Protecting & healing children traumatized by terror
Those of us who carry the banner of mental health most often are called on the scene after the damage has been done, to try our best to patch up broken lives and shattered dreams. My claim is that we as adults have no right to leave children vulnerable and exposed to the evil in this world, for which we, as adults, share the responsibility.
This chapter explores the subject of protection and healing children traumatized by terror on three accounts:
- Threat: An evidence based survey that highlights some of the most prominent facts about the damage done to children by exposure to terrorism and organized violence.
- Strategic planning: A strategic proposal that can be employed to prepare the educational system and deal with impending threat of terror (C.O.P.E.).
- Tactical operations – Methods to enhance recovery and healing: A holistic body/mind health oriented intervention model (B.A.S.I.C.Ph) and practical tool-box for enhancing coping skills that are needed to manage the threat and stress of terror, using the universal language of Arts, metaphors and non-verbal methods – to reach children beyond any cultural barrier.
The Threat: Targeting children – the horror of numbers
Terrorism has plagued our lives around the world, brutally targeting children, who have no understanding or power of will to take part in any political struggle. Graça Machel (1996), Mozambique’s Minister for Education until 1989 and a vehement advocate for children’s human rights, claims that there is an ongoing war on children, that children
(and their families) are not merely “collaterally damaged” but are being deliberately killed, mutilated, and violated by people who consider them their future enemies. The enormity of numbers and spread of children’s plight is totally devastating. Statistics of children’s death toll are unimaginable: One and a half million Jewish children, as well as unnumbered Gypsy children, were systematically murdered by Nazi Germany between 1939-1945 in concentration death camps Gas chambers in Europe; two million children were killed in wars in Africa, among them 333,000 in Angola, 490,000 in Mozambique alone, between 1982-1986 (Bellamy, 1996). In Angola, during 16 years of civil war between government forces (FMLA) and rebel forces (UNITA) more than 3 million people were either displaced or directly affected by the war. An estimated 100,000 children were orphaned, and large numbers suffered the shock of attack, displacement, separation from parents, destruction of home, hunger, inadequate health care, and crippling accidents from land mines. Nearly 10,000 children were forced to become soldiers. More than four million children in warring countries have been physically disabled through bombings, land mines, and torture; twelve million have lost their homes; five million were cast into refugee camps and more than one million have been orphaned or separated from their parents (Bellamy, 1996; UNICEF, 1996). A study on the effects of land mines in 206 communities in Afghanistan, Bosnia, Cambodia, and Mozambique found that one household in 20 reported a mine victim, a third of them dying in the blast; one in 10 was a child (Andersson, Palha, Sousa, & Paredes, 1995). In Kosovo following ten years of political oppression and two years of war, the prevalence of PTSD is estimated to be 25%, an extremely high percentage for any population. The most frequent symptoms observed in children from 5 through 18 were: concentration problems, separation anxiety, enuresis, hyperactivity, nightmares, various somatic complaints (especially from older adolescents), generalized anxiety, and behavioral problems
associated with alcohol and substance abuse. (Areliu, 2002). Terrorists and other military hostile males often target children for abuse and exploitation. Research conducted by UNICEF (1996; 1997) found that systematic rape is often used as a weapon of war in ethnic cleansing. More than 20,000 Muslim girls and women have been raped in Bosnia since fighting began in April 1992; many impregnated girls have been forced to bear the enemy’s child. In some raids in Rwanda, virtually every adolescent girl who survived an attack by the militia subsequently was raped, and their families and communities ostracized many of those who became pregnant. Ultimately, some abandoned their babies; others committed suicide. Children conceived in rape and born into violence often suffer social ostracism, and added to this is the fact that sexual violence brings with it a high risk of infection from sexually transmitted diseases, including HIV/AIDS. In his report on Rwanda, Cantwell (1997) writes that years after the genocide and the systematic rape, the problems of girls who suffered this abuse and the children born as a result are unresolved, many of these children were abandoned at birth, many are stigmatized and persecuted by their own people. The same is true for Angola, Bosnia-Herzegovina, and most other warring countries. The recent terrorist massacre of Beslan school children hit yet another cord on the war against children.
Suicide bombing glorified
Unlike any other kind of suicidal behavior, current suicide bombing is not stigmatizes but idolized, “martyrs” bombers are not condemned but praised and advocated, projected through the global media outlets. The adulation of suicide bombing, especially in the Moslem world, enhances suicide bombing as a strategic choice of weapon to achieve political and religious goals. Feurstien, in her recent book of evidence of survivors of suicide bombing, maintains that “if there had been an international outcry at the primary
targeting of civilians by the bombers and their masters following the deluge of such bombing against targeted Israeli civilians since 1994 up to date, perhaps the following years might have been less bloody for civilians around the world” (Feurstien, 2005).
Ganor, he international expert on terrorism compares it to criminal activities: “The actions of the terrorist – murder, sabotage, blackmail – may be identical to those of the common criminal. However, for the terrorist, these are all means to achieve wider goals, whether ideological, religious, social or economic. The way to the terrorist’s ultimate political goal runs through a vital interim objective – the creation of an unremitting paralyzing sensation of fear in the target community. Thus, modern terrorism is a means of instilling in every individual the feeling that the next terror attack may have his name on it” ( Ganor, 2002). The nature of terrorist activity is such that it calculatedly and systematically wreaks terror on random defenceless civilian populations. The arbitrary choice of victims conveys that terror can victimize anyone, anywhere, anytime. Terrorism aims to demoralize the population, to win a psychological and political war and to gain public awareness through publicity in the media. (On 9/11/2002 memorial day a sharp observation was made, stating the Bin Laden never needs to launch another attack on America, as every media exposure of the collapsing WTC replicates his outstanding achievement and its consequent horror). Politically, terrorism is trying to extort something from a third party, such as a government or an organization, by using random people as pawns. Randomizing and maximizing the number of casualties is a method of infliction fear of danger that is always impending and unpredictable. Obviously, it is effective only against societies that place a high value on human life, as the act of terrorism is intended to make them give in to protect their people. It will be ineffective in the terrorist culture lacking in reverence for human lives, that prompts young people to become suicide bombers by
promises of sexual and other gains in heaven for sacrificing their lives to kill others, either for political or religious purposes. Consequently, no wonder that terrorists target children, who are the most precious and vulnerable members of society. In most cultures children are precious not only to their parents, but to the community as a whole. Children are the future. In Israel, for example, children are the proof that the Holocaust genocide had failed to eradicate the Jewish nation. Palestinian terrorism has sharply cut into this collective wound by targeting infants and schools children (Ayalon & Waters, 2002) by assaults upon Israeli nurseries and schools, seizing children as hostages, hijacking airplanes, drive-by shooting, booby-trapping and suicide bombing of civilian population. In Russia recently more than 300 school children were massacred in the town of Beslan by terrorist who had also mutilated and raped some of their victims.
Children pay the price
Children may be randomly targeted by terrorists, taken hostage or crowded in shelters to
hide from air-raids and rockets. In countries involved in prolonged military squabbles,
such as Israel (Ayalon,1998), Lebanon (Bredy, 1983), and Northern Ireland (Cairns, 1987; Fraser, 1973), children are relatively protected within a functioning community, but they are still aware of the looming danger and carnage. Children may be exposed to homes, schools and neighborhoods destroyed by shelling, they may live under the threat of terrorism, they may participate in random evacuations from a community in peril, and they may witness casualties directly or via the mass media (Macksoud, Dyregrov, & Raundalen, 1993; Rosenblatt, 1983; Schlenger et al., 2002).
War, terrorism and other forms of organized violence damage children’s trust in others and the much needed assumption that their world is or will ever be safe. The
psychological price children pay for being exposed to terrorists’ direct and indirect
threats involves a traumatic ruptures in the child’s assumptions about the world as a safe place and hopes for a better future (Gordon & Wraith, 1993). Most traumatized children are unable to grasp the full implications of their loss nor can they come to terms with the reality of the situation – because it is inexplicable, unbelievable, and incomprehensible. Another damaging effect on the child’s psyche happens when the imagery of terrorist violence becomes an unconscious organizing principle, determining how children see the world and how they choose to act. Some, for example, might develop a militaristic coping strategies, tinted with paranoid suspicions that may precipitate a new round of violence. Others may develop a “victim’s identity” and suffer though their lives from feelings of anomie and helplessness. In numerous cases of terrorist attacks children are exposed to sheer brutality, they are confronted with terrorists who seem to enjoy causing suffering. Such experiences have been reported by children who were held as hostages in Israel (Ayalon, 1988), in Beslan an attack of terrorism imposed its brutality on an ever widening circles of the injured, their keen, near-miss, rescue workers, health personnel, teachers, therapists and many unidentified others.
The following example highlights the range of responses to children’s exposure to terrorism.
A team of trauma researchers (Ayalon & Soskis ,1986; Desivilya, Gal, & Ayalon, 1996) conducted a twenty years follow-up study of Israeli children & adolescents survivors of terror of the Ma’alot Massacre. During this attack on a school building 105 children were captured by three terrorists and held hostage for 16 hours. 22 children were killed, many others were wounded.
The survivors reported on their immediate and delayed responses:
- The arbitrariness of the attack intensified fears and shook their sense of personal identity: “I don’t know who I am any more”.
- The l inability to escape or defend themselves and others increased frustration, that in turn bred aggression that was directed inward and turned into desperation: “I feel as if I had died 20 years ago”.
- Some experienced ambivalent attachment to the terrorists on whom they became dependent for the most basic and private daily functions, such as mobility, speech, food or toilet.
- Guilt and self-disgust resulted from some attempts to communicate with the perpetrators. One girl, who had shared bread with one of the captors, developed later an aversive reaction to eating bread, which for her became contaminated and repulsive.
In the long-term some felt a perpetual disruption of their sense of self and continuity of their personal life-line, as if time had stopped for them at the moment of the attack. The brush with death shattered their illusion of invulnerability. Others responded to the trauma with violence – perhaps in an attempt to overcome their worst inner fears, to awaken a sense of feeling in an otherwise “frozen” psyche, or to find a legitimate outlet for massive grief and anger. Some survivors suffered guilt, became chronically suspicious or angry, or turned their unspent aggression inward, damaging themselves mentally or physically. Some emerged from the disaster with a bleak outlook on life, feeling depressed and helpless, while others adopted a heroic attitude and sought to become “saviors.” Twenty years after the event, well into their young adulthood, more than half of the survivors still suffered from the following symptoms: hyper-alertness, sleep disturbances and recurrent dreams, intrusive images and thoughts, reliving the catastrophe through fantasy, avoidance of objects and places that reminded them of the
event, and startle reactions to abrupt noises. A minority complained about depressive reactions, numbing of sensations (psychic numbing), social withdrawal, memory and concentration blocks. A few had feelings of persecution and expectations that the event will reoccur. Some searched for prophetic signs (omens and portents), felt regret and guilt towards those who perished, were suspicious and alienated (“Nobody could ever understand what I’ve been through”). A few showed a great drive for excellence, achievement and altruistic contributions to society, while some took great pain to hide their past predicament even from their own children.
Warlike activities and military occupation extract a damaging toll from children and their families. This is evident in testimonies from the Palestinian communities under Israeli occupation. The strains of living under occupations in an area also undergoing rapid social changes have created severe mental and psychological health problems among the majority of Palestinian men, women and children (Thabet, Abed et al. (2002). Trauma and stress-related troubles Palestinian children, are increasing, according to psychologists at the Qalandiya refugee camp in the West Bank. “Palestinian children have lost all sense of normalcy. They don’t know whether they’ll be able to go to school, whether they’ll come home safely because of curfews and (Israeli) army incursions, or indeed, whether they will be asked to blow themselves up” (Punamaki, 1982).
On top of the physical pain and horrendous fear, such exposure to brutality may
completely destroy a child’s basic assumption of what is considered acceptable human behavior. It may also evoke the danger of emotional leakage or contagion of aggression from perpetrator to victim. Surging aggression in the child-victim is fed by frustration
and reinforced by perceptions of the aggressor as an authority whose power is derived from absolute physical advantage. This process is especially dangerous for children who may identify with the aggressor and, in a paradoxical way, cast the terrorists into their role models, similarly to battered children who identify with their abusive parent (Ayalon & Waters, 2002).
The ripple effect of Indirect Exposure
While acts of organized violence or terrorist attacks victimize children directly, many more children are caught up in the traumatic ripple effects: like a stone cast into a pool of water, the ripples of the disaster spread throughout the pool, affecting the entire community and other children in it (Ayalon, 1993). Many children who are socially or psychologically close to the targeted victims, such as siblings, peers, schoolmates, neighbors or even eyewitnesses and TV watchers become “near miss” victims: the thought that “it could have happened to me” may be as real as the hit itself and generate emotional and physical symptoms. By becoming witnesses to a terrorist attack such children may absorb the helplessness of watching the sights and sounds of death and destruction. Children who are thus vicariously traumatized become hidden victims and carry unseen scars. Parents or caretakers may not realize how wounded they may be. Family, school, law enforcement agencies and mental health professionals often neglect the needs of secondary victims. In a terror stricken environment it is paramount to identify those agents in the community who are available to identify these children and give support. An attack of terrorism imposes its brutality on an ever widening circles of the injured, their keen, near-miss, rescue workers, health personnel, teachers, therapists and many unidentified others.
Responses to living in dangerous environments differ from child to child, depending on individual factors such as age, sex, direct or indirect loss, and the availability of family and community support systems. Differences in outcome studies of the impact of war on
children reflect the different degrees of exposure to stressors and even the manner in which stressors are perceived and defined (Kuterovac, Dyregrov, & Stuvland, 1994). Some children can be sheltered and protected from the actual fighting, while information
is mediated by parents and peers or filtered through mass media. Some may be proud of fighting fathers and brothers or mourn their death. These protective factors have emerged both in Palestinian and in Israeli societies. For example, studies of Palestinian children traumatized by the occupation related armed struggle (El-Sarraj & Meldrum, (2002) stress family ties as a protective measure against morbidity. Ideological belief systems, resilience and degree of exposure are interactive factors that affect the post traumatic effects of terrorism on adolescents in Israel (Solomon, Laufer & Lavi, 2005).
The psychological impact of an impending threat to one’s life, to one’s family and community demands a thorough understanding of the many faces of the trauma spectrum. It also demands a broad perspective of all psycho-social interventions prior, during and after terrorist attacks. There is a challenge for those who carry the banner of social responsibility to be able to identify the risk factors in the different scenarios of impending attacks, identify the populations within the “circles of vulnerability”, make contingency plans and have intervention programs ready to use on demand.
The growing number of children who live in dangerous environments world-wide has
prompted the formation of newly adapted age-appropriate socio-educational methods to enhance resilience and develop stress related coping skills (Ayalon & Soskis, 1986; Ayalon & van Tassel, 1987; Meyers, 1994; Gurevicth & Messenbaugh ,2001). But along with the growing awareness there is also an obvious ambivalence among professional around this issue. On one hand – “child experts” are on the lookout for a conceptual as well as practical “healing packages” to carry with them and share with others
wherever healing is called for – in refugee camps, schools and communities, families and
groups wherever they are. There is also a need for a healing language that will bridge the lingual and cultural gaps between helpers and local populations, and enable each helper to extend a helping hand to children when their world falls apart (Rosenfeld. Caye, Ayalon & Lahad, 2005; Ayalon, 2005; Ayalon, in print). On the other hand policy makers and psychologists have evaded for a long time the issue of preparing and using trauma-preventive programs for children. The first steps toward implementing an intervention policy were documented in Israel, a country that has often been considered a laboratory of traumatic stress and coping strategies. When confronted with a wave of terror attacks on children in schools, nurseries and families in the years 1974-1978 (Ayalon, 1979), the educational system that had to deal with child survivors of these attack and with the rising level of anxiety and vigilance in schools, supported the first major crisis intervention program. It was geared to deal with direct and “near miss” victims in the aftermath of terrorist attacks and was implemented in schools by educators and mental health professionals, (Ayalon, 1978). The program was later consolidated and published in two handbooks in Hebrew: Life on the Edge (Ayalon & Lahad, 2000) and On Death and Life (Lahad & Ayalon, 1995).
These publications contained specially designed creative activities, oriented
towards resilience and coping. They provided stress and trauma “preventive and interventive curricula” for teachers and counselors. Since then, the ongoing threats of terrorism spread to many countries and set in motion further multimodal interventions that became prominent in the last decade. One such comprehensive model for crisis intervention with children and their families in the wake of terrorist attack is Meyers’ handbook for mental health professions called: “Disaster and response and recovery” (Meyers, 1994). Following the bombing and carnage in Oklahoma City in USA, a program called “Healing after trauma skills” (Gurevicth & Messenbaugh (2001) presented educational and treatment materials to address symptoms and behavioral difficulties associated with trauma and loss. It is conducted by mental health professionals or school personnel and relies on group format, although it may be used for individuals (Gurwitch, Sitterle, Young & Pfefferbaum, (2002). The introduction of intervention programs into the educational system inspired innovative research (Pat-Horenczyk, 2004; Baum (2004) ), but the chaotic circumstances of implementing such programs during and soon after a disastrous event and the enormous variety of circumstances make research on the effectiveness of these programs very difficult. Most existing research is descriptive, trying to bridge the gap between intervention research and practice (Chemtov, & Taylor, (2002).
The Art of healing when trauma is “beyond words”
The need to bear witness
The cost of trauma in human suffering and distress is very high both for victims and 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. * 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.
Healing through the Arts
Traumatized children 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 the affected population needs some special help from the outside. People need a helping hand to guide them to discover their hidden coping resources and develop new coping skills to regain control over their life.
The art of healing uses the Arts as expressive body/mind self reflection beyond language and cultural constraints. The healing Arts offer ways to communicate the inexpressible experiences, to achieve a measure of control over them, manage the fear of terror and find inner the resources of resilience and coping. The power of the Arts
in healing is in combining reality and fantasy, creating a transformation of fear and loss into a new expression, that is one step removed from the traumatic experience (Knafo, 2005).
The healing arts dwell in the “transitional space” where healing takes place. According to Winnicot, the “transitional space” lies between the external world that harbors violence and atrocities and the internal vulnerable “sense of self” that is uniquely individual (Winnicot, 1971). This” transitional space”, that is the domain of imagination, play and creativity, offers opportunities for healing and growth. This “transitional space” can be the bridge between the situational terror events and the psychological traumatic experience. In this arena the child’s natural activity of play and creativity can have a cathartic effect. It is the space for internal conflict resolution and healing from the trauma, of attending to children, listening to them, assessing their needs, and using creative methods to create order in uncertainty or chaos and start to heal the wounds inflicted by the terrorist violence (Ayalon, 1998).
The following is an example of one such strategic program: C.O.P.E. psycho-social Community Oriented Preventive Education, that uses different art and creative modalities. C.O.P.E. is a generic stress and trauma preventive/interventive program, that was initially developed for the Israeli school system in response to massive terrorist attacks on civilian population since . An English handbook, Rescue! (Ayalon, 1992) published in USA, has since been adapted and implemented in various countries afflicted by war and terror throughout the world, such as Angola, the Balkans, former-Yugoslavia (Ayalon, 1995a), Northern Ireland, South-Africa, Russia, Turkey, with refugees in Thailand (Ayalon, 1991), torture victims in Finland (Ayalon, 1995b), and in Argentina following Buenos Aires terror attack (Ayalon & Lahad, 1995).
C.O.P.E. is designed to deal with individual and collective trauma, specifically human-induced violence of war & terrorism. It is a psycho-social integrative, wellness-oriented package containing different modes and methods of interventions (cognitive, affective, behavioural, verbal & non-verbal modes). C.O.P.E. is based on the assumption that both individuals and groups own inherent resilience and acquired coping resources that need to be nurtured and prompted in times of need. The package includes intervention protocols for different sections of the population inflicted by terrorism: children & youth, families, school personnel, rescue workers. C.O.P.E. Program may be used in three critical phases:
- In the pre-disaster phase as stress inoculation, intended to reduce the psychological damage that may be caused by an impending trauma. The experience of successfully coping with manageable levels of stress enables us to develop a sense of “learned resourcefulness” that prepares us to deal effectively with impending dangers and loss (Seligmann, 1998).
- To ameliorate acute stress during war and terror related crisis, especially if it is prolonged and lasts for days, weeks or even longer,.
- For recuperation and healing the trauma in the post-crisis period,
Each of these phases has a specific focus:
- 1. Pre-disaster phase: Focuses on preparing a contingency plan for crisis management and intervention in case of a terrorist outbreak. This plan may include evacuation to a safe location and the establishment of emergency communication networks, preparing alternatives to conducting school activities in the event of a critical incident, establishing crisis headquarters, interactions with parents to help them develop a family disaster plan., rehearsing and assessing Stress Inoculationcurricula in schools.
- When disaster strikes: In case of a terrorist attack, the primary requirement for children of all ages is to experience safety. Psychological first aid should be brief, adjusted to the severity of the crisis, and focused on the immediate needs of the survivors. What children need most following a disaster is to restore their sense of a secure “home base” and to resume their contact with their parents or reliable care-takers, helping children understand what happened during and after the attack providing physiological relaxation and tension reduction (in a safe location) providing a clear (even if slim) sense of the future and hope for relief. This requires that parents or significant others be involved and supportive during the process of crisis intervention, reuniting family members and verifying information about losses, giving clear directions of “what to do, where to go,” etc. When adults assume leadership they provide a model of behavior 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.
- Post trauma interventions: Managing the fear of terror demands a thorough understanding of the trauma spectrum and a broad perspective of psycho-social interventions prior, during and after an attack of this kind. The psychological trauma may linger on long after the physical damage is healed. An important step towards healing the psychological trauma is processing it by telling the trauma-story in front of an empathic and supportive audience.
Tactical operations: Methods to enhance recovery and healing
First step for recovery and healing is to reach physical and psychological safety and security. In this safe space it is possible to vent feelings, by verbal and nonverbal means, to share dreams, nightmares and other traumatic reactions. When appropriate, mourning and memorial rituals can promote positive affirmations of resilience.
In order to encompass the different agendas that often emerge in trauma healing practices, a holistic multi-modal framework evolved that contained six facets of experiencing the world: Physical behavior, cognitive learning, imagination/creativity, social support, affective expression and belief systems (Ayalon 1992; Ayalon & Lahad 2000, Lahad, 2000a). These in the reverse order created the acronym “B.A.S.I.C. Ph”. Different protocols can be derived according to the demand of the critical situation. The following are a few examples:
The following examples from cross-cultural research bring some of the vast evidence accumulated about the function of the `multi-dimensional model of coping resources’ as a generic container for specific situational and cultural modes of coping. Ph-sensory and motor coping resources. Most traumatic situations involve extreme sensory exposure. Specific sensory stimuli such as smell, sight, noise or touch may later become triggers for emerging intrusive memories. Body awareness, body-work, active relaxation and planned activity help to channel or extinguish the shock and the intrusive memories stored in the body (Rothchild, 1993). Relaxation training has proven very beneficial in abating anxiety when employed with Israeli children who had to spend prolonged periods of time in air-raid shelters. It was also effective in reducing hyperventilation when children had to wear gas-asks in sealed rooms against Iraqi missile attacks in the Gulf war (Ayalon, 1993b; Solomon, 1996).
Physical (body/mind) coping modes: Van der Kolk (2005) maintains that “given the subcortical nature of trauma imprints, effective therapy needs to help survivors tolerate the sensory reminders of trauma and to physically experience efficacy and purpose in response to stimuli that once triggered feelings of helplessness and dependence”. As the trauma stored in the body evokes non-voluntary responses, such as crying and trembling, helpers should allow these natural reactions to occur and to physically support the shaken (and perhaps shaking) child and provide emotional reassurance until the tension stored in the body is totally spent and the child regains control. Levine and Frederick (1992) suggest the use of Somatic Experience & body awareness for unfreezing the somatic trauma by expression and regaining body-mind control.. Another body/mind method considered among the most effective methods to date is Eye Movement Desensitization and Reprocessing (EMDR) (Shapiro & Forrest 1997; Silver & Rogers, 2001).
Cognitive reprocessing: This channel includes such methods as cognitive-behavioral tasks for unfreezing body-mind stress, cognitive methods for gaining control over post-traumatic issues, controlling painful memories by drawing visual images and prolonged exposure techniques (Foa, Yadin & Doron, 2005).
Affective methods couples with Imagination & creativity : Children 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 telling the trauma
story is to revisit the scene and, in so doing, release its grip of terror and horror. The value of Verbalizing and putting the event in context cannot be overstressed. There is a plethora of techniques to promote verbal expression in the post trauma intervention. 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 verbalize 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 When trauma is “beyond words”, creative Arts offer many ways of expressing painful memories, such as by using visual images, giving shape and color to something so amorphous as pain helps to control and “de-catastrophize” it. For example, we use images that are presented in the “COPE cards for trauma and healing”, which are metaphoric story-telling cards that help elicit the personal narrative. Any COPE card (or combination of several cards) can function as a trigger for the narration of the event and responses to it.
A-affect: ventilation and expressing emotions as a coping resource. Children have a great need to tell their story, express their horror, guilt or rage and ask unanswerable questions. Shutting up the trauma story becomes a secondary victimization, and hinders recuperation. As children’s natural language is play, the debriefing program should promote free play, projective play and role-play, as well as other verbal and non-verbal expressive methods such as drawing, dancing, singing and story-telling (Ayalon & Flasher, 1993).
Therapeutic responsibility and ethics are often breached when severely traumatized children are offered a brief opportunity to ventilate, but all expectations for compassion and dependency are curtailed by the end of the brief one-time encounter. This can also happen when the number of victims outnumbers and overwhelms the therapeutic resources which are limited. In other
instances, children are pressured into telling and retelling their `horror stories’ to journalists and researchers. The retelling is not always in the best interest of the child. It may compromise a child’s rehabilitation and reintegration, as he sees his or her value only in regard to his or her identity as a victim, soldier, or worse-as a ‘killer’.
When surviving is at stake, it is more responsible to encourage the coping and challenging aspects and refrain from compromising the children by opening the raw emotional wounds. In situations of imposed passivity, for example when children hide in shelters during air-raids, distraction of their minds by humor and games is preferred to ventilation of fears (Ayalon & Lahad, 1990). Only in relative safety is it recommended to encourage ventilation. For most victimized children, it is important to create a context of hope and future meaning.
C-cognitive coping resources. Children are helped by learning about normal reactions to trauma and loss. Telling the truth about injuries and death and about the destruction of homes or schools helps to anchor them in reality and start the process of grief and recuperation. Stress inoculation skills (Meichenbaum, 1985), positive affirmation, assertiveness and self-regulation are all important cognitive tools for coping with adversity.
Giving and receiving Social support – by using metaphoric rituals of mourning and leave-taking rituals (van der Hart, 1983, 1988) and metaphoric stories. These proceses are facilitated by the use of small objects, figures, animals, trees to allow non-threatening identification. It must be stressed that mourning is basically a family process and family coping depends on the ability of each member to work through grief, both individually and as a group. It is a process that may be complicated by the fact that members of a bereaved family may be going through different phases of mourning at the same time and be unaware of each other’s struggles to cope (Pynoos, 1992; Webb, 2002). Understanding the dynamics of the family system is absolutely necessary.
S-social belonging and support as coping resources. Peer support groups promote children’s integration of the trauma by providing age-appropriate communication of the shared experience, continuity and stability, a relief from conflict with the adult world, and opportunities for fun activities. Youth leaders help the younger children reintegrate their pre-traumatic life experiences with the new life-style and opportunities. This model was developed in Israel as a response to the urgent need to absorb the numerous child survivors of the Holocaust since 1945, and found useful even now in helping refugee/immigrant children separated from their parents. Refugee camps in south east Asia, the former Yugoslavia, South African townships, and children’s camps in Angola have also adopted this model (Ayalon, 1995).
Belief systems: When children exposed to a disaster show signs of reconciliation with the traumatic past, they are facing a new challenge: creating a new future (Herman, 1992). In this process the “victims” regain their world and become victors. B-belief systems. In all cultures, religious prayers are used to obtain help or guidance in threatening situations. In Rwanda, for example, this common principle has been used to prompt parents and religious leaders to encourage children to tell or draw their traumatic stories to God, as a form of `communication from the powerless to the almighty’ (Dyregrov & Raundalen, 1995). Rituals like memorials for the dead, traditional mourning ceremonies such as the Jewish ‘Shiva’ or even therapeutic `metaphoric burial’ (Van der Hart, 1986) can help children to process feelings of loss. Our longitudinal study of children hostages (Ayalon & Soskis, 1986; Soskis & Ayalon, 1985) unfolds the major role of religious faith, political ideology and value system as coping strategies. This area of belief systems, overlooked for a long time by psychologists, needs to be better understood and used in certain post-trauma interventions.
I-imagination and creativity as coping resources. Creative imagination is the most prominent resource in the formation of the `potential space’-the `sea ofpossibilities’. Spontaneous ‘flight’ into fantasy is reported by survivors of prison camps or torture and kidnapped hostages as their salvation in maintaining their sanity (Terr, 1987). The power of imagination to expand our existence beyond limiting realities has been repeatedly confirmed by prisoners of war and hostages (Ayalon, 1983), by abused children (Ayalon & Zimrin, 1990), by torture victims, dying patients and other survivors of adversities. Imagination is the core of spontaneous play and play-therapy, of drama therapy and enactment. It nurtures the creative process of drawing and sculpting, of poetry and prose writing, of dancing and of making music. This triggers the imaginative power to conduct metaphoric `parting ceremonies’ for bereaved children (Lahad & Ayalon, 1994). Healing imagery and laughter have been known to strengthen the individual’s immune system, and the community’s esprit de corp.
Following are two examples that try to put some flesh on the bones of the theoretical arguments leading to our reconciliation methods used with children, after having been experienced by the teachers themselves.
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. Each level of difficulty deserves close attention. Teachers are encouraged to bear in mind all three levels while trying to help their students cope with the trauma of the current situation (Flashman, 2003). These tasks, which sometimes are unattainable by direct approach, are greatly facilitated by the use of metaphors. One of our most effective tools in eliciting healing metaphors are a set of illustrated cards called COPE Cards2, that belong to a specially designed genre of associative cards (the OH Card series). These cards enable their users, whether playfully or therapeutically (or both!) to access flexibility and imagination and touch deep feelings. By using COPE Cards participants can learn to identify their own particular ways of coping with crisis, stress and trauma. The experience of randomly selecting cards and dealing with the associations they evoke can open up the richness of new ideas and possibilities instead of repeating familiar patterns of thought and response. COPE Cards can help us reach our inner pain and discover our inner strength. A sort of “virtual training” takes place in dealing with challenging situations, in surfing beyond time and space, in experimenting with possible solutions to conflict laden issues – all within the safe world of image and metaphor (Ayalon, 2003).
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 traumatization 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.
Metaphoric stories triggered by the visual images on the cards are one step removed from anguished reality. This “creative distance” facilitates recall and the working though of trauma experience. The use of images and imagination serves as a protective screen against being. Thus it represents an international joint effort to deal with the consequences of traumatic events and help heal the psychic wounds.
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.
The COPE Cards can help us reach our inner pain and discover our inner strength. In trying out various methods, exercises or games a sort of virtual training takes place in dealing with challenging situations, in experimenting with possible solutions to problematic issues – within the safe world of image and metaphor. The stories that emerge from the cards are unique, personal and original, reflecting as they do the innermost ideas and feelings of the people who tell them.
COPE Cards activities
Identifying Your Coping Channels with the “BASIC Ph” Model Background: This activity aims to discover what our own coping channels are, the ones we use to deal with daily hassles and stress, and in situations of crisis. In this game 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 6 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. Select blind 6 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, 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-dependant 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.
What do children need in the wake of trauma?
Children need to process the experience of trauma at their own individual pace. It is important that helpers support and honor this. * Children 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 children 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. * children need to enhance their “BASIC Ph” coping resources.
This chapter highlights several key issues pertaining the traumatic effects of terrorism on children and ways of intervention that try to ameliorate these effects. There is a need for interaction between helpers and researches to develop empirically based interventions for child victims. There is an urgent need to evaluate existing trauma-related interventions for the different phases of recovery from the traumatic exposure to terrorism. Issues such as cultural differences, age, gender, ethnic background, family situations, developmental stages, resilience and coping skills demand special attention, special training of helpers and available support for helpers in action. The answer lies in preventive intervention and in systems approach, respecting the fact that parents and teachers play a vital role in buffering the experience of terror and have a major influence on children’s wellbeing.