Three Tiers of Mental Health Intervention

1
Three Tiers of Mental Health Intervention
Tier 1 General post-trauma support to a wide
population of children through their schools,
community agencies, and religious
institutions Tier 2 Identification of high risk
children, adolescents and families extreme
exposures and losses, high levels of current
distress and developmental risk Tier
3 Identification of children and adolescents with
serious psychiatric disorders
Adapted from Pynoos RS, Goenjian AK, Steinberg
AM (1998) A public mental health approach to the
post-disaster treatment of children and
adolescents. Psychiatric Clinics of North
America 7195-210.
2
Selected Intervention Foci Tier One

• Mutuality of disruption of a protective shield
• Fears of recurrence
• Impact on developmental negotiation of danger,
  safety and protection
• Reactivity to danger cues

Adapted from Pynoos RS, Goenjian AK, Steinberg
AM (1998) A public mental health approach to the
post-disaster treatment of children and
adolescents. Psychiatric Clinics of North
America 7195-210.
3
Examples of InterventionTier One

• Safety and restoring the protective shield
• Reduce unnecessary secondary exposures
• Focus on constructive responses
• Encourage and support help-seeking behaviors
• Create a supportive milieu for the spectrum of
  reactions and different courses of recovery

Adapted from Pynoos RS, Goenjian AK, Steinberg
AM (1998) A public mental health approach to the
post-disaster treatment of children and
adolescents. Psychiatric Clinics of North
America 7195-210.
4
Five Foci of Trauma-Grief Focused
InterventionTier Two

• Traumatic Experience(s)
• Trauma and Loss Reminders
• Traumatic Bereavement
• Adversities and Current Stresses
• Developmental Progression

Adapted from Pynoos RS, Goenjian AK, Steinberg
AM (1998) A public mental health approach to the
post-disaster treatment of children and
adolescents. Psychiatric Clinics of North
America 7195-210.
5
Traumatic Experience(s)

• Psycho-education regarding trauma-related stress
  reactions
• Reconstruction and reprocessing of the traumatic
  experience, including worst moments and
  attributions of meaning
• Clarification of distortions, including
  misattributions linked with excessive guilt and
  shame
• Address maladaptive behavior used to cope with
  distressing memories
• Increase tolerance for traumatic memories
• Exploration of intervention thoughts and
  traumatic expectations

Adapted from Pynoos RS, Goenjian AK, Steinberg
AM (1998) A public mental health approach to the
post-disaster treatment of children and
adolescents. Psychiatric Clinics of North
America 7195-210.
6
Trauma Reminders

• Identify current reminders of traumatic
  experiences
• Identify links between traumatic experiences,
  reactivity to reminders and current maladaptive
  behavior
• Increase cognitive discrimination between the
  present and the past
• Increase tolerance for expectable reactivity
• Develop / facilitate the appropriate use of
  support-seeking and other coping behavior to
  contend with reminders
• Increase pro-active measures to reduce
  unnecessary reminders

Adapted from Pynoos RS, Goenjian AK, Steinberg
AM (1998) A public mental health approach to the
post-disaster treatment of children and
adolescents. Psychiatric Clinics of North
America 7195-210.
7
Grief

• Identify grief reactions and provide
  psycho-education about the variable course of
  bereavement
• Promote acceptance of traumatic losses
• Facilitate mourning through construction of a
  non-traumatic mental representation of the
  deceased
• Identify and increase tolerance for current and
  future reminders of losses
• Address conflicts over past interactions that
  evoke regret, guilt, or shame
• Examine influence of losses on current choice of
  relationships
• Assist with skills to re-evoke and revise a
  mental relationship with a lost person,
  appropriate to needs of future developmental
  stages

Adapted from Pynoos RS, Goenjian AK, Steinberg
AM (1998) A public mental health approach to the
post-disaster treatment of children and
adolescents. Psychiatric Clinics of North
America 7195-210.
8
Post-Trauma Stresses and Adversities

• Identification of post-trauma difficulties,
  including family, work, health, and living
  circumstances
• Promotion of acceptance and adaptation to changes
  and losses
• Develop / facilitate the appropriate use of
  emotion coping and problem-solving skills to
  contend with adversities
• Assist with management of aggression
• Increase social skills for genuine disclosure
  about traumatic experiences and losses
• Assist family members and employee/co-workers
  with addressing practical/interpersonal problems
  that interfere with post-trauma recovery

Adapted from Pynoos RS, Goenjian AK, Steinberg
AM (1998) A public mental health approach to the
post-disaster treatment of children and
adolescents. Psychiatric Clinics of North
America 7195-210.
9
Developmental Impact

• Identify missed developmental opportunities
• Challenge maladaptive developmental expectations
  and coping
• Support resumption of compromised developmental
  activities
• Facilitate normal developmental progression
  through participation in age-appropriate
  activities
• Promote pro-social efforts, leadership skills and
  peer mentorship
• Support group behavior to create a more favorable
  recovery environment within the family, school,
  and community

Adapted from Pynoos RS, Goenjian AK, Steinberg
AM (1998) A public mental health approach to the
post-disaster treatment of children and
adolescents. Psychiatric Clinics of North
America 7195-210.
10
Selected References

• Goenjian, A, Pynoos, RS, Karayan, I, D, Najarian,
  LM, Steinberg, AM, Fairbanks, LA (1997) Outcome
  of psychotherapy among pre-adolescents after the
  1988 earthquake in Armenia. American Journal of
  Psychiatry 154536-542.
• Saltzman, W.R., Pynoos, R.S., Layne, C.M.,
  Steinberg, A.M., Aisenberg E (2001). Trauma- and
  Grief-focused intervention for adolescents
  exposed to community violence Results of a
  school-based screening and group treatment
  protocol. Group Dynamics Theory, Research and
  Practice, 5 291-303.
• Saltzman WR, Steinberg AM, Layne CM, Aisenberg E,
  Pynoos RS (2001) A Developmental Approach to
  School-Based Treatment of Adolescents Exposed to
  Trauma and Traumatic Loss. Journal of Child and
  Adolescent Group Therapy 1143-56.
• Pynoos RS, Goenjian A, Steinberg AM (1995)
  Strategies of disaster intervention for children
  and adolescents. In Hobfoll S.E. and de Vries M.
  (Eds.) Stress and Communities Dordrecht, The
  Netherlands M. Kluwer Academic Publishers
  Publications, 445-471.
• Pynoos RS, Steinberg AM, Wraith R (1995) A
  developmental model of childhood traumatic
  stress. In D. Cicchetti and DJ Cohen (Eds.),
  Manual of Developmental Psychopathology New York
  John Wiley Sons, 72-93.
• Pynoos RS, Goenjian AK, Steinberg AM (1998) A
  public mental health approach to the
  post-disaster treatment of children and
  adolescents. Psychiatric Clinics of North
  America 7195-210.