between ‘helpers and victims and bereaved’ (Smythe,
M – e-mail communication 1999).
An advantage of external services in the Omagh situation was that we as external
helpers could raise issues and concerns and name processes from the knowledge and
experience of other events. We could step over some of the very subtle boundaries
that communities establish to maintain the status quo. Staff teams could speak more
openly with us about organisational issues than with internal managers. We could
manage the process more openly than would be possible by those too embodied in
the existing culture. We were also able to transcend sectarian barriers. However it
was essential that we maintained complete respect for, and care of the boundaries of,
our role and work. It was a matter of ensuring a very balanced approach.
We discovered yet again that the way support is offered is perhaps more crucial than
whether it is someone from within or outside the community. Our style of operation
is informal, flexible, strategic yet opportunistic, always paying close attention to
culture and context. It is guided by crisis management principles and based on our
experience and attention to personal internal processes. We have found our style
works particularly well in Irish communities, where personal, human and
spontaneous responses are at the heart of human interaction. It especially helps us to
reach people whose voices are not easily heard.
There were also pragmatic reasons for our presence. The Chief Executive recognised
that this task was too big for the existing systems and procedures to handle. Many
staff were still away on holiday and would return to deal with their own shock, loss,
distress and grief. Schools were to return within the week, so as well as returning to a
new school year they had the added concern of the effects of the aftermath of the
bomb and managing grieving pupils. The over-riding immediate concern was ‘How
can we deal with the first day of term?’ Without the structure, direction and role
definition of a recovery plan it would have been impossible to manage the day to day
business of the Education authority and combine it with the development and
implementation of recovery processes. Moreover, our experience meant that we were
not overwhelmed by the scale of the disaster and could offer hope, backed by
realistic action plans, that they and the community would find a way through the
chaos.
Dealing with denial in Education systems
School systems around the world are particularly immobilised by denial. A teacher
writing after the Enniskillen bomb stated that “many teachers deny feelings of
anxiety, suppress emotions and argue that ‘things must go on’” (Doherty, 1991).
Often it is those in senior positions, under pressure to return the school ‘to normal’,
who hold this view and deny the needs of staff and pupils. That this is a world-wide
feature of school responses is supported by the research and experience of ourselves
23
(Capewell, 1994) and others in schools in many different places and cultures from
Jordan (Fisher, 1993) and Israel (Lahad 1993) to Australia (Heinecke, 1991;
Rowling, 1995) and the USA (Johnson, K, 1989). After the Oklahoma bomb it was
found that many children in schools were denied access to services because ‘school
principals use their own coping styles as a yard-stick for judging needs’ (Zinner et al,
1999).
The CCME Response to the Omagh Bomb
The account of this response will include the principles guiding our work and
practice followed by our response in the immediate, medium and long-term. The sub-
headings will highlight key themes and issues.
The principles informing our practice:
Our approach to post-disaster management resonates with the view of Aileen
Quinton, whose mother was killed by the 1987 Enniskillen bomb. She writes, ‘What
can be useful from those with appropriate skills and experience, as early as it can be
provided, is facilitation; that is supporting the local communities to help themselves.’
(Quinton, 1996)
In working out our response we combine the principles of Crisis Management
(Raphael, 1986, EMA 1998, CSPC) and crisis response in schools (Klingman &
Ayalon, 1980, Johnson, 1989, Pynoos, 1988) with the principles of Community work
(Henderson, 1980) and community models of crisis management summarised in
Zinner (1999) using the philosophies and practice embodied in Action Research now
consolidated by Reason and Bradley (2000). We are guided by values of partnership
and empowerment but we also work pragmatically with what is possible given the
whole situation. Early after a disaster, a more directive approach may be needed and
we always work with an expectation that power, information and skills will be
handed over to clients as soon as possible.
Our work relies on the engagement and training of local ‘mental health agents’
(Klingman and Ayalon, 1980). These ‘agents of recovery’ include teachers, youth
workers, clergy, voluntary groups, health visitors and the young people reached
through schools (Lahad & Cohen, 1993).
In schools we promote the view that the responses where possible should be teacher
led, specialist supported and expert guided at key points. Ayalon supports this view
when she states;
‘Schools are in a unique position to mitigate the effects of trauma.
My years of experience have shown me that early help is best given
in school by teachers under the guidance of people who have
specialist information and experience. Teachers are the most natural
resource for helping parents deal with children’s behaviour and
reactions and they should be given the skills to do so.’ (Klein, 1996)
Offering information, skills and alternatives (Kfir, 1988) through a range of systems
and media to mobilise and enhance existing resources increases the choices available
for people as they take charge of their own recovery. Often, the process itself is
enough for some people to start their move to recovery as it provides the stepping
24
stones to break the stigma, myths and barriers that prevent so many people believing
they have the right to asking for help.
In order to translate the principles into usable practice in fraught situations, we have
devised a series of questions to establish the needs of the specific situation before
deciding on the response:
• What are the facts & significance of the event?
• Is it our business – if not, whose?
• Who is in charge?
• Who is available to respond? (checking resources, availability, ability,
resistance)
• Who is directly involved in the incident? (dead, injured, bereaved,
witnesses, rescuers)
• Who else is affected? (ripple effect – near misses, friends, relatives, those
who identify)
• Who needs to know? (what happened, sources of support, information for
coping)
• How shall we tell them? (look for variety, appropriate media, repetition at
each stage)
• What can we do now?
- practical responses? (physical, social needs, supportive procedures)
- psychological responses? (individual, group, classroom, community)
- media responses? (proactive contact to inform and seek information)
• How shall we receive and record data, review, and communicate?
• What to do now for the future? (anticipatory guidance, preventive
education)
• How do we care for ourselves ? (clear limits, roles, remuneration, support)
Running through this process is an awareness that we:
1. Concentrate on the immediate issue.
2. Keep an eye on the next step.
3. Defer or delegate whenever possible – never do what
local people can do for themselves.
Our Immediate Response to the News of the Bomb.

The immediate response work took several forms:
1. Pre-contract -Spontaneous personal support to the Director of
Community Care and others I had known in the area from previous work
there, followed by the collation of information about disaster reactions
and response they could send out to schools and others.
25
2. Consultancy to Education authorities and the Health and Social Services

Trust in the development of a co-ordinated approach to the bomb
response by statutory and voluntary organisations.
3. Direct crisis response facilitation with Education and community groups
4. The establishment of a contract and ‘rules of engagement’. Bearing in
mind that we as consultants needed to build in our own safety, this
included an insistence upon at least 2 consultants working together at
any one time, especially as the full extent of the work was not yet
known.
Preparation for our arrival:
Information dissemination is critical (Raphael, 1986; EMA 1998). It needs to be the
right information, at the right time, to the right person and in the right amount. Too
much information swamps people and they are unable to assess, and use it
effectively. However, too little information creates anxiety, dependency and is
disempowering. Following these principles we provided:
• Information prior to arrival in Northern Ireland.
• Material allowing teachers to assess the vulnerability and immediate needs
of their own class groups.
• Information packs for staff to manage students’ and families’ reactions,
affirming good coping skills to be made available to all schools for
distribution.
Building a partnership with local professionals:

As external consultants, our work and role had to be given legitimacy and
credibility by the key holders of power. We therefore met and explained our
aims and methods to the Board of Governors and key managers. The
development of internal liaison and co-ordination was enhanced by the
appointment of a senior officer to act as liaison and logistics organiser. This
made possible timely feedback to the CEO, key personnel in management
and communications with field staff and schools.
Establishing information channels:
These processes established an information flow which was supported by
senior management and allowed CCME to assess strengths, coping skills,
need and vulnerability, blocks and difficulties. It also established a model
for open, careful communication.
Networking:
One of the most productive features of CCME’s approach was the
establishment of many networks combined with a process which valued and
evaluated all information from many sources, while at the same time halting
rumours and challenging negative myths and metaphors. This was a
constant process because new information needed consideration and
assessment. Ways had to be found to connect the formal and informal
26
narratives we collected from different parts of the organisation. Networking

took place at many levels. Conversations with people in shops, with parents,
voluntary agencies, government services, support workers, bus and taxi
drivers, small business owners, media and contacts from education services
in the Republic all contributed to the picture, reported regularly to the Chief
Executive and Director of Community Care. These meetings provided a
time for anticipation of the developing issues and a chance to discuss
various options for solving them. The liaison and co-ordination with internal
professionals meant that schools, youth groups, libraries and services
needing attention were identified and meetings with staff were established
quickly. When this was combined with the other needs assessments, the
team was able to identify the most vulnerable areas and direct resources and
services appropriately.
Crisis management programmes in schools in and related services
Given a two week time and a large organisation managing 80 schools, plus
libraries and youth centres, what could be done? The style of work needed
was entrepreneurial, fast, responsive to emerging needs and conditions,
simple and accessible to staff still in shock. It also needed to be embedded,
but not trapped, in the existing culture and conditions of the organisation
and linked to the work of other agencies. It needed to combine strands at
different levels - working with individuals, throwing lifelines to schools and
others that needed immediate help, as well as giving attention to the
organisation as a whole (strategies and support of Managers). Our work
moved in and out from the practical (e.g. what to do and say on the first day
of term), to educating people about disaster response to facilitation (e.g.
creating opportunities for needs and issues to emerge), while always
keeping an eye on the next step and long-term future so that strategies and
systems could be planted. The informal work undertaken in brief
interactions in corridors, restaurants and shops, over lunch and at breakfast
were as influential as some of the more formal interventions.
Planning our programme:
There was no set timetable at the start, just a set of principles and
information to work with. These principles involved the assessment of the
significance of the incident, the assessment of needs and the extent of the
ripple effect through mapping circles of vulnerability (Ayalon, 1993). The
work was guided by the principle that early facilitation concentrating on the
building of coping skills and preventative education will reduce existing
problems and prevent unnecessary secondary stress. Schools, libraries and
the youth service were seen as vital agents in providing this help
strategically and directly. By working in harmony with existing systems,
help could be given in a manner which did not stigmatise or re-traumatise
affected staff and children. These organisations have existing mechanisms
for both delivering information to the wider community and providing
routes through to specialist help for those who need it. They can also help in
27
the important task of healing the community and its parts as well as
individuals.
Past experience has shown how children and young people in turn pass on
valuable information and ideas to their families and community. (Lahad
1998) Disaster creates ripples of shock and reactions through the
community and our aim was to create positive ripples to initiate support and
help to stimulate the whole process of adjustment.
Once we had fixed a few key meetings, a timetable began to emerge. The
clerical staff assigned to us worked with great speed and efficiency to reach
different groups of Board and school staff to invite them to information
sessions. Many staff were away on holiday and the clerical team often bore
the anger of those who were not contacted in time. We made sure that the
work of the clerical team was recognised and valued by senior managers.
Over the next two weeks, we undertook two day-time sessions and an
evening session every week day, using Saturdays for other meetings.
Sundays were used for planning and rest, though on one we spent the
afternoon learning first-hand about the inconvenience of bomb hoaxes and
inability to get back to one’s car. Information sessions were offered
separately to Advisors, Education Psychologists and Welfare Officers, and
education staff at all levels. Other meetings were arranged with the Child
Mental Health team, Social Services, Clergy, library staff and the Inter-
Agency Strategy team.
The Content of Sessions:
Though each meeting had to be adapted to the group concerned, a general
pattern emerged. Because of the emotionally charged atmosphere and short
concentration s, we chose to work using models described below and
metaphor as a way of imparting ideas and information. This was enough
information to give an over-view of the task in hand and to stimulate a
dialogue through which concerns could be raised and questions posed.
Every session ended with small problem-solving groups to model the
support and information sharing forums which we hoped would be
developed throughout the system.
Models of dealing with trauma:
The CCME Trauma Process Model
This is acyclical model (Capewell, 1991, revised 2003) developed from our
various experiences of crisis to provide an overview of the long-term tasks
ahead and to show what needs to be done to prevent long-term problems by
improving the choices available to people dealing with their trauma
experience (See Fig 1). We also used it for planning and to illustrate the
appropriate timing of different interventions (see Figure 2).
28
TRAUMA PROCESS MODEL

© Elizabeth Capewell, CCME, 1990 (revised 2003)
Trauma
images
stored as
memory
9. INTEGRATION
New life and reality
1. PRE-TRAUMA
Existing beliefs
and life-style 2. TRAUMATIC INCIDENT
Overwhelms coping
7. HEALTHY 3. THE VOID

COPING Shock, disbelief,
Insight, learning confusion
redemption
reconnection
8. TRAUMA
REVISITED
6. Re-
Emergence
4. FULL IMPACT
EMERGES
Intense emotions
physical
Impact behaviour
change
5. ‘THE PTSD
WHIRLPOOL’ Suicide
Cumulative social, KEY:
economic &
Points
psychological of
problems Life stuck Choice
in trauma
29
KEY ELEMENTS OF CRITICAL INCIDENT MANAGEMENT

Using the Trauma Process Model for Planning a Response
9. INTEGRATION
Recognition Living the
learning
2. 2. TRAUMATIC
1. PRE-TRAUMA INCIDENT
Planning. Staff Management – Rescue.
training. Reunion, Re-
Curriculum stabilisation,
development Crisis intervention.
7. HEALTHY COPING
Maintenance and
encouragement 3. THE VOID
Watchfulness ‘Making sense’
Use normal curriculum Support & Manage
– learning, creative Rituals. Routines.
expression, telling the 8.Reminders Information systems
story, action. Rituals, Review &
memorials processing.
Support,
6. RE-
EMERGENC 4. IMPACT REALISED
E Nurture 1:1 counselling, group
support, referral.
Manage context and
school work.
Anticipate & manage
differences.
5. THE WHIRLPOOL PTSD
Specialist help Suicide
Manage context.
Maintain
connections.
Medical treatment
ON-GOING WORK
INFORMATION, SUPPORT, IDEAS.
WATCHFULNESS & ANTICIPATION
MANAGING DISTRESS, REMINDERS
& DIFFERENCES
STAFF TEAM SUPPORT &
DEVELOPMENT
© Elizabeth Capewell, CCME, revised 2003
30
This model shows the different paths that can be taken by survivors and
what can be done to promote positive choices in coping. The model has no
time scale and though it is shown simply for ease of understanding, it
recognises the messy complexity of real journeys of adjustment after direct
and vicarious trauma which can spiral up and down many times before any
sense of adjustment may be reached. Some never reach it and some stay
stuck in the whirlpool of unhealthy choices. It will not fit every experience -
it is a map to be used as a guide and as a method which can be used to help
people draw their own maps of recovery. The phases (fully described in
Capewell 2003), which are never rigidly defined, are as follows:
1. OLD BELIEFS (Pre-incident) - the fixed or mistaken beliefs
(Adler, 1927) about self and the world that are likely to be challenged by
disaster. People are thrown into crisis when disaster challenges core beliefs
and coping which form the lynch pin for their stability. Not everyone is
thrown into crisis even if the incident is traumatic - it depends on the
strength and variety of their coping and the significance of their loss to them.
2. THE TRAUMATIC INCIDENT – which challenges all aspects of a
person (physical, emotional, spiritual) and can affect their family, social and
economic context. In this model, it is experienced as a betrayal, indicated by
gut reactions such as ‘It shouldn't have happened like this, why me?’, and
‘Why did ‘They’/God let it happen – I’ve done nothing wrong?’
3. ‘THE VOID’ - the world feels as if it is turned upside down, nothing
makes sense, people are in shock and the feelings underneath are intense.
Others may try to 'move people on' or people themselves deal with the
anxiety of this phase by for distraction, avoidance, keeping busy and alcohol.
They may reject or not ‘hear’ offers of help. However, this is the phase when
people may also be very receptive to help, if it is given sensitively. They
need ‘permission’ or encouragement to ‘gather their thoughts and feelings’
and make sense of things before they move into unhelpful coping or activity.
Methods include: Listening and being alongside the distress, defusing and
forms of debriefing, practical support, mobilising local support and self-help,
finding a place for reflection, getting the facts straight, supportive rituals.
4. FULL IMPACT EMERGES - Once the shock begins to go, strong
feelings begin to be felt and the full impact and significance of the trauma
and repercussions are realised. The ability of the person to deal with strong
emotions and other reactions and the nature of support they receive will
influence the path they choose next. The incomprehensible and seemingly
inhuman actions of external bodies, such as the legal system, employers and
the medical system are often the trigger to people moving into the
'whirlpool'.
5. THE ‘WHIRLPOOL’ - The right to choose their own path is,
however, part of the process and people will often choose coping strategies
which increase their problems. Some people choose to turn feelings inwards
or against others or they choose a path of action and coping that creates more
31
stress. Guilt can be turned to blaming and scape-goating, anger to bitterness

and revenge, sadness to self-pity and depression. Creating more chaos may
serve to blot out the primary pain and distress. This route can lead to actions
against others or against self and can have an impact on family, health, work
and society. Thus secondary reactions and trauma follow. Some will fall into
a downward spiral which is difficult to leave without the support of others
and some will choose suicide or develop full PTSD. Medical treatments may
be needed and families and friends will need support. However, going into
this 'whirlpool' may be a turning point that eventually may lead to growth
and transformation.
6. RE-EMERGENCE Finding a way out of the whirlpool often feels
like a re-birth and care in managing the transition and newly found energy is
needed to sustain the move forward.
7. HEALTHY COPING - This is the time when people realise that
though they cannot change what has happened and there may always be
pain, they have the choice to deal with their experiences positively. They
will begin to: take control of their lives, enjoy life again, rediscover that fun,
love and trust are possible, talk of getting the colour back into life and
transform difficult feelings into positive actions, learning or creative
projects. Acceptance of the reality may be possible and there may be an
aspiration to explore forgiveness.
8. REVISITING THE TRAUMA - reminders of the incident come
through the re-activation of emotions and physical sensations - one of the
characteristic features of trauma reactions. It may happen with a physical or
symbolic reminder such as location, reminiscent sounds, smells, sights,
tastes, TV programmes, and certain people. Anniversaries, birthdays and
festivals will bring reminders of what has been lost. The task is to help
people be aware of these emotional activators so they can be prepared and
supported through them. The aim is to make the reminders less troublesome
and to defuse the emotional charge associated with the images by helping the
brain to store them as memory. Techniques such as EMDR and the NLP re-
wind method may help.
9. INTEGRATION – this may happen quickly or only after many
journeys around the cycle. When this point is achieved, the trauma is no
longer the main focus of life and life is no longer defined by it. Learning is
used to engage in new activities, often the result of new discoveries about
self and the world. New dimensions of life and living have been discovered
and realities about what the world really is, not what it 'should be', are
accepted. There is often a change of direction, values or life style. The
trauma is not forgotten but it has been found a place and images have been
stored properly as memories without restimulating strong emotional
reactions.
32
Multi-dimensional model of coping

A multi-dimensional model of coping developed by CSPC (Lahad 1993)
was also explained in its simplest form, with small adaptations to the
mnemonic for use with children.
THE MULTI- MODAL MODEL (Lahad 1993)
ORGANI-
SELF- INTUITION REALITY ACTION
EMOTIONS SATION
VALUE HUMOUR KNOWLEDGE PRACTICAL
ROLES
B A S I C Ph
BELIEF AFFECT SOCIAL IMAGINATION COGNITION PHYSICAL
FRANKL FREUD ERIKSON JUNG LAZARUS PAVLOV
MASLOW ROGERS ADLER DE BONO ELLIS WATSON
ATTITUDES LISTENING SOCIAL CREATIVITY INFORMATION ACTIVITIES

LIFE- SKILLS ROLE PLAY ORDER OF GAMES
BELIEFS EMOTIONS STRUCTURE PSYCHODRAMA PREFERENCE EXERCISE
VALUE - VENTILATION SKILLS “AS- IF” PROBLEM RELAXATION
CLARIFI- ACCEPTANCE ASSERTIVE- SYMBOLS SOLVING EATING
CATION EXPRESSION NESS GUIDED SELF- WORK
MEANING GROUPS FANTASY NAVIGATION
ROLE-PLAY SELF-TALK
Community Outreach:
Coping tips and rumour reversal
Community outreach methods were employed in recognition of the importance of
increasing accessibility to information and services. Information and basic tips for
coping were in great demand and needed to be placed where they would easily be
seen or given out directly. Rumours were also rife and we were aware of the
gruesome stories being traded around the community, leaving traumatic images in
the minds of children and adults. Leaflets designed especially for children and young
people were distributed through libraries and schools. The local paper agreed to print
some basic tips for coping, though they would have preferred to print ‘human
interest stories’.
Permission to be affected- creating circles of healthy coping
Time after time, we observed how people denied themselves and others permission to
be affected unless they were very directly involved or bereaved. Therefore the central
message contained in the leaflets was that children had the right to their own
individual reactions, to use their own ways of coping, and the right to seek help if
they needed it when they needed it. If those on the edges were healed then they could
give better support to others. Information was given on different ways of coping and
where help could be obtained if self-help were not enough. We also encouraged
33
anyone we met to dispel rumours and to curtail the spread of stories. Simple
techniques for dealing with stuck images were also passed on and we asked others to
do the same.
Support of Senior Managers - Role and work overload
Looking back over the initial response it is easy to forget that work was being
undertaken in a highly charged environment where belief systems have been turned
upside down. Professionals often found themselves working out of role with many
extra duties to perform. For example, the Chief Executive, several school Principals
and other staff had been present through the 36 hours of the body identification
process in the Recreation Centre, often unclear about how best to help. Staff were
working in unusual environments, having to learn new information and skills or
adapting existing ones. Decisions had to be made based on incomplete information
and changed as new information emerged. Major interruptions also arose
unexpectedly which took senior managers away from their teams and the core tasks of
crisis management.
Media and visits of dignitaries:
Such distractions included demands from the media for interviews and visits by
dignitaries. We were able to assist the Chief Executive in the use of Press Releases to
ensure some control over media activity, especially on the return of children to
school, and to use the Press as an important mechanism for disseminating information
to the community. The visit of the U.S. President, Bill Clinton, and the Prime
Minister, Tony Blair, took the energy of key people away from the primary crisis
response task. We saw it as our role to suggest that such an event was a fact of post-
disaster life which had to be handled in a way which would bring benefit to the
community. We were able to act as a sounding board for the concerns of the Chief
Executive for the welfare of the 150 children invited to be present in the High Street
during the President's 'walk about'. As a result he took action to ensure the children
were comfortably accommodated until the last possible moment before they had to
move to their allocated position. Jealousies in schools between those children chosen
to attend and the rest were anticipated and managed. During the visit, we were able to
facilitate more connections and networking between principals and teachers.
First disengagement and establishing longer-term plans:
We left Omagh after 15 days work with barely a break. Embryonic systems had been
set up and information, ideas and support thrown out like many life-lines and safety
nets. There were many appreciative words but it was impossible to tell how the life-
lines had been used or how effectively. My guess is that some caught the line and
used it well, some did not see it, some chose to think they did not need it and carried
on treading water until exhausted or suddenly noticed that others were struggling
around them. Some grasped it lightly but did not realise how choppy and deep was the
water they were in, some threw it back or misunderstood its purpose and used it
wrongly, taking them into deeper water. Many contacts were made. There was much
left to be done and we were left with the fear that the vision of the early intervention
might be swamped by the pressures of the everyday world and the needs of dominant
voices that want the community to move on before many have even begun to know
where they are.
34
Unfinished business- Negotiating the next stage of the response:

This was the time of confusion where needs and perceptions diverge down different
paths at different rates (Raphael, 1986; Johnson, 1989). Commonly, managers and
people divorced from those affected will report that everything is fine and people are
coping and all that is needed is to get back to normal and put the disaster behind
them. Such messages drive those who are struggling or discovering that coping has a
cost begin to hide their needs. While some schools were stating that all was well,
young people began to find their way to the Trauma Support centres complaining that
their reactions and needs at school were not being addressed. Our previous
experience of the long-term impact of major disasters told us that the embryonic
system we had initiated would need more feeding and nurturing if it was to survive
and not be wasted. Common sense told us that what we were able to impart in the
short sessions with the groups of shocked teachers and principals was only a fraction
of what they needed to sustain a long-term response. We had also identified some
key areas of resistance in those support services that might have been expected to
play a vital role in school and individual recovery. These blocks prevented important
groups of staff, who were to be our key ‘agents of recovery’, from taking any role at
all. Such blocks sometimes took the form of behaviour that directly sabotaged the
response and I still find some of this unbelievable.
Medium Term
Consolidating the earlier work
At first, this difficult transition phase was successfully negotiated. Plans were made
to continue the work over the medium term to give more form and substance to the
previous work. Since good support is a crucial factor in effective recovery (Caplan
1964) we wanted to encourage the Education authority to create a stronger safety net
of support to schools while they continued to assess the on-going impact of the
disaster on their school community. We aimed to empower staff to become their own
assessors of the situation and their own action researchers who could enquire and
investigate problems and solutions over the next stages of the response and over the
next 2 years.
This is not an easy task at a time when few can yet know or believe the often bizarre,
complex and lengthy road that adjustment to trauma can take. People also confuse
restoration - the superficial normality where people get back to work and school and
look as if they are coping, with real adjustment or recovery which happens internally,
is often hidden from the outside world and needs time for assimilation of difficult and
changing realities (Johnson 1989). Asking people ‘Are you coping?’ or ‘What do you
need?’ does not always elicit a true response at a time when they are desperately
wanting to gain control of an overwhelming situation and haven’t a clue about what
they or others need or what is on offer to help. Informed, practised people need to do
the assessment in a systematic manner. After a month it was decided by senior
Education officials that all schools were coping and all pupils needing help were
receiving it, thus mirroring the experiences mentioned in schools after the Oklahoma
bomb (Zinner and Williams, 1999).
35
The rejection of the ‘Window of Opportunity’ for Preventative Education - The cost of
premature closure:
In the month or so following the disaster, the Education authority ended the
programme believing that all was well. They were satisfied that the initiatives they
had set up such as the Christmas card design competition and the specially written
school assemblies were a sufficient response for schools to be taking and that the
Trauma Centre would deal with individuals. This was totally against the advice of
many people within the organisation and other statutory service agencies sharing the
response. The idea of using this ‘window of opportunity’ for preventative education
and anticipatory guidance (Lahad, 1993) was overcome by the need to get on with the
‘real task of school.’ The idea that it took time for the full impact to emerge impact
was not believed and the conviction that people ‘would be better soon’ held.
The community was still actively engaged in projects – to get people back to shop in
town, fund-raising, visits from football teams and boxing stars and preparations for
Christmas illuminations and concerts. Resourcefulness in the community was high, as
has been found in other disaster communities (Zinner et al, 1999) Media presence
remained high as preparations began for filming survivors up to the first anniversary
and some of the bereaved became actively, and in a few cases aggressively, involved
in campaigning to save the local hospital from closure. Structural damage was being
repaired and the bombed buildings made safe or demolished. The Chamber of
Commerce had the difficult task of working with shop-owners to try and make swift
decisions about the future redevelopment of town. Some of the seriously injured
began to return home from hospital and thoughts turned to the needs of the physically
disabled who would be a visible reminder of the bomb for years to come. By
Christmas, a large number of young people had found their way to the Trauma
Centre, claiming there were many more who had not yet found the courage to attend.
Many of their complaints focused on the difficulties of going to school and having to
get on with work and exams as if nothing had happened.
For CCME this period involved the continued voluntary informal support of internal
professionals and community leaders. For example, youth leaders were advised on the
positive management of the potentially difficult invitations to take groups of young
people, including survivors and bereaved, to high profile exchange visits to England.
Our formal work continued with schools covered by adjacent Education authorities.
In order to do this, we took on the role of advocates and brokers for the school
Principals who were desperately wanting our help. We discovered their requests had
been ignored when the main response programme was terminated. At a time when
they were exhausted by the post-bomb involvement and feeling the burden of grief
and responsibility, they had the further stress of fighting for resources and for
Education officials to understand their needs.
When funding eventually became available, programmes were devised to suit the
stage and conditions of each staff team to create conditions of safety which would
allow them to process some intensely difficult and divergent experiences of the
trauma. The stress from the incident had now been compounded by stress from the
36
repercussions and having to fight to have their needs met. In one school the bomb
trauma was complicated by previous and subsequent traumas including the death of
one of two pupils with leukaemia. This little rural school of just 70 pupils with an
indescribable catalogue of horror to bear eventually got the help it deserved
(Capewell, 2003). Our programme in another school will be described in a later
volume of “Community Stress Prevention”.
Our Long-term Response
Thoughts about the role of external consultants and timing of their input
The role of organisations such as CCME can be likened to that of a surgeon or a
paratrooper. We move in rapidly in chaotic situations when those on the ground are
immobilised or overwhelmed. We do what is needed to re-stabilise the situation and
mobilise internal resources and systems. When there is enough stability and skill on
the ground, we leave. Sometimes we need to be around a little longer for the period of
‘intensive ‘care. We may return for check-ups and maintenance work, supporting
people through the difficult times and helping them to keep faith with the process. In
the rush to ‘get back to normal’, the need for this and long term review and learning is
not always understood. On the whole, the long-term work will be accomplished by
others.
We, and others, felt that well-timed further work was needed over the next few
months with the Education authority mainly responsible for the response. The purpose
would be to consolidate what had been started and to lighten the burden of the local
inter-agency Trauma team. Though this was not to happen, we learnt that after our
departure some of the ideas we left behind were taken up. For example, the Trauma
Centre psychologists negotiated the continuation of our work in schools, though this
increased their already heavy workload. They were eventually able to convince
Principals that many pupils were indeed in need of specialist help and gradually the
Education authority initiated on-going groups for staff. Eventually, a year later, an
extra youth worker was appointed specifically to liaise with the Trauma Centre. Some
schools developed excellent long-term strategies for supporting pupils, one with the
help of a retreat centre providing school staff with regular sessions of relaxation. We
observed that the school that had already begun to develop a crisis management team
before the bomb used our time and information best and continued a planned
programme of staff and pupil support for longest.
However, several reports came to us later from senior professionals saying that the
Education authority had made a big mistake by ending their response prematurely.
Two years later, in a chance meeting with a senior manager, he told me that
‘everything you had warned us about, especially the fragmentation within the
community, had happened. This comment raised once again the key questions facing
Crisis Response professionals who believe in the value of preventative work rather
than reacting only after problems to develop:
‘How can we as professionals help people with little understanding of the
repercussions of disaster to believe what they have not yet experienced in
order to prevent it happening?
37
‘And if they do have the courage to engage in preventative strategies, how

can we help people understand what their action has prevented or reduced?’
Prior training and preparation are of course a large part of the answer as long as the
training includes an experiential element that allows people to understand how their
thoughts and reactions can be distorted when caught up in the reality of a traumatic
incident. If we cannot find a way through these dilemmas, then the words of a senior
teacher in Enniskillen, Northern Ireland written about schools after the 1987
Remembrance Day bomb will continue to be true:
“As time goes on there is inevitably a shift of focus to other issues and
pupils may seem to be coping. Experience has shown that that this
impression can be very false. There can be resistance from other staff
whose instinct is to push it into the past and feel it is not helpful for
pupils to be reminded of what happened” Doherty (1993).
Community resourcefulness and creative coping strategies:
Elsewhere in Omagh, many creative community initiatives were emerging which
engaged many people in activities which engendered many of the elements needed for
recovery. One beautiful project involved the pulping of all the many floral tributes left
in the streets and their transformation into works of art which went on public display
and permanent ‘bouquets’ for the bereaved families.. A self-help group for the
bereaved and survivors formed, and some of its members have also been prominent in
the campaign to save hospital facilities and seek the arrest of known perpetrators. As
with self-help groups formed after UK disasters, they have been the means of
recovery for some but not for others and the emergence of self-empowered victims
and bereaved creates tensions for many, as described by Mick North in his book about
the Dunblane shootings (North, 2000).
Others in the community organised groups, for example using transpersonal and
relaxation therapies without wanting any publicity for what they did. Some people
have found these a less stressful way of dealing with their trauma than the more
clinical approaches in statutory services showing the importance of variety and
choice. The first anniversary memorials were the result of careful preparation between
statutory, voluntary and community groups and the clergy and links with the bereaved
and injured in Madrid have been forged.
Some members of the community have also gained support from the media through
the making of documentaries for the first anniversary of the bomb. We developed a
mutually helpful relationship with some very sensitive and responsible journalists and
TV producers whereby we could increase their understanding of the dynamics of
disaster and support them when they felt the stress of distressful meetings with
bereaved families and rescuers, who often used them as ‘counsellors’. Several of us
found that we shared a role, as outsiders perceived to be ‘safe’, whereby local
professionals and clergy in particular felt able to discuss their problems with us face
to face or by e-mail.
38
Development of the statutory Trauma Centre

The Trauma Centre continued its work and major research projects have been
undertaken to assess the impact on the community, adults and children, as well as
staff involved in the rescue and early recovery. An important liaison role has
continued with victims and bereaved, for example in relation to Anniversaries,
memorials and media contact. In 2002, the Centre received major funding to become
the Northern Ireland Centre for Trauma and Transformation headed by David Bolton,
the former Director of Community Care.
Our long-term involvement took several paths:
• We ‘walked’ alongside staff, parents and Governors in a badly affected 70 pupil
school giving support, ideas and information in digestible amounts and helping
them resolve difficulties in relationships with managers and other agencies. A
two-year team programme was eventually achieved with visits to the school on a
termly basis for training and review of progress.
• We worked with the staff team of the school in Buncrana, Irish Republic who had
lost children in the bomb to help them gain funding for a team ‘trauma processing‘
and training programme, eventually achieved 3 months after the bomb.
• We undertook Review and Action days with the Health Board Trauma team in
Buncrana and with a second Education authority in Northern Ireland. These
allowed professionals and senior officers to reflect on their practice, learn for the
future and incorporate it into the system. By going through their post-trauma
journeys, they came to a better understanding of the consequences of disaster
which they found hard to believe or understand when they were so caught up in
the experience.
• We worked with the Health Authority for the North West of Ireland to review
their emergency plans and ran several training days for staff in Health and
Education over the next three years.
Productive Spin-offs for Future School Crisis Management
Perhaps the most pleasing spin-off from our work after the bomb was the invitation
by the General Secretary of the Irish National Teachers’ Union, in conjunction with
the Protestant Ulster Teachers’ Union, to develop guidelines for dealing with critical
incidents which will go to schools throughout the Irish Republic and Northern Ireland.
A booklet, ‘When Tragedy Strikes’ was produced in 2000 and circulated to all
schools in Northern Ireland and all Junior schools in the Republic. This has stimulated
further training courses of Education Boards around Ireland and many schools have
used it to develop emergency plans and procedures.
The repercussions of disaster never end
Paying attention to the differences created
Recovery is a long and irregular process. This is a process needing anticipatory
guidance and preventative work to reach out to those less obviously affected and
provide stepping stones for those in need who are afraid of seeking specialist help.
39
Above all there is a need to manage the differences which quickly emerge in a
disaster community, usually in relation to the distribution of compensation funds,
planning of public rituals and memorials and different styles, needs and speed of
recovery. In the early days no community wants to believe that they will experience
long term difficulties. In Omagh, we were often told that it was the power of the Irish
funeral ritual, the ‘wake’, and the large close-knit families that made them different
and would promote a quick recovery without any external help. My belief is that the
test of any community is not how perfect it seems to be but how it enables difficulties
to be aired and differences to be contained. Like many disaster communities, Omagh
and district was, and still is, caught up in a complex process which swings between
repair work and potentially damaging polarisation and retrenchment. My weekly
study of the local newspapers, the Ulster Herald and Tyrone Constitution, showed
that only once or twice during the first 20 months after the incident was there a week
in which the bomb and related issues were not mentioned. The formal organisations
are doing their utmost to deal with emergent differences and difficulties, even when
they themselves are fiercely attacked and criticised.
As well as differences within the town, there have also been differences between
people in rural areas, where half of the dead are buried. They feel their needs have
been forgotten by the people in the town. This dynamic was also found between
Hungerford and the area around after the 1987 shooting massacre and is well
described by Mick North in his book about the Dunblane school massacre (North,
2001). Other jealousies occurred between Omagh and towns previously hit by bombs
which did not receive the same level of Government help and political attention.
People bereaved by previous less high profile events also became resentful of the
money and services available to Omagh victims. Keeping the secrets of the impact of
the Troubles had, after all, had a cost. Further, Omagh has had to suffer the continued
frustration and terror of regular bomb threats which mean the closure of the town
centre for several hours. Thus the community lives with constant reminders of the
atrocity and the town’s economic livelihood is threatened.
The political situation - Have they died in vain?
Unlike other types of disaster, the political context of this one has extended the
trauma long after the event. The hope that this bomb would be the last atrocity and
promote Peace and thus mean that loved ones ‘had not died in vain’ has not held. The
Peace process has ground to a standstill and others have died. Only one alleged
perpetrator has been caught. The others are known but cannot be brought to justice
causing mistrust of politicians who promised that this would happen. The Police
Ombudsman has made serious criticisms of the handling of the case by senior
Officers.
In Conclusion
We, as outsiders, were privileged to be invited in to be part of an exceptional response
to an exceptional act of violence. We were a small but significant part of a response
that allowed a partnership between local, regional, national and external organisations
at a most vulnerable time in the immediate aftermath. In our role as external
consultants we had to navigate around sensitive issues and delicate boundaries. At this
40
stage of understanding and preparedness for disaster recovery in the UK, no response
could be thorough enough for the impact of this disaster and the needs of many will
remain unanswered. But the attempt was made and the learning is there for others to
use for the future. My concern is that with the increasing medicalisation of trauma and
concentration of research on treatments of individuals, the work of practitioners using
models of Prevention, Education and professional-community collaboration who enter
the terrifying world of a community in chaos will remain misunderstood and
undervalued. Since our work cannot be easily recorded and measured by traditional
scientific methods, new paradigms of generating and passing on knowledge of
practical use in the moment of action need to be developed and valued.
Our belief in the role of schools in community recovery has been confirmed in a
report on the lessons learned from Omagh. They write:
“Immediate focus should be on community education, providing
reassurance, normalising acute stress reactions, highlighting the particular
needs of children… Schools and other groups and organisations will
benefit from reassurance and briefings, and from reassurance about the
contribution they can play in the recovery of the community. Empowering
and legitimising the work of such institutions is an important contribution,
providing guidance, reassurance and ideas will help them play a key part in
the overall recovery and stability plan.” (Bolton, Duffy and Gillespie
2000).
Bibliography
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Ireland Victims Commissioner
Bolton, D., (1998). ‘Meeting the needs arising from the Omagh bombing.’ Sperrin
Lakeland Trust Report
Bolton, D., Duffy, M. & Gillespie, K. (2000). Lessons from the Omagh bombing
tragedy. Key steps in the wake of community tragedy. Sperrin Lakeland Trust
report
Capewell, E. (1994). ‘Systems for managing critical incidents in schools’, Report to
Churchill Memorial Trust. London
Capewell, E. (1994). Responding to children in trauma. - a systems approach for
schools' bereavement care 13, 2-7.
Capewell, E. (1991). (revised 2003) ‘Mapping a journey through chaos: A trauma
process model’ CCME, Newbury
Capewell, E. (2003). ‘Post-trauma responses in schools after the Omagh bomb’
CCME, Newbury
Caplan, G. (1964). Principles of Preventive Psychiatry NY: Basic Books
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Doherty, K. (1991). The Enniskillen Remembrance Day Bomb 11 November 1987 -

Reflections on the strengths within a school’ Pastoral Care, 1991 Vol. 9.3
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(2nd ed. revised 1998) Alameda: Hunter House
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London 23 August
McKittrick, D.S., Kelters, B., Feeney, C. & Thornton, T. (1999) Lost Lives. The
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Raphael B. (1986). When Disaster Strikes. London: Hutchinson
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Philadelphia
42
Six Part Story Making in the Assessment of Personality Disorder:
History, Practice and Research
Kim Dent-Brown
This story was recently told to me by a client. What do you imagine they might have
been trying to communicate? Would I be justified in inferring anything from this
story about the client’s personality?
“Once upon a time there was this bear in a dark room, he was scared and
he wanted to get out. The only way out of it is to get the key, on the other
side of a brick wall. The only thing he had was some dynamite, so he
thought he would blow up the wall to get the key. He used the dynamite and
it broke the wall down, but the darkness went into the room with the key, so
it was dark as well. Now all the room was dark and he had hurt himself for
nothing, it was just the same as the other side of the wall. Where he thought
it would be bright, it was dark. The moral is that the grass is not greener on
the other side, no, the grass is not greener.”
Introduction
This chapter will describe the use of 6-Part Story Making (6PSM) in the assessment
of personality disorder, with examples drawn from the psychotherapy service in
which I work. It will start with a review of the development of 6PSM from its
historical roots in the morphological study of fairy tales through to the present. Next I
will describe the personality disorder service in which we have used 6PSM since
1995, and give further examples of stories that have been produced by our clients.
Then I will describe the research I have been doing since 1999 to establish the
psychometric reliability and validity of this method with this population. I will make
some suggestions about other ways of working with 6PSM material, and finally I will
make some suggestions about how the mechanisms of 6PSM can be understood.
6PSM has been described in an earlier volume of this series and elsewhere by
(Lahad, 1992) and (Lahad & Ayalon, 1993) and readers should look there for a fuller
description. Briefly, the technique involves helping a client to create a fictional story
in six parts, and then using the story to understand more about the client’s state of
mind. The six parts in their usual order are:
1) A main character
2) A task or problem to be coped with
3) Things that help the character cope
4) Things that cause the character more difficulty
5) How the character copes with the task or problem
6) What happens after the problem is dealt with
Historical Survey
The roots of 6PSM can be traced back at least to the work of Vladimir Propp on the
morphology of fairy tales. Propp’s work was done in the early years of the 20th
6 PSM in the Assessment of Personality Disorder
century, and his major work was published in Russian in 1928. He was interested in
common themes running through the extensive canon of Russian fairy tales, and he
produced a list of dramatis personae and elements that he felt were exhaustive.
Although neither every actor nor every element appeared in every story, he believed
that he had identified a sequence of events and characters that always appeared in a
certain order. He made four observations that summarise his work (1968):
1. Functions of characters serve as stable, constant elements in a tale,
independent of how and by whom they are fulfilled. They constitute the
fundamental elements of a tale.
2. The number of functions known to the fairy tale is limited.
3. The sequence of functions is always identical.
4. All fairy tales are of one type in regard to their structure.
The dramatis personae he identified were these:

• The hero
• The dispatcher (who gives the hero the task)
• The princess sought by the hero
• The princess’ father
• The villain (who opposes the hero)
• The provider (who gives things that help the hero)
• The helper (who actively aids the hero)
• The anti-hero (who impersonates the hero or tries to steal his prize)
In reading this some premonitions of 6PSM can already be sensed. Propp was not
saying that every story had exactly these eight characters; in any story the villain and
the anti-hero might be the same person, and the dispatcher may also be the provider
for example. But he maintained that all these functions were played out in every
Russian fairy tale he analysed.
French structuralists and semioticians took great interest in Propp’s work, starting
with (Tesniere, 1959) who looked at the dramatis personae and came up with the
concept of the actant. He defined actants as:
“…beings or things that participate in the process (of the story) in any way
whatsoever, even as mere walk-on parts or in the most passive way.”1
This helpful definition moves the focus wider than just people. Tesniere makes it
clear that animals and even inanimate objects can be actants; for example a story
about a prisoner in a cell seems only to have one actor, the prisoner struggling for
freedom. But there are two actants; the cell that confines the prisoner is just as much
a part of the story as the prisoner him or herself.
1
"…les êtres ou les choses qui, a un titre quelconque et de quelque façon que ce soit,
même au titre de simples figurants et de la façon la plus passive, participent au
proces."
44
Subsequently (Greimas, 1966) used Tesniere’s concept of actants to codify Propp’s

dramatis personae, simplifying them into a system of six actants set out thus:
Sender Object Receiver
Helper Subject Opponent

Greimas considered that this structure might describe all stories, not just Propp’s
large but circumscribed body of fairy stories. The core of the story is the subject-
object pair, or what might be seen as the hero and their task. As an example Greimas
suggested what the ‘story’ told by Marxist ideology might look like. A more current
example is also given in the table below. Now the shape of the six part story becomes
even more recognisable, particularly if the helper and opponent are seen as parts
three and four respectively of 6PSM:
Greimas Marxist ideology The Lord of the Rings 6PSM

Subject Humankind Frodo Baggins 1
Object A society without classes The destruction of the Ring 2
Sender History Gandalf ?
Receiver Humanity The people of Middle Earth ?
Opponent The bourgeoisie Sauron 4
Helper The working class Sam Gamgee 3
The work of Greimas and others such as (Genette, 1980) were well-known to Alida
Gersie, a Dutch dramatherapist based in the UK since the 1980s. At that time she
used an adaptation of Greimas’s 6-part structure to develop a therapeutic
storymaking structure that she called the Story-Evocation Technique (SET). This was
not an assessment method, but a means of getting clients to create stories, the very
production of which would be therapeutic. The SET method has not been published,
but led on to other work such as that described in (Gersie & King, 1990). At this time
Gersie was in contact with Mooli Lahad and Ofra Ayalon in both the UK and Israel,
and they took on the method with their client groups. Ayalon was working
therapeutically with children and adolescents and Lahad with school populations.
The SET structure had between seven and nine parts, but was reduced to six when
Lahad and Ayalon used it as the basis for 6PSM. This was devised in response to the
need for a projective assessment tool to help clients identify preferred coping
mechanisms. It was developed in the context of the school system in the northern
Galilee region of Israel, which was under constant threat of bombing, shelling and
other attacks at that time. The idea, described in (Lahad & Ayalon, 1993), was that
45
the six elements described in the introduction would evoke a story about successful
coping.
This would then be analysed by the BASIC Ph system, to identify preferred coping
strategies based in the domains of beliefs, affect, social, imagination, cognition and
physicality.
From the 1990s onwards Mooli Lahad returned periodically from Israel to the UK to
teach, and brought back the newly modified 6PSM to a new generation of
practitioners, among them myself and my colleague Mary Dunn. She was developing
a new psychotherapy service for people with personality disorders, based in the UK’s
National Health Service and described in (Dunn & Parry, 1997).
The Specialist Therapies Service
The Specialist Therapies Service (STS) was designed not to provide specialised
psychotherapy treatment to clients, but to allow psychotherapy thinking to impact on
their treatment in the front-line community mental health teams (CMHTs). By the
mid-1990s in the UK almost all mental health clients were seen in CMHT settings
rather than as in-patients in hospital, and even in-patient episodes were kept very
short (an average of less than four weeks from admission to discharge.)
One particular group of clients was the focus of attention for the STS. These were
clients who defied conventional psychiatric diagnosis but who presented with
problems such as suicidality and repeated self-harm by overdosing on medication,
cutting or other means. They were frequently labelled by teams working with them as
‘behavioural’, ‘manipulative’ and ‘not genuinely mentally ill’. Despite this latter
judgement, the mental health services were unable to rid themselves of these
‘unsuitable’ clients, but neither were they able to offer any kind of useful treatment.
A typical episode might start with a client asking for admission because they felt they
could not cope. A CMHT worker would assess them but determine that they were not
clinically depressed and admission would be refused. The client would cut their wrist
and they would then be admitted to a psychiatric bed from the casualty unit
(emergency room). The admission would break down after a short while with the
client being discharged (often because they had broken some rule on the psychiatric
unit). Follow up by the CMHT would be patchy, with the client often refusing to be
seen until the next crisis blew up.
The STS based their service on Cognitive Analytic Therapy (CAT), a model of
psychotherapy developed in the UK during the 1980s. The practice of CAT is well-
described by its originator, Antony Ryle (1990). One core idea is the notion of
reciprocal roles; that roles are not played out in isolation but in dyadic patterns
between at least two people. The cycle described in the paragraph above could be
drawn as:
46
ROLES PLAYED OUT ROLES PLAYED

IN THE OUT DURING
COMMUNITY ADMISSION
Acts as judgmental, Paternalistically

ROLES abandoning, rejecting, or ‘takes care’ of client
PLAYED BY even abusing. Refuses to by admitting them,
CARE acknowledge client. treating them as ill,
SYSTEM taking responsibility
for them.
ROLES Becomes angry with Acts as ill, sick,

PLAYED BY system, withdraws, tries needy, dependent.
CLIENT to make it alone. Treats professionals
as idealised carers.
A fundamental part of the practice of CAT is the identification of these reciprocal

roles, from examples in the client’s everyday life. This is done co-operatively, by
client and therapist working together.
A second feature of CAT is the sharing of a written formulation, usually at about the
fourth session of a 12-16 session course of therapy. The formulation aims to describe
the client’s current relationships (often in terms of reciprocal role patterns) and to set
some aims for the rest of the therapy. The formulation is addressed to the client as a
partner in the therapy and is meant to be both a summary of the assessment made so
far and a springboard into the next stage of therapy.
• The STS took these two concepts, the reciprocal roles and the shared
formulation, and devised a model of a four-session assessment for the kind
of clients who have been described. The sessions included elements such as:
• getting the client’s perspective on current relationships, particularly
those with the mental health services
• asking the client to tell their personal history, from birth to the present
• the use of psychometric tests such as the MCMI (Millon, Davies, &
Millon, 1997)
• asking the client to produce a 6-part story
Following the four session assessment a draft formulation would be written and
presented to the client for their feedback. The formulation would be amended in line
with their comments and at a sixth and final session the STS team member would
meet with the client and their CMHT key worker to hand the client’s care back to the
CMHT. The hope was that the formulation would provide both the client and the
CMHT with an overview of their mutual roles in perpetuating a cyclical relationship,
47
and that with this insight both parties would be able to alter their modes of behaviour
in the future.
The role of 6PSM in the assessment and formulation process was twofold. Firstly, the
hope was that the client’s own view of themselves, relationships and the world as a
whole would be reflected in the story they produced. Secondly, the story would
provide a fund of metaphor and image that would help promote the understanding
and acceptance of the formulation. These two facets are explained more fully below.
The Contribution of 6PSM to the Assessment

This follows the original idea of 6PSM as described by (Lahad, 1992):
"Thus our assumption is: in telling a projected story based on the elements
of fairytale and myth, we will see the way the self projects itself in organised
reality in order to meet the world."
However the method of eliciting the 6-part story was changed for our purposes. The
original 6PSM was developed for a general population with an assumption that these
were people who had coping resources, but just needed to identify them. In this new
setting we were working with clients who almost by definition were coping very
poorly, if at all. For example, one client had first been given a more straightforward
cognitive-behavioural approach looking at problem solving and suggesting some
methods of managing her life better. Her response to this was that “if you think my
life is going to be improved that easily than you obviously haven’t understood quite
how bad things are for me!”
The 6PSM instructions were changed thus:

ORDER ORIGINAL 6PSM MODIFIED 6PSM
1 A main character A main character in some kind
of setting
2 A task or problem to be coped A task facing the main character
with at the start of the story
3 Things that help the character Things that cause the character
cope more difficulty
4 Things that cause the character Things that help the character
more difficulty
5 How the character copes with the The main action: whether (and
task or problem how) the character succeeds or
fails in their task
6 What happens after the problem is What happens after the main
dealt with character’s success or failure
In the first picture the client is explicitly asked to describe the setting, so that the
client’s view of self in relation to environment can be explored. The second picture is
to be of a task, without any suggestion being made that the main character is going to
cope with it successfully. The order of the third and fourth pictures is changed, with
precedence being given to problematic factors over coping factors. The original
6PSM wanted to clarify coping methods. We wanted a clearer view of the client’s
48
perception of their difficulties, because we knew already that they had great difficulty
in coping and few resources to do so. The fifth picture is described as the main
action, and in the instructions it is made explicit to the client that this could just as
likely end in failure as in success. The assumption here was that the decision made
by a client about success or failure was an important one; given such a free choice,
different things could be inferred about clients who choose success rather than
failure. The sixth picture reflects the possibility of failure in the fifth.
Borderline, Narcissistic and Schizoid Personality Disorder

We were interested in a way of looking at personality disorder based on the work of
(Manfield, 1992). He sees three basic types of personality process, given the labels
borderline, narcissistic and schizoid. I have described our use of 6PSM in personality
disorder elsewhere (Dent-Brown, 1999) but this will be expanded on below with
examples from each personality process.
The borderline state involves a search for “perfect” care from an idealised other,
usually obtained at the cost of being ill, sick or needy. When this falls down the
person feels abandoned and abused by a hated and denigrated other, and may become
"ill" in order to return to the cared-for state. (This is the cycle described in the four
part reciprocal role diagram above.)
The story given at the start of this chapter comes from a client who has a strongly
borderline process. What we have found is that stories often show only a part of the
process, an arc of the cycle rather than the cycle as a whole. The story of the bear
who cannot get the key to escape, and hurts himself trying shows the lower half of
the borderline cycle, with the bear struggling alone. No others appear in the picture,
neither as idealised carers nor as persecutors. But there is a sense in which these
others are not far away. Who has put the bear in this dark room, and locked the key
on the other side? Presumably it was the abandoning, rejecting, abusing other. And
who is the client addressing with the story of a hopeless, self-harming teddy bear? It
is the therapist who hears the story, with its message that “I am soft and non-
threatening, and I am in pain, and I have no hope. Please come and take care of me.”
The therapist is being invited to step into the role of idealised carer at the top right of
the diagram.
Not all stories from borderline clients have them in the abandoned/helpless lower
half of the diagram. Ryle’s reciprocal role theory proposes that early exposure to
abandoning (or conditionally care-taking) role models makes those adult-derived
roles available to be played in later life. Some clients with a borderline process have
produced stories with a rescuing, care-taking main character or (less often) one who
is cruel, harsh or abandoning.
The schizoid dilemma is one between two equally unsatisfactory positions. Either the
person feels devoured, overcome and annihilated by others who are too close, or feels
vanishingly distant and non-existent because others are too far away. Life involves a
constant shuttling between the two extreme states.
49
One story from such a client went like this:

“Once upon a time there was a sailor on a desert island. His task was just to
survive, which he did because of a palm tree with coconuts and he drank the
water that dripped from the leaves. He built a pile of leaves in case he saw a
ship coming so he could signal to them, but he wasn’t sure if they’d see it, or
even if they’d change course if they did. One day he saw a ship and lit the
fire, and they did come to rescue him. But once he was on board the crew
began to wonder why he had been on the island; had he been marooned by
another ship because of some crime, or was he the sole survivor of a
shipwreck and did he bring bad luck? At the same time he began to worry
about them and whether they were going to kill him and throw him
overboard. In the end the crew marooned him on another desert island.”
Unusually, this story does seem to show the whole schizoid cycle from isolation to
threatened attack and back again. Even at the beginning on the desert island the main
character doubts whether others will see him or want to rescue him - or perhaps the
doubts are his own? (Interestingly, in the picture drawn to accompany the story the
smoke from the signal fire was shown curling up in a way that made a distinct
question mark in the sky.) Nevertheless the sailor reaches out from his isolation only
to find that being with others is equally painful and anxiety-provoking. He returns to
the desert island dissatisfied that once again he has failed to find a happy medium
distance. Interpersonal distance is always experienced by him as too great or too
small. This story was an unusually elegant and clearly drawn metaphor for the
client’s own process, and in the telling of the story and the subsequent discussion
both he and I were profoundly affected by it.
The narcissistic disorder has a grandiose, haughty state where everyone else is seen
as somehow inferior, and where great efforts are made to prove this. The opposite
state is a small, weak, powerless, ridiculed position which is more realistic but
infinitely more painful to be in. Hence much of the time is spent trying to maintain or
return to the grandiose state.
“Once upon a time there was a boy called Jack who made the mistake of
getting his sister pregnant. He was confused because he didn’t like being in
that position, he wasn’t used to being in the wrong. He went with her when
she had a scan, because he wanted to support her but also if he didn’t
support her she might tell their parents and he didn’t want that. He’s in the
hospital trying not to draw attention to himself and she starts to go into
labour. He wants the best for his sister but he’s also angry that it happened.
He’s resentful but he acts nice. What helps him is that a beautiful nurse
comes in and they look at each other. He’s thinking that she is a solution, but
she doesn’t know it. His sister has the baby and the Jack is with the nurse
and thinking ‘This could be something better’. He wants to hide his face and
not even look at the baby in the bed. A year later Jack and the nurse are
50
getting married and his sister is alone with her baby. But he does have a
guilty conscience and in another year he might start drinking or whatever.’
We have found that stories with a very clear-cut narcissistic element tend to be few,
perhaps because of the hidden shame that lies at the heart of the narcissistic
condition. This story hints at that shame however, as well as showing the difficulty
that the narcissistic client has in accepting that norms and standards that apply to
others also apply to them. At one extreme of narcissism lies the antisocial personality
type, where other’s needs cease to have any relevance and relationships are purely
used as means of meeting the individual’s needs in a selfish way. The consequences
of one’s own actions are never accepted, and others are not seen as having emotions
leading from these consequences. It is interesting that in this story Jack’s emotions
are given prominence; those of the sister and the nurse are never mentioned. The
client who wrote this story met the DSM-IV criteria for both Narcissistic and
Antisocial Personality Disorder. What is more interesting is that the client is female,
and we must ask who she is identifying with in the story. She may at one and the
same time be identifying with the amoral, self-centred Jack but also with the
dramatically wronged sister.
In all three of the above cases, the stories contributed to the process of assessment on
an equal footing with the data from the psychometric tests and personal interviews. It
has always been our experience that findings from these three perspectives
corroborate one another, making the final assessment firmer by a process of
triangulation. It could be argued that if the three perspectives never disagree why not
just use one or two and save time? There are two answers. One is that we are making
an assessment that could have an important bearing on the whole of a client’s future
treatment by the mental health services. Such decisions should be well-founded on
the maximum evidence available. We have found that even when there is no
disagreement between perspectives, there is often some crucial insight gained from
one or the other that would have been missed if it had been excluded. Just as when
three viewers of a sculpture can all agree that they have been viewing the same piece,
but each has seen something unique because each has a different viewpoint. The
shared details provide mutual validation, while the unique details provide valuable
clinical detail. The second answer relates to the way in which 6PSM facilitates the
communication with and about the client.
The Contribution of 6PSM to Communication

The clients we work with have almost without exception been in the mental health
system for years. They have grown understandably cynical about successive waves
of fresh, enthusiastic clinicians and their new theories. They have probably
experienced being described in different terms by many different people: depressed,
manipulative, poorly adjusted, borderline, attention-seeking…. Some find it hard to
think in psychological terms, or have been described in other people’s terms and not
their own.
51
6PSM offers the opportunity to use the client’s own images and metaphors to reflect
back to them their own picture of themselves. When the picture is one they have
drawn themselves it may not be pretty to look at, but it will be recognisable. This is
the first requirement of the formulation, that it should describe the client in terms
they recognise.
Clients very often use narrative language to describe their history and current
problems, describing courses of events in detail but sometimes unable to get beyond
these descriptions to recognise patterns underneath. For their part, clinicians can
often get carried away with their diagnostic cleverness and spend much time
describing what the client has in common with other depressed (or anxious or
borderline patients). This neglects what is unique and personal about the client’s
story. 6PSM seems to give client and clinician a common language which they can
both understand and communicate in, a language that is all the richer because it is
laden with densely packed images and symbolism. The potential for this kind of
language has been described very fully by (Cox & Theilgaard, 1987).
Research into 6PSM and Personality Disorder

After working for several years in this way, we were beginning to receive interest in
our approach and in the way we used 6PSM. Several people asked us what research
evidence we had to back up the particular use we were making of 6PSM. For
example, could different raters agree that a particular story showed borderline or
narcissistic features? Would two stories by the same client show the same features?
How exactly did results from 6PSM correlate with results from other measures of
personality?
Research on these questions is now under way, and some preliminary answers are
becoming clear. The method used has been to recruit clinicians from the CMHTs
with whom we work and teach them to conduct 6PSM sessions. For the purposes of
the research they have been given a script to follow so that every client is given as
nearly as possible the same instructions in the same way, so that their stories have
been prompted by identical stimuli. Each clinician has then recruited two clients from
their caseload; one with a possible personality disorder and one more mainstream
client. Where more than one possible client is on a given caseload a random selection
was made. Each client was asked to record two story sessions, one month apart.
Between the two sessions, I have conducted a long interview with the client using the
SCID-II (Structured Clinical Interview for DSM-IV Axis II) devised by (First,
Gibbon, Spitzer, Williams, & Benjamin, 1997). Clients have also completed two self-
report questionnaires: CORE (Clinical Outcomes in Routine Evaluation) devised by
the (CORE System Group, 1999) and IIP-32 (Inventory of Interpersonal Problems)
devised by (Barkham, Hardy, & Startup, 1996).
So far over 70 stories have been recorded and transcribed, some from the clinicians
themselves as part of their training and most from the two groups of clients. The aim
so far has been to produce a rating scale that is quick and easy to fill out and does not
require special training for raters. A set of over 60 possible statements has been
52
tested and good item inter-rater reliability has been shown for many of these items.
Raters are asked to fill in a five-point Likert scale to show their agreement or
otherwise with the statement (from Strongly Agree to Strongly Disagree). Some
statements with good item inter-rater reliability include:
In this story there is a rescuing, caring character.

Obstacles are overcome with faith, persuasion, skill or problem-solving.
The picture has obvious images of conflict, violence or death in it.
The items showing the best inter-rater reliability have been retained, and the scores
for each item compared with the concurrent data from the SCID-II, CORE and IIP-
32.
One example of good concurrent validity is with the CORE Risk subscale. This
subscale of 6 self-report questions asks the client to report on their subjective
assessment of the risk they pose to themselves or others. Seven of the statements
from the study correlate highly with the CORE Risk subscale and when added
together they produce a risk score that can be plotted against the client’s self-rating.
The maximum possible risk score from the story is 28 and the minimum is zero. The
CORE Risk score has been transformed to have a mean of 0 and a standard deviation
of 1. Even without this information it is clear from the linear shape of the plot that
the two scores correlate highly. A test with Pearson’s correlation coefficient confirms
this (r=.80, n=20, p<0.001). It can also be seen that anyone scoring over 18 on the
risk score from the story is very likely to have a positive diagnosis for Borderline
Personality Disorder. It is interesting to look at the seven items that make up the
story risk score:
STATEMENT SCORED
The story as a whole seems to be pessimistic or negative. Positively
The whole atmosphere of this story is barren, bleak and lonely. Positively
The content of the story is minimal, stark and brief. Positively
Some characters in this story are superior, grandiose, of high rank, Negatively
celebrated or admired.
The main character has likeable, admirable qualities. Negatively
Characters in this story seem to have belief & confidence in themselves. Negatively
Themes of admiration or deference are very important in this story Negatively
53
SCATTER PLOT OF STORY RISK SCORE vs CLIENT SELF-ASSESSMENT
1
CORE Risk z-score
0
Borderline diagnosis
Yes
-1 No
0 10 20 30
Risk score from story

In summary, clients who report themselves as being at high risk are more likely to
produce brief, pessimistic stories with stark, barren themes. They are less likely to
produce stories with narcissistic elements of grandiosity and admiration, or to have
main characters with positive qualities. Clients scoring highly when rated with this
measure are much more likely to have a Borderline Personality Disorder. This
description certainly has good face validity, a validity which can now be tested
statistically as described above. Inter-rater reliability on this scale is also good, as can
be seen from the scatter plot below:
The plot below illustrates good inter-rater agreement on this seven-item scale (r=.83,
n=20, p<0.001).
54
SCATTER PLOT OF TWO RATERS’ RISK SCORES FROM STORIES

30
20
Second rater's score
10
0
0 10 20 30
First rater's score

This scale has been derived from a subset of only 20 stories, the first to have been
completely transcribed and scored. As more stories are transcribed and rated we hope
that further patterns will become apparent. Nevertheless this promising start indicates
that something as rich and diverse as a 6-part story can be scored in ways that allow
statistical analysis while remaining simple enough to be undertaken by any clinician.
New Ways of Processing Six Part Stories
During the research we have been trying out some new methods of understanding the
material produced by 6PSM. These will be tested more rigorously as the research
continues but two of them will be described here. Both could be done independently
by the clinician after the story session, but my preference would be that these
methods be employed co-operatively by client and clinician together.
In the first method, the client is asked to identify the three most significant actants in
the story (using Tesniere’s definition of what constitutes an actant.) Taking the story
of the bear given at the start of the chapter, the three main actants might be:
A) The bear
B) The dynamite
C) The wall
55
Each is then paired with the others in turn, giving three pairs: A-B, B-C and C-A.
The client is asked how each member of the pair acts towards the other, and from the
answers three reciprocal role pairs can be drawn up:
A: Approaches for help, B: Destroys, C: Confines,

tries to make use of breaks down restricts
B: Hurts, wounds C: Is impotent to resist A: Resists,

destroys
This provides fruitful ground for discussion with the client. Do they recognise these
role pairs from life? Do they find themselves being hurt when they try to get help? Or
avoiding asking for help in case they get hurt? Do they fight against restrictions with
force or even violence? In the case of the client being described, the answers to all
these questions would be yes. With a client who is not psychologically minded, or
who cannot see the patterns they play out in their own life, it seems 6PSM gives
enough psychological distance to allow these patterns to be seen more clearly.
The second method is based on the Core Conflictual Relations Technique (CCRT)
described by (Luborsky, Crits-Cristoph, Mintz, & Auerbach, 1988). The CCRT
suggests that client narratives extracted from therapy transcripts can yield
information about the central themes - the core conflicts - that concern them. The
core conflictual relations are in three parts; the wish of the self, the reactions of
others to that wish and the reaction of the self to others. The CCRT work suggests
that each of the three parts can be reduced to just eight basic themes.
In analysing the 6-part story, the wish (or task) of the main character is taken as the
starting point. The client can be shown the adapted list of eight wishes below, or
asked to put the main character’s wish into their own words.
Wishes and Wants of Main Character
1 The main character wants to assert themselves and be independent, have
self-control, be their own person.
2 The main character wants to oppose, hurt or control others.
3 The main character wants other people to be responsible for them; to control
them, help them or hurt them.
4 The main character wants to be distant and avoid conflicts with others, to
not be hurt by others.
5 The main character wants to be close and accepting, to respect others, to be
open to others and have others open up to them.
6 The main character wants to be loved and understood, liked, accepted and
respected by others.
7 The main character wants to feel good and comfortable, to have stability, to
feel happy and good about themselves.
56
8 The main character wants to achieve things and help others; to better
themselves, to be good, to be useful.
In the case of the first story (the bear) the wish for escape from the dark could be
seen as number 1, with the means of escape number 2 (and a possible unspoken wish
for number 3 - but this becomes more speculative.) In the second story (the sailor)
there is a twofold wish, comprising of numbers 4 and 5 simultaneously - no wonder
his wish is hard to fulfil! In the third story (Jack) the wish is perhaps best expressed
as number 7.
Next one or more of the eight possible forms of others’ responses would be chosen
by the client (remembering they are choosing descriptions of the story, not their own
life) and finally one or more of the eight possible responses of self. Finally the
sequence of three can be linked up. For example the second story might look like
this:
WISH OF SELF To be distant To be close

and avoid conflict and in contact
RESPONSE OF Others reject or Others approach

OTHERS TO WISH withdraw from but are seen as
main character threatening
RESPONSE OF SELF Main character feels Main character

TO OTHERS alone and unwanted threatens others
in self-defence
Once again this detailed description of the character’s relationship to others can then
be compared with the client’s own experience of relationships. In the example given,
the wishes and responses join up in a neat cyclical way that reflects the cyclical, back
and forth nature of the story. Linear configurations (often branching) seem in fact to
be more frequent.
These two methods of investigating the 6-part story are being investigated in the next
phases of the research. This will involve less testing of psychometric properties and
more qualitative methods, using the grounded theory approach of (Strauss & Corbin,
1998) to work with clients towards methods of interpretation that allow clients to
analyse their own stories rather than relying on the ratings of others.
57
How Does 6PSM Work?

Grounded theory is also being applied to try to elaborate a fuller theoretical picture of
how and why 6PSM works. Clients who have been interviewed so far consistently
say things like:
“You told me to set the story as far away from real life as I could, but I
couldn’t keep it there. The more I told, the more it seemed to be about me.”
Remarks like these seem to confirm the projective hypothesis initially set out by
(Frank, 1939) in his seminal paper on projective methods. Frank described the
projective process as giving the client:
“…a field (objects, materials, experiences) with relatively little structure…
so that the personality can project upon that plastic field his way of seeing
life, his meanings, significances, patterns and especially his feelings.”
Paradoxically, it is the very distance from real life that gives the field of 6PSM its
fruitful lack of structure. It is as if, like a slide projector, the greater the distance the
image is thrown the bigger it is and the easier to see.
Another client said:

“I felt a bit silly at first but then I just got into it and the story seemed to
take over. I didn’t realise what I’d done until afterwards when we were
talking about it.”
This resembles very closely the concept of aesthetic distancing described by (Jones,
1993), where the metaphorical nature of the story is seen as acting as a mechanism
for controlling distance between the client and her material. At first the client feels
self-conscious, but the distant nature of the metaphor allows her to play with the
material more freely. It is only later that she notices, paradoxically, how close to her
own issues the story has moved.
Clinicians have also been interviewed for their views on how 6PSM works. One said:
“I’m aware that when I depart from the script and start asking my own
questions the story changes and becomes one that we create together. I’m
no longer sure if it’s the client’s story or our story.”
This inter-subjective, co-created nature of the story is hinted at by (Winnicott, 1971)

- although he does not use those words. He talks of the potential space (p.107)
between mother and infant (or patient and analyst) where play, creativity and healing
can take place. His concept of the intermediate zone - neither a wholly internal,
subjective experience nor a wholly external objective one - may also describe what
happens in 6PSM.
Summary
In our service we have adapted 6PSM not to look for preferred coping mechanisms in
the general, well-adapted population, but to look at the view of self, others and the
58
world in clients who may have a personality disorder. We have found this to be
helpful both in making assessments of the nature and extent of personality problems,
and in communicating these assessments to clients and others.
Research is now being undertaken into the reliability and validity of 6PSM in this
context, and preliminary results suggest that acceptable, easily rated scales can be
produced that have good face validity. Stories produced by clients with a borderline
process have been shown to be more pessimistic and barren, with main characters
described negatively and stories ending in equivocally or in failure.
Clients’ and clinicians’ accounts of using 6PSM are beginning to yield insights that
can go alongside existing theories of projection, aesthetic distance, play and
creativity to explain the way 6PSM works. When this research is finished we hope to
have a comprehensive system for 6PSM including a theoretical base, a protocol for
administration and scoring and norms for determining the nature and extent of
personality disturbance.
Up to date information on research progress can be found at www.dent-brown.co.uk
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Manfield, P. (1992). Split Self, Split Object: Understanding and Treating

Borderline, Narcissistic and Schizoid Disorders. Northvale, NJ, USA:
Jason Aronson Inc.
Millon, T., Davies, R., & Millon, C. (1997). Millon Clinical Multi-axial
Inventory-III Manual (2nd ed.). Minneapolis: National Computer
Systems, Inc.
Propp, V. I. (1968). Morphology of the Folktale (L. A. Wagner, Trans. 2nd

revised ed.). Austin, Texas: University of Texas Press.
Ryle, A. (1990). Cognitive-Analytic Therapy: Active Participation in

Change. Chichester: John Wiley and Sons, Inc.
Strauss, A., & Corbin, J. (1998). Basics of qualitative research: Techniques

and procedures for developing Grounded Theory (2nd ed.). Thousand
Oaks, California: Sage Publications.
Tesniere, L. (1959). Elements de Syntaxe Structurale. Paris: C. Klinksieck.
Winnicott, D. W. (1971). Playing and Reality. London: Tavistock

Publications.
60
The Crucial Cs for Encouraging Communication
Some Tools for Building Resilience
Ilse Scarpatetti
Introduction
This contribution focuses on tools for use in everyday practice rather than
highlighting research and theoretical considerations. If psychology is defined as
dealing with the human mind on a scientific level, we must not forget to re-translate
our findings and experiences into a language that is understandable – and, most of all,
into the corresponding actions. The practitioner does not only find useful rules for
communication; the quotes and stories at the beginning of each section fit into the
tradition that telling stories is the oldest method of teaching and healing.
Characteristics of communication and behaviour in emergency situations
Sticks and stones can break your bones,
even names can hurt you
but the thing that hurts the most
is when a man deserts you (Mc.Kuen, 1958).
It is a common phenomenon in all human beings: the more we suffer, the more we go
back to less organised developmental stages. Severe pain, for example, makes us cry
out instead of communicating our feelings in appropriate words. Pressure or
weakening by internal (health, lack of sleep) or external (climate, environment)
factors reduces our skills for verbal expression. Everyone has had these experiences
at one time or another. In traumatic situations, however, they may be even more
pronounced and persistent and should be taken into account. Language becomes more
primitive; use of absolute terms like “always”, “never”, “nothing at all” etc. increases,
indicating the antithetical mode of perception typical for pre-school children (and so-
called borderline personalities). Vocabulary is reduced, and when using a foreign
language, the accent of the mother tongue is more pronounced. In the wake of this
regression, sensitivity to what is said between the lines is heightened. Paraverbal
expressions and actions become more important than words.
When people are scared, it is reassuring and comforting not to be alone. For some
actual or potential victims of modern day, however, things have changed: whereas
being in a group of people used to provide safety, groups are more likely to be targets
nowadays. Be it a Kamikaze fighter, a military force or a gunman running amok - if
the aim is to maximise number of victims at minimal expense, it can be dangerous to
gather together. One bomb blast can destroy an entire family in a refugee camp or all
the passengers of a bus, and one gun can kill almost a whole government, staff of
teachers or classroom full of students. Physical community, once providing a feeling
of safety, has turned into its contrary - a risk factor. If survivors have to go on
working together after an assault, a formerly functioning group can be destabilised,
depending on the quality of communications.
Encouraging Communication
Typical mid- to long-term consequences of disaster

Students asked a wise man:
“Why are people always so unhappy? What is it that man wants but obviously
cannot get?”
The wise man smiled.
“The answer is simple. The answer is in a single word.”
“Does man want riches?”
“No”
“Love?”
“No”
“Fame?”
“No”
“Power?”
“No”
“So what is it? What does man want?”
“As I said: the answer is to be found in a single word. What they want is
“More”.
When the “honeymoon stage” (Training Manual, 1978) is over and the flow of public
interest and sympathy, promises and solidarity is ebbing away, some ugly remnants
can reveal:
a) For those directly involved/ victims and survivors:
• Group destabilisation
• Loss of cohesion
• Constantly enhanced state of alertness that leads to irritability and
destructive interaction
• Power contests
• Hostility
• Cynicism
• Lack of cooperation
Needless to say that this leaves very little energy for task-oriented work.
b) For third parties
• Exploiting the vulnerability of target group (threats, blackmail)
• Lowered threshold for similar actions
• “Disaster vultures“
• Disappointment and/or anger if offered help is not accepted
• General destabilisation of the community due to loss of basic
values and safety (“The incredible did happen - when will it happen
again?”)
The list is by no means complete.
62
A small example to illustrate this: In September 2001, a gunman running amok

killed 12 of 14 members of the government of the Swiss canton of Zug. This
was a situation totally new to this country where parliament sessions and
debates were public until then. Soon after this incident, politicians from other
cantons were threatened with similar actions by grudging citizens. Eager
scientists swept the place in order to interview the survivors and statistically
evaluate the situation. Smart businesspeople wanted to sell "emergency boxes"
and contracts with their quickly founded companies for “emergency
psychology”. Lots of benevolent citizens offered all kinds of help. Lots of
people presented damage claims. The situation had thus become even more
chaotic on my return for my "six months after"-visit. The city looked peaceful
as it had before, I could have my meeting without the two élite policemen in
riot gear guarding the door, but the offices, once in an beautiful historical
building, had now moved into a kind of fortress with heavy metal doors,
security locks, cameras and intercom. How to deal with the wide range of
citizens? On one hand, their offers and complaints needed to be listened to, on
the other hand, the politicians needed to focus on getting back to their routine
work in an organised way. (To meet both needs, I suggested a mediator. This
was discussed and agreed upon within the government, and now is in its trial
stage).
From a “minus” to a “plus”
A mandarin has a vision: he sees hell.
Hungry, starved hollow-eyed people sit around a huge bowl of rice. Each of
them holds huge chopsticks, about 2 meters long, and in trying to get food,
they hinder each other and the rice is knocked off the chopsticks before it
has a chance to reach any of the hungry mouths.
This is such a terrible sight that the mandarin turns away - and sees heaven.
The same huge bowl of rice, the same huge chopsticks, but the people
looking friendly and well fed. In this case, the chopsticks don’t cause any
problems, as each one feeds the other.
Coping can be seen as a function of “load” on one hand and “capacity” on the other.
In emergency situations, the impact of stress is high, and for reasons of primary,
secondary and tertiary prevention of long-term disorders, building strength /
improving capacity is the strategy of choice.
Most of what is presented here has roots in Adlerian training programs for teachers
and psychotherapists. Long before terms like prevention or salutogenesis became
popular, Adler and his students focused on how to build strength and mental health -
resilience - instead of just targeting what is “wrong“ or “missing“. Moreover, Adler
stated: “Being human means feeling inferior”. As this inferiority feeling stimulates
compensation, it is the most important motor for development. Successful
compensation leads to progress and increase in skills, but there are also forms of
miscompensation:
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Instead of overcoming a weakness, an individual might completely rely on others to

do for him what he should be able to do himself (undercompensation). Symptoms of
undercompensation can be depression, anxious-anaclitic behaviour or substance
abuse. Secondary gains can reinforce this.
The striving for superiority/power/significance can also become absolute and
generalised (overcompensation). This overcompensation can show in aggressive and
highly competitive behaviour, power contests and a strong tendency to depreciate
others.
The problem to be solved can be evaded altogether and fights in other areas
(“secondary battle sites”) are started instead. Someone who has little success in the
workplace, for example, and sees no way to improve the situation might act this out in
domestic violence. When the appropriate grief after loss and bereavement is evaded,
this can result in generalised hostility and violent behaviour.
Whether this compensation will lead to results on the “useful” or “useless side of life”
(Adler), depends on the degree of “Gemeinschaftsgefühl”, translated as “common
sense”, “community spirit” or “social interest”. It is the counterpart to the inferiority
feeling and can be regarded as an indicator for mental health. Common sense/social
interest is present in every human being, but it has to be nurtured. In short: “useful”
compensation of inferiority feelings means enrichment of the individual and the
community as well, a real developmental progress; “useless” is supposed to serve the
individual only at the expense of others (Ansbacher & Ansbacher, 1972).
Encouragement and the Crucial Cs
Two frogs find themselves in a huge bowl filled with a fluid. In vain they try to
get out; the wall is too slippery. After some time, one of them gives up, and he
drowns in the unknown liquid.
The other goes on paddling and fighting, all the time thinking: "There must be
way out! I want to get out, there must be a way!" While he is struggling on
and on, the fluid gradually thickens, the struggling gets more difficult, but still
the frog goes on - till at last the butter is solid enough for him to be a basis to
jump into freedom.
Encouragement can be described as verbal and nonverbal behaviour that enhances the
feeling of acceptance and belonging. Discouragement, on the other hand, is any
communication, verbal or nonverbal, that makes the person feel inferior (judging,
being sarcastic, critical, moralistic, etc. “Courage“ and “encouragement” are key
concepts in Adlerian psychology, encouragement being a major aspect of Adlerian
psychotherapy and counselling. Courage is the willingness to act in line with the
social interest in any situation. It is fundamental to a successful adaptation. To
encourage is to promote and activate the social interest, that is, the sense of
belonging, value, advisability and welcome in the human community. The loss of
courage, or discouragement, is understood by Individual Psychology to be the basis
of mistaken and dysfunctional behaviour. The discouraged person has the same goal
as the person with courage: to belong, to be valued, to have the respect of others, etc.
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However, if he or she lacks the courage to operate on the useful side of life in line
with the social interest, he/she may seek to achieve a place on the useless side through
neurotic, sociopathic, or psychotic processes and operations (Griffith & Powers,
1984).
Based on Adler and Dreikurs, (1984) Bettner (2001) highlighted four basic human
needs: belonging (Connect), improving (be Capable), significance (Count) and
encouragement (Courage) as well as the typical symptoms indicating their lack.
Crucial Perception Feeling if missing Behaviour if missing

Connect “I have a place” Alienated Attention seeking
Capable “I can do it” Inadequate Power, superiority
Count/ “I can make a Unnecessary Revenge, significance
Contribute difference”
Courage “I can handle what Inferior Withdrawal
comes”
Being encouraging means basically to (re)establish and strengthen the experience of

• Counting,
• Connecting,
• being Capable and
• Courageous.
Whereas this concept is valuable and useful in any other context, be it in the
classroom, in therapy, counselling or everyday life communication, it is of special
importance to keep in mind when working with trauma victims and also within
emergency response teams. It is generally agreed upon that group support is one of
the most important protective factors, and it can be improved by encouraging
communication. How this can be done is demonstrated in the next section.
Some rules for encouraging communication
A non-Jew is looking for a Rabbi who can explain the Torah to him while
standing on one foot. Everyone of tells him, “This is impossible!” At last,
when he is almost about to give up, to his great surprise, Hillel says: “Of
course I can explain you the Torah! Its essence is simple: "Do not unto others
that which you would not have them do unto you, the rest is commentary – go
and learn!" – and that can easily be said while standing on one foot.
Here are some practical rules for encouraging communication. They take into account
the aforementioned "Crucial Cs".
Be honest! (Count; Connect)
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No one really likes to the bearer of bad news. Temptation may be great to act as if
things were “not all that bad” and lie in order to give (false) hope. Taking into
account, however, the heightened sensitivity for paraverbal messages in a disaster
situation, this would lead to a rupture in trust. Being honest does not necessarily mean
telling all the truth at once, but definitely excludes twisting the truth, or telling things
you don’t believe in yourself.
Don’t make promises you cannot keep (Connect)
Sometimes temptation is great to relieve suffering by making promises that might not
be kept or even are unrealistic. If you promise to return, to be available, to give a
phone call or the like, it is absolutely necessary to act accordingly! It is easier
sometimes to keep your mouth shut than to keep a promise; in case of doubt, decide
the former.
Be specific (Count; Capable; Connect; Courage)
Note attributes and accomplishments specifically. Information has to be clear and
unambiguous.
Examples:
"Something you do that I admire/ think is unique/pretty/special/neat/unusual...”
"I'm impressed by the speed/thoroughness/courage you demonstrated when you..."
"I’ve noticed that you seem to have a special ability..."
Don’t do what clients can do themselves; express confidence in their ability to
handle their situation (Capable; Count; Courage)
Well-intended as it might be, an overdose of caring can give the discouraging
message: “you cannot do this yourself“. The goal however should be that the client
regain control. The additional energy that is set free in a fight/ flight reaction can be
guided into useful channels.
Examples:
"I'm confident you can straighten this out, but if you need any help you know where
to find me."
"I can understand how you might feel, but I'm convinced you can handle it."
"Do you have any ideas about how you might handle that?"
Assign tasks/ ask for help (Connect; Count; Capable; Courage)
Besides giving control, this also enables to master the situation by contributing.
"Would you be willing to give me a hand with...?"
"You could sure help me/us/the others by..."
"Since you're skilled at... I was hoping you'd..."
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Maintain availability (Connect)

Do not leave without securing contact with another person or at least a transitional
object.
Examples:
“This is my colleague, Mr./Mrs. ..., he/she will stay with you“ / “...please refer to
him/her when you come back to the centre tomorrow”
“I am sorry I have to leave for an hour or so, but I’ll be back. Meanwhile my teddy
bear will stay with you”
Encouragement is not “just being nice”. Within teams, it is sometimes necessary to
deal with conflicts. If this is not done in a constructive manner or avoided at all,
tensions and irritability build up. Conflicts can be addressed and solved by using
additional encouraging communication techniques:
Speak for yourself / “I-statements” instead of “you-statements”
A statement presuming the other person’s attitudes or motives - typically beginning
with “you...” - is often perceived as an attack and leads to defensive reactions or
counter-attacks. If the same message is given as the own opinion - typically starting
with “I...” - goal directed behaviour and constructive problem solving are more likely.
Compare:
“You make everyone nervous when you...“ vs. “I get nervous when...”
Say what you want rather than reproach
Reproaches (often phrased as "you-statements") lead to defence and counter-
reproaches. As in fact they are wishes in disguise, it makes more sense to formulate
them as what they are. Compare:
"When will you ever arrive in time! You’re always late!" vs. "Would you please be
punctual? I don’t like waiting"-
Self-encouragement
A great drought had come over the land. First the grass died, then bushes
and small trees. All men and animals died, and still no rain came.
One small flower had stayed alive because a tiny source was still able to
provide a little water. But the source was desperate: “Everything is drying
and dying of thirst, and I cannot change anything! What’s the use of me
squeezing some drops of water out of the earth” ?!
An old tree who stood near-by because his big roots had reached deep down,
heard the complaint and said to the source before he died: “No one expects
you to make the whole desert bloom! Your job is to give life to ONE flower -
nothing more”.
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A major reason for burnout is unrealistically high expectations. The higher the
standards, the higher the probability of failure and discouragement. Professional
helpers and teams should take care of their own psycho-hygiene in order to do their
work well. Discouraged helpers cannot encourage others, it is as simple as that. The
tools for encouraging communication as described here can be used in every
interaction. In addition, there is a simple self-encouragement technique that works as
follows:
Get yourself a small common exercise book. On opening it you get a double page.
The left page is for writing down own accomplishments, constructive initiatives,
contributions, etc. – “What I gave / did (well) today”. The page on the right is for
pleasant things that happened through others’ initiatives, be it an unexpected phone
call from a friend, a smile, an invitation, a child’s drawing, a good meal, etc. “What I
got”. This balance is to be written down daily on a regular basis, and both pages
completed. The statements have to be specific so they can be remembered later, and
even the smallest accomplishments or events deserve mentioning. In fact this is a
training in perception. Seeing pleasant things alongside everything else helps to build
capacity; Hans Selye, the renowned expert on stress, pointed out the role of gratitude
and thankfulness in developing resilience. No one can be perfect, but knowing about
our “pluses” helps us deal with our “minuses” more efficiently.
Sometimes common sense gets lost when it is needed most to keep in touch with
reality. And sometimes the most obvious things are overlooked. This chapter is
intended to be a reminder.
Bibliography
Ansbacher, H. & Ansbacher, R.: (1972) The Individual Psychology of Alfred Adler.
A Systematic Presentation in Selections from his Writings. Basic Books, New
York.
Bettner, B. L. Parenting. Lecture at ICASSI 2001 (Elspeet/Netherlands). Since the
“Crucial Cs” were first conceptualized in Bettner, Betty Lou and Lew, Amy:
Raising Kids who can. (Connexions Press 1990) the term has become standard
knowledge at ICASSI and also formed an important part in Edna Nash´s seminar
on “The Art of Encouragement” (see www.icassi.org)
Griffith, J. & Powers, R. L. (1984) An Adlerian Lexicon - Fifty-nine terms associated
with the individual psychology of Alfred Adler. Adlerian School of Professional
Psychology; ASIN: 0918287006; (June 1984)
McKuen, R. (1958) Soldiers who want to be Heroes. Stanyan Music-ASCAP
Training Manual for Human Service Workers in Major Disasters. U.S. Department of
Health and Human Services. (1978, 1990) Rockvill MD.
68
Israeli and Palestinian Teachers Learn about Children and
Trauma: Security, Connection, Meaning
Alan Flashman
Setting the stage
The Middle East Children’s Association is a nonprofit Bi-National Israeli-

Palestinian Organisation. Created by its directors, Dr. Ghassan Abdullah of
Ramallah, P. A. and Ms. Adina Shapiro of Jerusalem, Israel, the association works
to bring together Palestinian and Israeli educators for joint efforts in a variety of
educational areas such as “oral history”, “non-violence”, “civics” or
“mathematics”. The original intention was to hold bi-weekly bi-national meetings for
some dozen parallel groups. Due to the outbreak of violent conflict between Israelis
and Palestinians since the fall of 2000, this structure became untenable, as all
possibilities of finding a mutual meeting place were curtailed. During the height of
the violence, many teachers on each side expressed the wish to come to grips with the
impact of the morbid traumatic situation on the children in their classrooms. As a
response to these needs, the Association sponsored in the summer of 2002 an
exceptional bi-national meeting for some 80 teachers from the two sides on a neutral
ground in Rhodes, followed up with uni-national meetings on each side in the fall of
2002. This reports summarises the theory and practice that informed much of these
meetings. The dilemmas are reported as they are experienced from the Israeli side
alone. Hopefully a later report could summarise the Palestinian experience directly.
It should be stressed that the material presented here was designed for application by
Israeli and Palestinian teachers in their classrooms, as a primary community
intervention for the alleviation and secondary prevention of excessive stress due to
the on-going violence and its traumatic effects.
Levels of coping with trauma: theory and practice

Children are faced with three levels of difficulty facing trauma. These levels can be
described as relating to needs for personal security, for a sense of connection with
others facing the trauma, and for giving voice to the personal meaning that the
traumatic situation bears for each child (Flashman, 2002). Each level of difficulty
deserves close attention in its own right. This report is devoted to an overview, to
demonstrate each level and the differences between them. A brief sketch will be
made of one possible approach to the needs of each level. Finally, one approach that
could integrate the three levels together will be demonstrated. The participant
teachers were encouraged to bear in mind all three levels while trying to help their
students cope with the trauma of the current situation.
Children and Trauma – Security, Connection, Meaning
Security
Definition
Trauma is a condition in which children feel overwhelmed, and the child’s regular
defence mechanisms are unable to provide the child with a feeling of security. Such a
situation can be described by a developmental analogy. A young baby does not feel
master or author of her/his body.
Rather, one-year-olds feel that their body is the
“larger framework” of their experience, and
the experience of the self, the “I”, is one part
of this body. This situation could be visualised
as follows: me
By the age of two years, children have grown

into a different relationship with their bodies.
They now feel that “I” is more broad and
includes within it the body. They are then able
to speak of and relate to their body as a part of
my body
the self, the “I” (Kegan, 1981).
In a similar way, trauma feels at first too large for the child. The child feels that the
feelings aroused in her are greater than herself, her “I”. This creates a feeling of
regression, that is, the child feels reduced to a less independent developmental stage.
This regression in itself creates a feeling of helplessness and shame.
Restoring security to the child involves repeating the same basic developmental
sequence, this time, with the overwhelming pain:
me my pain
70
Practice and experience
One way to invert the I/Pain relationship involves giving name to the pain. Giving
name both encourages emotional ventilation and provides mastery in that the child is
the one who names the pain.
In the bi-national training in Rhodes, Dr. Ofra Ayalon taught a method for giving
name to pain called the FEELING WHEEL. (Ayalon & Lahad, 2000) In our small
training groups, both Palestinian and Israeli teachers practised making their own
FEELING WHEEL, experienced the
process of naming feelings and of
associating the different feelings
written before them to recent events.
Only after having processed their own
reactions they moved to discuss
different applications in their different
school environments.
According to the instructions for using
this method in schools, children are
offered a circular format, on a large
sheet on which they can stand. In the
circle the children write the names of
their feelings. Younger children may
be offered a wheel with feeling-words
that they can recognise by name or by
an image. In this way a “wheel” is
created of the different experienced emotions, and the feelings are given a place and
a name. In the classroom, children could be asked to plot the first thing they felt on
hearing of a recent terror attack or a military raid. Active listening and acceptance of
each individual story without criticism create the conditions of re-building security.
Following the participants’ positive experience of relating their personal stories

within an atmosphere of acceptance, additional suggestions for enhancing security
emerged. Children could be encouraged to make good use of their physical
environment to restore security. Teachers could help a class define the kind of
environmental touches, that help restore security. These could include particular
music, fragrances, food and drink and even lotions and creams that are felt to be
calming - especially for younger children. Choice of calming music would be
especially important for adolescents.
Connection
Definition
In addition to a sense of security, children need to feel that what they experience
connects them as members of a group. Particularly when faced with overwhelming
trauma, a child may feel only s/he is being affected so strongly, that s/he is different
from others and thus isolated in her reactions.
71
Often creating a group “position-statement” regarding the source of the child’s pain
restores the necessary sense of connection. Thus a group feels connected, for
example, when they can feel and express anger together at a particular “enemy”.
Usually, the clearer the trauma, the more defined and possible the creation of a group
“position-statement.” One of the special difficulties of the current security situation
in the Middle East is that a group “position” is very hard to come by despite the
direct and painful trauma. Children face a society of adults who feel frustrated and
paralysed. This fact itself is poorly recognised or acknowledged. To my experience, a
great number of Israeli adults themselves find it difficult to be sure whom to “blame”
for the current impasse, or what steps could be expected or demanded and from
whom - in order to reach a reality of basic security. This very quandary makes it
doubly hard for adults to speak with children.
One possible group “position” would involve articulating together the dilemma in
which children find themselves. The “position” itself would involve giving voice to
the perplexity and uncertainty in which children live, to the vacuum of clarity about
what to expect from the adult world, to the shared sense that while each child feels
something different at any given time, all the children share the burden of an
uncertain childhood. This would restore the sense of WE-ness, of connection
between the children, and would relieve the isolation of each individual child.
One important way to conceptualise the importance of the “WE” continues a theme
of trauma stated before. While children need to move from being overwhelmed by
pain to being the master or author of that pain, the “WE” contributes an intermediary
phase. It is far easier for children to feel as a group that “WE” are able to contain
“OUR” pain. This later helps the child to feel the master of her own pain:
me our pain

In the Rhodes training, we used “therapeutic cards”1 as a group activity that could
create this sense of connection. We used the HABITAT2 set of cards, which Dr. Ofra
Ayalon selected and donated for the demonstration. A group of six teachers
volunteered to sit in a small circle. All the HABITAT cards were spread out on a
table nearby.
1
www.OH-Cards.com http:// http://www.nordbooks.co.il
2
Habitat is one of a dozen or more sets of therapeutic cards used to enhance group
activities, described in the book: Strawberries Beyond my Window, by Waltraud
Kirschke.
72
1. Each teacher was asked to choose one card that gave expression to
a dominant feeling she experienced when her community had been
threatened, as a response to a recent terrorist attack (against
Israelis) or a military raid (against Palestinians). Teachers
approached the table one or two at a time until each had chosen her
card.
2. All the teachers revealed their cards together while sitting in the
circle. Thus each teacher could see the inner experiences of the
other group members represented simultaneously.
3. In turn each teacher took all the cards. She placed on the ground in
the middle of the circle first her own card. Then she positioned the
other cards which she collected from her colleagues according to
how her feelings related to the other feelings. Thus this teacher
now could see how her feelings connected with the group feelings.
4. The other members of the group (both Israeli and Palestinians)
were invited to experience through the cards how their colleague
experienced herself in relation to their feelings. This way each
teacher saw how this colleague experienced her own feelings and
absorbed the feelings of the group.
5. Steps 3 & 4 were repeated for each member of the group.
6. In the end the group created a sense of WE by seeing how each
individual found a particular place and related in a special way to
the feelings of the rest of the group.
This exercise was demonstrated to the entire group of participants. Teachers were
encouraged to think in their own culturally appropriate ways of modifying such an
approach in their Israeli and Palestinian classrooms.
Meaning
Definition
Once children feel individually secure and collectively connected, they can safely be
helped to give voice to the meaning of their situation. Now they can express their
differences one from the other, standing together on connected ground.
I think that the important meanings that need room - and help to be expressed, are the
meanings that the adult world does not like to hear. These are meanings connected to
how children feel towards the adult world that has failed them. They are the voice of
protest, of anger with adults, of a sense of being entitled to a better world, of betrayal
by adults who do not protect them, of fear of having to rely on these adults and of
despair with the world of their parents.
These are entirely normative questions. Naturally, children may confuse a good
question with a definitive answer (not only children do this). They will need the help
that comes from careful listening to the details of the protest or despair, the way in
which each child has something unique to say. This listening provides recognition, an
73
echo that gives the child assurance that there is value in what s/he has to say, even if
the answer is not at hand.
It is very easy to gloss over the level of meaning. It is rather natural for adults,
especially teachers who devote their lives to helping children, to want to provide the
answers for the children. Now, security and connection are really more like answers,
they are feelings we help children to acquire. Meaning, however, is the place for the
unanswered question. It is here that the child confronts the gaps in reality. No one
can spare a child confrontation with these gaps, the same way that no one can spare a
child the necessary pains of growing up. But the child’s experience of herself is
entirely different when the truth of her painful questions is acknowledged as
important.
Imagine the opposite situation. Imagine that children, who are upset by traumatic
events, are helped to calm down and to feel part of the class. Then they are expected
to proceed to “business as usual”, as if to say that being calm and connected is
enough. The children in this class may well feel silenced by a well-meaning teacher
who “takes care” of them without then listening to them. Children will feel that they
are expected to feel according to what adults want them to feel. They will become
confused by the feelings of anger or despair that they still feel but will understand
that they are not to give them voice. Anyway, if they were to persist, they would only
be “calmed down” more.
This subtle but serious silencing will become the lot of all children, who are not
actively helped to find and express their full inner voice, including the protest against
the very adults who are trying to help them. Adults hold all the power over
expression, because children need the help of adults to formulate their authentic
voice. It is far too easy and self-serving for adults to be “silencers” in the guise of
protectors. Of course, adults must be ready themselves to listen to a voice that
currently many adult Israelis find difficult to express or receive. This will be part of
the teachers’ preparation. A “silenced” adult will have trouble helping a child to give
voice. Current feminist developmental literature has demonstrated this amply (Brown
& Gilligan, 1992; Taylor, Gilligan & Sullivan, 1995).
What would be the result of leaving children silent? What do children do when faced
with inner feelings of protest that are not acknowledged? I think they will seek a
pseudo-resolution for these feelings. In our situation of armed conflict, children will
be vulnerable to a process of demonisation. It will feel safer for Israeli children to
direct all of their frustration and anger at the anonymous other, “the Palestinians”, as
Palestinians could just as easily relate to “the Israelis” or “the Jews.” In my
experience the only antidote to demonisation is to give adequate voice to the
meanings of protest. Otherwise, teaching “against” demonisation will be experienced
by children as another form of silencing and be deeply resented and rejected.
Demonisation
Violent conflict arouses violent emotions. During Israel’s current violent conflict
with the Palestinian Authority one violent emotion to which we are particularly
susceptible is the demonisation of the Palestinian people. The mechanism of
74
demonisation is the psychological defence mechanism of projection: parts of our

“selves”, which are temporarily difficult to accept, are seen as belonging solely to the
other (Ayalon, 1998). Projection has its uses in normal everyday psychological
balance. And the battered and bewildered Israeli psyche surely needs better defence
than Israeli bus stations and cafes. Demonisation of an entire people is the expression
of massive group projection. What are the effects of such demonisation upon our
own children’s development?
Defence mechanisms play a useful role in our emotional life when they create
temporary and partial solutions that remain open to further work and to further input
from reality and from our thinking. The crucial question for children becomes its
effect on further development: Does the temporary arrangement enhance and
facilitate further development or does it retard or obstruct such progress?
Massive projection becomes a developmental danger for children because it is too
absolute, too final, and too irreversible, in short - virtually irresistible. It offers a
pseudo-solution, a partial truth, which is “too good”, and thereby obstructs rather
than facilitates seeking and finding better solutions (Waelder, 1936). Massive
projection takes a toll on every aspect of emotional balance and development:
• On aggression: By projecting murderous impulses upon Palestinians alone,
Israeli children become estranged from their own aggressive instincts.
They feel less control over their own natural inner violence, as the
violence they project upon Palestinians is considered out of control. This
will make it more difficult for them to be normally aggressive with each
other and thus learn how to make their personal aggression work in
concert with other parts of their personality. Projection makes our own
aggression a “loose cannon.”
• On conscience: It is only in grade school that children begin to reliably feel
responsible for their own actions. They gradually take inside themselves
the voices of parents who tell them what is right and wrong, permitted
and forbidden. We help a child all along this path by pointing out that
while it is hard to criticise herself, she gains more self-control and
autonomy by learning to see her own failings and take responsibility for
them (Furman, 1980). Massive projection runs directly counter to this
sensitive, new developmental achievement. By demonising the
Palestinians, children are encouraged to feel that our side is free from
self-critique or responsibility, because their side deserves anything we do.
A parent would be horrified if his child insisted that this was the only way
to understand why the child has done something. “It’s his fault” is exactly
what we are trying to help children grow beyond.
• On thinking and learning: Children go to school not just to learn
information. They learn about learning, and particularly they learn the
pleasures of learning and thinking, what psychoanalysts refer to as
sublimations (A. Freud, 1965). They learn that thinking before acting,
that talking about feelings give them pleasure and mastery, and are
effective in mastering reality. Demonisation of Palestinian children leaves
75
little room for thought or learning. Projection is a far more primitive –

and therefore attractive – psychic mechanism than sublimation. In an
atmosphere that condones and encourages massive projection, children
will find it very difficult to attend to the more complex and tedious
formation of sublimations necessary for learning.
• On reality: Knowing an answer may seem to be preferable to having a
question. We generally wish to help children to approach reality with
questions. One of the most pressing questions of our current reality would
be, “What is it like to be my age and live in the Palestinian Authority
today? How do children there cope day by day? What losses and fears
and threats do they encounter?” These questions are foreclosed by the
answer that demonisation provides. Foreclosing one question risks
foreclosure of other questions, indeed the risk in foreclosing just one
question runs the risk of barring an open attitude to reality altogether.
Children burdened by demonising the Palestinians become burdened with
answers that precede questions.
• On fantasy: Human creative experience depends upon the existence of a
realm where the imaginary and the real can intermingle. The British
Psychoanalyst Donald W. Winnicott called this the “transitional zone.”
(Winnicott, 1971) A common example involves the suspension of the
question “is this real” that allows us to become emotionally involved in a
film or novel. Artists commonly rely on this lifting of the barrier between
fantasy and reality to create with materials form each realm. Access to
this transitional zone is as vulnerable as it is essential for growth.
Now, demonisation is an example of invasion of fantasy into reality.
Devils, hobgoblins, vampires are all the lawful denizens of our fantasy
world. We can meet them safely in our transitional zone. But when an
entire, neighbouring people are made into demons, and the media upon
whom we rely to report reality confirms this assignation, then this fantasy
becomes too frightening and too convincing – precisely because it has
roots so close to home, right in out own fantasies.
This invasion creates a need to close down the transitional zone, and
separate reality from fantasy. Some children will respond with a choice of
reality only, although that reality will be infused with fantasy in a
frightening, flooding, unproductive way. Such children will become
aggressive towards their “real” enemies, including Israeli children who
are “soft” on the enemy. Other children will retreat into fantasy, and leave
no place in reality for even assertion or self-protection form others. Both
children will have their creative life narrowed severely.
• On voice: Carol Gilligan and her colleagues have recently described the way
in which girls “know” and “say” a lot more about social relations during
their primary school years than they do as adolescents. These researches
have shown how the need to become a “good girl” who is acceptable to
all friends and pleasing to adults creates the risk that the girl may “lose
76
her voice” and settle for pseudo-relationships at the cost of real

relationships. (Brown & Gilligan, 1992). Now many an Israeli schoolgirl
could naturally imagine her age mates in the Palestinian Authority
suffering a nightmarish daily reality. This intuition would be easily
suppressed by the demonisation expected by parents and peers. But the
girl who loses voice about one matter runs a developmental risk of loss of
voice regarding many other social insights. So I believe there could be a
particular risk to girls who are silenced from casting doubt on the
demonisation process.
• On history: Children take part in the great group narrative we call history.
They need a story that provides coherence and affiliation. They need a
“we” that is present through time with whom they can feel connected.
Demonisation tends to collapse the story of who we are into the much less
helpful story of who they are. Our own complex, fascinating and inspiring
history needs no demonic Other to be told. Children can understand that
there is a tragic conflict and that the solution is not yet clear. Once they
are offered the demonic Other, their interest and ability to appreciate the
story of who we are pales into the hatred of that Other.
• On family: The family is normally a place for learning about normative
conflict. Siblings make rival claims for parental attention or protection.
Spouses have competing needs for resources and affection. The Other is
always a member of the group. With demonisation afoot, family members
may find more freedom to demonise others in the family, the in-laws, and
the other sibling camp. Alternatively, the family may become “united”
around defending itself against Others who are different. This creates a
pseudo-unity in which normative conflicts are erased by the need to
“stand united.” Pseudo-unity comes at the price of disavowing the
presence or possibility of resolving the real conflicts in the family.
Students of Family Therapist Murray Bowen know that family health
requires the ability of real conflict to find real resolution. (Bowen, 1978;
Hoffman, 1981) Families with a higher level of “differentiation” allow
room for conflicting members to settle their differences. More poorly
differentiated families form “triangles” in which conflicts are displaced
upon other relations. For example, spouses may deflect their own conflict
by teaming up, with or against a given child, or grandparent, or school.
Demonisation of the Palestinians could provide an Israeli family with too-
convenient a triangle upon whom to displace all normative inner
conflicts, which are then doomed to be remained unresolved, with a
lowering of the families level of differentiation.
• On social relations: Peer relations are the great training ground for social
relations as adults. We would like to believe that children learn to respect
their peers, to listen to differences, to assert their own needs without
erasing the needs of others. We would be horrified to learn that children
have demonised another child or another group. When we find this has
happened – as it often does – we like to believe that we respond in a
77
vigorous adult educational manner to challenge the very process of mass

projection. But in the current climate of demonisation of Palestinians,
children are more likely to learn of the acceptability and indeed
advantages of mass projection. They become more likely to apply this
strategy in their own relations. Hate and projection do not tend to stay
put, and more commonly fall back upon the group using them.
• On spirit: Those Israelis who wish to teach something about the world of
Spirit generally look to the notion of human brotherhood as a
fundamental principle in which the presence of One Creator is realised.
(See Kovel, 1991) In the brotherhood of man there are conflicts,
tragedies, enemies, - but not demons. The very notion of a different form
of human being, who only hates us and who is not like us in any way –
this invites in children a Gnostic dualism on earth that is easily
transferred onto the celestial sphere. Those who find in Martin Buber’s
(1970; Schlipp & Friedman, 1967) theology of dialogue an important
statement of Jewish spirit will find the spread of demonisation antithetical
to this approach. Even in times of crisis and conflict – and perhaps
especially in such times – children are most open to lessons of the Spirit
(see Coles, 1986), and most vulnerable to the suffocation of spirit by
chauvinism and demonisation.
• On hope: I recently concluded a piece for the Jerusalem Post ( 2002) with
the sentence:
“Nothing gives children more hope than the understanding that children
of the enemy side are very much like themselves, - also growing up in
times of pain, solitude and silence”.
This sentence was removed by the editor. But I stand by this sentence –
indeed its fate prompted part of this essay. To what can Israeli children
turn in hopes for a brighter future? To a resumed conquest? To an even
more extreme and aggressive “solution?” All of my experience with
children suggests that children need to hope that on the other side there
are children like themselves, who wish to live in a quiet and just way,
protected and safe. I believe that by demonising the Palestinian people –
including their children – we deny our children a lost ray of hope, and
condemn them to a future of mutual demonisation, bloodshed, and
hopelessness.
Several questions for class discussion were suggested both to the Israeli and
Palestinian participants. These are intended to help all children give voice to their
inner meanings, and to include the issue of demonisation within such discussions.
1. What do adults expect from children? For example, how do adults
insist that children resolve their differences on the soccer field?
78
2. What do children expect from adults? This could include a

discussion of how children experience the behaviour of adults
around them, at home or in school, or in society. A consideration of
the contradictions between adult expectations and adult behaviour
is invited.
3. How does one survive disappointment? Children could be
encouraged to give examples of frustrations that they live with in
personal, social, and political spheres.
4. What is it like to grow up as a Palestinian in these times? What is it
like to grow up as an Israeli in these times?
Integration
Definition
The classroom does not approach the three levels outlined here in an orderly fashion.
The levels are separated here only for the sake of definition. In the real world all
three levels are experienced together. One example was demonstrated that could
create a climate that approaches all three levels. This approach was called: “A Safe
Space”.

One teacher volunteered to report on a difficult experience she had with a child
deeply affected by the recent disturbances.
She was asked to choose four helpers:

• two to sit on either side
• two to sit opposite her
The volunteer was asked to relate a situation in which she

felt great difficulty in helping a child traumatised by one
of the recent attacks of violence. While she spoke, she
was encouraged to make use of her helpers, and they were
encouraged to offer support, checking with the volunteer
that the help they wanted to offer at any moment
coincided with her needs. For example, those sitting by
her sides could offer shoulder-to-shoulder closeness,
those opposite could ask questions to make sure they were
understanding the story well. I want to emphasise here a few additional pointers
regarding this method:
1. The rationale involves having the volunteer assume responsibility for enlisting
the help of others in creating her own safe environment.
2. The volunteer should be able to experience three levels of help.
• Those beside her are meant to establish security.
• Those opposite her are meant to acknowledge meaning.
79
• The entire group is experienced as connection.

3. In actual practice such a group would move in and out of these three levels as
needed by the volunteer.
4. A facilitator leading such an exercise would be aware that the helpers opposite
might attempt to understand meaning before there is enough security and
connection. The facilitator would be careful to check with the volunteer
regularly whether her needs for help were being met at every moment.
5. In the full exercise each member of the group would in turn become the
volunteer.
• Each new volunteer rearranges her helpers in the way best suited for herself.
She will choose whom she wants in each position.
• When a full round of turns at relating a personal story is anticipated, each
helper is always also thinking about what kind of help she will want when her
turn comes. In this way the group task is to become each time an effective
helping group – the same people, constituted in different roles. This reflects on
the connection aspect of the group in the exercise with the cards described
above.
6. The exercise gives practical experiential acknowledgement to the tremendous
need for a safe and connected environment in which trauma can be related.
7. Teachers were encouraged to explore the possible application of such a technique
with their pupils.
8. Teachers were encouraged to remind themselves and each other of their own
experiences and especially intuitive successes in creating an integrated
experience of security, connection and meaning.
The school
How can teachers create an atmosphere of security, connection, and meaning for
themselves? Several participants raised this crucial question. Adults need to create an
integrative experience for themselves before they can transmit it to their pupils.
Teachers and principals were encouraged to confront the needs of the adults in each
school as a necessary basis for deep work with children. This will hopefully be
addressed in future meetings.
Bibliography
Ayalon, O. (1998). Reconciliation – changing the face of the enemy. In: O. Ayalon,
M, Lahad & A. Cohen. (eds.) Community Stress Prevention 3. Kiryat Shmona,
Israel: CSPC.
Ayalon, O. and Lahad, M. (2000). Life on the edge/2000. Haifa: Nord
Bowen, M. (1978). Family Therapy in Clinical Practice. New York: Aronson.
Brown, L. M. and Gilligan, C. (1992). Meeting at the crossroads. Cambridge, Mass.:
Harvard University Press.
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Buber, M. (1970). I and Thou. Trans. Walter Kaufmann. New York: Scribner’s
Coles, R. (1986).The Political Life of Children. Boston: Houghton Mifflin
Flashman, A. (2002) in Mason, R., Kids caught in conflict: pain, silence and
solitude. Jerusalem Post, March 13, 2002.
Freud, A. (1965).Normality and Pathology in Childhood. New York: International
Universities Press.
Furman, E. (1980). Transference and externalization in latency. Psychoanalytic Study
of the Child 36:267-84.
Hoffman, L. (1981). Foundations of Family Therapy. New York: Basic Books.
Kegan, R. (1982). The Evolving Self. Cambridge, Mass.: Harvard University Press.
Kirschke, W. (1997). Strawberries Beyond my Window, Games of association for
opening the door to creativity and communication. Kirchzarten, Germany: OH
Verlag.
Kovel, J. (1991). History and Spirit. Boston: Beacon.
Schlipp, P. A. and Friedman, M. (1967). The Philosophy of Martin Buber. LaSalle:
Open Court.
Taylor, J. M., Gilligan, C. & Sullivan, A. M. (1995). Between Voice and Silence.
Cambridge, Mass.: Harvard University Press.
Waelder, R. (1936). The principle of multiple function. Psychoanalytic Quarterly
21:93-123.
Winnicott, D. W. (1971) Playing and Reality. London: Tavistock.
81
COPE CARDS for Trauma and Healing
Ofra Ayalon
Coping is a skill. Situations arise every day that require us to exercise it. Some such
challenges are easily resolved by making use of already acquired responses. Other
challenges are new, more serious or even traumatic: threats for which we find
ourselves unprepared. Within such crises there also lies a potential for healing and
growth.
The concept of COPE Cards, to be used as a tool for enhancing coping with trauma,
was initiated by the Israeli trauma therapist Dr. Ofra Ayalon. This collection of 88
images was painted by the Russian artist Marina Lukyanova under the guidance of
Dr. Ofra Ayalon and the German publisher, Moritz Egetmeyer. Thus it represents an
international joint effort to deal with the consequences of traumatic events and help
heal the psychic wounds. These therapeutic cards, which have been widely accepted
by teaching and social professionals as well as by lay people in many countries and
of many cultures, facilitate authentic expression in a non-competitive and judgement-
free context. In a world in which conflict - whether private, domestic or international
- is erupting constantly, the experience of trauma seems pervasive. All trauma
therapies aim to disentangle people from the constricting influence of an event. While
COPE Cards are not meant to replace other therapeutic approaches, they serve to
complement them, when they are used to protect, to connect and to validate the
personal or the group experience. The COPE Cards can enhance the process of
uncovering and giving expression to each person’s outlook and to each one’s unique
strategies for dealing with pain and grief. Bearing witness to pain, whether it is your
own or that of another can bring insight and lighten the load.
Underlying Principles of the COPE Cards
1. Normalisation
COPE Card process begins with the assumption that trauma, a response to a
devastating event, can happen to anyone, anytime, anywhere. All different trauma
responses are considered normal ways of dealing with adversity. Each person's
pattern of response is as singular as a fingerprint and deserving of appreciation and
respect. Focusing on the skills of coping rather than on pathology allows COPE Card
process to proceed without undue emphasis on negative after-effects of trauma. To
ameliorate painful consequences of trauma, COPE Card work helps to mobilise
“exiting skills” and enhance new coping opportunities. It allows every individual to
find a unique pathway to recovery after traumatic stress.
2. Gaining mastery
Exposure to natural disaster, human cruelty, feelings of dehumanisation and the
experience of powerlessness create a diminished sense of self. The healing
relationship between trainer and trainee must be collaborative: the work is a shared
journey whose course will be set and re-set as pitfalls are met and unanticipated paths
are discovered. The healing relationship must foster a sense of security, trust, support
and empowerment.
3. Expressing and sharing

Working through grief, expressing fear, dealing with traumatic imagery through
metaphoric story-telling, social interaction, spirituality and humour: All of these
contribute to the healing of the whole person. The COPE Cards trainer, in promoting
these aspects of healing, serves as a guide and a coach, offering concepts that might
be new to the client and shaping abilities that may be latent.
4. Developing a personal healing theory
When we take a card and begin to respond to it, it is ourselves we find in the card and
our own inner story that emerges. A possible next step in the process might be to
communicate this personal, subjective interpretation to others, or to listen actively to
someone else doing the same. Actively listening means being attentive plus
refraining from interpreting another person’s cards while they speak. A personal
story told through using the COPE Cards creates a metaphorical forum for coming to
terms with what happened in the past and, consequently, for cultivating optimism and
confidence for the future.
It is all in your hands

An elderly sage reputed to be a mind-reader came to town to preach. The
townspeople anticipated his visit with respect, even awe. All, that is, but one: the
local mischief maker, a boy of thirteen. He had a brilliant idea for challenging the
sage’s reputation. He would run out to the fields and catch a butterfly. Then,
concealing it in his hands, he would face the old man and ask, “Sage, what is it I
hold in my hands?” The sage would no doubt answer, “It is a butterfly.” Then the
boy would ask, “And is it alive or dead?” If the sage said “Alive” the boy would
squeeze it between his hands and reveal before everyone the butterfly, dead. But if
the sage said that the butterfly was dead he would open his hands and let it fly. And
so it came to be that when the crowd assembled to hear the sermon, the boy
approached the sage and posed his question: “Sage, what is it I hold in my hands?”
The old man looked at him a moment and answered slowly, “A butterfly, my son. It is
a butterfly.” With a glint in his eyes the boy continued: “And is it dead or alive?”
The old man closed his eyes as he pondered, opened them again, and said in a soft
voice, "It is in your hands, my son, it is all in your hands.”
We humans tend to regard difficulty, disaster or trauma (i.e. events beyond our
control) as dealings from the hand of fate. But it is important to remember that, no
matter where or how such events originate, the way we deal with them is in fact in
our hands. This is what coping is all about. To cope means to face and to contend
with difficulty, disaster or trauma - and with a measure of success. Each of us is
naturally endowed with certain coping resources, others we develop with experience.
All coping methods can be enhanced through training or specifically oriented
therapies. In this card deck six cards with images of HANDS represent the following
categories of coping resources, or coping styles:
83
Cope Cards for Trauma and Healing
Belief may be faith in god or a supernatural power, trust in other

human beings or trust in oneself. When we seek reinforcement
through our belief system to cope with difficulty, our hands may
rise in prayer and in this way seek nurturing for confidence and
hope.
Affect is the inward disposition, or the feeling aspect of

consciousness. The heart is the treasure chest of the emotions: love
and hate, fear and courage, grief and joy, jealousy and compassion,
and so on. This mode of coping involves first and foremost the
ability to recognise feelings and to name them. Then comes the
expressing of feelings we have identified, by verbalising (telling,
writing, dramatising) or through non-verbal modes, such as free play or dance,
painting, sculpting or making music.
Social coping skills seek interaction with others. Such interactions

include supporting and being supported, both with those close to us
(family members and friends) and with professional helpers, taking
on a role of responsibility and the developing of leadership. Social
interactions which begin within an intimate circle also have the
potential for spreading into broader circles that include strangers or
the larger community.
Imagination is the core of creativity. It allows us to dream, to

intuit,to be flexible, to change, to seek solutions in fantasy, to find
new ways for dealing with distressing situations, to alter undesired
circumstances.
Cognitive coping relies on the ability to think logically and

rationally, to assess risks, to learn, to plan ahead, to seek new
strategies, to analyse and problem-solve.
Physical coping involves the senses: what we hear, see, smell, taste,
etc. It may be characterised by body sensations, such as constriction
in our throat or stomach, heart beats, changes of body temperature
or tension, and also in movements, such as making an effort, using
power, being active, doing, performing physical chores, overcoming
physical difficulties, dealing with reality, interacting with nature
84
These six coping channels are acronymed for easy reference as " BASIC Ph”. In
actual traumatic situations people usually employ a combination of coping styles to
survive (Lahad, 1997). The following story illustrates this well:
Rorik, a boy who survived shipwreck, spent many hours fighting the waves of a rough
sea until he was washed up onshore. In reviewing his ordeal he said, "I used all I
ever learned about swimming and breathing (C). My body obeyed my orders not to
panic, just to swim with the current (Ph). I prayed to Poseidon, the god of the sea, to
take care of me (B). And when I was exhausted I just floated on my back, letting the
waves carry me (Ph). During the long hours when I felt hungry and cold, I had vivid
fantasies and memories (I) of our warm dining room at home and could actually
smell the food (Ph) that my loving mother (A, S) placed on the table. All of these
helped me to survive.”
Elements of Traumatic Stress

Living in dangerous environments
Crisis, extreme stress and disaster are part and parcel of life today for vast numbers
of people of all ages and persuasions both in the Western civilisations and in the so-
called "third world". Exposure to dangerous environments occurs through war and
terrorism, ecological, natural or technological disasters and urban violence. Also
poverty, child slavery, racial persecution and physical or sexual abuse cause suffering
and trauma, as do domestic and individual crises such as loss and death of dear ones,
destruction and loss of home, abandonment and betrayal. Survivors of such disasters
can be left with feelings of helplessness or depression, may feel chronically plagued
with guilt or anger, or suffer from the debilitating effects of post-traumatic symptoms
(Ayalon, 1987).
Stressful change and disruption of continuity

Some changes we love to embrace, like those that give us a break form everyday
routine - a surprise party or taking a holiday. Other changes, however, come
unwanted, taking us out of control and throwing us off balance. Loss of work or
social position, immigration to a new country, getting divorced or being widowed,
being involved in a traffic accident or caught in a house on fire: these are just a few
examples. Such unpleasant and imposed changes upset our familiar environment,
interrupt old habits and render invalid our ordinary ways of solving problems. When
the perceived continuity of our existence is disrupted, we are faced on every step of
our way more demands than our existing coping skills can deal with. Our past no
longer predicts the future. We may then experience extreme stress and a sense of
confusion, vulnerability and personal failure, which in turn may trigger old fears and
failures from the past and render us helpless, anxious or paralysed.
Traumatic stress
Any event that contains a threat to our vital concerns can trigger a traumatic
response, whether it be abrupt and powerful, prolonged or recurring. The five major
traumatic threats are:
85
• Threat of death, exposure to gruesome death, bodily injury, or dead or

maimed bodies
• Threat of loss of or harm done to family and friends, loss of communication
with or support from close relations
• Threat of pain, injury or impairment, extreme environmental destruction or
human violence, extreme fatigue, weather exposure, hunger, sleep
deprivation
• Threat of losing home, possessions, neighbourhood or community
• Threat to self-worth, religious faith, trust in other human beings, value
system and integrity
Responses to trauma
Traumatic stress activates involuntary defence reactions, triggered by the organic
arousal of the autonomic system - hormones, nerves and muscles. These reactions are
known as the three F's: Fight, Flight or Freeze.
Fight: a surge of anger or frustration triggering aggression and/or destruction.
Flight: an overwhelming fear leading to regression and dependency may bring on
haunting nightmares, frightening fantasies, passivity and illness.
Freeze: a shock response typified by mental and/or physical paralysis, accompanied
by feelings of helplessness.
What are normal stress reactions in the wake of traumatic experiences?

Most disaster survivors (children and adults as well as disaster rescue or relief
workers) experience normal stress reactions after a traumatic event. These reactions
may last for several days or even a few weeks and may include:
• Emotional reactions: shock; fear; grief; anger; guilt; shame; feeling helpless
or hopeless; feeling numb; feeling empty; diminished ability to feel interest,
pleasure, or love
• Cognitive reactions: confusion, disorientation, indecisiveness, worry,
shortened attention span, difficulty concentrating, memory loss, unwanted
memories, self-blame
• Physical reactions: tension, fatigue, edginess, insomnia, bodily aches or
pain, startling easily, racing heartbeat, nausea, change in appetite, change in sex
drive
• Interpersonal reactions: distrust, conflict, withdrawal, work problems,
school problems, irritability, loss of intimacy, being over-controlling, feeling
rejected or abandoned.
Severe reactions to trauma

Studies show that as many as one in three disaster survivors have severe stress
symptoms that put them at risk for lasting Post Traumatic Stress Disorder (PTSD).
Symptoms may include:
• Dissociation (de-personalisation, de-realisation, fugue, amnesia)
• Intrusive re-experiencing (terrifying memories, nightmares, or flashbacks)
• Extreme emotional numbing (total inability to feel emotion, as if empty)
86
• Extreme attempts to avoid disturbing memories (such as through substance

use)
• Hyper-arousal (panic attacks, rage, extreme irritability, intense agitation)
• Severe anxiety (debilitating worry, extreme helplessness, compulsions or
obsessions)
• Severe depression (loss of the ability to feel hope, pleasure, or interest;
feeling worthless)
When the trauma is not treated, a full blown PTSD can develop, either within a short
time, or with its onset delayed for even years after the event and then triggered by a
new loss or crisis. PTSD may include any of the following symptoms: prolonged
anxiety, intrusive memories and flashbacks, sleep and eating disturbances, loss of
memory, difficulties in concentration and learning. Relationship with other people
can be impaired a result of inability to trust others. Survivors may suffer from
emotional block - as if they cannot feel anything at all (it is often called "emotional
numbing"). They may lose interest in intimate and sexual relations. In other cases
they may burst out with unexpected violence, elicited by behaviours that trigger
traumatic memories. Many suffer from "survivor guilt", blaming themselves for
being alive when others perished in the disaster.
Circles of vulnerability: Who needs help?

To explain who needs help we may use the metaphor of a pond full of frogs. When a
stone is thrown into the pond, it kills the frogs that are directly hit. But then, what
happens to all the other frogs? They are caught in the ripples and suffer from shock.
This is the ripple effect of fear and anxiety. When a trauma hits and kills victims, the
eyewitnesses are also traumatised. Families who lost their dear ones, friends, peers,
are all victimised. So are the rescue workers and media reporters who come in close
contact with the horrors of death and injury. These "circles of vulnerability" include
also the medical staff, social workers, teachers and psychologists who are exposed
vicariously to the trauma of their students and clients. Many of them are hidden
victims who carry hidden scars. Often they themselves don't realise how wounded
they are. They are often neglected by post trauma health services as well (Ayalon,
1983).
The need to bear witness

The cost of trauma in human suffering and distress is very high both to victims and to
those around them. Shock, anxiety, pain, rage, guilt and despair continue to hurt like
thorns in the spirit. The traumatic experiences need to be acknowledged, expressed,
listened to, witnessed by caring others, tolerated, contained, treated and healed.
Major obstacles may block the need of victims and survivors to voice their emotional
turmoil and be heard by others, such as:
• The traumatic experiences are often so horrendous, that words are
insufficient to describe them, to express the severity of the mental pain, the
sights, the sounds, the haunting memories.
• Family and friends may be unwilling or unable to listen and bear
witness, to help absorb and contain the shock.
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• There may be no support available. Trauma also occurs in the lives of

people who lack a supporting human environment. It also pushes people
towards seclusion and isolation if others around regard victims and survivors
as pariahs.
A helping hand
Since people are generally expected to recover from a bad experience within a few
weeks, sufferers may find that support and sympathy begin to disappear when they
need them most. Fear of reawakening painful memories, fear of appearing weak and
out of control and disbelief that there is an available treatment for unseen mental
scars are some of the reasons for reluctance to seek help. These are the times when
we need some special help from the outside. We need a helping hand to guide us to
discover our hidden coping resources and develop new coping skills to regain control
over our life.
What people need in the wake of trauma

• People need to process the experience of trauma at their own individual pace.
It is important that helpers support and honour this.
• People need encouragement to use natural support systems (family, circle of
friends), meaning: to talk with intimates and co-workers when they are ready.
They should follow their natural inclinations with regard to how much and
with whom they talk.
• Most people in distress do not seek professional therapy to deal with the
emotional impact of traumatic events. If someone consults a professional in the
immediate aftermath period, that professional should listen actively and
supportively but not probe for details and emotional responses. Let the person
say what they feel comfortable saying without pushing for more. Validate a
normal, natural recovery.
• People need to enhance their "BASIC Ph" coping resources.
About Children and Trauma

The fact of being a child offers no protection against loss, grief and other emotional
traumas. Even the most loving of parents cannot necessarily save their children
from illness, accident or death. Disturbing events in their own families, in the lives
of their friends or in the world beyond may leave children feeling confused,
uncertain, and frightened. Self-esteem may suffer damage as a result of traumatic
experience, and relief and re-assurance may be sought in drugs. Under severe
circumstances children may try to escape the turmoil of their lives by running away
or, even more tragically, in suicide. Children with immature coping styles and those
dependent on adults for an understanding of the events around them are especially
vulnerable. The loss of family, friends and caregivers may shatter their world and
put them in grave risk. Children tend to regress, suffer from sleeping and eating
disorders, lose trust in others, have impaired concentration, and fall behind in their
schoolwork. Some become aggressive and violent. Small children may repeatedly
re-enact the trauma in their play and/or experience recurring nightmares. And, it is
possible for children to be victims of trauma many times over before they reach
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adulthood. Early traumatic life-experiences set the stage for re-victimisation on the
one hand and for the danger of becoming perpetrators on the other. Recent studies
have indicated that at least 80% of those in prison have been traumatised in early
life. Parents, teachers and mental-health helpers can potentially prevent years of
suffering and help stop the cycle of violence itself by being sensitively aware of
signs of distress in children and by using gentle and innovative tools in trauma
therapy with them.
Using the COPE Cards with Children

When small children experience trauma, special methods are called for to help
them defuse that experience. The main considerations of working with children are
these:
• A child has a limited ability to verbalise and process information cognitively.
• A child's attention span is short.
• A child is endowed with spontaneous imagination.
• Play is the natural language of children and functions as a spontaneous "auto
therapy”.
COPE Cards debriefing with children can be conducted in three steps:

1. The child is offered a choice of one card and introduces himself or herself
to the helper or the group via this card. (The group must not include more than
5 children).
2. The card is given "a voice" to tell the story. The child tells how the figure
in the card felt during the event, and then tells how it feels in the present.
3. There is an exchange of suggestions of how to "cope" with the figure's
story (how to sleep better, how to push away fears & bad dreams, express anger
etc.). The discussion stays within the metaphor.
This method was used by a teacher after a traumatic event. She encouraged the
group of children to pick one card each. Next, she described the rules of the new
game: each child tells the story of his or her card, talking only when their turn
comes. The teacher's card was a bird. The teacher's bird modelled the process for
the children.
Bird said: “Good morning. I am a bird and my name is Bulbul. I live in this village
on a high tree from which I can see the whole place. Last night I was on my tree
and I heard loud noises. I went straight into my nest and peeped outside to see
what was going on. I could feel my heart beating and my wings pressed tightly
against my body. Did any of you hear that noise?”
Then the children told the story of what had happened through their cards. Bulbul
expressed her feelings and fear, and the others also used their cards to tell their
reactions and feelings. Then Bulbul chose a new card to show what helped. Each
card-holder added a new card - the card that helped - and then shared "what
helped" with the rest of the group. At the end each child put the “fear" card on the
floor, and covered it with the "help" card. The fear was not denied nor made "all
better" but was balanced by the images of coping (Lahad, in print).
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Resilience and Coping

Traumatic stress may cause a crisis for an individual or group, yet, paradoxically, it
may also stimulate growth and development and trigger previously untapped coping
resources, as the concept of “Crisis” comprises both Danger & Opportunity.
The most effective way of dealing with crisis is to delve into the experience itself and
work it through. Regaining a sense of mastery and developing new insight are
potential gains of this work.
Resilience is the ability to recover, either on one’s own or with the help of others,
despite setbacks, problems and disabilities. Searching for resilience implies a change
in perspective from trying to understand how people "fail" to trying to understand
how people survive and thrive. It’s a fact that human beings are survivors by nature
and that most of us have at our disposal a range of "emergency equipment" to help us
survive crisis and stress. However, in order to not only survive traumatic stress, but
also to thrive in its wake, both physically and mentally, we also need to update our
behaviour patterns, learn new social roles and re-order expectations. To enhance our
range of coping resources means to employ the Belief (spiritual), Affective, Social,
Imaginative, Cognitive and Physical Channels. Some pre-designed tools can help
in this intricate process, whether it occurs as self-help or at the hand of a professional
helper, therapist, counsellor, guide, trainer or coach. Among the most effective of
such tools are those that help gain access to the traumatic experience frozen in the
brain and unfreeze it, enabling both identification of the trauma and expressing it, as
well as discovery and application of appropriate coping skills. This is one of the
major functions of the COPE Cards. We can call them "facilitating triggers for
enhancing resilience and coping”.
Telling the Trauma Story and Finding Coping Resources

Any COPE card (or combination of several cards) can function as a trigger for the
narration of the event and responses to it. Using the COPE Cards provides
opportunity for telling personal recollections of traumatisation within a safe
environment. Persons who suffer traumatic after-effects may feel "trapped in the
trauma" and unable to recall the past without fear of overpowering emotions. Or they
may be flooded by memories, and at a time when they are least prepared to
remember. The purpose of baring the details of the trauma story is to revisit the scene
and, in so doing, release its grip of terror and horror.
Metaphorical stories triggered by the visual images on the cards are one step
removed from anguished reality (Ayalon, 1992). This "creative distance" facilitates
recall and the working though of trauma experience. The use of image and
imagination serves as a protective screen against being overwhelmed by intense
emotions. When the memories become too much to bear, one can always return to
the imagined story, or look for other cards that may serve as anchors for a sense of
thriving, surviving and healing.
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The COPE Cards as an Agent of Spiritual Healing

Spiritual growth is a type of healing from which most any of us can benefit, most of
the time. A victim's sense of spirit, however, may be acutely dimmed for some
period of time following the victimisation. The act of working with the COPE Cards
can re-stimulate the experience of spirituality, in the sense of feeling fully alive again
and open to the moment, of belonging and having a place in the universe, of deep
appreciation for the natural world, of openness to surprise, serenity and joy. Over
time, as a victim heals on all levels, his or her potential for spiritual growth may
increase becoming not only greater than it was before the trauma, but may also be
greater than that of those who have not been forced through outside circumstances to
face experientially the inevitability of mortality.
Goals in COPE Cards Work

The goals of using the COPE Cards as a tool in the wake of traumatic experience are:
to PROTECT: to help preserve participants' safety, privacy, and self-esteem
to CONNECT: to help participants communicate supportively, either one-to-one or in
small groups with family or peers
to VALIDATE: to present through informal card work opportunities for affirming the
worth and normalcy and of each individual's reactions, concerns, ways of coping,
goals for the future.
Getting Started
The COPE Cards belong to an extensive family of associative cards (the OH Card
series) that present an attractive and feasible forum for examining our lives in a
creative and original manner. These cards enable their users, whether playfully or
therapeutically (or both!), to access flexibility and imagination, to move up to a
higher level of thought, to touch deeper feelings. Using the COPE Cards people can
learn to identify their own particular ways of coping with crisis, stress and trauma.
The COPE Cards can help us reach our inner pain and discover our inner strength.
Many applications are possible. In trying out various methods, exercises or games a
sort of virtual training takes place in dealing with challenging situations, in surfing
beyond time and space, in experimenting with possible solutions to problematic
issues - all within the safe, exuberant world of image and metaphor. The experience
of randomly selecting cards and dealing with the associations they evoke can lead us
into the richness of new ideas and possibilities instead of into familiar anxieties about
failure or success. We can actually learn through using these cards to be less hesitant
about the future and more confident in our ability to face the unknown and to
incorporate chance elements into our lives. These cards are amenable for use both in
small groups and individually. All examples and suggestions provided in this chapter
can be used together with a facilitator, with a friend or alone, bearing in mind that
these images speak to our emotions and that their purpose is to heal. Respecting
personal integrity is always of foremost importance throughout this process.
Following are two examples for using COPE Cards to discover and enhance coping
resources.
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COPE Process #1: The Hero's Journey

Background: This activity is inspired by the Jungian analysis of myth, fairy-tale and
folk-tale. The Hero’s Journey is an individual/ metaphorical story of individuation, of
leaving the safe home to go on the search and growth of the inner self.
All such tales, whatever culture they emerge from, share a structure composed of the
following six steps:
1. Hero is introduced.
2. Hero leaves home on a mission, a challenge, a task.
3. Hero meets helpers.
4. Hero encounters obstacles.
5. Hero copes with obstacles.
6. The story ends!
By making up a story based on these universal elements, one may be able to see the
way that the "self" meets the world and copes with hardships.
Process: A story will be told without words to the facilitator or the whole group, by
following the instructions:
Divide a page of paper into six spaces and place it in front of you. Six cards will be
selected to fill them up.
Card 1. Select a card to represent the heroine or hero of the story.
Card 2. What is your hero/ine's mission? The second card will represent the task. .
Card 3. The third image shows who or what will help the hero on this journey.
Card 4. The fourth image represents the obstacles or hardships that confront the hero.
Card 5. The fifth card: how will s/he cope with this obstacle?
Card 6. The sixth image: “and so the story ends.”
Tell your story to another participant or write it down.
Together try to figure out the context of the story, its themes or its message. Try to
discover what are the dominant coping modes revealed in the story (refer back to
"BASIC Ph” coping resources). Each picture gives us information on the emerging
coping modes. If, for example, the hero is a fairy, that assumes the use of imagination.
The goal of the journey might be connected with values and beliefs. The help might be
practical or imaginary, or may well be an inner belief. The obstacle could be social,
imaginary, or realistic and solution-focused. As we learn from the BASIC Ph, coping
can occur in different modes. The conclusion of the story can be emotional,
intellectual, social or imaginary. Therefore it is important to pay attention to modes
that may appear frequently in a story, as well as to those which don’t appear at all.
Those coping modes frequently mentioned are the ones most used in reality.
COPE Process #2 Identifying Your Coping Channels with "BASIC Ph” Model
This activity aims to discover what our own coping channels are, those ones we use
to deal with daily hassles and stress, and those we use in crisis situations. In this game
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participants will also identify those coping channels that are blocked in times of crisis.
What resources would be required to open them up and make them, too, available in
times of need?
Process:
1. Spread the six coping “hand cards” face up on the table and
describe each of them according to the BASIC Ph model
(belief, affect, social, imaginative, cognitive, physical).
2. Pick up at random six cards from the COPE Cards deck and
place them randomly and face down on top of to the “hand
cards”.
3. Turn each card up in turn, making connections between it and
the “hand card” you placed it on. Describe with the help of this
card how you tend to use the relevant coping channel in your
life, either in a positive or a negative way. For example: My
"imaginative" coping mode helps me detach myself from my
worries (positive), and my "social” coping channel makes me
over-dependent on others (negative).
4. Now think of a time in your life when you experienced severe
stress or crisis, or remember an event that was traumatic for
you. Scan the rest of the open COPE Cards deck, and choose 3
cards that describe this experience.
5. Looking at the “hand cards” try to identify which of the coping
channels you used to deal with that crisis. Use the cards to tell
the story of your coping.
6. Try also to identify those channels that you did not use - and
turn their representative cards face down. These cards
represent those coping channels that were blocked in the
traumatic event.
7. Find cards that will help you re-activate those blocked
channels.
8. Reflect on the whole process of identifying your existing
resources for coping with crisis and activating additional
resources. Share your reflections. Tell a new story of coping
with crisis, using all 6 channels.
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Bibliography
Ayalon, O. (1983). Coping with terrorism - the Israeli Case. In: D. Meichenbaum, M.
Jaremko. (eds.) Stress Reduction and Prevention N.Y.: Plenum publications.
pp. 293-339.
Ayalon, O. (1987). Living in a dangerous environment. (with Van Tassel) in: M.
Brassard, R.Germain & S. Hart (eds.) Psychological Maltreatment of Children
and Youth, New York: Pergamon Press. pp.171-182.
Ayalon, O. (1992). Rescue - Community Oriented Prevention Education for Coping
with Stress. Ellicott City: Chevron Publishing Corporation U.S.A.
Campbell, J. (1988). The power of myth. New York: Doubleday
Gersie, A. & King, N. (1990). Storymaking in education and therapy. London:
Jessica Kingsley Publishers.
Lahad, M. (1997). BASIC PH – The story of coping resources. In: M. Lahad & A.
Cohen. Community stress Prevention 1&2, Kiryat Shmona: CSPC. pp. 117-145
Lahad, M. (in print) in: Rosenfeld, L., Caye, J. Ayalon, O. & Lahad, M. When their
world falls apart: Helping families and children manage the effects of disasters.
North Carolina:
von Franz, M.L.(1987). Interpretation of Fairytales. Dallas: Spring Publications.
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The Media and the Understanding of the Trauma Vortex at the
Political Level
Gina Ross
The situation in the Middle East seems hopeless. Every day, the media reports stories
of trauma and violence and seemingly irreconcilable political positions agitated by
individual passions. We become intimately acquainted with stories of enormous
suffering on both sides that leave us ever more resigned and helpless at the
incomprehensibility and futility of the situation. We say that the violence is
contagious and spinning out of control. But in reality, trauma is contagious. It
manifests in violence, which begets more trauma, which begets further violence.
This article explores the role of the media in the healing of trauma as well as the role
of trauma in conflicts between nations. My intent is to create new thinking about
why and how the media can disseminate information on trauma to help the public: to
create guidelines on how to present tragic events so they will contribute to a better
coping rather than amplifying trauma. I also aim to shift the way we view political
situations such as the Israeli-Palestinian conflict.
In truth, creating peace through cease-fires and pact signing does not resolve trauma.
As it seethes beneath diplomacy, repeated violence is inevitable. We need innovative
thinking. I offer a novel framework that allows for hope and new solutions to
emerge. I present the concepts of the trauma and healing vortices, terms coined by
Peter Levine, creator of Somatic Experiencing. With the help of the media, these
concepts can transform our understanding and the resolution of the problem.
The “Trauma Vortex” and the “Healing Vortex”
The “trauma vortex” (Ross, 2003) is a metaphor that describes the whirlpool of
chaos in trauma’s aftermath. Also called the “black hole” of trauma, it is a downward
spiral that traps the traumatised. They become unable to control their sensations,
images, feelings, thoughts, and behaviours. The “healing vortex” refers to mankind’s
innate resiliency, the capacity of people to cope with tragedy and to heal on their
own. When this vortex gets stuck, it needs awareness and resources to reengage it.
The trauma and healing vortices apply at the individual and collective levels. The
interplay between the two will determine whether individuals, communities, or
countries will engage in destructive actions such as conflicts, violence and war or
constructive measures, such as forgiveness, rebuilding, and peace.
The Trauma Vortex
Wrenching events, whether they happen to individuals or nations can leave people
and whole nations traumatised. Trauma occurs when a person is overwhelmed by a
harrowing and distressing event that his nervous system is unable to assimilate. The
arousal was too great and too rapid to digest. Instinctive survival mechanisms
summon powerful energies to meet the threat. In trauma these energies are not
completely discharged and remain stuck in the system. This excess energy throws the
Understanding the Trauma Vortex
system off balance and symptoms may manifest in myriad ways in one or more of
the following manners:
• Traumatised people cannot stop revisiting the horrible images of the event.
Unable to control their thoughts, they ruminate obsessively, repeatedly asking
themselves the same questions: “Why me? What if…? How can I change what
happened? What’s wrong with me?” They cannot control feelings of fear and
terror, even though the event is over.
• They are overcome by a sense of utter despair and hopelessness. Everything
seems meaningless. Life’s normal sense of security and ease seems to be gone
forever. Nothing seems trustworthy anymore.
• Deep feelings of inadequacy, shame, guilt, and hurt pride come by waves.
Especially when they are the victims of man-made traumas, people have a
profound feeling of being out of grace, feeling abandoned by God, by others,
and by life. Their essential needs for safety, the right to exist without danger,
the trust in the good will of the other, and the sense of empowerment are
shaken. The sense of predictability, competency, and the ability to control
one’s destiny are gone.
• The strength of these chaotic feelings, sensations, and thoughts leaves them
bewildered and questioning their sanity. They cannot use reason. They lose
their capacity to see events and situations in a balanced, composed way.
Everything feels extreme and off.
• They are vulnerable to all triggers that remind them of their initial pain,
helplessness and suffering.
• People different from them suddenly appear threatening and dangerous.
They feel polarised in their thoughts and emotions.
• Anger and rage mount, coupled with a deep sense of powerlessness at their
ability to right the situation. It is a rage that can be turned against themselves
or against others.
• The effects of trauma can manifest rapidly or have a long gestation period.
They are manifold and can be devastating. At the individual level, traumatic
symptoms manifest as psychosomatic problems.
o Physically: chronic pains, hyper-arousal, flashbacks and nightmares.
o Emotionally: feelings of terror, rage and helplessness, depression,
numbness, and confusion.
o Mentally: paranoid beliefs, blame, judgement, criticism, and polarised
thinking.
o Behaviourally: family disputes, break-ups, divorces, impulsive behaviour,
addictions, family violence, more risky behaviour, rise in car accidents.
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• At the collective level, whether between groups or nations, we see not only
the above symptoms assailing individuals and their families, but also polarised
thinking between different groups, demonising and dehumanising the other.
Seeking justice through violence and revenge appears logically to be the only
choice.
The trauma vortex is contagious and its pull magnetic. It occupies all of our attention
and energies. When traumatised, nothing else matters. Our focus becomes narrowed.
We ruminate only on our traumatic narrative, which becomes increasingly distorted
over time, as more elements of our traumatic lives become subjugated to it and
contaminated by the original event. In fact, this traumatic narrative encourages and
maintains our traumatic state. Victimhood becomes an identity. It may give us a
sense of righteousness, a deep relief in thinking we are good and right and that we
have been greatly wronged. But it also implies powerlessness and lack of control
over our lives.
Our responses, now informed only by trauma, create more traumas in our lives. As
we approach life with trepidation, caution, and lack of trust, we generate in turn
mistrust and suspicion around us, confirming our initial feelings. Moreover, the
media may unconsciously amplify the trauma vortex since it mirrors what is going
on and is itself caught in the trauma vortex. Traumatic reactions can be re-triggered
on anniversary dates or by similar stimuli or even predictions of such events.
However, trauma can also trigger the healing vortex: people reflecting on their own
values, turning towards their families, healing tense relationships, choosing
compassion, restraint and forgiveness. Some may commit to charitable work and
important causes; others may curtail their materialism. Nations let go of their
grievances, offer a helping hand to each other and commit to truce, joint projects,
and economic and cultural exchanges.
It is crucial to help people understand that they might be caught in the trauma vortex;
to help them re-ignite hope, and re-establish dreams; to help them direct themselves
towards life-affirming beliefs; to provide knowledge on how to cope best with
trauma. There are healing methods that will help traumatized individuals manage
their hyper-arousal and contain their explosiveness and hyper-sensitivity. This can
be done by:
• Shedding light on the pull of the trauma vortex
• Shedding light on the need to encourage the healing vortex through
support groups and safe forums to vent anger and frustrations
• Helping people develop or reconnect with their individual or
national resources
It is imperative to understand the nature of traumatic reactions and how individuals
and countries oscillate between the two vortices from hope, optimism, energy, and
altruism to fatigue, frustrations, disillusionment, and polarised thinking and back
again.
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Trauma is a Root Cause of Violence

Researchers have established that the most serious repercussion of unresolved
trauma is violence. Trauma begets violence, which begets more violence, which
begets more traumas. Furthermore, when a critical mass in a population has been
traumatised, the general population is impacted. The most dangerous aspect of the
trauma vortex is the loss of all reasoning power and the hijacking of one’s emotions
by the part of the brain called the amygdala. Like any individual, any nation can be
vulnerable to the irrationality of the trauma vortex.
National signs of the trauma vortex can include:
• Aggressive and bellicose language regarding other nations
• Instilling hatred in children
• The use of visual or written media to incite polarised thinking
• Demonising of the other
• Incitement to hatred and violence
How might we benefit from better understanding the dynamics of trauma? How can
we, as individuals and a society, better deal with traumatic events taking place
almost daily? How do conflicts between nations arise and what makes them erupt?
Finding answers to these questions, although an always pressing question, has
become a critical one as the Middle East trauma vortex is in full swing and as
national trauma has burst on the American scene with the events of September 11
that threaten to engulf the whole world.
Unhealed trauma compels one to re-enact the ordeal and to polarise, creating an
ever-expanding cycle of trauma and violence. We are just beginning to recognise
how much collective national traumas may underlie most international conflicts.
Knowledge of trauma’s impact must inform our analysis of how warring nations act
toward each other. This knowledge must inform the interventions of the
international community.
Once we recognise the dynamics of trauma and violence, we may be able to slow
that process. We may be able to help nations identify when they are under the
influence of the trauma vortex. We may able to warn them and even pressure them,
if need be, as soon as we notice the first signs of the trauma vortex.
The Urge to Repeat or the Pull of the Trauma Vortex
The urge to re-enact trauma has major implications for society. Though we’d like to
think that “time heals all wounds,” often trauma persists if memories have not been
integrated or accepted as part of one’s past. Instead, the traumatic event exists as if in
the present, independent of other experiences, with a life of its own. The signal of
impending danger is now internalised. Traumatised individuals relive memories with
the same intensity as if the event were repeatedly occurring in the present. Replayed
incessantly, these images add more distress and sensitisation until their effects
become difficult to reverse. This repetition forms a destructive learning loop that can
result in hyper-alertness and hyper-arousal. It can create paranoia and impair our
ability to discriminate between stimuli and can set the stage for reenactment.
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The compulsive urge to repeat trauma is one of its most frustrating, disturbing, and
dangerous aspects. It is an unconscious attempt of the nervous system to achieve
resolution. Experiencing and confronting trauma helps us learn what to avoid, how to
protect ourselves. The re-enactment is really an attempt to seek completion and
mastery of unresolved traumatic situations, but it is unlikely to accomplish those
positive ends. Instead, it perpetuates and deepens the cycle of pain. Because
completion cannot be achieved, the nervous system stays stuck in a hyper-aroused
state, unable to discharge the excess energy and its associated thoughts, feelings,
sensations and behaviours. Only awareness and consciousness can break the cycle of
re-enactment. Only discharging the energy can re-establish the balance in the
nervous system and stop the need for re-enactment.
The drive for re-enactment is a major factor in the perpetuation of trauma.
Sometimes the re-enactment is blatant: one of my clients came in with a history of
seven car accidents, another was raped several times, and another broke his knee
once a year for the last five years. At other times, the re-enactment is indirect: a
sexually abused girl may become promiscuous or a war veteran may provoke fights
in bars. Even more tragically, this drive for re-enactment also contributes to the
escalation and perpetuation of violent behaviour. Often abused and traumatised
children grow up to become perpetrators and violent offenders, wife-beaters or self-
mutilators.
On a larger scale, traumatised social groups often organise their identities around
revenge, leading to ethnic strife, civil war, and war between nations. Historically, we
have many examples of the trauma vortex in action. The Hundred Years War
between England and France provides an old and classic example of a full-blown
trauma vortex that lasted a century and that may inform contemporary conflicts. The
present on-going struggles between Catholics and Protestants in Northern Ireland;
the Israelis and Palestinians; the Serbs, Croats, and Bosnians in Eastern Europe; the
Tutsis and Hutus in Rwanda; the Pakistanis and Indians in Kashmir, the Hindus and
Muslims in India have the same character: unresolved trauma creating a vortex in
which each act of violence on one part sparks another act of violence from the other
part into an ever-escalating spiral of chaos, pain, and destruction.
Serbia may be a clear recent example of unresolved trauma being re-ignited. In 1989,
Serbia commemorated its six hundred year old 1389 defeat in Kosovo at the hands of
the Ottoman Empire. This set the stage for the revitalisation of the fears of loss of
territory and being attacked. It did not help that Milosovic, the Serbian leader, had
ambitions for a Greater Serbia or that the aspirations for autonomy of the diverse
populations of Yugoslavia was led by Muslim mujahedeens.
Furthermore, the trauma vortex had already been reawakened in the twentieth
century when these ethnically diverse populations were at each other throats. World
War II, in particular, saw hundreds of thousands of Serbs massacred or sent to
concentration camps when the Muslims sided with the Third Reich. The troubled
Serb leader, himself a product of intense personal trauma (the suicide of his parents)
was able to re-ignite the unresolved trauma of his people by continuously replaying
traumatic images from World War II on television.
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Caught in the trauma vortex and its spiral of fear, terror, paranoia, and rage, the
Serbs began re-enacting their war traumas and, in face of Muslim opposition, lost all
sense of perspective. In the true spirit of the trauma vortex, they relived the
humiliation of losing their power when Croatia and Slovenia wanted their
independence and turned their rage on the ethnic and religious groups they felt had
traumatised them decades or centuries ago, forgetting that they had been living with
these same people in relative peace for decades. A macabre detail of re-enactment
was impaling their enemies’ decapitated heads on spears, just as it was done under
the Ottoman Empire.
Eventually the trauma vortex runs its course (as in Serbia), but not before leaving
untold destruction and suffering in its wake. How long the vortex lasts depends on
the momentum behind it, the depth of the unresolved trauma, the amount of present
frustration and unmet needs of the populations under its spell, its impact on the
global community, and the subsequent interventions of outside forces.
We cannot afford to let trauma vortices start spiralling unbeknownst to us; we cannot
let the momentum of trauma accelerate once we have been able to identify them. The
trauma vortex taking shape in front of our eyes in the Islamic world and the one
already in full force in the Middle East will leave unimaginable mayhem and
devastation if we let them develop or feed them unwittingly.
The truth is, any nation can eventually escape the trauma vortex. Often it runs out of
steam when people are no longer willing to pay the price of its aftermath or when
other powers intervene.
The Role of the Trauma Vortex and Survival in International Conflicts
How can the trauma vortex perspective change the way we perceive some of the
conflicts raging in the world, and particularly the daunting Israeli-Palestinian one?
To get an idea, we can look at some events through the lenses of the trauma vortex.
In 1967, the Egyptian army engaged with other Arab armies, in one more war with
the Israeli army, in a re-enactment of the 1948 war. When the Israelis
counterattacked, the media focused on images of thousands of soldiers’ boots left in
the sand, depicting the Egyptian army in cowardly retreat in the face of an invincible
Israeli army. However, if we look at this event in terms of the instinctive fight-flight
survival instincts, it is completely understandable that an army that was not fighting
for survival would run for its life when it recognised the deadly superiority of its
enemy. There is nothing shaming or cowardly about that; to the contrary, it was the
survival instinct at its best.
On the other hand, the Israeli army, despite its superior training, was fighting for the
survival of its people and country. It had to fight and win—there was no other
choice. But ridiculed as cowardly, the Egyptian army had to return to the battlefield
years later, even knowing it would probably lose the overall war, to save the pride of
its people, paving the way for the 1973 Yom Kippur War. The latter allowed the
Egyptian army to show its courage and valour. Indeed, the Israeli army, lulled by its
supposed invincibility, had let down its guard, suffered heavy losses, and almost
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succumbed. Egyptian president Anwar Sadat was able to reach out for peace from a
place of strength and dignity.
The last Israeli soldiers in Lebanon at the first months of the year 2000, afraid of
dying and wanting to go home, were not cowards, as some in the Israeli media have
suggested, nor had they lost their power as the Arab media wrote. They were merely
in touch with their survival instincts. As long as they believed they were defending
the security of their country, they did not protest and dutifully served, although
soldiers’ lives were lost weekly. Once their government pledged to depart from
Lebanon, they were no longer defending their country but merely sitting ducks to an
ever-emboldened enemy. No one wanted to be among the last soldiers to die in
meaningless skirmishes. They had not lost the will to defend themselves; they were,
instead, asserting their instinct to survive. An accurate reading of their motivations
might have dampened attacks by the Hizbollah, whose leaders believed the Israelis
had left out of fear.
If we apply the trauma vortex to the latest situation between the Israelis and
Palestinians, we can recognise the trauma of both people in action. The Palestinian
trauma is the loss of the 1948 War after the Arab refusal to let foreign powers dictate
the division of Palestine. This trauma kept being re-ignited in the subsequent losses
of the 1956 and 1967 wars against Israel, and the helplessness of being unable to
control their destinies under Egyptian, Jordanian, and Israeli rule. Furthermore their
situation is intrinsically linked to the Arabs’ historical vortex of trauma that includes
domination by the Ottoman Empire and then Europe. It is a trauma of defeat and lack
of control over one’s destiny.
Both the 1987-1993 Intifada and the current ongoing uprising (called the Intifada Al
Aqsa by the Palestinians and the Palestinian terror campaign by the Israelis),
however tragic, may have helped in their own ways to re-establish a sense of pride
and dignity among the Palestinians after such a deep loss of control. Having the
power to inflict fear and losses on a militarily more powerful adversary was
important to the Palestinians, despite serious costs to their own safety, autonomy,
and infrastructure.
It is a perfect example of trauma vortex in action, attempting to redress a perceived
wrong and re-establishing some measure of power and justice. As with all actions
driven in this way, solutions that come from the urge to re-enact lead to further
trauma and destructiveness, not the least the tremendous price of sacrificing their
children’s lives.
Nevertheless, having re-established Palestinian pride and dignity by having been able
to inflict fear and losses onto a much more powerful enemy may allow the
Palestinians to reach for another type of resolution to the political impasse in much
the same way that Egyptian president Anwar Sadat did. With the clear support of all
the world’s leaders for an independent Palestinian state, they may take the lead and
be the ones to offer Israel security and the right to live in peace. Clearly Israel can
and will survive. But whether or not it does so in security is in the hands of the
Palestinians.
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The Israelis’ trauma vortex is somewhat more complex. The still operative
declaration by most Arabs (including Palestinians) of their intent to fight for the
demise of Israel, and a virulent reawakened anti-Semitism in Europe and anti-Jewish
propaganda in the Muslim world have legitimately reawakened the fear of survival in
many Jews in Israel and in the Diaspora.
Furthermore, for the first time in the last 2000 years, the Israelis are able to exercise
their instinct for physical survival. In the past, Jewish efforts have been devoted to
surviving spiritually and morally as Jews were relatively powerless to assure their
physical survival. Today, Israeli society and the Jewish world are split between these
two needs: to recuperate a healthy survival instinct and to maintain spiritual/ ethical
survival, as a people that does no harm to others, that they fought for in the Diaspora.
The 50 year-old impasse between the Israelis and Palestinians has polarised the
Jewish world into two camps, each vying to protect the issue they believe most
relevant. The effect of Intifada II may be to help both of these compelling
preoccupations come together instead of splitting the fabric of Israeli society into
two opposing camps. It behooves everyone truly interested in the well-being of
Palestinians and Israelis to avoid playing on the Israelis’ existential fear. Otherwise
the Israelis, feeling totally isolated and threatened, will keep pushing their
governments for knee-jerk, short-term security measures. Unfortunately, these often
result in prematurely toppling the Prime Minister when a disillusioned populace
becomes disappointed that the measures did not work. No Israeli leader has time to
stabilise his government long enough to search for creative solutions to a most
daunting problem.
A stable and reassured Jewish state might be able to integrate these two main
preoccupations: access to a healthy government with the unequivocal right to defend
itself within the context of spiritual/ethical survival which demands that they care for
and deal in fairness with the Palestinians and the Israeli Arabs. (Israeli Jews know
well what it means to be disadvantaged.) A stable Israel may also have more money
to develop infrastructures for all its citizens and help neighbouring populations.
Understanding the nature of survival instincts, of the impact of psychological trauma,
and of the urgent need to process trauma at national levels can change the direction
of conflicts between countries and inform solutions for peace. Peter Levine travelled
to Washington hoping to warn President Clinton not to return the Serbs to Albania
without some pre-emptory healing efforts first. He did not succeed in his attempts to
reach the President. As he had anticipated, the traumatised Kosovo population,
which had had no opportunity to process its individual and collective Serbian-
inflicted traumas, slaughtered their returning neighbours.
Everyday it becomes more urgent to bring this knowledge to the international
community as the trauma vortices developing before our eyes risk death and
destruction. These vortices are fed by so many confluent winds that they will leave
no place in the world untouched. We all are at great risk. To bypass the terror of
using nuclear power, we have developed ever more sophisticated biological and
germ warfare. Even more lethal, we have developed a communication network that
allows mere individuals to use these biological and germ weapons.
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We all intuit today that trauma is contagious. But governments and media need to
know that the trauma vortex is easily instigated when unconsciously fanned. The
pull of the trauma response is hypnotic. Trauma re-enactments have often spun over
many generations and have made entire nations and cultures act out violently. The
intense feelings that trauma generates, allied with tribal conflicts, ethnic and
religious differences, and threats to national interests, render large social groups
more susceptible to violent, irrational behaviour. Because trauma creates
disconnection, it makes it easier to externalise the “other” and blame him for one’s
unresolved distress. It becomes easy to dissociate from the pain one causes the
“other”. But, in reality, when revenge is chosen as a response, people simply end up
participating in furthering their own traumatisation.
Nations must learn to recognise the presence of the traumatic energy, let it run its
course, and not succumb to the urge to retaliate. Groups caught in the vortex need
help to allay their fears and to focus on how life was before trauma overtook them.
They need to resolve their trauma at the national level. All resources must be used to
prevent panic and despair and curtail the desire for revenge. Witness the government
of Sri Lanka, which ordered the soldiers who were traumatised from fighting against
the fierce Tamils to undergo treatment. They needed support to contain their
traumatic reactions and not take them home. Validation of suffering and grievances
is helpful and a forum to air national distress can be crucial.
What would have happened at the Durban Conference on Racism, Racial
Discrimination, Xenophobia and Related Intolerance if the United Nations leaders
had already understood what the trauma vortex is and what needs to be done to stop
it instead of being pulled by it or being helpless in face of it? For days the
Conference turned into a row over the Middle East, with the extremists Arab
countries attempting to politicise it, delegitimising the State of Israel by equating
Zionism with racism and singling out the Palestinian issue. The 160 delegates had to
meet a ninth extra day, the US and Israeli delegates walked out in protest, and the
leaders of the Conference struggled to stop a conference against racism from turning
into a conference promoting racism.
Both the media and the diplomatic community must become fluent in the language of
trauma and recognise its role in regional and international conflicts. The recognition
of trauma dynamics at play opens the door to a paradigm shift in framing the broader
political issues of our times.
Is There a Collective Trauma Vortex?
Trauma is a universal condition; everyone is vulnerable to it. Cultures pass on their
historical traumatic events through literature and art. Cave paintings depict life-and-
death confrontations with predators. The Bible is full of disaster, violence, and
tragedy, as are the myths of most cultures. In the traditional hero's journey, the
pursuit of an ideal requires the hero to first descend to the underworld, successfully
encounter a dangerous situation, and gain some quality of mastery in order to
survive. Humankind may well be defined by our ability to learn and to tell stories. So
it has always been.
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But something has happened over the last one hundred years to change our
relationship to storytelling. Even early in this century, a resident of a village or small
town might be touched by a few calamities per year—family conflicts or sickness, a
flood, a fire, an explosion, perhaps a few murders or rapes that became public
knowledge, possibly a regional or national conflict that impinged somehow on the
lives of local citizens. People paid serious attention to these events. Newspapers
wrote about them. But such trauma did not make up the majority of people’s reality.
But during the twentieth century, events and information became national and then
global: commerce, trade, politics, technology and communications, war, and crimes
against humanity. We now live in simultaneous cultures in which our stories are told
by global instantaneous media. Crimes and calamities in Istanbul and East Timor are
witnessed and felt in Slippery Rock, Pennsylvania. The media is a mirror. It always
has been. Today it is a global mirror and a magnifying one. However, the media
supplies the vast majority of our collective reality.
The healthy process of dealing with traumatic stories moved from the individual into
a collective trauma vortex. Once the collective consciousness is traumatised, even
those not personally traumatised participate in its effects. Untold millions around the
globe, their number growing every day, share in broadcast trauma. This may well
generate a hunger and a compulsion to repeat and re-enact. In our collective trauma
vortex, too many of us suffer from chronic stress or chronic numbness. As mirror
and storyteller, media members confront in their audiences a rising threshold of
stimulation, sensation, and speed and as they are part of the collective, they are
affected as much as everyone else, if not more.
The Role of the Media
Many media professionals have themselves experienced first hand trauma by being
on the front lines, witnessing war, violence, and tragedy, or, more personally, by
being threatened and beaten or even killed by governing entities angry at their
reports. Also consider the subtle moral and psychological trauma resulting from
being coerced to report only what these governmental entities approve of in order to
have access to information. Some may even suffer from the Stockholm syndrome, in
which, when challenged by the difficulty of handling incongruence, it becomes
easier to adopt the philosophy of the entity that threatens.
As the media reports tragedies, war, and violence globally on a daily basis, it is, in
fact, exposing us to these traumas every day. It can have a central role in educating
the public about trauma, its costs to individuals and society as well as its impact on
political policy nationally and internationally. Reporters can thus be ideally and
uniquely positioned to help us recognise the long-term impact of trauma on
individuals and nations and to play a role in healing trauma domestically and
globally.
The media can reduce the immediate impact of trauma and have far reaching effects
on the physical and mental health of the world because of its capacity to disseminate
information to billions of people at the same time. It can play an influential role in
minimising the impact of trauma by raising political awareness. It is the only organ
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that can put trauma on the global agenda and increase awareness of solutions to heal
it.
Indeed, to effect that healing, we must offer validation of suffering and international
forums for handling grievances. We must help with mediation teams well grounded
in the knowledge of history and cross-cultural understanding. We must introduce
cutting-edge methods of trauma treatment that can be taught at mass levels. It is a
monumental task that can only be accomplished with the help of a media well versed
in trauma. A safer and healthier world will emerge when trauma can be more fully
understood in this context. Trauma specialists must work hand in hand with the
media, to bring this awareness to governments and international bodies, as they
continue to explore trauma’s impact on political events.
The Media and Second Hand Trauma
Second hand trauma, like second hand smoke, refers to the impact trauma has on the
witnesses associated with trauma victims. Also known as "vicarious traumatisation"
or "compassion fatigue", it arises from the simple fact that, in dealing with the fear,
pain, and suffering of traumatised people, professionals and other bystanders often
experience similar emotions and after-effects themselves.
Secondhand trauma is also emotionally contagious. Anyone who comes in contact
with a traumatised person is exposed to possible secondhand trauma, especially those
on the front lines: people in the healing, helping, and protective professions such as
therapists, doctors, nurses, medics, social workers, firemen and police, clergy,
emergency and disaster workers. Police, firefighters, and rescuer workers, already
aware of the impact of secondary trauma, have introduced the practice of debriefing
as an initial attempt to diffuse harmful effects of exposure to trauma. Non-
governmental workers must also become aware of the impact of secondhand trauma
on themselves and their judgement. Working with the victims of trauma in a war
zone can make them easily espouse the polarised beliefs and emotions of its
constituents and lose their impartiality without knowing the other side of the story.
We see the world through the media, which is to say we see it through the lenses of
individual reporters, editors, and packagers of news. What kind of lenses do these
individuals wear? What happens to each of them when they view traumatic events
day in and day out? Is the very lens through which we perceive the world shaped by
the trauma the media reports on? Is not second hand trauma at work with media
personnel too? Just like firefighters and police, print and video reporters, news media
editors and researchers, newscasters, and camera personnel spend much time
covering the fear, pain, and suffering of individuals and groups when reporting on
traumatic events. Consequently, they are continually at risk for secondhand trauma.
Indeed, there has been a growing realisation in the industry that, despite long-held
journalistic tradition, members of the media can hardly operate as impartial
witnesses. They are human beings with their own psyches, emotions, and personal
histories, and they are far from immune to the events they report or photograph.
Perhaps the ultimate argument for a sincere reappraisal of trauma in the news media
is that reporters are themselves suffering from secondhand trauma that is injurious to
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their health. Awareness is growing that covering gruesome stories can create much
psychological stress and that denying or “stuffing” the aftermath of trauma is likely
to cause the stress to build resulting in nightmares, flashbacks, and intrusive images.
Moreover, research shows the effects of witnessing horror can be cumulative. Media
people must be aware of the risks involved in their jobs. They must be encouraged to
seek help when they recognise traumatic symptoms in themselves without risking the
loss of important assignments.
They also must recognise that untreated personal traumas from their past might make
them more vulnerable to biased reporting, job stress, and burnout; that it can
influence their choice of what is newsworthy and their style of coverage. When
journalists truly understand how they are affected by secondhand trauma, they can
recognise how it can impair their ability to represent the whole spectrum of human
experience as they proceed in their work. Having themselves shut down
psychologically, they cannot access their full range of emotions. Trauma is so
arresting that the person’s attention focuses on it automatically, even compulsively.
It is obvious how reporting can become compromised.
There are, however, other forms of second hand trauma with which we must
familiarise ourselves. Trauma’s hypnotic pull explains the public’s drive for
repetitive viewing and the media’s repetitive showing of violent and tragic events.
Audiences who gravitate to extreme programming, who are “glued to the tube,”
hypnotised repetitively by traumatic images are quite vulnerable to second hand
trauma and along with media professionals can be caught in a collective traumatic
vortex.
What to Do About Second Hand Trauma
As the media better understands trauma-based dynamics, it can take action to
interrupt the vicious cycles of trauma related to news coverage. There are
constructive ways in which the media can truly serve the public. If violence were
shown as a public health issue, then audiences would emerge educated, enlightened
and empowered. There are practical ways to do this:
• The media can explain to the public that they must keep reporting the
tragedy so that viewers can tune in at all times.
• They can explain the pull the trauma vortex has on especially sensitive
people and how it keeps them glued to the tube, ingesting the same traumatic
images over and over.
• They could recommend to their viewers to get the information offered and
then turn to other programs or activities that will calm them.
• They could suggest that viewers tune in later for further news and
resources.
In a broader context, media organisations can sponsor well-funded and rigorous
research on the media’s impact on society. They can take a leading role in hosting
public discourse on values and policies. They already hold politicians and public
institutions responsible for demonstrating integrity in their public functions. They
need to develop their own watchdogs for themselves. An excellent example of such
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organisations include the recently created Norman Lear Center, whose mission is to
study the impact of the media on society’s values and the Creative Coalition.
The Media’s Influence and the Copycat Phenomenon
The copycat phenomenon refers to individuals acting out or “copying” a reported
event. There are compelling examples of the effect of copycat phenomenon in our
own media history. We are reminded of beneficial examples from as far back as a
decades old episode of Happy Days. The teenage role model, Fonzi, applied for a
library card, and the following week, thousands of young students got their own
cards. Oprah Winfrey interviews a woman who reveals her sexual abuse as a child
for the first time, and hundreds of women dial for a therapist to process traumas
they’d hidden for their whole lives. Oprah talks to her audience about how a book
revolutionised her life, and the book becomes an instant bestseller.
Alternately, the tragic side of the copycat coin was illustrated right after the news
coverage of the Littleton tragedy. Immediately following the rampage at Columbine
High School, 1,000 bomb scares in Mexico and hundreds of copycat threats and
some actual occurrences popped up in the United States and Mexico. The same held
true after the first anthrax letters were discovered.
When the media is blamed for the results of a copycat crime, it may rightly become
defensive, fearing legislation, legal sanctions, or a limiting of freedom of speech.
With a few exceptions, confrontations and counterattacks rather than communication
and problem solving have been the norm between the media and its accusers.
Responsibility needs to be shared by all: the media, the government, and the general
public.
Consider how the presentation of events can inspire copycat phenomenon. CNN
shows excited and angry young Pakistanis joining the Taliban in Afghanistan. They
also show a demonstration of a few thousands Pakistanis against their government
for its cooperation with the America. These images typically increase a sense of fear
and anxiety in the West. But more seriously, they may also incite many Muslim
young men, offering excitement and a “raison d’être” they might not find elsewhere
in their lives, to join the fight, influenced by what they see on television.
One possible way to counteract these images may be to put their numbers in
perspective and show in the same report or soon thereafter the millions of Pakistanis
who do not think joining the Taliban’s war is a good idea. Programming can include
calls of religious leaders cautioning their youth against this influence, or mention
casualties that have already occurred among the Taliban and their allies.
The media has been seriously concerned with the copycat phenomenon and is
attempting to address this issue. This is an area where collaboration with
psychologists and trauma specialists is of crucial importance. For example after
September 11, the media set up a forum for intelligent discourse, analysing all the
elements involved in current terrorist activity: the ideological reasons for it, the
cross-cultural nature of the conflict, the effect of our responses, and the public’s
reaction. It helped the public by televising dialogs on the possible triggers
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surrounding the attack. Adding the trauma and mass psychology angle as an
influence on the copycat phenomenon can shed further light.
It is particularly crucial now to be aware of the copycat phenomenon on the
international scene regarding the behaviour of groups and nations during the current
political events. The searing images of the collapsing Twin Towers repeated over
and over and the later ongoing threat of anthrax and biochemical terrorism brought
home to Americans feelings of helplessness and deep worry that their country has
been weakened. However, these repeated images can drive the picture of a
vulnerable America deeper into their adversaries’ psyches, and inspire more
terrorism as it reinforces the terrorists’ sense of power. We have already seen the
media utilise discernment regarding how adversaries and the public may react to
certain data and the way it is delivered. Cooperation with our government’s request
to limit Bin Laden’s airtime was well received. Is there more that can be done?
A recent and hopeful example of collaboration is the London Conference, organised
by the BBC World Service in partnership with the Dart Center for Journalism and
Trauma. More than 60 journalists, psychotherapists, editors and journalism educators
from Britain and the U.S. met to discuss new ways to support journalists who report
on traumatic events. It is the beginning of a more elaborate dialogue to better serve
the public.
The Accusation of Sensationalism
“It seems to me that we make money out of exploiting suffering. We package
trauma,” said Akila Gibbs, a journalist I interviewed. Though she thought the media
would be reluctant to change, she also acknowledged that it had often recognised and
mirrored necessary changes in society. Certainly, after September 11, both news and
entertainment media are more aware of trauma and its impact and much more open
to the possibility of playing a crucial role in the recovery process.
The traumatic shock of the attack is a clear example of how widely and immediately
trauma can affect hundred of millions at once. This traumatic shock seemed on the
verge of turning into a traumatic vortex that could well engulf the whole Islamic
world and consequently the planet. Instinctively, the American and the international
media responded well. If the media had focused only on the Americans’ angry
response, they would not have helped the public place it in a larger perspective of
further stages of resolution. The anger phase could have spread like a virus and could
have manifested with angry policymakers, supported by an enraged public,
determining premature or inflexible military actions. It could have spun further into a
larger trauma vortex.
As it is, the media acted responsibly and addressed the different quandaries reflected
in the population. It focused on anger, but also on the determination and courage of
the American public, its soul searching and its intent to protect civil liberties and
religious freedom, including the well being of its Muslim population. It is apparent
that the media is the entity that can carry to the public a comprehensive
understanding of the different stages of traumatic responses and how to cope with
trauma.
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It is vital for the media to bring the same care of wider perspective and complex
coverage to other traumatic situations in America and elsewhere. It would have been
irresponsible and downright self-destructive to fan the home trauma. The same sense
of responsibility and self-preservation needs to be brought in covering other
tragedies. The world is so interconnected that every tragedy reverberates
everywhere, even when it doesn’t seem to impact us. In covering war in other parts
of the world, we must understand the inadvertent capacity to incite more violence
just by the media’s presence, not to mention the fuelling of violence when coverage
is lopsided.
The Dangers of Subtle Manipulation
During the Gulf War, Iraqis watched CNN reports to get information on the fate of
their own country. Today, many countries have their own well- organised media. The
governments of some countries have been and are presently using the press for
indoctrination and the promotion of a spirit of war. The international media can be an
unwitting participant even with “objective” reporting when indoctrination media is
unidentified and is reported as news only. The press must be aware that it can be
subtly manipulated to further the promotion of conflict. One must be keenly
conscious of the total impact of whatever is reported. Today, nothing falls on
objective ears. Furthermore, this kind of awareness may help the international
community warn and put pressure on the countries where indoctrination is taking
place.
Nations in conflict escalate the trauma vortex by continuously running on television
traumatic images from the past or the present. Recently, Arab television even
showed fabrications of traumatising images in order to incite hatred—scenarios of
Israeli soldiers raping Arab girls or throwing poison-laced candies to Arab
youngsters. The reporting of unchecked pronouncements of hundreds of people
massacred in Jenin by the Israeli army, served to further polarise public opinion in
the Arab world and encourage stabbings of Jews around the globe, acts of arson and
desecration of Jewish property and cemeteries. The Taliban showed Americans
throwing food packages laced with poison to Afghani children. Some Arab leaders
exacerbate the trauma of their people to encourage a more fundamentalist outlook.
The leaders themselves are driven by unresolved previous personal, cultural, or
national traumas into an apparently distorted interpretation of their Islamic values.
The Media’s Opportunity in the New Millennium
Clearly, the media has the power to stir up passions. It has long been used as a
vehicle to mobilise people around an issue, be it American newsreels rallying
concerned citizens during World War II, the German media rallying Nazi
sympathisers to the Third Reich, or Al Jazeera rallying the Muslims around the
world. The media is the most powerful force in shaping the world in the twenty-first
century. It is more influential than ever: information is now instantly accessible to
the entire world, seven days a week, twenty-four hours a day. The capacity to
televise anything live from anywhere has changed the impact of information. Critical
though this change may be, we may not have slowed down long enough to analyse
this shift or evaluate its effects.
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The media’s challenge in the new millennium is as follows: if coverage of trauma

helps to “normalise” violence, then coverage of our collective healing capacity could
normalise harmony. Members of the press can take on leadership roles that support
the best values of our society in unprecedented ways. The media determines what the
general public will see, and it knows how to use the power of suggestion. It can
reflect society in ways that foster well-being by covering tragic events in the context
of the healing vortex. For instance, when the press focused on people in New York
helping each other instead of dwelling on looters, it demonstrated its capacity to be
guided by the healing vortex. If this becomes a voluntary policy, such a visionary
role can interrupt the cycle of trauma and violence and create meaningful bonding
and loyalty between the media and its public.
The media can further counteract the pull of the trauma vortex by consciously
tipping the scale towards the coverage of positive and uplifting events. It can
collaborate with trauma specialists to develop models and test strategies on how to
inform the public with as little secondhand traumatisation as possible. We can align
visionary professionals in both fields to work together on transforming the media’s
impact on society in relationship to trauma.
If the threat of a Third World War is looming, much of it might be fought through
the media. This implies an involvement that was not part of the media’s original
mission—to report objectively and to inform the public about world events. The
media’s added task might be to counterbalance the effect of unwittingly amplifying
the trauma vortex sometimes just by its coverage (like in scientific research, the
media is the observer that changes the object of its observation), as well as the effect
of state-run media in non-democratic countries exacerbating and inciting trauma.
As of this writing, there is no clear picture of the impact of the copycat phenomenon
on this critical situation. Therefore, it behooves us to look carefully at all the issues
that may negatively affect an already aggravated public. It is crucial to engage our
best minds including media trendsetters in a comprehensive analysis of the
phenomenon, so that more destruction does not take place. Transcending politics, the
media must become a healing force by addressing the impact of trauma on society as
well as on international politics. At the same time, it might be in the position to
engage in constructive countering of the trauma vortex and emphasising the healing
vortex.
Consciously searching for, empowering, and supporting the voices of reason and
moderation that now have a timid presence in the majority of the Arab world would
be a clear example of encouraging the healing vortex. Other efforts could include
recognising cultural traumas and validating grievances without indulging in the role
of the victim. Specialists in trauma, in the psychology of human behaviour, in
mediation and cross-cultural awareness can clearly be of help. This type of
collaboration may change how things have been done until now.
Our Hope: The Healing Vortex
What is most energising about trauma, paradoxically, is that its healing is
transformative for the individual as well as for society. Knowing how unresolved
trauma engenders pessimism, cynicism, despair, and paralysis of the will, on one
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hand, and desperate and uncontrolled acting out, on the other, we can understand
how healing opens the door to hope, optimism, and the desire for creative action.
The capacity to heal is always present and accounts for humanity’s remarkable
resiliency. Given the amount of traumatisation, neglect, and strife in the world, it is
amazing that people do so well. But often, innate healing does get blocked when
unresolved traumas trigger a downward spiral. We need to respect and work with
our physiological and neurological patterns in order to restore the healing capacity.
In the last several years, the scientific community has developed a number of
methods to release and master traumatic events, memories, and patterns, such as
Somatic Experiencing, Prolonged Exposure, Eye Movement Desensitisation and
Reprocessing, Thought Field Therapy, Traumatic Incident Resolution, etc. With
these proactive interventions, trauma's momentum can be reversed and the equally
dynamic upward cycle generated. These techniques can help develop resiliency from
trauma, a task crucially needed in the immediate future.
The only way to reduce our individual and societal traumatic legacies is to transform
them. Levine’s ‘healing vortex’ is really just a transformative process. Immediately
after a traumatic event, the swirling motion of the trauma vortex is immediately
counteracted by its opposite, the motion of the healing vortex. But because our
bodies and psyches have been overwhelmed with so much collective trauma this last
century, we need more awareness to help activate the innate healing vortex. To
remedy this problem, we must learn how to reconnect to our animal instincts. We
must restore the body/mind connection. We can do so by being fully aware of the
sensations in our body and by using our intelligence in a compassionate way.
Witnessing what’s going on with us at the sensation, emotional, thinking and
behavioural level, allows our body to return to the natural cycles of trauma and
healing, to our natural capacity to cope with tragedy. When we regain this balance,
both personally and collectively, we can then hope of bringing our children into a
safer world.
Bruce Perry, professor of child psychiatry at Baylor University School of Medicine
and author of Maltreated Children, points out that humans evolved through
community. This is a critical piece of information. The biology of the brain is
designed to keep small, naked, weak, individual humans alive by being part of a
larger biological whole—the family, the clan. We survived and evolved
interdependently with one another—socially, emotionally, biologically.
The participation of one’s community is fundamental to the healing of trauma. An
example still fresh in our minds is of New Yorkers, who astounded us as well as
themselves with their deep well of compassion and resources shown after the attack.
And the media chose to broadcast this very wonderful humane side of humanity so
that the rest of us could share in the feelings of healing in community.
The mass media has enabled change to occur in the way people in many nations
think and act regarding race issues, gender differences, and the environment, to name
a few. In the United States, great educational strides have been taken against drunk
driving, unprotected sex, and smoking. Society has a huge reservoir of healing
efforts with which the media can and does collaborate to make information available.
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Specific Ways the News Media Can Help

When the media develops an accurate understanding of the patterns of traumatisation
and the pull of the trauma vortex, it will recognise that an emphasis on the violent,
the abnormal, and the tragic is an understandable but dangerous manifestation of the
trauma vortex. They will see its relentless pull in conflicts and war between tribes
and nations and how it affects both selection and delivery of news. They will add to
their coverage the awareness of this pull. They will add the attempts of people and
institutions to work with the healing vortex. This new perspective can foster an
organic and balanced shift in the media’s coverage of events as well as in the
creation of entertainment.
There are simple but specific changes in news coverage that have the power to bring
about a healthier society. This can be done by:
1. Inserting healing images along with the coverage of traumatic events.
2. Becoming aware of the “tunnel vision” of a trauma-saturated perspective.
With an understanding of the trauma vortex, the media has the opportunity
to balance the effects of tragic stories. A heavy focus on negative news
unwittingly reinforces people’s fears. At any given moment, there are
endless examples of violence and catastrophes to cover as well as endless
examples of courage and resiliency. Assess whether a news item is likely to
add to the well-being of society or worsen it. A choice of what to cover is
taking place anyhow. Questions to ask: Which events should we choose?
How many of each kind? What are the criteria? Does the public truly
benefit from this piece of news, rather than this other one? Does it serve the
trauma or the healing vortex?
3. Recognising and analysing the copycat phenomenon with the help of
psychological researchers. Consulting the therapeutic community on how to
present tragedies in a manner that does not feed the copycat phenomenon
might have helped in the aftermath of Columbine, for instance. (This would
include neither disclosing the identity of the perpetrators, nor giving air
time to their distorted messages).
4. Warning viewers of upcoming disturbing images. Besides children, older
people and many sensitive women do not turn on the TV for fear of seeing
traumatic images. Suggesting to them to take the bad news in small doses
and engage immediately thereafter in a calming activity that helps them
relax, an activity that is a resource for them.
5. Blacking out gory details such as remains or disposal of bodies, visual
evidence of brutality, instruments of torture, etc. We routinely bleep sexual
and curse words. We could readily obscure gory details once we
understand how disturbing their effects are on children and sensitive adults.
6. Avoiding incessant coverage of events involving violence or tragedy and
repetitive showing of disturbing images: the repetition drives the image
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deep into the psyche and exposes people to flashbacks and obsessive
thoughts.
7. Warning viewers that incessant watching could be disturbing. For instance,
one station decided not to cover the Littleton, Columbine tragedy until
11:00 p.m. to mute its impact on children. That is a perfect example of
sensitive and responsible coverage. Consider this situation: a four-year-old
boy, watching the Columbine shooting being shown over and over thought
that kids were shooting other kids in many schools, not understanding his
station was rerunning the same tape. A car chase reported on the 6 o’clock
news ended in the chased driver killing himself, live on television. Some
news stations, shaken by what happened, decided to allow a few second
intervals between the live shooting of a scene and its transmission, for fear
that this kind of traumatising occurrence might happen again. It is true that
it is up to the parents to choose what their children watch, but the first
evening news is broadcast during family hour, and the media and the public
must be made more aware of children’s vulnerability.
8. Informing viewers of the help available while the tragic events are being
reported. Many children have watched images of fire and felt desperate
because nobody seemed to be doing anything about it. Scenes of firemen
putting out the blazes would be helpful here.
9. Recognising that the observer of any event becomes part of the event (Niels
Bohr’s theory). Media people, as observers of society, influence it just by
the act of observing, and more significantly, the act of reporting. They must
reassess what they think of as objectivity.
10. Avoiding reporting speculation and rumours that can cause anxiety and
provoke erroneous conclusions that are much harder to dispel. Clearly many
media members have made real efforts in this regard lately. But the pressure
is great to deliver cutting-edge news, and the damage done by speculation
can be shattering.
11. Understanding the vulnerability of victims and avoiding unnecessary
broadcastings of details that embarrass, humiliate, or hurt victims of crime.
Victims’ lack of privacy destabilises the privacy and sense of safety of all of
us. Do we really have the right to know everything about a person in the
public eye, even if this piece of information does not add to our lives, but
creates havoc in the person’s life? Ted Koppel, in his “Sixty Minutes” show
aired on January 15th, 2002, accused the press for unnecessarily revealing
the drug problem of the English Prince. Did the information help the public
or did it create unnecessary pain and shame in the targeted people?
12. Checking the tendency to look for spins on coverage to keep a story in the
news.
13. De-emphasising the cult of celebrities, specially the ones who act out or
commit crimes or violence. Too many celebrities and political figures are
left unscathed by their behaviour and this serves as examples of impunity.
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14. Withholding the identity of perpetrators to deprive them of their “fifteen

minutes of fame.” Too often, they are allowed to pronounce their
destructive messages. The public is ready for more upbeat reporting.
Witness its positive response to the firemen in New York as heroes.
Specific Ways the Entertainment Media Can Help
The public is angry. Much data has been compiled on the effects of entertainment on
violence, especially among young children. Numerous parental organisations as well
as health and government agencies have accused the entertainment industry of being
the source of the violence that exists in our society. Unfortunately, the entertainment
industry also focuses on trauma and violence as subjects for creativity. Targeting a
society of "channel surfers," it can inadvertently spread the impact of trauma.
Shifting the perspective toward the healing vortex can be accomplished by:
1. Recognising that ratings alone, important as they are, cannot be the bottom
line. Luckily the public seems ready to cooperate. Changes in programming
do not need to affect the earnings. On the contrary, today many people turn
off violent programming. The entertainment industry could create more
characters and stories showing helpful and inspiring behaviour and events,
including more effective ways to address violence, cruelty and evil.
2. Portraying violence in a manner that does not encourage it. For instance,
programs could show the public the consequences to the perpetrators of
violent acts, as well as the physical suffering of the victims. This also means
avoiding violent behaviour where the consequences to the perpetrators and
the victims are not shown. When neither regrets nor grief over violent acts
are expressed, this negatively influences impressionable and troubled
people.
3. Avoiding violent scenes which include: a clear intention to harm or injure;
portrayals of physical and verbal abuse; violence that leaves the viewer in
an aroused state; violence that is uninterrupted and not subjected to critical
commentary; violence portrayed realistically. All of these scenarios
influence the viewer already predisposed to act aggressively.
4. Avoiding portrayals of well-intentioned heroes who use violence and
aggressive behaviour that seem justified. Children are highly influenced by
the actions of characters they can identify with and by violence that has
cues similar to ones in real life.
5. Understanding that humour combined with violence trivialises viewer’s
perception of the violence and its consequences.
6. Promoting people that show courage, dedication, and heroism as having
both entertainment and news value.
7. Telling stories with a healing reframe and showing how people have
successfully recovered from tragedies.
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8. Promoting stories that encourage connections between people and their

communities.
How Do We Activate the Healing Vortex?
At the political level, the media can help bring forth resources and validate
people’s historical traumas. They can help people reframe the underpinnings of
violence and horrors committed as a trauma vortex spiralling out of control instead
of demonising nations and individuals or calling them evil. The media and the
international community must understand how the media can unwittingly (and in
state-run media not so unwittingly) amplify the trauma vortex. International
institutions and governments interested in helping must make judicious use of the
media to engage the healing vortex, instead of feeding the trauma vortex.
The media can encourage the healing vortex by:
• Reporting on healing rituals for collective mourning such as community
vigils, contributions of time, money and goods to help victims,
acknowledgement and rewards ceremonies, appreciation of heroic deeds.
• Reporting national, cultural and historical celebrations.
• Promoting the healing arts (music, dance, poetry, literature, theatre, movies)
• Giving information on mass healing techniques.
• Helping people understand the concept of resources and its importance in
helping us become more resilient in coping with trauma and preventing trauma.
We call a resource any belief, activity, place, person, characteristic or object that
allows a person or group to calm down, feel stronger and more empowered, that
brings the community together and that does not rouse negative passions.
Individuals and groups can be directed to engage in as many resources as they
can--nature, poetry and literature, singing, dancing, prayer, hobbies--to explore
their cultural strengths, their ethical and moral values, and to enhance the
capacity for acceptance and forgiveness of which all cultures are capable in
times of tranquillity.
• Teaching people how touch and hugging can help heal trauma. Touch is
therapeutic. It is received as a healing message by the primitive brain (brain-
stem response). People can be encouraged to hold hands, rock, sing in sadness
and mourning, as well as in relief (music healing). We do not want to take away
the enormity of the sadness. We just need to acknowledge that we are still
horrified by what we had to do.
• Reporting innovative trust-building measures such as babies-mothers-
blanket exercises in which mothers from rival groups put their babies in the
same blanket and swing and rock them while singing ethnic songs from both
groups.
• Helping national or ethnic groups recover pride in their identity, focus on its
positive aspects and help identify the negative ones.
• Helping the public reframe rage, the desire for revenge and violence as
understandable attempts to redress wrongs that nevertheless backfire and further
their victimisation. Though valid, these defensive responses also create and
perpetuate their own guilt, as we do know deep inside when we are betraying
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life. (Remorse is connected to the instinct to love and we all have the instinct to
love.) Because guilt and remorse are painful, difficult feelings to experience,
they further compel us to demonise the other in order to justify our
destructiveness. It is thus easier to convert these feelings into further righteous
hatred and violence. We are impelled towards more polarisation in order to
justify our actions; all of us feel the horror of killing even if we believe we must
do it.
The media can help translate these deep psychological insights and help us
acknowledge, expose, and process the complexity of our inner world. When we feel
hurt and violated, the desire to destroy and harm is normal, but we also must
acknowledge the horror and damage of polarisation. Only then can the healing start.
Indeed, the media must report stories that serve the healing vortex. One Arab
restaurant was bombed because it was assiduously frequented by Israeli customers.
The Arab owner vowed to keep the restaurant open and serve the same clientele
because he wanted to serve peace and not give in to violence. Another Palestinian
refused to put a mark on his car identifying it as belonging to an Arab so that he
would not get shot at by Palestinian youth. He did not want to do anything that
would encourage discrimination. For every story of negligence, abuse or violence,
there are dozens more that show courage, caring and commitment for co-existence.
These are the stories that can help people come out of the trauma vortex and start to
trust each other.
Summary
As the media’s role has expanded, its responsibility has expanded. As we recognise
the powerful influence of the mind, the media’s responsibility to incorporate that
reality fully into its presentation also expands. This is an invitation to put trauma, its
impact and healing on the global agenda and to bring awareness to the effects of
instantaneous communication.
The media mirrors society and society mirrors the media. This interrelationship takes
on a more pointed meaning when related to trauma. Media members, trauma
researchers, and clinicians are invited to engage in a dialogue on the expanding field
of trauma knowledge. The media are the eyes, ears and voice of our collective body.
We must trust them and help them to serve us well.
Bibliography
Ross, G. (2003). Beyond the Trauma Vortex: the Media's Role in Healing Fear,
Terror and Violence, Berkeley, CA: North Atlantic.
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The Development of CIPR Debriefing in Israel
Mooli Lahad & Alan Cohen
Introduction
The concept of Critical Incident Stress Debriefing (CISD) for emergency service
personnel was originally developed by Jeffrey Mitchell (1983) to assist crisis response
teams to handle the psychosocial effects of the traumatic incidents they encountered in
their work.
Debriefing itself is not a new idea and forms of what we call “debriefing” have been
common for a long time (Tehrani 1998). Soldiers after particular missions would be
debriefed by their commanders and whilst recounting technical details they would also
add personal elements to the telling. With rescue teams, the “chaps” at the station
would get together and discuss what they had been through over a pint of beer. Those
with sympathetic ears at home (or with a family eager for gruesome detail) would
recount the ordeal of that tough day’s work. However, due to the lack of consistency in
this method, a more certain approach of team debriefing evolved.
It was clear that according to early studies (Mitchell, 1983a; 1983b) that these response
teams were benefiting from structured interventions and that they were helped in
returning to work and sick leave was reduced. This was also found to be true in the
case of other homogeneous work environments after critical incidents such as bank
staff after robbery (Leeman-Conley, 1990).
Our interest in debriefing at the Community Stress Prevention Centre stems from the
early years of the centre’s activities and correspondence with Dr. Mitchell in the mid-
1980s. What interested us was whether the principles applied to the traditional
debriefing activity were valid for groups other than rescue service teams such as
children, random individuals involved in a terror incident and groups with differing
degrees of proximity to an incident. Before trying to answer these questions let us
examine the nature and process of debriefing.
Psychological Debriefing
The term “debriefing” describes a group procedure that takes place after a critical
event. Its aim is to protect the mental health of those who were involved in that
incident: victims, members of their family, friends and peers, and helpers such as
rescue workers, ambulance and medical staff, policemen, social workers.
Wraith (2000) distinguishes among the concept, the process, and the techniques of
debriefing. As a concept, debriefing provides an opportunity for the sequential
recognition and validation of feelings and behaviours concerning the event. It is offered
as a structured way to elicit the personal story of the experience with an emphasis on
sensory perceptions (sight, smell, sound, touch, and taste), thoughts, feelings and
behaviours experienced during and shortly after the event. These are shared with others
in the “shared fate” small group, composed of people with similar roles (e.g., helpers)
and/or similar traumatic experience, under the common conviction that any response to
the disaster is accepted and normalised through the group sharing process.
As a process, debriefing is geared towards engaging victims and helpers in integrating

their bizarre and shattering experience into a cohesive cognitive, emotional, and social
frame; in other words, the goal is to help group members find meaning and order in a
chaotic and unexpected life experience. Dyregrov (1999) emphasises the importance of
exploring process issues in the group, which has to do, in large part, with finding ways
to express the inexpressible, communicate, listen, and give and receive acceptance in
the group.
The debriefing technique, initially developed as a group-work protocol, “defines rules
about leadership, venue, timing, confidentiality and the progression of stages within a
complete session” (Wraith, 2000, p. 199). It relies upon a chronological approach for
addressing the crisis event step by step. The facilitator asks the participants to remember
what happened to them at the time of the trauma, what happened in the aftermath, and
what they expect to happen in the future. If the trauma is particularly severe, it is
recommended to pace the group session slowly, as a protective device against the
danger of flooding participants and overwhelming them with their intense feelings. 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?” thus
creating an anchor in the continuity of the pre-disaster period.
Debriefing is neither counselling nor therapy. In other words, this procedure is not
intended as a cure! Rather, debriefing is used to provide group members with an
understanding of initial trauma reactions, to increase their sense of personal control,
and to use the group for support. Thus, debriefing cannot always prevent post-traumatic
symptoms, but it can help traumatised persons accept and understand their meaning,
and take additional action if necessary (Ajdukovic & Ajdukovic, 2000). If at all
feasible, participants should be observed for some time after the initial debriefing
encounter, and offered other interventions, such as counselling, when the need arises.
Such recommendations help participants who may not be aware of the later
consequences of the trauma to access other forms of psychological assistance. For
family members who do not participate in the actual debriefing session, they need to be
informed, either by direct contact or by written letter, of the possible effects of the
trauma and the help available. It is possible to hold separate meetings with family
members to help them help the traumatised member (Hodgkinson & Stuart, 1998).
Practical Considerations in Setting up Debriefing.
The debriefing procedure should be carried out as soon as possible after the disaster, as
details of the incident tend to fade away and become distorted. Proximity to the site of
the incident is often sought, but safety is an overruling consideration. If the area of the
disaster is not safe, debriefing needs to be conducted in a place removed from the
dangerous area.
Those who conduct debriefing must be well trained and skilled in group facilitation,
interpersonal communication, and trauma management. They need to be able to contain
the stress, fear, anger and mourning responses of their traumatised participants. It is
best to have two facilitators, no matter what the group size is. The facilitators should be
able to create an atmosphere of trust and support for all group members. They are
expected to be able to identify those participants who show excessive signs of
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suffering, either by expressing or by suppressing their feelings, and who need

individual attention and further treatment.
Wider Applications of Critical Incident Stress Debriefing
The original CISD protocol with seven phases covering most aspects of the encounter
with the disaster (Mitchell, 1983) yielded promising results as far as helping rescue and
other helping personnel to deal with their preliminary reactions to traumatic events
(Pynoos, 1993; Robinson & Mitchell, 1993). Mitchell (1983) found emergency workers
to be resilient, self-selected and accustomed to trauma. They have developed unique
coping methods and make excellent use of informal supportive groups. However, since
its application to non-helpers and by non-professionals, CISD has generated much
criticism. For example, Raphael, Meldrum, and McFarlane (1995) suggested that a
single session with victims might sensitise them to the horrors of their experience
rather than support them, and in some cases worsen their condition. In the Cochrane
Report (Rose et al 2001) “No current evidence that psychological debriefing is a useful
treatment for the prevention of post traumatic stress disorder after traumatic incidents”
was indicated.
Dyregrov (1999) found that lack of appropriate training of non-professional
facilitators was at the root of inadequate CISD, with 3-10% of participants rating it as
unhelpful and even harmful. Based on their review of a large database of CISD studies,
Everly and Mitchell (2000) concluded that most CISD criticism is based on practices
that did not follow the rigorous procedures and criteria of the original Mitchell model;
for example, single sessions were held with no follow-up, encounters were too short or
groups much larger than recommended were formed.
In a trauma practitioner survey of 32 professionals in UK, Israel, South Africa and
USA (Galliano & Lahad, 2000), conducted by face to face or telephone interviews of
45-60 minutes in duration and focusing on key standards/practice issues raised by
literature review, 27 out of the those questioned were concerned about the risk of re-
traumatisation.. It is clear that in the case of terror attacks it is unwise to place people
who were direct witnesses together with those who were further away and did not see
horrific scenes in gory details.
Other major concerns of the surveyed practitioners were: The lack of a standardised
model of debriefing; poor or inadequate training of debriefers; the fact that the timing
of interventions was not standardised debriefers and an inadequate number of
interventions used.
Although recent evidence points to the efficacy of CISD (Deahl, Srinivasan, Jones,
Neblett, & Jolly, 2001; Irving & Long, 2001; Smith, 2001), the debate points to the need
for a revised protocol, one suitable for victims of all ages, and particularly for children
(see addendum).
A Revised Protocol for Current Israeli Reality
The mental health services are expected to “do something” after a critical incident, be it
an explosion, suicide in a school, a building collapse or a terror attack on a town or
village. When this “something” is available in a neatly packaged form of a debriefing
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protocol then it is very tempting to use the material as is. This availability easily
accounts for many cases of inappropriate use and incomplete implementation of the
debriefing procedure. Even when the major pitfalls are avoided by employing only
suitably trained staff, limiting the size of the group and insisting that there be a follow-
up meeting, there still remains the problem of the often heterogeneous nature of the
group to be addressed. Our research looked at some of these issues – is there any effect
of the age, marital status or educational background of the participants on the
effectiveness of the procedure? Is debriefing better suited for one type of event – an
accident as opposed to a terror attack for example?
Psycho-education (Lahad & Cohen, 1998) is one of the major aims of the debriefing, to
encourage the participants to gain new information about their own particular critical
incident, the nature of trauma in general and what specifically to do about it.
Another central point emphasised in our facilitator training is the concept of bridging
continuities, before and after the incident. Particular stress is placed on finding out
“what helped”; clarifying the coping resources utilised by some of the participants and
proffered to others in the course of the session. An additional, important factor is the
availability of individual attention from a trained professional following the session
often as a suggestion from the co-facilitator who has had more opportunity to observe
the participants in the course of the debriefing.
These principles guided us in our decision to be flexible with certain types of
population in allowing accompanying family members to be present at the debriefing
This flexibility also extended to allowing organised interludes for drinking or smoking
rather than insisting on an uninterrupted session. We have discussed in the past (Lahad
& Cohen, 1998) the truncation of the seven phases into five phases which include three
rounds of participant involvement with a further option of adding comments at the end
if time allows.
The five phases we recommend in our guidelines are:
1) Facilitators’ self-introduction, presentation of instructions and contract,
2) The facts phase,
3) Emotions, thoughts and sensations,
4) The resources mobilised so far – summarised by the facilitator according to
the BASIC Ph model,
5) Psycho-education on symptoms, other relevant information and fixture of
next meeting.
One on one consultations are also available for all those wishing to speak in private
with a trained professional either to clarify a particular matter or to arrange an
appointment for a longer meeting.
Other refinements to the overall procedure include corridor support for participants
who are overwhelmed during the session, support for relatives of the participants and
limiting the number of participants in the group to ten. There is a telephone follow-up
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between the first and the second meeting. This combined approach has been termed
CIPR – Critical Incident Processing and Recovery (Galliano & Lahad, 2000).
Research
Before the debriefing takes place we request participants to fill in an “Impact of Event
Scale” (IES) questionnaire (Horowitz et al 1979). Following the session they are asked
to fill in a further questionnaire giving feedback on the various components of the
debriefing procedure, whether they helped them (and to what degree) or were
detrimental. We also ask for some basic biographical information. Ideally this would be
completed after a few days allowing the participants to take stock of the changes and
return it by post. (This was in fact the case with the Jerusalem debriefing, all replies
were returned by mail one to two weeks later). This however, reduces considerably the
response rate. Another possibility is having the telephone follow-up ask all the
questions, rather than enquire in general terms as to the wellbeing of the participant.
The questionnaires did not require personal identification of the participants.
In examining the feedback questionnaires we were interested in a number of issues.
The questions themselves could be divided into four groups, roughly parallel to four
coping modes in Lahad’s (1997) integrative coping mode (BASIC Ph). The four
categories were Social, Affect, Cognition and Beliefs/values. We were able to measure
a degree of validity for the questionnaire by comparing answers within each group – a
high degree of correlation on questions of the same sort indicating high validity. We
then investigated any links between the biographical data and coping modes. We also
compared between groups of people were involved in four separate incidents to see if
there were any large differences between the groups. The incidents in questions were:
1) a suicide bombing in a Jerusalem street, 2) a terrorist attack on a village in the
Jordan valley, 3) a suicide bombing on a Tel Aviv bus and 4) terrorist gunmen attack in
Bet Shean.
Results
Table 1. Level of helpfulness of CIPR – mean score
Question Mean Standard N
Deviation
Q1 – How much it helped being together with people 5.02 1.27 45
who have been through same experience
Q2 – Contribution of how facilitator related to what 4.44 1.53 45
you said
Q3 – Contribution of how facilitator related to what 4.76 1.28 45
others said
Q4 – Contribution of information added by others in 4.71 1.41 45
the group
Q5 – Contribution of hearing how others 5.24 1.07 45
reacted/thought/felt
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Q6 – Contribution of telling group how you 4.86 1.23 45

reacted/thought/felt
Q7 – How much it helped hearing others in the group 5.36 0.82 45
saying what helped them cope
Q8 – How much it helped telling others in the group 5.30 0.88 44
what helped you cope
Q9 – Contribution of information added by facilitator 5.33 0.97 43
about physical and mental reactions after such an
incident
Q10 – Contribution of taking part in meeting to your 4.88 1.03 41
coping
Q11 – How much the meeting contributed to feeling 4.07 1.31 41
better
Q12 – Contribution of meeting to feeling connection 4.25 1.23 40
with others in the group
Q13 – Would you recommend this type of meeting to 5.51 0.68 41
others who have had similar experience
Q14 – How much you feel the need for another such 5.00 1.08 42
meeting
Question responses:
1 – Was harmful; 2 – No help; 3 – Helped a little; 4 – Helped; 5 – Helped a lot;
6 – Exceedingly helpful
The total number of subjects (N) for this study was 45.
Average age 37.8, SD 13.3, 16 males, 24 females, (5 did not respond).
Average education 12.2 years, SD 2.5. 29 married, 9 single, 2 widowed.
In all cases, participants registered in the Moderate or Severe range on the IES
following the incidents in which they had been involved.
Correlation (Pearson, 2-tailed) between groups of questions from the same coping
category was significant (p<0.05).
There were no significant differences between the four groups (the different incidents
in which the participants were victims).
In general there was an across the board positive response to the debriefing session. An
average response on questions between 4-5 corresponded with the report that that
particular item was helpful somewhere between an intermediate degree and to a large
extent. On cognitive items as a group and belief/values items the contribution of the
session was rated between helpful to a large extent and extremely helpful.
122
Discussion
The overall aim of this survey was to gain an impression of the impact of CIPR on the
victims of acts of terror. Within the limitations of this survey which we shall shortly
discuss, the following outcomes were clear: that even though certain people related that
certain items were not helpful or were even deleterious, the total average result was one
of satisfaction and improvement on all the measured categories. This is particularly
encouraging from the Jerusalem group as they responded by post some days after the
session.
Some interesting and significant correlations were revealed when looking at the group
as a whole.
A) With increase in age of the participants there was a reported decrease in
being helped by the emotional (Affect) components of the debriefing.
B) Reported help as a result of the session also decreased with age.
C) Information (Cognitive) as a source of help also decreased with age.
D) With increasing age participants felt more connected to others in the
group as a result of the session.
E) Men were more likely than women to report a significant improvement on
cognitive, social and emotional scales (in that order).
F) The facilitator’s relation to the group was significantly more helpful to
married participants than singles.
In many researches men are shown not to exhibit emotion or share their feelings. Here
we see that they are prepared to do so and even report improvement to a significant
degree more than women participants. All four modes of coping represented in the
questionnaire were declared to be helpful with cognitive input generally being graded
by participants more helpful than emotional expression.
Age seems to be related to reported benefit from the session but further examination
will be necessary to determine if the reason for this is due to those mature participants
being less distressed to start off with (and therefore reporting less improvement) or the
openness of the younger participants being helped by the session. Similarly, reasons for
married participants reporting significantly greater benefits will need to be investigated
so as to enhance coping factors for singles.
Information given by the facilitator and his/her relationship to the group were also
important factors in contributing to the improvement reported by participants. This
points to the importance of the facilitator training and supervision process. Whereas the
standardised protocol can account for much of the factors facilitating improvement, the
personal response of the facilitator and the conduct of the group are additional
important factors.
Even though the preliminary results are encouraging, we are a long way from proving
the effectiveness of the debriefing technique. We need to measure IES both
immediately after and incident and a month to six weeks later with groups that have
123
experienced debriefing and people exposed to the same incident but who have not
undergone debriefing. Obtaining data from people who were victims is not always
easy, many are “not in the mood” for questionnaires and if left to complete them at
some later date the rate of response is even lower.
The correlations obtained above present some interesting material which if
corroborated could lead to establishing guidelines for directing further groups of
victims to enhance the positive outcomes recorded. There is certain evidence for the
need to include as many different approaches as possible, mobilising different coping
strategies, within the existing debriefing framework so as to appeal to the natural
coping modes of a wide range of the civilian population.
Adaptations of “Debriefing” Procedures for Children
There is a continuing search for a brief and effective method for debriefing individuals,
families, and groups following traumatic events. In recent years different protocols,
built on the original concept but varying in their techniques, have been used for crisis
intervention with victims of all kinds, especially children of all ages and stages of
development.
The concept of debriefing inspired experimentation with different forms of adaptations
for groups of children involved in disasters (Ayalon & Soskis, 1986; Galliano & Lahad,
2000). New protocols were designed to provide age-appropriate understanding and
naming of the events, emotional processing, ventilation, and normalisation. These new
procedures take into account the needs of traumatised children for re-establishing a
sense of belonging and support in the very preliminary stages after the event
(Boatright, 1985). The new procedures are specifically geared to mobilise group
solidarity and promote individual strength and coping, and also to prepare children for
possible future eventualities.
A newly adapted protocol for children, called Critical Incident Processing and Recovery
(CIPR; Galliano & Lahad, 2000), stresses the need to establish the survivors’ sense of
“continuity of experience.” In order to anchor the children in their relative pre-disaster
stability, when their world seemed familiar and predictable, the first questions addressed
to an individual or to the group focus on activities and experiences during the hours prior
to the incident. Striking the same note, the sessions end with an emphasis on looking for
signs of returning to some level of routine or normalcy. Another revision, pertinent for
children but recommended for adults as well, is to include in the process family
members and relatives available for support and nurturance, either in the session or just
outside the room where the debriefing takes place (Lahad & Cohen, 1998). An important
addition is a safeguard procedure of short individual interviews and assessments
following the group encounter.
A further adaptation of CIPR for young children (3-6) introduces toys in the debriefing
procedure (Lahad, 1999). Young children have a limited ability to process information
cognitively and verbally, but engage spontaneously in imaginative play and “make
believe” with toy figures. They also have a short attention span and a tendency for
imitation and social desirability. In order to elicit a trauma story from a group of young
children, the facilitator uses hand-puppets representing different human and animal
124
figures. When interviewed, the puppets would “tell their story,” expressing their
feelings during the event and at the present time. Suggestions on how to cope, how to
sleep better, how to fight back fears and bad dreams, express anger, and so on, are
directed to the puppet.
The whole debriefing procedure is carried out on a metaphoric level, using the
language of the children and projective play techniques. The debriefing takes place
within the metaphor, as the children identify with the puppets and at the same time the
puppets provide a safe distance from which the children can touch their own
frightening experience (Ayalon, 1993a, 1993b). To ensure the group process is
successful, it is highly recommended that the facilitators be people known to and
trusted by the children.
Bibliography
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Ayalon, O. (1993a). Death in literature and bibliotherapy. In R. Malkinsom, S. Rubin,
& E. Vitztum (eds.), Loss and bereavement in Israeli society (pp. 155-175).
Jerusalem: Ministry of Defense. (Hebrew)
Ayalon, O. (1993b). Post traumatic stress recovery. In J. Wilson & B. Raphael (Eds.),
International handbook of traumatic stress syndromes (pp. 855-866). New York:
Plenum Press.
Ayalon, O., & Soskis D. (1986). Survivors of terrorist victimization. In N. A. Milgram
(Ed.), Stress and coping in time of war: Generalizations from the Israeli
experience (pp. 257-274). New York: Brunner/Mazel.
Boatright, C. (1985). Children as victims of disaster. In J. Laub & S. Murphy (Eds.),
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Deahl, M. P., Srinivasan, M., Jones, N., Neblett, C. & Jolly, A. (2001). Commentary:
Evaluating psychological debriefing: Are we measuring the right outcomes?
Journal of Traumatic Stress, 14, 527-529.
Dyregrov, A. (1999). Helpful and hurtful aspects of psychological debriefing groups.
International Journal of Emergency Mental Health, 1, 175-181.
Everly, G. S., Jr., & Mitchell, J. T. (2000). The debriefing “controversy” and crisis
intervention: A review of lexical and substantial issues. International Journal of
Emergency Mental Health, 2(4), 211-225.
Galliano S., & Lahad, M. (2000). Manual for practice of CIPR, London: ICAS
[Independent Counselling and Advisory Services]
Hodgkinson, P. E., & Stuart, M. (1998). Coping with catastrophes: A handbook of
post-disaster psychosocial aftercare (2nd ed.). New York: Routledge.
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Horowitz, M., Wilner, M. and Alvarez, W. (1979). Impact of Event Scale: A measure
of subjective stress. Psychosomatic Medicine, 41, 209-218.
Irving, P., & Long, A. (2001). Critical incident stress debriefing following traumatic
life experiences. Journal of Psychiatric and Mental Health Nursing, 8, 307-314.
Lahad, M. (1999), The use of drama therapy with crisis intervention groups, following
mass evacuation. The Arts in Psychotherapy, 26(1), 27-33.
Lahad, M., & Cohen, A. (Eds.). (1997). Community stress prevention, volumes 1 and
2. Kiryat Shmona, Israel: Community Stress Prevention Centre.
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Leeman-Conley M. (1990) After a violent robbery, Criminology, Australia, 4, 4-6
Mitchell J. T. (1983a). When disaster strikes: The critical incident stress debriefing
process. Journal of Emergency Medical Services, 8(1), 36-39.
Mitchell J.T., (1983b) Guidelines for psychological debriefings. Emergency
Management Course Manual. Emmitsburg, MD: Federal Emergency
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Pynoos, R. S. (1993). Traumatic stress and psychopathology in children and
adolescents. In: R. S. Pynoos (Ed.), Posttraumatic stress disorder: A clinical
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Raphael, B., Meldrum, L. & McFarlane, A. (1995). Does debriefing after psychological
trauma work? British Medical Journal, 310, 1479-1480.
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3. Oxford, UK: Update Software.
Smith, S. M. (1983). Disaster: Family disruption in the wake of natural disaster. In C.
Figley, & H. McCubbin (Eds.), Stress and the family: Coping with catastrophe
(pp. 120-147). New York: Brunner/Mazel.
Tehrani, N. (1998) Does debriefing harm the victims of trauma? Counselling
Psychology Review, Vol. 13 (3) pp. 6-12
Wright, J. C., Kunkel, D., Pinon, M. & Huston, A. C. (1989). How children reacted to
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(2), 27-45.
126
The HANDS Project: Helpers Assisting Natural Disaster Survivors
Ofra Ayalon,
In collaboration with Alan Cohen, Mooli Lahad, Shulamit Niv, Yehuda Shacham1
The Turkey Earthquake of 1999
On August 17, 1999, one of the most powerful earthquakes in the past 100 years
jolted Turkey. The centre of the earthquake, which measured 7.4 on the Richter scale,
was in Izmit, but the shock ravaged large areas in the country. The earthquake
affected a 280-kilometre-long stretch (about 174 miles), which began in Istanbul and
continued eastward throughout the country. The death toll was estimated at 25,000
people. It left over 350,000 people homeless, and an estimated million more sleeping
in the streets for a couple of weeks, afraid to sleep in buildings. Damage, however,
was uneven, with the most densely populated cities and towns suffering the most
devastation. Structures in some areas were totally demolished, while in other areas
most buildings were left standing. The effects seemed almost random.
Planning a disaster response
Planning a disaster response needs to consider both the immediate consequences
of the disaster and how these effects are likely to multiply soon after the disaster. The
earthquake, having shaken the national infrastructure of the country and caused the
loss of numerous lives, called for an external aid and an innovative approach to crisis
intervention and disaster management, especially as the local caregivers were as
traumatised as the rest of the population. The psychosocial crisis intervention offered
by the Israeli CSPC team came in three stages. The first stage was immediate first aid
(Slaikeu, 1990), carried out by Israeli medical and military rescuers. They worked
through the rubble to save lives, erected a field hospital to care for casualties in the
epicentre of the quake and dealt with the most immediate needs of the population in
makeshift camps for the dislocated population, in collaboration with local authorities.
The second phase of early crisis intervention in which the CSPC team of Israeli
trauma psychologists volunteered to train local psychologists and care-givers. This
training took place 9-12 days after the onset of the disaster. The third phase of
psychosocial intervention, the “tertiary prevention” (Caplan, 1964), continued
through the first year after the disaster, with follow-up throughout the next year.
Immediate first aid – strategic considerations
A week into the disaster, a team of five experts from the Israeli Community
Stress Prevention Centre landed in Istanbul in response to a appeal from the Istanbul
based psychologist Dr. Leyla Navaro, head of Nirengi Centre for Group Therapy and
with the help of the Istanbul Jewish community. The aim was to train the local
mental health professionals in the skills and techniques of crisis intervention of such
magnitude.
1
We are indebted to Leyla Navaro and to Rina Lerner for their initiation and support
of the project.
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The HANDS Project
In the first phase, which took place very soon after the earthquake, the CSPC
team conducted an intensive seminar for about 100 attendants, psychologists,
physicians, school counsellors, social workers and other therapists, recruited mostly
by word of mouth. The demand exceeded the available space and quite a number of
eager, potential attendees had to be turned down.
The CSPC team faced three major challenges:
1. As the professional orientation of most of the participants had been
geared toward individual therapy or consultation in clinical or
educational settings, they had no previous experience in community
work or in disaster intervention. The challenge for our team was to bring
about a shift in the professional paradigm: from the existing
“clinical/psychopathological” approach to a “community intervention
approach that emphasised resiliency and coping resources”. This
transition called for a new focus: a focus on field work with reluctant and
traumatised populations in a chaotic situation, with no clinical facilities.
It demanded reaching out for uprooted families and individuals and
working in groups with mixed and different ages. As trainers in disaster
intervention, our team had accumulated many years of experience in
community-based work, both in Israel (Ayalon & Lahad, 2000) and in
other traumatised communities around the world (see Ayalon, Lahad &
Cohen (eds.), 1999).
2. The second challenge arose from the fact that the participants in this
training were either survivors of the same disaster, or knew people who
were direct victims of it. It has been established that caretakers who are
also part of the “circle of vulnerability”, are more prone to develop
posttraumatic stress disorder than helpers who are outsiders (Ayalon,
1993). The Israeli CSPC team members met this challenge with their
own experience, of being helpers exposed to professional and personal
disasters, whilst living and working in areas of frequent war and terrorist
attacks.
3. The third challenge stemmed from the cultural differences between the
helpers and the helped populations. Turkey is a Muslim country of 65
million people, of which 60 million are rural, traditional and religious.
Family structure, the patriarchal role of men and the submissive role of
women are all part of the current tradition. Western type psychosocial
interventions, used in our training, were not familiar in these regions.
This gap became even more obvious when traditional religious leaders
claimed total authority over the victims and survivors of the earthquake,
sometimes indicating that the disaster was a “divine sign”, and using it to
intimidate believers into greater religious devotion. This conflict
between attitudes toward mental health was also familiar to the Israeli
trainers, as Israel is a country with a large minority of Muslim
population. Thus the trainers were acquainted with the Muslim
traditional background and could acknowledge, understand and contain
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this gap. Our team has been using cross-cultural, sensitive methods in
many foreign cultures, (in the recent past with their crisis intervention
training in Bosnia during the Balkan war).
Immediate first aid – methodological proceedings
The training included disaster theory and practice. The theoretical part introduced
basic concepts of psycho-social disaster management of all those who are included in
the “circles of vulnerability”, diagnosis and therapeutic orientations for wide
traumatised populations, as well as the concept of “resiliency and coping”, based on
the BASIC Ph integrative model of resiliency (Lahad 1992). The practical part
contained rehearsals of direct intervention methods. For example: Participants
practiced a variety of debriefing techniques, specially adapted for families and
children of different ages, including verbal and non-verbal methods such as
movement and expressive arts. Participants learned first-aid traumatic relief and short
term interventions such as EMDR, Somatic relaxation and Desensitisation.
Participants gained a great deal of attention for their own traumatic experiences and
personal losses. The training emphasised empowerment for those who wished to go
out and help the beleaguered communities.
The “H.A.N.D.S.” project: Helpers Assisting Natural Disaster Survivors
The H.A.N.D.S. project was a joint initiative of the Israeli Community Stress
Prevention Centre (CSPC), the Joint Distribution Committee (JDC) and the Nirengi
Centre for Group Therapy, Turkey. A systematic training project followed a few
weeks later as a result of that training. A dedicated group of 20 psychologists
volunteered to take part in an intensive, one year training with CSPC team. The
contract, drawn up by a local aid organisation, set up a “cascade model”: each
member agreed to train 12 other professionals, who would then train 20 local helpers
(teachers, nurses, community workers, community volunteers). Thus, the training set
by a small Israeli team of five experts managed to reach approximately 4,500 people.
This project had the following aims:
• To train a core group of professionals in the CSPC methods and skills
of Trauma & Recovery work.
• To train these professionals as trainers of other professionals in Turkey
• To adapt CSPC methods to local norms and values.
• To serve as supervisors and supporters to those rendering help to others.
The H.A.N.D.S. training proceeded to cover four areas:
1. Dissemination of knowledge and basic concepts on the subjects of
trauma, coping and recovery.
2. Teaching methods and techniques for helping trauma victims, their
next of kin and other groups at risk. The instruction was
accompanied by “hands-on” experience and supervision.
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The HANDS Project
3. Catering for the participants’ needs to share their personal

dilemmas and to be empowered for the tasks of helping survivors
in the disaster areas.
4. Teaching the cascade model and its application in the field
Five weekend seminars spread over a period of approximately six months. Each
seminar focused on a different aspect, that always contained a body of knowledge,
skills, joint development of the field project and supervision. A workbook (translated
into Turkish) following each seminar contained new materials, methods and skills.
Sessions outline:
Seminar I focused mainly on processing loss and bereavement. The supervision
focused on teaching how to plan the post-disaster intervention project and implement
it in the field.
Session II focused on groups and basic family interventions following disaster.
Special attention was given to methods of working with children of all ages.
Session III focused on coping and resiliency strategies.
Session IV introduced creative coping methods: creative arts, dramatherapy,
movement and bibliotherapy - their use in trauma and recovery work.
Session V focused on parting, closure and evaluation methods.
The H.A.N.D.S. project lasted almost a year. In mid-2000 the local team was
fully operational and self-sufficient. In many ways this project represents our concept
of “islands of resiliency”, where a local group of helpers takes responsibility and
launches a project, using “community development” concepts. These “islands of
resiliency” radiated strength and capability and conveyed empowering messages and
a sense of coherence and meaning to the community at large.
Transformation in professional role: from the clinical setting to “community and
resiliency work”
In order to become a helper in disaster, mental health staff need to “set aside
traditional methods, avoid the use of mental health labels, and use an active outreach
approach” (Myers, 1994, p3). Psycho-social first aid should be brief, adjusted to the
severity of the crisis, and focused on the immediate needs of the survivors. Although
each single strategy of intervention reflects the particular circumstances surrounding
the disaster, there are several elements that such intervention strategies have in
common:
• reuniting family members and verifying information about losses (these
are the most urgent needs in this stage)
• giving clear directions of “what to do, where to go,” etc. (when adults
assume leadership they provide a model of behaviour for the children in
their care; therefore, direct guidance for parents about dealing with their
own disaster responses provides indirect but effective guidance for their
children)
130
• helping children understand what has happened during and after the
crisis
• providing physiological relaxation and tension reduction (only in a safe
location)
• providing a clear (even if slim) sense of the future and hope for
improvement
• focusing on empowerment by emphasizing coping, resourcefulness and
resiliency.
The focus on children

A broad spectrum of brief therapeutic methods was used with individuals,
families, and groups. Helpers were trained to screen children, who might have been
at high risk for severe emotional problems as a result of the enormity of their loss,
their tender age, their previous vulnerability, and other factors. It was noted that
children who did not immediately show signs of psychological distress could have
been badly shaken (Lindy, 1989). The variety of children’s immediate responses
demanded that helpers use flexible approaches when they conduct crisis
intervention. Many found, contrary to the common expectation that children are
needy and passive immediately after a disaster, that an active role in taking care of
themselves, of younger siblings, or other domestic chores helped many children to
gain control, and enhanced their resourcefulness (Ayalon, 1993, 2001; in print,
Gibbs, 1994; Speier, 2000). Adults were recruited to help children build group
support, accept a variety of emotional expressions, and engage in step-by-step
problem solving and planning for the future.
Participants’ Account
The following is an account of two Turkish Crisis Workers, psychologists Neylan
Özdemir and Nevin Dölek, who worked with the victims of the earthquake of
August 1999. They had had some previous experience of disaster work with
Kosovan refugees, but had only a general idea about the effects of large-scale
disaster and coping strategies. They went to the site of the disaster only on the fifth
day after the quake, because they were also under the influence of the shock. They
didn’t realise how serious the event was and how it affected such a large number of
people. At that time they were working independently. They established a group of
young volunteers, all of them students (their children and friends were among them).
Neylan Özdemir and Nevin Dölek report:
“Sorrow, grief, fear but also hope and courage for helping were the main
feelings that we were experiencing at that time. In this situation the main
question was how to reach the victims, while we were experiencing these
feelings. Before the training, we were helping the others without thinking
about ourselves.
“We were doing everything in the area; collecting and distributing clothes
and food as well as doing therapeutic activities. We didn’t realise that we
also needed help, until these experts came to help us.
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The HANDS Project
“In these training sessions, they helped us heal ourselves, they taught us to
share our feelings and to gain awareness that most of our feelings and
behaviors were normal in such an abnormal situation. After completing this
programme, I realised that without this training it would have been very
difficult for me to go to the disaster area and continue to help. First of all
we learned how to help ourselves, and then I gained valuable knowledge
about crisis and intervention techniques. With this training I gained
confidence that I have the potential to help others.
“We spread out what we learned and we supported so many other helpers.
We are grateful to our friends from Israel for their kind and warm
cooperation with us. After the training we worked in İzmit. We were a
group of 15 in İzmit Çamlıtepe area and we established several sub-
committees as “Teacher training”, “Work with Children”, “Work with
mothers and adults” and “Material help”.
“We worked with the “children’s group” as a psychologist. We trained
volunteers from the area and also from Istanbul. The volunteers who
completed their training were assigned to groups of children and worked
with them. We also worked with another volunteer group from Istanbul.
We were meeting twice a week, once for teaching these volunteers what we
learned during the H.A.N.D.S. training, the other time for organisation
purposes. After these meetings we would go to the earthquake area, twice
every week to be together with the children who were living in tents. In this
tent area an association (ÇYDD) had a big tent for children and volunteers
from that association came every day. Local volunteers were helping and
playing with the kids. They grouped the children according to their age and
named each group differently.
“We used three corners in the tent area. The first corner was used to build
or to create several things with drinking straws and adhesive tape. The
second corner was for making puppets, using socks and decorating with
paints. In the third one we were playing therapeutic games; doing
debriefing-relaxation-storytelling-playing, with the help of the puppets
they made.
“Every child in the group visited every corner. At the end of the day we
wrote everything we did and left the notebook in the tent for other
colleagues. This was our communication link. In all activities we used
experiential learning method. Our intervention plans were based on
“BASIC Ph”, Mooli Lahad’s integrative approach that we learnt during
our training.
“Among the techniques we used for interventions were: Debriefing,
Drawing, Physical Activities and Plays, Biblio-guidance and Biblio-
therapy, Group Discussions, Community Service Projects, Free Writing,
Psychodrama techniques, Self relaxation techniques.
“Look backing we realise that we mostly trained the helpers, who in turn
went to the disaster area and helped the survivors in several ways.
“It was very important for many reasons to help the helpers:
132
1- Helpers, working very hard at serving others, did not realise how
much they were exposed. No matter how good our coping skills or how
great our experience, there were times that our defense mechanisms broke
down. Our observations showed that many volunteers were in shock but
were still going there everyday or stayed there without looking after
themselves properly, and they were just at the edge of traumatic stress.
They were so enthusiastic to help others, but didn’t know about the
survivors’ psychology or needs.
2- “We, a group of psychologists, developed several training programs
for several groups. Although every program was developed based on
BASIC Ph dimensions, there were slight changes according to the needs of
the every group. After the training programs, they all appreciated what they
learned. They said that they felt better, they were more confident about
what they were doing with the survivors. This way we spread out our
knowledge and supported many helpers to help themselves and support
others.”
Evaluation
Evaluation was based on two types of reports, reports by the participants in the
supervision groups and by the field coordinators and supervisors. Another form of
evaluation was a documentary film that followed the work from the training in
Istanbul to the application of the knowledge in the field. The documentary
interviewed participants, coordinators, facilitators and beneficiaries in a quasi-
qualitative study style.
Most of the difficulties in the implementation were due to practical problems such
as transportation to the homeless relief sites (HRS), the slow process of building the
group, group members’ continuous participation and making sure that the trainees in
the field would transmit the knowledge and skills to other beneficiaries (e.g. trained
teachers to their pupils). Despite these drawbacks most of the Core group participants
were able to form their own training and intervention groups and to support the
further dissemination of both skills and knowledge.
In a videotaped interview with participants, they evaluated the project on various
levels. Some said they didn't know where to start, what to do in such instances and
how to deal with their own fright and shock. They claimed that the training helped
them to process some of their anxiety and trauma, and encouraged them to spread the
knowledge and skills. As one psychologist described it: "the women in the HRS were
reluctant to come to the group-debriefing we offered, and we were afraid too. These
women were very depressed and did not want to do anything, not even to activate a
school or a centre for the children. Still we managed to engage them in the debriefing
process (Mitchell 1983), and the next day it was like a miracle, they came and
opened the place for the children".
In some cases, very special group work emerged such as a female carpenters
support group. Among the women who operated a carpenter's workshop, some were
widows, others had lost children and others next of kin. The support group was held
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The HANDS Project
in the workshop itself and run by a member of the core group. Another example was
an adolescents’ amateur theatre group, which formed the basis of a support group for
the adolescents. One of them said in a videotaped account: "Marmora was the stage
for the worst play (the earthquake) I ever took part in."
However, one of the main setbacks of these projects was lack of funding for a
structured, comprehensive and prolonged evaluation. This is a major hindrance in
many field-based projects, which are implemented by volunteers. For humanitarian
reasons, money is allocated mostly to the actual intervention and evaluation is
considered of secondary importance by the resource providers (i.e. donors). Still,
second and third year projects have evolved from the first year and that various,
training courses and centers were built in Turkey implementing the basic concepts of
the H.A.N.D.S. project, further education in the field was requested and granted. All
these are signs of the wide applicability of H.A.N.D.S. concepts and methods.
A word of caution
Crisis intervention was believed for a long time to help reduce or even
eliminate PTSD. However, evidence indicates that people with severe and chronic
PTSD are not just manifesting a “normal reaction to an abnormal situation”, rather,
they are responding in ways that reflect severe underlying problems. “Crisis
intervention” is not expected to eradicate totally the danger of posttraumatic
syndrome, but rather to reduce acute symptoms. Such interventions can help
disaster survivors who are moderately affected to use their natural coping
recourses, to rebuild the lives that had been disrupted by the traumatic events, and
to function at a normal level (Myers, 1994). But as the vast majority (about 80%)
still react “normally” to an abnormal situation, many would gain from such
interventions.
Bibliography
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International Handbook of Traumatic Stress Syndromes. New York: Plenum
Press. pp. 855-866.
Ayalon, O. (2001). The impact of terrorism on Jews in Israel: An interview by F.
Waters. Journal of Trauma Practice, 1, 3/4, pp.133-154.
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COMMUNITY

This edition was published with the help of UJIA Canada

About the authors

Chapter 3 Six Part Story Making in the Assessment of Personality

Chapter 6 COPE CARDS for Trauma and Healing.

Chapter 7 The Media and the Understanding of the

Chapter 8 The Development of Debriefing in Israel.

Community Stress Prevention Volume 5

About the Authors

Dr. Ofra Ayalon

Elizabeth Capewell M.A.

Alan Cohen M.Sc.

Kim Dent-Brown M.A.

Alan Flashman M.D.

Prof. Mooli Lahad

Dr. Shulamit Niv

Ruvie Rogel M.Sc.

Training and currently completing his PhD in Educational Management, researching

Gina Ross MFCC

Ilse Scarpatetti, Lic. Phil;

Dr. Yehuda Shacham

• Children were highly sensitive to post-disaster distress and conflict in

room. In the emergency room, short-acting benzodiazepines (e.g. lorazepam) or high

Preliminary Summary and Conclusions

In-patient treatment and follow up

with the psycho-social interview. In some incidents different voluntary organisations,

• what procedures should it include: EMDR, PD (CISD),

Carlier Collective As soon as 46 M voluntary 8 months later no

Hobbs Individual 24-48 hrs. 54 received 1hr. PD had worse

CSPC Immediate ASR Intervention Protocol.

Thus the three general aims of ECI are:

Bunn, T. & Clarke, A. (1979) Crisis Intervention: An experimental study of the

The Omagh bomb – The Incident

Our Immediate Response to the News of the Bomb.

2. Consultancy to Education authorities and the Health and Social Services

Building a partnership with local professionals:

narratives we collected from different parts of the organisation. Networking

TRAUMA PROCESS MODEL

7. HEALTHY 3. THE VOID

KEY ELEMENTS OF CRITICAL INCIDENT MANAGEMENT

© Elizabeth Capewell, CCME, revised 2003

stress. Guilt can be turned to blaming and scape-goating, anger to bitterness

Multi-dimensional model of coping

ATTITUDES LISTENING SOCIAL CREATIVITY INFORMATION ACTIVITIES

Unfinished business- Negotiating the next stage of the response:

‘And if they do have the courage to engage in preventative strategies, how

Development of the statutory Trauma Centre

Doherty, K. (1991). The Enniskillen Remembrance Day Bomb 11 November 1987 -

The dramatis personae he identified were these:

Subsequently (Greimas, 1966) used Tesniere’s concept of actants to codify Propp’s

Sender Object Receiver

Helper Subject Opponent

Greimas Marxist ideology The Lord of the Rings 6PSM

The Specialist Therapies Service

ROLES PLAYED OUT ROLES PLAYED

Acts as judgmental, Paternalistically

ROLES Becomes angry with Acts as ill, sick,

A fundamental part of the practice of CAT is the identification of these reciprocal

The Contribution of 6PSM to the Assessment