Crisis Counseling: an Overview

Psychology in the Schools, Vol. 46(3), 2009 Published online in Wiley InterScience (www. interscience. wiley. com) C 2009 Wiley Periodicals, Inc. DOI: 10. 1002/pits. 20370 CRISIS COUNSELING: AN OVERVIEW JONATHAN SANDOVAL, AMY NICOLE SCOTT, AND IRENE PADILLA University of the Paci? c Psychologists working in schools are often the ? rst contacts for children experiencing a potentially traumatizing event or change in status. This article reviews basic concepts in crisis counseling and describes the components of psychological ? rst aid.This form of counseling must be developmentally and culturally appropriate as well as individualized. Effective intervention can prevent post-traumatic stress syndrome and facilitate normal mourning processes associated with any losses experienced. These prevention activities are also discussed. Some children may need resources beyond those that the school can provide, and appropriate referrals can link children and adults to a variety of treatments such as psychotherapy and medication, also brie? y outlined. C 2009 Wiley Periodicals, Inc.Most children and adults are resilient and have ways of coping with stressful events. In fact, according to the National Institute of Mental Health (NIMH; 2001), recovery from crisis exposure is the norm. Children usually need minimal assistance from family members, teachers, clergy, or other caring adults. Others, particularly those with few social supports, enter into a crisis state (Barenbaum, Ruchkin, & Schwab-Stone, 2004; Caffo & Belaise, 2003; Litz, Gray, Bryant, & Adler, 2002; Ozer, Best, Lipsey, & Weiss, 2003). People in crisis are in what Caplan (1964) terms a state of psychological disequilibrium.This disequilibrium occurs when a hazardous event challenges normal psychological adaptation and coping. Individuals often behave irrationally and withdraw from normal social contacts. They cannot be helped using usual counseling or teaching techniques. Nevertheless, children in crisis are usuall y also in school. School psychologists and other guidance personnel must be able to support teachers, parents, and the children themselves during periods of crisis. The primary goal in helping an individual who is undergoing a crisis is to intervene in such a way as to restore the individual to a previous level of functioning.For children, this means returning to the status of learner. Although it may be possible to use the situation to enhance personal growth, the immediate goal is not to reorganize completely the individual’s major dimensions of personality, but to restore the individual to creative problem solving and adaptive coping. Of course, by successfully resolving a crisis an individual will most likely acquire new coping skills that will lead to improved functioning in new situations, but that is only a desired, possible outcome, not the sole objective of the process (Caplan, 1964).Because failure to cope is at the heart of a crisis, the promotion of coping is an o verall objective of crisis intervention. P SYCHOLOGICAL F IRST A ID School psychologists and other mental health personnel working in schools are in a position to offer psychological ? rst aid (Parker, Everly, Barnett, & Links, 2006). Analogous to medical ? rst aid, the idea is to intervene early when a hazardous event occurs for an individual, and offer compassionate support to facilitate adaptive coping. At the same time, the need for further intervention may be assessed and planned.According to The National Child Traumatic Stress Network and National Center for Post Traumatic Stress Disorder (PTSD) (2006) there are eight core psychological ? rst aid actions. Of course, the exact actions taken need to be tailored to the particular circumstances of crisis victims. Correspondence to: Jonathan Sandoval, Department of Educational and School Psychology, Benerd School of Education, 3601 Paci? c Avenue, Stockton, CA 95211. E-mail: [email  protected]? c. edu 246 Crisis Counseling Overvi ew 247 Making Contact The ? st action is to establish a relationship through verbal and nonverbal means with the child. Generally speaking, the sooner contact is made the better. By simply being physically present with the child and supporting nonverbal behavior alone, anxiety can be lessened. Providing Safety It is important to protect children from further harm by moving them to a secure location and attending to their basic needs for food, drink, sleep, shelter, or freedom from further danger. To relieve tension, it is also helpful to provide a place for play and relaxation.Children need to be protected from the eyes of strangers and the curious, and they need to be spared watching scenes of a traumatic event in the media (Young, Ford, Ruzek, Friedman, & Gusman, 1999). Stabilizing Affect Counselors must demonstrate nonverbally that they are able to be calm and composed. Adults modeling calmness and competence can communicate that problems may be solved and emotions can be control led in time. A counseling relationship will be important to help the child manage fear, anxiety, panic, and grief. Nondirective listening skills are most effective.However, it is also important not to offer unrealistic reassurance or to encourage denial as a defense or coping mechanism (Sandoval, 2002a). Addressing Needs and Concerns Once the crisis worker has been able to formulate an accurate, comprehensive statement about the student’s perception of the situation by identifying all of the sources of concern, it will be possible to begin the process of exploring potential strategies to improve or resolve the emotionally hazardous situation. Jointly, the crisis worker and pupil review the strategies explored and select one for trial. The outcome should be an action plan.This is much like the problem solving that occurs in conventional counseling, but must be preceded by the steps previously mentioned. Moving too quickly to problem solving is a common mistake of novices. Howe ver effective the problem solution is, the very process of turning attention to the future and away from the past is bene? cial in and of itself. Provide Practical Assistance Helpers need to be direct with children and take an active role in managing their environment. Because parents may be disabled by the disaster, it is comforting to see some adult taking control and making decisions.Some solutions may involve actions by others, such as teachers or school administrators. To the extent necessary, the crisis worker may act as an intermediary communicating with authorities on the child’s behalf. When working in schools, a task will be to reunite children with their parents or loved ones. Plans need to be in place to communicate with parents and track children should a disaster occur at a school site (Brock, Sandoval, & Lewis, 2001). Facilitate Connections with Social Supports Finding social supports may be particularly dif? cult during times of crisis.In a disaster, for examp le, whole communities are affected. There is a disruption of both schools and social services. There is often an absence of adults with whom children can process feelings of loss, dread, and vulnerability. Psychology in the Schools DOI: 10. 1002/pits 248 Sandoval, Scott, and Padilla Nevertheless, it is usually possible to ? nd either a group of peers or family members who can provide emotional support and temporary physical assistance during the crisis. In this way the pupil’s energies may be devoted to coping with the crisis.Being with and sharing crisis experiences with positive social support systems facilitates recovery. Conversely, lower levels of social support often predicts traumatic stress reactions (Barenbaum et al. , 2004; Caffo & Belaise, 2003; Litz et al. , 2002; Ozer et al. , 2003). If family is not available, there are often community resources that may substitute and the crisis worker should be knowledgeable about them. Facilitating Coping During the process o f crisis intervention, the student will have temporarily become dependent on the crisis counselor for direct advice, for stimulating action, and for supplying hope.This situation is temporary and before the crisis intervention interviews are over, the crisis counselor must spend some time planning ways to restore the student to selfreliance and self-con? dence. This restoration may be accomplished by consciously moving into a position of equality with the student, sharing the responsibility and authority. Although earlier the crisis counselor may have been very directive, eventually he or she strives to return to a more democratic stance.Techniques such as one-downsmanship [where the counselor acknowledges the pupil’s contribution to problem solving, while minimizing the counselor’s own contribution (Caplan, 1970)] permit the counselee to leave the crisis intervention with a sense of accomplishment. Helping individuals to ? nd alternative rewards and sources of satisfa ction using problemfocused coping (Lazarus & Folkman, 1984) is most helpful. Providing anticipatory guidance involves connecting children to knowledge and resources, and involves providing information about stress reactions and future challenges that the client will face.It acts to reduce distress and promote adaptive functioning. Any action strategies must be implemented in the context of what the student thinks is possible to accomplish. Crisis ? rst aid providers can emphasize what positive there is in the situation, even if it seems relatively minor. For example, even the victim of a sexual assault can be congratulated for at least surviving physically. The crisis situation often leads to a diminution in self-esteem and the acceptance of blame for the crisis.With an emphasis on how the child coped well given the situation so far, and how the person has arrived at a strategy for moving forward, there can be a restoration of the damaged view of the self. Drawing from the self-conc ept literature, it may also be important to emphasize positive views of the self in speci? c areas, as self-concept has been theorized to be a hierarchical and multidimensional construct (Marsh & Shavelson, 1985; Shavelson, Hubner, & Stanton, 1976). According to the compensatory model (Marsh, Byrne, & Shavelson, 1988), which holds that selfconcept in different domains may be additive, it may be bene? ial for students to increase their self-concept in one area if it has been diminished in another area as a result of a traumatic event. Helping children recognize competence in other areas besides the ones affected by the trauma will protect feelings of self-worth. This notion of building up other branches of self concept, such as academic self-concept, is also supported by Shavelson’s hierarchical model (Shavelson et al. , 1976). Create Linkages with Needed Collaborative Services Prime candidates for resources in many cultures are clergy, but these resources may also be an in? e ntial neighborhood leader or politician. In non-western (and western) cultures the family is an important system of support during times of crisis. Keep in mind that de? nitions of â€Å"family† do differ considerably. Psychology in the Schools DOI: 10. 1002/pits Crisis Counseling Overview 249 In many non-western cultures when individuals enter a crisis state, they turn to individuals (shaman) who are acknowledged within their communities as possessing special insight and helping skills. Their helping skills often emphasize non-ordinary reality and the psychospiritual realm of personality (Lee and Armstrong, 1995).Referral Although this is not one of the core psychological ? rst aid actions, as the ? rst and perhaps only person on the scene, the school psychologist should be helpful. Attend to physical needs, offer appropriate reassurance and anticipatory guidance, and help those in a crisis state to take positive action to facilitate coping (Sandoval, 2002a). As soon as poss ible, however, facilitate an appropriate referral to a culturally appropriate helper and/or to community-based services, and follow-up to determine that a connection has been made.D EVELOPMENTAL I SSUES I N C RISIS C OUNSELING A child of 5 and an adolescent of 16 have radically different faculties for dealing with information and reacting to events. Differences in cognitive, social, and emotional development mean that they will respond differently to hazards and will need to be counseled differently should they develop a crisis reaction (Marans & Adelman, 1997). The same event (e. g. , the death of a parent) may be a crisis for a preschooler as well as a high-school senior, but each will react and cope with the event differently.Counseling with younger children often involves the use of nonverbal materials, many more directive leads to elicit and re? ect feelings, and a focus on concrete concerns as well as fantasy. The use of drawing, for example, has proved very effective in getti ng children to express what has happened to them (Hansen, 2006; Morgan & White, 2003). In terms of increasing self-concept with children after a crisis, one must consider the dimensionality of self-concept as it relates to cognitive, language, and social factors (Byrne, 1996; Harter, 1999). Self-concept dimensions tend to increase with age.That is, young children are able to make judgments about themselves in terms of concrete and observable behaviors and tend to display all-or-none thinking. Thus, self-concept at this age tends to have few dimensions. Children at this age describe themselves in relation to certain categories, such as â€Å"I am 5† or â€Å"I have blond hair,† and are able to make simple comparisons such as â€Å"I am crying and he is not crying† (Harter, 1999). Although young children tend to have very positive descriptions of the self, negative life experiences, such as a traumatic event, may cause them to view themselves negatively.During mid dle childhood, self-concept dimensionality increases and children are able to make more global statements about their self-concept. However, they will often overestimate their abilities. Their descriptions change from being concrete to traitlike. Children during this stage also begin to use social comparison as they judge themselves and they can make social comparison statements, such as â€Å"I am more shy than most kids† or â€Å"I’m good at (one subject) and not (other subjects). † All-or-none thinking may continue at this stage, which may cause children to view themselves negatively (Harter, 1999).Traditional talk therapies such as nondirective counseling capitalize on a client’s capacity for rational thought and high level of moral development and are more likely to be effective with adolescents. With adolescents, the school psychologist can also acknowledge and use the ageappropriate crisis of establishing an identity. During adolescence, more diffe rentiation of the self occurs and peers may be used for social comparisons. Abstract concepts are used to describe the self, and there is an awareness of â€Å"multiple selves,† where they may behave or act differently in different contexts.Adolescents begin to make statements with interpersonal implications, such as, Psychology in the Schools DOI: 10. 1002/pits 250 Sandoval, Scott, and Padilla â€Å"Because I am shy I do not have many friends† or â€Å"People trust me because I am an honest person† (Harter, 1999). In reviewing the crisis intervention principles and procedures just outlined, it seems reasonable to expect that younger children would have a greater dif? culty acknowledging a crisis, and would be more prone to use immature defenses such as denial and projection to avoid coping with a crisis (Allen, Dlugokinski, Cohen, & Walker, 1999).In contrast, an adolescent might use more advanced defenses such as rationalization and intellectualization. In coun seling children, more time might be spent on exploring reactions and feelings to the crisis situation and establishing support systems that engage in lengthy problem solving. With older adolescents, then, it may be possible to focus much more on establishing reasonable expectations and avoiding false reassurance, as well as spending more time on focused problem-solving activities. ATTENDING TO C ULTURAL D IFFERENCESMany events that frequently stimulate a crisis reaction in the dominant culture, such as a death, a suicide, or a natural disaster, may or may not have a similar effect on members of other cultures (Sandoval, 2002b). Sometimes a reaction to a traumatic event will be culturally appropriate but will seem to western eyes to be a breakdown of ordinary coping. Extreme outward expression of grief by wailing and crying followed by self-mutilation and threats of suicide following the death of a loved one may be normal coping behavior expected of a survivor in a particular culture (Klingman, 1986).A cultural informant will be useful in indicating what normal reactions to various traumatic events are for a particular culture. One of the most important manifestations of culture is language. Many important cultural concepts cannot be satisfactorily translated from one language to another, because the meaning is so bound up in cultural values and worldview. If possible, crisis interveners should speak the same language as their client and be familiar with their cultural perspective.In an emergency, this kind of match of counselor and client may not be possible, so school psychologists need to be prepared to work with interpreters and cultural informants. Attention to nonverbal communication is also important during a time of crisis. A number of behaviors including form of eye contact, physical contact, and proximity can be different between members of different cultures (Hall, 1959). Because these behaviors are subtle, counselors may easily miss them without hel p. Training in cross-cultural work may be delivered through workshops or by consultation with an experienced psychologist.A ? rst step in working with children from different cultures will be to learn the extent to which the client has become acculturated to the dominant culture. One cannot assume that a child is fully a member of either the culture of the family’s origin or of the American mainstream. Working with the child and family will be individualized on the basis of culturally appropriate intervention. P REVENTING PTSD The common goal of responding to children experiencing situational crises is to prevent the formation of PTSD. This syndrome, ? st identi? ed among military combat veterans, also manifests itself in children. Their reaction is similar to that in adults, although their reactions may be somewhat different and the symptoms will vary with age (American Psychiatric Association, 2000). To be diagnosed with PTSD, a person who has been exposed to trauma must ha ve symptoms in three different areas: persistent reexperiencing of the traumatic stressor, persistent avoidance of reminders of the traumatic event, and persistent symptoms of increased arousal.These symptoms must be present for at least one month, and cause clinically signi? cant distress or impairment in social, occupational, or other important areas of functioning (American Psychiatric Association, 2000). Children are more likely than adults to have symptomatology related to aggression, anxiety, depression, and regression (Mazza & Overstreet, 2000). As noted earlier, traumatic stress reactions Psychology in the Schools DOI: 10. 1002/pits Crisis Counseling Overview 251 are to a signi? ant extent dependent on the child’s level of development (Joshi & Lewin, 2004). Especially among younger children, traumatic stress reactions are less connected to the stressor and more likely to take the form of generalized fear and anxiety. It is certainly not true that all children, if untr eated, will develop PTSD. In fact, recovery is the norm (NIMH, 2001). Recent studies regarding the prevalence of PTSD in children and adolescents estimates that about 15% –43% of children have experienced at least one traumatic event in their lifetime.Although estimates vary by extent and type of trauma, a conservative estimate is that 12% –15% of children may develop PTSD six or more months following a disaster (La Greca, Silverman, Vernberg, & Prinstein, 1996; McDermott & Palmer, 1999). In a review of the literature, Saigh, Yasik, Sack, & Koplewicz (1999) report that rates of psychological trauma among children and adolescents (as indicated by the presence of PTSD) vary considerably both within and between types of crisis events (with rates of PTSD ranging from 0% to 95%).Some may even develop longterm characterological patterns of behavior following a disaster, such as fearfulness (Honig, Grace, Lindy, Newman, & Titchener, 1999). These character traits, exhibited la ter in life, may originate as negative coping responses to the trauma. Severity of symptoms is related to the magnitude of exposure to the event itself, and the degree of psychological distress experienced by children in response to trauma is measured by several factors. The closer a child is to the location of the event (physical proximity), or the longer the exposure, the greater likelihood of severe distress.Having a relationship with the victim of trauma also increases the risk (emotional proximity). A third factor is the child’s initial reaction; those who display more severe reactions, such as becoming hysterical or panicking, are at greater risk for needing mental health assistance later on. The child’s subjective understanding of the traumatic event can sometimes be more important than the event itself. That is, the more the child perceives an event as threatening or frightening, the greater the chance of increased psychological distress.Additionally, children who experience the following family factors are at an increased risk: those who do not live with a nuclear family member, have been exposed to family violence, have a family history of mental illness, or have caregivers who are severely distressed themselves (Fletcher, 2003). Children who face a disaster without the support of a nurturing friend or relative appear to suffer more than those who do have that support available to them. Symptoms in children may be more severe if there is parental discord or distress and if there are subsequent stressors, such as lack of housing following a disaster (La Greca et al. 1996). The traumatic death of a family member also increases the risk of stress reactions (Applied Research and Consulting, Columbia University Mailman School of Public Health, & New York Psychiatric Institute, 2002; Bradach & Jordan, 1995). Finally, children who have preexisting mental health problems or previous exposure to threatening or frightening events are more likely to experience more severe reactions to trauma than are others. Symptoms may also be heightened among ethnic minorities (La Greca et al. , 1996). La Greca and her colleagues (1996) discuss ? e factors related to the development of severe symptomatology: 1) exposure to disaster-related experiences, including perceived life threats; 2) preexisting child characteristics such as poverty and illness; 3) the recovery environment including social support; 4) the child’s coping skills; and 5) intervening stressful life event during recovery. These factors may interact with biological factors that make the child particularly vulnerable, such as genetically based premorbid psychopathology and temperament (Cook-Cottone, 2004).Clearly intervention must supply an appropriate recovery environment that is suited to a child’s characteristics and facilitates coping. Determination of what intervention is appropriate for a given student should be based on assessment of risk for psychologi cal traumatization. Nevertheless, school is an important environment where prevention and healing can take place. Cook-Cottone (2004), drawing from the literature on children with cancer, has outlined a protocol for reintegrating children into school following a traumatic experience that has led to their absence from school.Psychology in the Schools DOI: 10. 1002/pits 252 Sandoval, Scott, and Padilla FACILITATING THE G RIEVING P ROCESS Grieving, and mourning the losses common to most potentially traumatic events, will be among the counseling objectives. Losses may include those of signi? cant others as well as loss of status. However, emotional numbing and avoidance of trauma reminders that accompany trauma can greatly interfere with the process of grieving. Trauma work often takes precedence over grief work; nevertheless, ultimately appropriate mourning must be facilitated (Hawkins, 2002). Worden (2002) has identi? d four tasks of mourning. The ? rst task is to accept the reality o f the loss and neither deny it has occurred nor minimize the impact on the child’s life. It is common for children to fantasize about a reunion or that there has been a mistake about the loss, or that divorced parents will reunite. Before a child can progress to the second task, there must be a reduction in spiritual, magical, or distorted thinking (Hawkins, 2002). Worden’s second task is to experience the pain of grief. There are many pressures, both cultural and familial, to not express or feel sadness at a loss.Children are told not to be a â€Å"crybaby† and to â€Å"act like an adult. † However, if the emotional pain is not experienced, there may be a manifestation in psychosomatic symptoms or maladaptive thinking or behaving (Hawkins, 2002). The third task of coping with a loss is to adjust to a new environment that does not include the lost status or relationship. The child must learn to create a new set of behaviors and relationships to replace th ose lost. The goal is to build a meaningful and authentic new lifestyle and identity.A failure to accomplish this task leaves a child feeling immobilized and helpless, clinging to an idealized past. The ? nal task of mourning is to withdraw emotional energy from the lost status and reinvest it in other relationships and endeavors. By holding on to the past, lost attachments rather than forming new ones, a child may become stuck. Instead, the trauma victim must eventually embrace a new status. Worden (2002) believes that, when the tasks of mourning are accomplished, the individual will be able to think of the loss without powerful pain, although perhaps with a sense of nostalgia and perhaps some sadness.In addition, the child or adolescent will be able to reinvest emotions in new relationships without guilt or remorse (Hawkins, 2002). T REATMENT School-based Counseling Galante and Foa (1986) worked in groups with children in one school throughout the school year following a major Ita lian earthquake. The children were encouraged to explore fears, mistaken understandings, and feelings connected to death and injury from the disaster using discussion, drawing, and role playing. Most participants, except those who experienced a death in the family, showed a reduction in symptoms.Another feature of disasters and terrorist acts is a lowered sense of control over one’s destiny and heightened fear of the unknown. Thus, a focus on returning a sense of empowerment to children will be important. If children can be directed to participate in restorative activities and take some actions to mitigate the results of the disaster, no matter how small, they can begin to rebuild an important sense of ef? cacy. Finally, there may be issues of survivor guilt, if there is widespread loss of life or property. Survivor guilt is a strong feeling of culpability often nduced among individuals who survive a situation that results in the death of valued others. Those individuals spar ed, but witnessing the devastation of others, may have extreme feelings of guilt that will need to be dealt with. Children, particularly, ascribe fantastical causes to the effects they see. Consequently, some may Psychology in the Schools DOI: 10. 1002/pits Crisis Counseling Overview 253 need to explore their magical thinking in counseling or play therapy about why they escaped injury or loss. School community–based support groups can provide one vehicle for feeling connected to others and working through these feelings.Ceballo (2000) describes a short-term supportive intervention group based in the school for children exposed to urban violence. Her groups are designed to 1) validate and normalize children’s emotional reactions to violence, 2) help children restore a sense of control over certain aspects of their environment, 3) develop safety skills for dealing with the environment in the future, 4) understand the process of grief and mourning, and 5) minimize the in? uence of PTSD symptoms on educational tasks and other daily life events. Such structured support groups can promote resiliency and promote constructive coping with problems.Depending on training and supervision, the school psychologist might also engage in therapies validated for the treatment of PTSD. These therapies are reviewed in the section on community-based therapy. Time and other constraints often make outside referral necessary. Bibliotherapy Bibliotherapy may also be useful following a disaster. A particularly useful resource for children is a book entitled I’ll Know What to Do: A Kid’s Guide to Natural Disasters by Mark, Layton, and Chesworth (1997). The authors focus on four concepts they view as fundamental to recovery: information, communication, reassurance, and the reestablishment of routine.They explore children’s feelings that often emerge in the aftermath of a disaster, and offer useful techniques to help young people cope with them. Another technique in which the child is an active participant in the creation of a book about personal experiences is called the resolution scrapbook (Lowenstein, 1995). Here the child is guided through a set of experiences and activities designed to help the child reprocess traumatic experiences and place completed work in a scrapbook. Evidence for the effectiveness of this technique is largely anecdotal to date. Other Adults in CrisisAn important feature of a traumatic event is the fact that the adults in the school as well as the children are affected. The teachers, administrators, and guidance staff would be as traumatized as children by an earthquake, terrorism, or an airplane crashing into the school. They will need assistance in coping with the aftermath of the crisis as much as the children will (Daniels, Bradley, & Hays, 2007). It is likely that outside crisis response assistance will be needed to help an entire community deal with disaster and mayhem associated with violence. Comm unity-based PsychotherapyCognitive behavior therapy. There are many treatments being studied for their effectiveness in the area of PTSD. Currently, much of the research suggests that cognitive behavior therapy (CBT) may be the most promising treatment for PTSD (Jones & Stewart, 2007). CBT is a structured, symptom-focused therapy that includes a wide variety of skill-building techniques. All are based on the premise that thoughts and behaviors can cause negative emotions and patterns of interactions with others. Making maladaptive thoughts and behaviors more functional is the goal of CBT (Jaycox, 2004).CBT uses techniques that integrate elements of cognitive information processing associated with anxiety with behavioral techniques—such as relaxation, imaginal or in vivo exposure, and role playing—that are known to be useful in the reduction of anxiety (Cook-Cottone, 2004). Psychology in the Schools DOI: 10. 1002/pits 254 Sandoval, Scott, and Padilla Another protocol fo r dealing with treating PTSD is eye movement desensitization and reprocessing (EMDR). It includes many of the same elements as CBT, with the exception of in vivo exposure, and includes rhythmic eye and other tracking exercises (Greenwald, 1998).It has been successfully used with school-age populations (Chemtob, Nakashima, & Carlson, 2002). Play and art therapy. Play and art therapy are also being studied to determine their effectiveness on PTSD symptoms, especially in young children because of issues in language development (Cole & Piercy, 2007). Because play is a child’s natural method of developing mastery over the environment and because many symptoms of PTSD are seen in children’s play, this is a natural course of treatment (Kaduson, 2006). The use of art therapy has also shown to be effective in group work (Hansen, 2006). Medication.As a measure of last resort, medication may be used to treat severe PTSD. Often the symptoms of anxiety or depression that have resul ted from exposure to a traumatic experience are treated. Selective serotonin reuptake inhibitors (SSRIs) in particular are often prescribed to treat the symptoms of anxiety and depression, including sertraline, paroxetine, and ? uoxetine (Foa, Davidson, & Frances, 1999). In the adult population, antipsychotic, antiepileptic, and other psychotropic medications have been explored and may be effective depending on the symptoms of the individual (Davis, Frazier, Williford, & and Newell, 2006).If medications are prescribed to a student, it is important that there be a liaison between the school and the treating physician or psychiatrist to monitor effectiveness and deleterious side effects. C ONCLUSIONS School psychologists are often the contacts in schools when there is a traumatizing event. School psychologists should be ready to administer psychological ? rst aid that is individualized and developmentally and culturally appropriate. By intervening and facilitating coping processes and the grieving process, it may be possible to prevent or minimize the development of PTSD.School-based protocols have been developed to respond to children in crisis. 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