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RAND’s publications do not necessarily reflect the opinions of its research clients and sponsors. R ® is a registered trademark. © Copyright 2009 RAND Corporation Permission is given to duplicate this document for personal use only, as long as it is unaltered and complete. Copies may not be duplicated for commercial purposes. Unauthorized posting of RAND documents to a non-RAND Web site is prohibited. RAND documents are protected under copyright law. For information on reprint and linking permissions, please visit the RAND permissions page (http://www.rand.org/publications/ permissions.html). Published 2009 by the RAND Corporation 1776 Main Street, P.O. Box 2138, Santa Monica, CA 90407-2138 1200 South Hayes Street, Arlington, VA 22202-5050 4570 Fifth Avenue, Suite 600, Pittsburgh, PA 15213-2665 RAND URL: http://www.rand.org To order RAND documents or to obtain additional information, contact Distribution Services: Telephone: (310) 451-7002; Fax: (310) 451-6915; Email: order@rand.org This work was sponsored by the National Institute of Mental Health under contract No. MH072591. The research was conducted in RAND Health. Library of Congress Cataloging-in-Publication Data Jaycox, Lisa. Support for students exposed to trauma : the SSET program / Lisa H. Jaycox, Audra Langley, Kristin L. Dean. p. cm. ISBN 978-0-8330-4732-8 (pbk. : alk. paper) 1. Middle school students—Mental health services—United States. 2. Middle school students— Counseling of—United States. 3. Psychic trauma in adolescence—Treatment—United States. 4. Teacher participation in educational counseling—United States. I. Langley, Audra. II. Dean, Kristin L. III. Title. LB3430.J39 2009 373.17'1—dc22 2009021948 iii Preface ese materials were adapted from a manualized group program called the Cognitive-Behav- ioral Intervention for Trauma in Schools, or CBITS, which was developed and initially eval- uated in the Los Angeles Unified School District. at program was developed for use by school-based mental health professionals, whereas the Support for Students Exposed to Trauma (SSET) program, the subject of this book, can be used by any school personnel with the time and interest to work with students affected by trauma. To adapt and develop the SSET program for teachers and school counselors, we consulted with school and mental health experts, conducted focus groups with school staff and parents, and used their feedback to develop the program and pilot test it in two Los Angeles Unified School District middle schools. Results of the pilot test were promising, showing that teachers and school counselors were able to deliver the program as desired, that students and parents were satisfied with the support groups, and that children showed small improvements in their distress symptoms. 1 We thank the many individuals who contributed to this project: Bradley Stein, Mar- leen Wong, Stefanie Stern, Steven Evans, Phyllis Ellickson, Sheryl Kataoka, Barbara Colwell, Roberta Bernstein, Pia Escudero, Fernando Cadavid, Suzanne Blake, Daryl Narimatsu, Patri- cia Fuentes-Gamboa, Yvette Landeros, Lajuana Worship, Maria Sanchez, Kathy Scott, Rachel Braude, Brian Spencer, Kris Evans, Carla Heiland, Benin Williams, Jonathan Brown, Windy Wilkins, and the many parents and students who helped us develop this manual. is book has three parts: a training manual for SSET leaders and other implementers, the SSET lesson plans, and the SSET lesson materials and worksheets that accompany each lesson. e training manual can be read first, followed by each lesson plan and its accompa- nying materials as they are referenced in the plan. e materials and worksheets are repro- ducible for use when implementing the SSET program. ey can be either photocopied directly from this book or printed out directly from the RAND Corporation’s Web site at http://www.rand.org/pubs/technical_reports/TR675/. is work was sponsored by the National Institute of Mental Health under contract No. MH072591. e research was conducted in RAND Health, a division of the RAND Cor- poration. A profile of RAND Health, abstracts of its publications, and ordering information can be found at www.rand.org/health. 1 Jaycox, L. H., Langley, A. K., Stein, B. D., Wong, M., Sharma, P., Scott, M., Schonlau, M. (2009). Support for Students Exposed to Trauma: A Pilot Study. School Mental Health. Published online on March 21, 2009. v Contents Preface iii Glossary of Terms vii GROUP LEADER TRAINING MANUAL by Audra K. Langley, Lisa H. Jaycox, and Kristin L. Dean Prevalence and Impact of Exposure to Violence 3 What Is SSET? 5 Goals and eory of SSET 11 Selecting Students for SSET 15 Forming and Scheduling Groups 19 Dealing with Trauma and Violence Exposure 25 Working with Students Who Have Been Multiply Traumatized or Abused 27 Disclosure by Group Members 29 Disclosure by Group Leaders 31 Clinical Backup and Consultation 33 Special Student and Group Issues 37 Matching Problems and Goals 43 Homework Assignments 45 Ending the Group 47 Scenarios: What to Do When You Can’t ink of an Example 49 LESSON PLANS by Lisa H. Jaycox and Audra K. Langley Lesson One: Introduction 53 Lesson Two: Common Reactions to Trauma and Strategies for Relaxation 61 Lesson ree: oughts and Feelings 69 Lesson Four: Helpful inking 77 Lesson Five: Facing Your Fears 85 Lesson Six: Trauma Narrative, Part One 93 Lesson Seven: Trauma Narrative, Part Two 99 Lesson Eight: Problem Solving 105 Lesson Nine: Practice with Social Problems and the Hot Seat 113 Lesson Ten: Planning for the Future and Graduation 119 LESSON MATERIALS AND WORKSHEETS by Lisa H. Jaycox and Audra K. Langley Lesson One: Introduction 127 vi Support for Students Exposed to Trauma: The SSET Program Lesson Two: Common Reactions to Trauma and Strategies for Relaxation 135 Lesson ree: oughts and Feelings 141 Lesson Four: Helpful inking 147 Lesson Five: Facing Your Fears 153 Lesson Six: Trauma Narrative, Part One 161 Lesson Seven: Trauma Narrative, Part Two 169 Lesson Eight: Problem Solving 177 Lesson Nine: Practice with Social Problems and the Hot Seat 183 Lesson Ten: Planning for the Future and Graduation 187 vii Glossary of Terms Brainstorming e act of eliciting any idea that pops into one’s head that may be relevant to the situation. Should include all thoughts without judgment. Distraction e act of engaging in one behavior to take one’s mind off another. May be used to help one endure anxiety during an exposure or as an option for managing a difficult social sit- uation. Examples of distraction include listening to music, talking to a friend, playing a video game, thinking about something else, and watching TV or a movie. Fear ermometer A tool for describing levels of negative feelings (e.g., fear, anxiety, worry, nervousness, upset) on a scale from 0 to 10, where 0 is “no problem at all; feeling good,” and 10 is “feeling maxed out; the worst.” Provides a common lan- guage for group members to describe and monitor their feelings; allows the group leader to gain insight into and monitor changes in an individual’s anxiety levels. Helpful thoughts oughts that are based on a realistic assessment of the situation, including checking the objective facts, conduct- ing an assessment of the most reasonable explanation, and reviewing the history of similar occurrences. Positive images Ideas or mental pictures that are associated with feelings of happiness, contentment, tranquility, calm, and relax- ation. Individuals may imagine themselves in a setting or situation that conjures these emotions, or they may simply imagine a picture that reminds them of this state of relaxation. Problem solving e act of figuring out ways to best manage difficult situ- ations. Includes brainstorming solutions, evaluating all proposed options, implementing the strategy deemed best to reach individual goal while maintaining the safety of all involved, and limiting negative associated consequences. viii Support for Students Exposed to Trauma: The SSET Program Relaxation Exercise(s) directed at reducing physiological arousal/ten- sion. May include deep breathing, progressive muscle tens- ing and relaxing, and positive visual imagery. Social support Care provided to an individual by another person (e.g., a family member, a friend, a neighbor, a teacher). SSET Support for Students Exposed to Trauma. ought stopping e deliberate act of willing oneself to stop a current thought. Typically done by visualizing a stop sign, saying “Stop!” out loud or to oneself, or doing something else that serves as a cue to stop the thought (such as snapping a rubber band or banging one’s hand on a table, book, or desk). Trauma narrative An individual’s relating of the story of his or her traumatic experience. A written, verbal, or pictorial expression of the occurrences that comprised one’s traumatic event. Trauma/traumatic event An event that is sudden and frightening and that poses a threat of injury or death to oneself or others. Usually makes an individual feel terrified, horrified, or helpless when it is happening. Unrealistic thoughts oughts that are not based on available objective evidence and may not be reasonable for the situation or context. [...]... Teach students to stop negative or problematic thoughts that are getting in their way Feelings • Teach students to relax their bodies • Help reduce the anxiety related to the trauma that happened to them • Help reduce the anxiety students feel when they are reminded of what happened to them Behaviors • Teach students to consider alternatives for what to do when there is a problem • Teach students to decide... processing trauma experiences that it is important to address 25 26 Support for Students Exposed to Trauma: The SSET Program Table 4—Common Misconceptions About Processing Trauma Common Concern Actual Experience of SSET Leaders If I ask a student to write or share what happened to him or her, I will be retraumatizing him or her Students are generally relieved to have the chance to talk about their traumatic... our pilot study for SSET are available upon request from Lisa Jaycox (jaycox@rand.org) 15 16 Support for Students Exposed to Trauma: The SSET Program Figure 2—Sample Letter and Permission Form for Parents Date: Dear Parents, [School name] is fortunate to have a special counseling program for students who have experienced stressful events We have found that students who have experienced trauma as victims... or risky behavior 5 6 Support for Students Exposed to Trauma: The SSET Program What Problems Are Not Intended to Be Addressed by SSET? The SSET program is not intended for use with • students in crisis who need an immediate referral to counseling • students with severe behavior problems that would make it hard for them to participate in a support group without disrupting it • students with severe cognitive... to refrain from making comments about students to other school staff and students in order to protect the confidentiality of the SSET group Dealing with Trauma and Violence Exposure Traumatized Students Working with stress or trauma survivors requires sensitivity and patience There are several points that are important to keep in mind: • Students who have been exposed to violence and who are symptomatic... encouraging students in the group to do the same • Use diversity as a topic to help convey group concepts For instance, the Helpful Thinking questions taught in Lesson Four can be used to challenge common assumptions and stereotypes about different racial or ethnic groups The diversity of the group members may help to dispel some of these unhelpful ways of thinking 22 Support for Students Exposed to Trauma: ... stay highly aroused for long periods of time—the natural process is for anxiety to gradually decline 14 Support for Students Exposed to Trauma: The SSET Program Imagine climbing to the top of a very tall tower Most of us would feel some anxiety or fear at first But as you stay up there (and nothing bad happens), gradually that fear or anxiety will decrease If you stay up there for a few days, it will... 38(4), 359–367 3 What Is SSET? Support for Students Exposed to Trauma (SSET) is a series of ten support groups that use a structured approach to reduce distress resulting from exposure to violence It includes a wide variety of skill-building techniques These techniques are geared toward changing maladaptive thoughts (i.e., toward challenging negative thinking, stopping automatic negative thoughts, distracting... leaders need to be consistent and predictable • Students often tend to “reenact” the stress or trauma and can sometimes try to provoke adults into being abusive Don’t fall into this trap Check your own anger and frustration often, and make sure that you do not in any way feed into the cycle of abuse that the students are accustomed to • Students who have been traumatized get scared easily Be conservative... whose children screen positive for the group are contacted initially by telephone Usually, they must provide written consent for the child to participate in the group How Are the Groups Formed? Once students have been identified for the group, it is important to meet individually with them to verify their appropriateness for the group Students can be excused from class for these appointments if the . review to ensure that they meet high standards for re- search quality and objectivity. HEALTH PROGRAM MANUAL Support for Students Exposed to Trauma: . 359–367. 5 What Is SSET? Support for Students Exposed to Trauma (SSET) is a series of ten support groups that use a struc- tured approach to reduce distress