PSYCHOLOGICAL SAFETY

Psychological safety refers to an internal sense of confidence that the distress aroused by danger can be tolerated and managed without feeling overwhelmed or out of control.

When a child hears about, witnesses or directly experiences violence or other dangerous events that threatens their physical or emotional safety, anxiety and fear are normal and necessary emotions that get aroused. They serve to alert us to danger. Their purpose is to stimulate appropriate protective action, rather than producing frozen or helpless states.

When a child becomes alarmed by a violent episode, parents should use this situation as an opportunity to promote the capacity to adaptively manage problematic emotional reactions. Doing so, can enhance tolerance for strong feelings and improve thinking and planning skills. Instead of telling children "don't be afraid," the message we want to get across it is more like "how can I help you feel safe, in spite of the bad feelings you are having?" We are trying to promote the capacity to adaptively manage problematic emotional reactions so they don't disrupt the ability to think and respond. To accomplish this we must first validate the child's feelings by helping him/her put them into words and/or play action. The goal is to reinforce their developing capacity to regulate any disruptive emotional or somatic reactions by encouraging as much expression as possible.

Meeting this goal is not a new expectation. Parents can draw on their prior experience of having automatically comforted their children when they were infants. The soothing physical responses they provided, such as picking them up; hugging and stroking them, combined with comforting sounds and words, helped the child to learn to feel safe and to regulate their reactions when they were distressed. As children get older, parental responses need to become more and more verbal and aimed at engaging them in active interaction with the parent and others. In this way we help children learn that personal relationships and social support provide strong barriers to feeling overwhelmed.

Most importantly, children need the opportunity to be heard, so they can talk about the feelings, thoughts and physical reactions they are having to the event. Just the willingness of the parent to 'be there" and to listen, listen, listen provides an important service. If a child can't put their reactions into words, he/she should not be pressed to talk. Instead, other avenues of expression like drawing can be offered. Many apparently silent children will readily share what is on their mind, when asked to draw a picture that shows what they are thinking or feeling and then being asked to talk about their picture.

Parents should also validate their reactions with statements such as, "I can understand that seeing something like that (i.e. an explosion scene on the TV news) would make you feel scared. "Let's see what we can do to help you feel better." This validates the appropriateness of their emotional reaction, be it fear, or anger, but does not validate any maladaptive self-regulatory coping attempts.

The offer to help the child feel better needs to build on his or her previous successful efforts to cope with distressing reactions. Thus parents might say "Remember when you were worried (scared etc whatever word the child uses to describe his/her current feeling) and you did (X or Y), do you think doing that would help?" If the child doesn't feel previous coping strategies will help or doesn't have much prior experience to draw on, then the parent can make suggestions posed as questions, i.e. "what if we try this" or "would it help if this?" Following up with a response gives their children the opportunity to learn new coping skills. The hope is to increase their skills in self-directed problem solving and to reduce their exclusive reliance upon their parents.

Possible responses include:

• Parent and child spending more time together, whether interacting or quietly doing separate activities near one another

• Limiting exposure to distressing images on TV. Constant viewing of the disaster scene can be re-traumatizing and the dose of exposure should be modulated.

• Using relaxation techniques like deep breathing or progressive relaxation exercises

• Drawing a picture that expresses something related to the event and then discussing with the child what he/she feels the picture conveys

• Doing something physical to discharge tension, like exercising or walking

• Listening to music or a relaxation tape

• Taking part in organized community activities directed towards responding to the problematic situation. This can be especially valuable for older children and adolescents.

PHYSICAL SAFETY

This refers to efforts to make the child's environment as safe and secure as possible without totally constraining freedom of movement. Parents need to work out effective ways to let their children know their whereabouts, as children seek to be in close proximity to their parents at moments such as this where many deaths have occurred. Parents need to take their cues from their child as to whether they need to accompany the child to school and how long they should keep this up. If the child feels comfortable going back in the company of friends, rather than with the parent that should be supported. The child should also be given a chance to ask questions and to be able to tell their parent and teacher if they feel comfortable entering or re-entering the program. All efforts at mature coping should be supported. Bedtime may become a time of increased vulnerability even when the child feels otherwise safe. Parents need to stay with children until they fall asleep. At the same time, as they work with the child to handle this time on his or her own.

REASSURANCE AND EXPLANATION

When something bad happens, the first reaction of adults is to want to reassure a child or explain "why" the event occurred. However, responding to this natural urge needs to be put on hold until we have listened to the child's reaction. Often children's "why" questions are not really requests for information, instead they are a way of expressing confusion and helplessness about what to do or whether their parents are safe. We need to remember that children of different ages see the world differently than adults. Consequently, our fears and concerns may not reflect what they are thinking and feeling. Children and adolescents often get a different message from premature attempts to reassure them. Rather than being comforted, they feel the adults are not interested in hearing how they really feel. Once their actual concerns are known, reassurance and/or explanation can be provided.

Children often have unrealistic concerns about their parents well being after a frightening incident. Consequently, predictability about parental whereabouts takes on greater significance now that both parents often work. Parents can provide a good deal of reassurance by letting their children know where and how to reach them during the day. If they are not available, they can show them how to get help from other adults. Explanation can be used to correct misunderstandings, such as the tendency to misinterpret a pounding heart. This is a typical physical response to stress, rather than a sign of a serious physical problem.

Parents and teachers can monitor children's responses to the event and to any interventions by paying attention to:

• Persistent fears

• Trouble sleeping

• Difficulty concentrating

• Avoidance of settings where problems occurred

• Irritability

• Jumpiness-tendency to startle easily

• Withdrawal/loss of interest in play or friends

• Physical reactions, i.e. stomach aches, headaches, loss of appetite, pounding heart

Over the next few days we may be called upon to do both individual and group crisis management work, please be advised that "debriefing techniques" are being debated as to whether they are useful, consequently rather than having relying on having people talk primarily about what they saw or experienced, we want to:

• Focus on safety and stability issues

• Stay with the "here and now"

Teach self soothing techniques to lessen states of arousal-- deep breathing, active visualization, progressive muscle relation techniques ( I can fax brief instructions if you need them.

Promote self care- i.e. adequate rest, food and exercise, avoidance of alcohol and drugs to calm arousal or poor sleep.

Normalize reactions "anyone experiencing such an event would be upset" It's not a shameful sign of personal weakness to be distressed.

Help people decide what cues might serve as "traumatic reminders", so they can anticipate events or stimuli that might re-trigger their reaction all over again.

These events will trigger old traumas, apparently this has been quite prominent for anyone who was in Vietnam and probably will be for those with family members in Israel or are Holocaust survivors.

Clearly this is not a complete list but should serve to structure our responses, however if people "just need to tell their story" validating that need is important

By now everyone knows of the horrible series of events that happened in New York and Washington. We know this is a moment of great uncertainty and tension. We would like to address the needs of our staff and their family members in any way that would be helpful. If you learn about any staff members or members of their family that either witnessed the events or were directly impacted by being at the scene of the tragedy, we would like to share some information on how to provide support for them over the next few days. This kind of support is known as psychological first aid and will be described below. If you think it would be helpful, please send to Dr. Abramovitz and Dr. Panzer the names of anyone that may have been exposed to these circumstances and let us know the type of reaction they are having. If they are receptive to help, we will facilitate the arrangements.

When events of this magnitude occur a person's response goes in one of two directions: they experience either a great deal of distress and arousal, or extensive denial and numbing. Some people fluctuate between those two extremes, and don't understand what's happening to them. Those people who are experiencing the arousal and distress will often show physical signs. This reaction is normal and happens to people who don't have any preexisting psychological difficulties. People usually need a mixture of supportive help, nonjudgmental general conversation, and attention to their immediate signs of physical and psychological distress. Below is a series of things that anyone can do to become a source of mutual support.

Take an inventory of your own reactions and find a way to be sure that you are calm and able to focus on other people. If you are not it is understandable.

Ask people how they are doing and what would be most immediately helpful to them.

Help people set useful limits in gathering information about the tragedy. The goal is to get information but not get overly aroused and stuck in the repetitive details of the tragedy. People can be re-traumatized by excessively over-viewing the events. If you notice someone getting progressively more upset by continuous attention to the news try to help them recognize that they need to limit the amount of their exposure, and try to help them shift their focus to calming themselves down.

Ask people to describe their immediate physical reactions, such as rapid breathing or racing heartbeat, this can be a useful way of helping people to start to talk about the impact of the events upon them.

Intervention should be focused on helping to mobilize the person's preexisting coping resources (i.e. talking with them about the things that have helped them to calm down in other situations of great distress), and reassuring them that the current arousal and distress will be time limited.

People need to anticipate that over the next few days they may have difficulty sleeping, nightmares, stomach aches, or find themselves forgetful or inattentive. This is the usual way that the mind and body tries to integrate overwhelming, irreconcilable information. Good self-care is paramount, such as practicing calming methods, i.e. deep breathing, meditation, etc., making sure to eat regularly, not drinking alcohol, and getting regular exercise.

People need to know that they will not be functioning at their usual levels but it will be helpful to try to maintain as much continuity and normality as is realistically possible.

Parents should expect that their children will be seeking very close proximity to them. Although this may seem like clinginess or reverting to younger-type behavior, it should be allowed. This will include needing more reassurance before falling asleep and being very concerned about the whereabouts of their parents. Specific information and availability is most important. Facts should be given to children on an age appropriate basis. While the impulse to offer blanket reassurance to children is understandable parents should first attempt to find the nature of their children's worries and fears before trying to reassure them.

As you interact with people who have been directly exposed, please pay attention to whether or not you are picking up indications of shame, blame, or helplessness, as these are indications of more complicated reactions.