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Mental Health Care for Children Appropriate to the Stage of Recovery in the Areas Affected(三羽・森永)

東日本大震災支援活動において協力関係にある、日本心理臨床学会・支援活動委員会の冨永教授(兵庫教育大学)が作成した「教師・心理職等(対人援助職)のみなさんへ」をもとに、冨永教授と共同作成したマニュアルです。
被災地で子ともたちのケアに関わる、心理士・教員などの皆様に向けた資料です。
東北地方太平洋沖地震と心のケア(日本心理臨床学会・支援活動委員会)にて、PDFファイルとしても公開されていますので、こちらもご活用ください。
より多くの方に知っていただくため、冨永教授による内容の確認および許可のもとこちらでも掲載しています。
日本語バージョンはこちら


Mental Health Care for Children
Appropriate to the Stage of Recovery in the Areas Affected
(Model of Needs Required for Survivors of the Disaster)


Created by Prof. Yoshiki Tominaga (Hyogo University of Teacher Education, Japan)
Summarized by Kyoko Morinaga, Ph.D. & Riichiro Miwa, Psy.D.
Translated by Riichiro Miwa, Psy.D.
……………………………………………………………………………………………………………

This model focuses on the different stages of needs that child should be progressed through during recovery from trauma

Stages: Safety → Social and Emotional Support → Psychoeducation → Self-Expression → Exposure
Order of the stages is critical
Avoid self-expression and exposure before acquiring a sufficient sense of physical safety since doing otherwise could cause secondary harm to the children

 Physical-safety and comfort are usually established within 2 weeks, but it is difficult to do so within that timeline in this disaster. For each separate area of devastation, assess at which stage of recovery the particular area is. The stages of recovery will differ for each area affected by the disaster.
……………………………………………………………………………………………………………

Stage 1: Safety and Comfort
 *The most basic requirement that needs to be provided throughout all the stages under discussion

Physical & Psychological responses
 a) Fatigue, insomnia, “Economy class syndrome” (*deep-vein thrombosis), etc.
 b) Fright reactions, anxiety, despair, acute stress reactions, etc.

Interventions
• Provide for basic physical needs, social support, and coping resources
 a) Basic physical needs
  a. Food / Water / Warmth / Ablution facilities (Baths / Foot Baths etc.) / Portable toilets / Privacy / Drills in preparation for aftershocks
 b) Social support
  a. Re-establish the reassurance gained from human connections and support
  b. Stay with the those who are informed of bad news concerning the safety of their friends and family
 c) Coping resources
  a. Provide physical exercise to prevent deep-vein thrombosis
  b. Provide hope for the recovery of lifelines

Stage 2: Awareness of physical and psychological responses
* After assuring physical safety.
• There will be emerging physical and psychological responses once physical safety has been provided for
Encour [Warning] Avoid debriefing!

Physical & Psychological responses
 a) Insomnia, lassitude, apathy, hopelessness, etc.
 b) Flashbacks caused by activated traumatic memories (recurrent and intrusive recollections causing distress)
  a. e.g., Nightmares, make-believe play (focused on the tsunami and earthquake)
  i. *Young children may exhibit repetitive play focused on themes or aspects of their traumatic experience
  b. Painful experience through all five senses, by which children may re-live the past
 c) Regression and over-dependence
  c. e.g., Clinging to a reliable person. Unable to perform tasks that s/he used to be able to perform

Interventions
• Careful and thoughtful interventions are essential
• Appropriate interventions should be provided toward recurring recollections, because they could result in post traumatic responses
• Relaxation exercises are helpful
 o Massage, dosa-ho, progressive muscle relaxation, deep-breathing, etc.
 a) Intervening with make-believe play
  a. Do not scold. (e.g., “Stop it! That’s not right!)
  b. Join in with the play and empathize with the children’s feelings, including anger, fear, anxiety, etc.
  c. Prevent dangerous behaviors and listen to their underlying feelings
 b) Intervening with regression and over-dependence
  a. Stay with the child until the child feels safe
  b. Regression and over-dependence are signs of recovery after such a massive shock
  c. Prevent dangerous behaviors and listen to their underlying feelings
 c) Coping with flashbacks
  a. Distract
  i. Teach thought-stopping and distraction techniques
   1. e.g., Stretching and self-talk, “Focus on my work!”
  b. Over time and only when appropriate, encourage the child to face and stay with the painful memories
    i. Encourage intentional and repetitive effort to stay with emerged feelings
   1. *Flashbacks become less-frequent and less-strong eventually
   ii. Avoidance will only prolong traumatic responses
  c. Utilize “Play Groups”
    i. Form groups with volunteers in the affected areas and shelters
   ii. Play with the children until they feel enjoyment and a sense of wellbeing
   iii. Be aware of anger and aggressiveness
    1. Once the children get used to the volunteers, they may try to physically assault them because of their anger and depression
    2. Sublimate children’s aggressiveness with sports, etc.
  iv. Provide for the volunteers to meet with professional therapists daily for supervision, advice, support, etc

Stage 3: Psychoeducation
* After Stage 1. In parallel with Stage 2
• Learning about:
 o Self-monitoring regarding one’s own post-traumatic responses
 o Effective coping strategies
• Reopening school
 o *Collaboration with school system is important in Japan
• School structures are organized and homeroom teachers are greatly involved in children’s daily activities in Japan

Physical & Psychological responses
 a) Insomnia, avoidance behaviors (avoiding beaches, water-related places, news about the disaster, etc.), truancy, social withdrawal, etc.
 b) Guilt feelings, anxiety, suicidal ideation, etc

Interventions
• Provide knowledge about post-traumatic responses and effective coping strategies
 o Post-traumatic responses are inaccurately learned responses and behaviors
 o Facilitating self-monitoring, self-expression, understanding of the responses, gradual exposure, et  c. will prevent children from developing stress-related disorders and other interferences
 a) Learn about post-traumatic responses and exposure
  a. Excessive avoidance behaviors from stimuli that cause post-traumatic responses
  i. One factor of maintaining stress-related disorder
  ii. Exposure needs to be provided gradually
  b. Post-traumatic responses
  i. Difficulty distinguishing safe stimuli from dangerous ones
  ii. Inaccurately perceiving safe stimuli as being dangerous and actively avoiding these stimuli
  c. Need to practice own coping strategies to rollback inaccurate learning as much as possible
  i. By gradually being exposed to the stimuli
   1. New learning
   a. The stimuli is safe and neutral
   b. One’s fear responses are unnecessary and excessive
  d. Sense of safety is essential when providing exposure to the stimuli
 b) Utilize questionnaires to facilitate self-awareness, while understanding children’s actual condition
• e.g., Health Questionnaire, PTSRED-TRAUMA25
  a. Questionnaires are helpful because of the frequently covert responses
  b. Helpful for the children to understand their post-traumatic responses
  c. Helpful in providing effective coping strategies to the specific issues
  d. In order to avoid negative reactions to the questionnaires, conduct them in a safe environment
  i. Assess and screen severe cases and provide further care (e.g., individual counseling)
  ii. Relaxation exercises can be provided before or after the questionnaire
  e. Warning:
  i. Questionnaires should always be provided along with psychoeducation, stress-management experience, preparation for follow up care, etc.
  ii. Need continuous care and support system
  iii. Do not exploit the victims for research purposes

Stage 4: Expressing life experience
*After Stage 1 & 2

Interventions
• Refer to the psychoeducation guidelines in the first step
• Facilitate implementing effective coping strategies
• School-based approach
 a) Exercise, games, relaxation activities (Stretching, deep breathing, etc.)
  a. After these activities, create a sober atmosphere and facilitate talk and self-expression
 b) Self-expression through speech and/or writing
  a. Sharing one’s own experience about the current experience
  i. e.g., “The things I did well in the shelter,” “Creative ideas in my everyday life,” “Enjoyable time with my friends,” etc.
  ii. Avoid expressions of direct experience of the actual disaster event (e.g., “How I ran away from the tsunami”)
  iii. Provide safe environment for expressing oneself
  iv. Empathize and accept their expression as it is
 c) Special class about psychological care
  a. Education in stress-management, social skills, peer support, etc.

Stage 5: Expressing traumatic experience
*After completing Stage 1-4

Physical & Psychological responses
 a) Stress-related disorders (e.g., PTSD)
 b) Various feelings related to traumatic experience

Interventions
• Refer to the psychoeducation second step
• Facilitate children to express their traumatic experience and to face it
• Do not coerce them and take things only at their own pace
• Separate facing fears and sadness from the fun activities of daily life

Stage 6: In vivo exposure
*After completing Stage 1-4, after some experience of Step 5

Physical & Psychological responses
• Avoidance behaviors (Unable to go to beaches, unwilling to swim, etc.)

Interventions
• Refer to the psychoeducation second step
 a) Psychoeducation (understanding the reason why exposure to stimuli that causes post-traumatic responses is essential)
 b) Gradual exposure to less painful/fearful stimuli
  a. Start from the level of 50-60/100 (Moderate anxiety)
  b. Help children experience that the stimuli are safe and neutral
  i. In case of severe post-traumatic responses, provide individual counseling

Stage 7: Mourning process

Physical & Psychological responses
• Anniversary reactions

Interventions
 a) Help children cope with the traumatic responses toward the memorial ceremony
 b) Separate coping time from playtime
 c) Have the children have an internal dialogue with the deceased person(s)

(三羽理一郎 加州公認クリニカルサイコロジストPSY21622)
(森永今日子 博士・学術)

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