Crisis counseling: An overview

Psychology in the Schools, Vol. 46(3), 2009 C© 2009 Wiley Periodicals, Inc.Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/pits.20370

CRISIS COUNSELING: AN OVERVIEW

JONATHAN SANDOVAL, AMY NICOLE SCOTT, AND IRENE PADILLA

University of the Pacific

Psychologists working in schools are often the first contacts for children experiencing a potentiallytraumatizing event or change in status. This article reviews basic concepts in crisis counseling anddescribes the components of psychological first aid. This form of counseling must be develop-mentally and culturally appropriate as well as individualized. Effective intervention can preventpost-traumatic stress syndrome and facilitate normal mourning processes associated with any lossesexperienced. These prevention activities are also discussed. Some children may need resources be-yond those that the school can provide, and appropriate referrals can link children and adults to avariety of treatments such as psychotherapy and medication, also briefly outlined. C© 2009 WileyPeriodicals, 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 isthe norm. Children usually need minimal assistance from family members, teachers, clergy, or othercaring 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 andcoping. Individuals often behave irrationally and withdraw from normal social contacts. They cannotbe helped using usual counseling or teaching techniques. Nevertheless, children in crisis are usuallyalso 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 wayas to restore the individual to a previous level of functioning. For children, this means returning tothe status of learner. Although it may be possible to use the situation to enhance personal growth, theimmediate goal is not to reorganize completely the individual’s major dimensions of personality, butto restore the individual to creative problem solving and adaptive coping. Of course, by successfullyresolving a crisis an individual will most likely acquire new coping skills that will lead to improvedfunctioning in new situations, but that is only a desired, possible outcome, not the sole objectiveof the process (Caplan, 1964). Because failure to cope is at the heart of a crisis, the promotion ofcoping is an overall objective of crisis intervention.

PSYCHOLOGICAL FIRST AID

School psychologists and other mental health personnel working in schools are in a position tooffer psychological first aid (Parker, Everly, Barnett, & Links, 2006). Analogous to medical first aid,the idea is to intervene early when a hazardous event occurs for an individual, and offer compassionatesupport to facilitate adaptive coping. At the same time, the need for further intervention may beassessed and planned.

According to The National Child Traumatic Stress Network and National Center for PostTraumatic Stress Disorder (PTSD) (2006) there are eight core psychological first aid actions. Ofcourse, 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 ofEducation, 3601 Pacific Avenue, Stockton, CA 95211. E-mail: [email protected]

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Crisis Counseling Overview 247

Making Contact

The first 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 withthe 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 andattending to their basic needs for food, drink, sleep, shelter, or freedom from further danger. Torelieve tension, it is also helpful to provide a place for play and relaxation. Children need to beprotected from the eyes of strangers and the curious, and they need to be spared watching scenes ofa 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. Adultsmodeling calmness and competence can communicate that problems may be solved and emotionscan be controlled in time. A counseling relationship will be important to help the child managefear, anxiety, panic, and grief. Nondirective listening skills are most effective. However, it is alsoimportant 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 aboutthe student’s perception of the situation by identifying all of the sources of concern, it will bepossible to begin the process of exploring potential strategies to improve or resolve the emotionallyhazardous situation. Jointly, the crisis worker and pupil review the strategies explored and select onefor trial. The outcome should be an action plan. This is much like the problem solving that occursin conventional counseling, but must be preceded by the steps previously mentioned. Moving tooquickly to problem solving is a common mistake of novices. However effective the problem solutionis, the very process of turning attention to the future and away from the past is beneficial in and ofitself.

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 controland making decisions. Some solutions may involve actions by others, such as teachers or schooladministrators. To the extent necessary, the crisis worker may act as an intermediary communicatingwith 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 ata school site (Brock, Sandoval, & Lewis, 2001).

Facilitate Connections with Social Supports

Finding social supports may be particularly difficult during times of crisis. In a disaster, forexample, 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, andvulnerability.

Psychology in the Schools DOI: 10.1002/pits

248 Sandoval, Scott, and Padilla

Nevertheless, it is usually possible to find either a group of peers or family members whocan provide emotional support and temporary physical assistance during the crisis. In this way thepupil’s energies may be devoted to coping with the crisis. Being with and sharing crisis experienceswith positive social support systems facilitates recovery. Conversely, lower levels of social supportoften 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 maysubstitute and the crisis worker should be knowledgeable about them.

Facilitating Coping

During the process of crisis intervention, the student will have temporarily become dependenton the crisis counselor for direct advice, for stimulating action, and for supplying hope. Thissituation is temporary and before the crisis intervention interviews are over, the crisis counselormust spend some time planning ways to restore the student to selfreliance and self-confidence. Thisrestoration 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 verydirective, eventually he or she strives to return to a more democratic stance. Techniques such asone-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 leavethe crisis intervention with a sense of accomplishment.

Helping individuals to find alternative rewards and sources of satisfaction using problem-focused coping (Lazarus & Folkman, 1984) is most helpful. Providing anticipatory guidance involvesconnecting children to knowledge and resources, and involves providing information about stressreactions and future challenges that the client will face. It acts to reduce distress and promote adaptivefunctioning.

Any action strategies must be implemented in the context of what the student thinks is possibleto accomplish. Crisis first aid providers can emphasize what positive there is in the situation, even ifit seems relatively minor. For example, even the victim of a sexual assault can be congratulated forat least surviving physically.

The crisis situation often leads to a diminution in self-esteem and the acceptance of blamefor the crisis. With an emphasis on how the child coped well given the situation so far, and howthe person has arrived at a strategy for moving forward, there can be a restoration of the damagedview of the self. Drawing from the self-concept literature, it may also be important to emphasizepositive views of the self in specific areas, as self-concept has been theorized to be a hierarchicaland multidimensional construct (Marsh & Shavelson, 1985; Shavelson, Hubner, & Stanton, 1976).According to the compensatory model (Marsh, Byrne, & Shavelson, 1988), which holds that self-concept in different domains may be additive, it may be beneficial for students to increase theirself-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 willprotect feelings of self-worth. This notion of building up other branches of self concept, such asacademic 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 bean influential neighborhood leader or politician. In non-western (and western) cultures the family isan important system of support during times of crisis. Keep in mind that definitions of “family” dodiffer considerably.



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 helpingskills. Their helping skills often emphasize non-ordinary reality and the psychospiritual realm ofpersonality (Lee and Armstrong, 1995).

Referral

Although this is not one of the core psychological first aid actions, as the first and perhapsonly person on the scene, the school psychologist should be helpful. Attend to physical needs, offerappropriate reassurance and anticipatory guidance, and help those in a crisis state to take positiveaction to facilitate coping (Sandoval, 2002a). As soon as possible, however, facilitate an appropriatereferral to a culturally appropriate helper and/or to community-based services, and follow-up todetermine that a connection has been made.

DEVELOPMENTAL ISSUES IN CRISIS COUNSELING

A child of 5 and an adolescent of 16 have radically different faculties for dealing with infor-mation and reacting to events. Differences in cognitive, social, and emotional development meanthat they will respond differently to hazards and will need to be counseled differently should theydevelop 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 withthe event differently.

Counseling with younger children often involves the use of nonverbal materials, many moredirective leads to elicit and reflect feelings, and a focus on concrete concerns as well as fantasy.The use of drawing, for example, has proved very effective in getting children to express whathas happened to them (Hansen, 2006; Morgan & White, 2003). In terms of increasing self-conceptwith children after a crisis, one must consider the dimensionality of self-concept as it relates tocognitive, language, and social factors (Byrne, 1996; Harter, 1999). Self-concept dimensions tendto increase with age. That is, young children are able to make judgments about themselves in termsof concrete and observable behaviors and tend to display all-or-none thinking. Thus, self-concept atthis age tends to have few dimensions. Children at this age describe themselves in relation to certaincategories, such as “I am 5” or “I have blond hair,” and are able to make simple comparisons suchas “I am crying and he is not crying” (Harter, 1999). Although young children tend to have verypositive descriptions of the self, negative life experiences, such as a traumatic event, may cause themto view themselves negatively.

During middle childhood, self-concept dimensionality increases and children are able to makemore 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 touse social comparison as they judge themselves and they can make social comparison statements,such as “I am more shy than most kids” or “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 themselvesnegatively (Harter, 1999).

Traditional talk therapies such as nondirective counseling capitalize on a client’s capacity forrational thought and high level of moral development and are more likely to be effective withadolescents. With adolescents, the school psychologist can also acknowledge and use the age-appropriate crisis of establishing an identity. During adolescence, more differentiation of the selfoccurs and peers may be used for social comparisons. Abstract concepts are used to describe theself, and there is an awareness of “multiple selves,” where they may behave or act differently indifferent contexts. Adolescents begin to make statements with interpersonal implications, such as,



“Because I am shy I do not have many friends” or “People trust me because I am an honest person”(Harter, 1999).

In reviewing the crisis intervention principles and procedures just outlined, it seems reasonableto expect that younger children would have a greater difficulty acknowledging a crisis, and wouldbe 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 advanceddefenses such as rationalization and intellectualization. In counseling children, more time might bespent on exploring reactions and feelings to the crisis situation and establishing support systems thatengage in lengthy problem solving. With older adolescents, then, it may be possible to focus muchmore on establishing reasonable expectations and avoiding false reassurance, as well as spendingmore time on focused problem-solving activities.

ATTENDING TO CULTURAL DIFFERENCES

Many 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 willseem to western eyes to be a breakdown of ordinary coping. Extreme outward expression of grief bywailing and crying followed by self-mutilation and threats of suicide following the death of a lovedone 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 eventsare for a particular culture.

One of the most important manifestations of culture is language. Many important culturalconcepts cannot be satisfactorily translated from one language to another, because the meaning isso bound up in cultural values and worldview. If possible, crisis interveners should speak the samelanguage as their client and be familiar with their cultural perspective. In an emergency, this kindof match of counselor and client may not be possible, so school psychologists need to be preparedto work with interpreters and cultural informants. Attention to nonverbal communication is alsoimportant during a time of crisis. A number of behaviors including form of eye contact, physicalcontact, and proximity can be different between members of different cultures (Hall, 1959). Becausethese behaviors are subtle, counselors may easily miss them without help. Training in cross-culturalwork may be delivered through workshops or by consultation with an experienced psychologist.

A first step in working with children from different cultures will be to learn the extent to whichthe client has become acculturated to the dominant culture. One cannot assume that a child is fullya member of either the culture of the family’s origin or of the American mainstream. Working withthe child and family will be individualized on the basis of culturally appropriate intervention.

PREVENTING PTSD

The common goal of responding to children experiencing situational crises is to prevent theformation of PTSD. This syndrome, first identified among military combat veterans, also manifestsitself in children. Their reaction is similar to that in adults, although their reactions may be somewhatdifferent 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 have symptomsin three different areas: persistent reexperiencing of the traumatic stressor, persistent avoidance ofreminders of the traumatic event, and persistent symptoms of increased arousal. These symptomsmust be present for at least one month, and cause clinically significant distress or impairment insocial, 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



are to a significant 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 andmore likely to take the form of generalized fear and anxiety.

It is certainly not true that all children, if untreated, will develop PTSD. In fact, recovery is thenorm (NIMH, 2001). Recent studies regarding the prevalence of PTSD in children and adolescentsestimates that about 15%–43% of children have experienced at least one traumatic event in theirlifetime. Although estimates vary by extent and type of trauma, a conservative estimate is that12%–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 childrenand adolescents (as indicated by the presence of PTSD) vary considerably both within and betweentypes of crisis events (with rates of PTSD ranging from 0% to 95%). Some may even develop long-term characterological patterns of behavior following a disaster, such as fearfulness (Honig, Grace,Lindy, Newman, & Titchener, 1999). These character traits, exhibited later in life, may originate asnegative coping responses to the trauma.

Severity of symptoms is related to the magnitude of exposure to the event itself, and the degree ofpsychological 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, thegreater likelihood of severe distress. Having a relationship with the victim of trauma also increasesthe risk (emotional proximity). A third factor is the child’s initial reaction; those who display moresevere reactions, such as becoming hysterical or panicking, are at greater risk for needing mentalhealth assistance later on. The child’s subjective understanding of the traumatic event can sometimesbe more important than the event itself. That is, the more the child perceives an event as threateningor frightening, the greater the chance of increased psychological distress. Additionally, childrenwho experience the following family factors are at an increased risk: those who do not live witha nuclear family member, have been exposed to family violence, have a family history of mentalillness, or have caregivers who are severely distressed themselves (Fletcher, 2003). Children whoface a disaster without the support of a nurturing friend or relative appear to suffer more than thosewho do have that support available to them. Symptoms in children may be more severe if there isparental discord or distress and if there are subsequent stressors, such as lack of housing followinga disaster (La Greca et al., 1996). The traumatic death of a family member also increases the risk ofstress reactions (Applied Research and Consulting, Columbia University Mailman School of PublicHealth, & New York Psychiatric Institute, 2002; Bradach & Jordan, 1995). Finally, children whohave preexisting mental health problems or previous exposure to threatening or frightening eventsare more likely to experience more severe reactions to trauma than are others. Symptoms may alsobe heightened among ethnic minorities (La Greca et al., 1996).

La Greca and her colleagues (1996) discuss five factors related to the development of severesymptomatology: 1) exposure to disaster-related experiences, including perceived life threats; 2)preexisting child characteristics such as poverty and illness; 3) the recovery environment includingsocial 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, suchas genetically based premorbid psychopathology and temperament (Cook-Cottone, 2004).

Clearly intervention must supply an appropriate recovery environment that is suited to a child’scharacteristics and facilitates coping. Determination of what intervention is appropriate for a givenstudent should be based on assessment of risk for psychological traumatization. Nevertheless, schoolis 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 childreninto school following a traumatic experience that has led to their absence from school.



FACILITATING THE GRIEVING PROCESS

Grieving, and mourning the losses common to most potentially traumatic events, will beamong the counseling objectives. Losses may include those of significant others as well as loss ofstatus. However, emotional numbing and avoidance of trauma reminders that accompany trauma cangreatly 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 identified four tasks of mourning. The first task is to accept the reality of theloss and neither deny it has occurred nor minimize the impact on the child’s life. It is common forchildren to fantasize about a reunion or that there has been a mistake about the loss, or that divorcedparents will reunite. Before a child can progress to the second task, there must be a reduction inspiritual, magical, or distorted thinking (Hawkins, 2002).

Worden’s second task is to experience the pain of grief. There are many pressures, both culturaland familial, to not express or feel sadness at a loss. Children are told not to be a “crybaby” and to“act like an adult.” However, if the emotional pain is not experienced, there may be a manifestationin 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 thelost status or relationship. The child must learn to create a new set of behaviors and relationshipsto replace those 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 anidealized past.

The final task of mourning is to withdraw emotional energy from the lost status and reinvest itin other relationships and endeavors. By holding on to the past, lost attachments rather than formingnew ones, a child may become stuck. Instead, the trauma victim must eventually embrace a newstatus.

Worden (2002) believes that, when the tasks of mourning are accomplished, the individual willbe able to think of the loss without powerful pain, although perhaps with a sense of nostalgia andperhaps some sadness. In addition, the child or adolescent will be able to reinvest emotions in newrelationships without guilt or remorse (Hawkins, 2002).

TREATMENT

School-based Counseling

Galante and Foa (1986) worked in groups with children in one school throughout the schoolyear following a major Italian earthquake. The children were encouraged to explore fears, mistakenunderstandings, 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 destinyand heightened fear of the unknown. Thus, a focus on returning a sense of empowerment to childrenwill be important. If children can be directed to participate in restorative activities and take someactions to mitigate the results of the disaster, no matter how small, they can begin to rebuild animportant sense of efficacy.

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 induced among individuals who survivea situation that results in the death of valued others. Those individuals spared, but witnessingthe 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



need to explore their magical thinking in counseling or play therapy about why they escaped injuryor loss.

School community–based support groups can provide one vehicle for feeling connected to othersand working through these feelings. Ceballo (2000) describes a short-term supportive interventiongroup 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 senseof control over certain aspects of their environment, 3) develop safety skills for dealing with theenvironment in the future, 4) understand the process of grief and mourning, and 5) minimize theinfluence of PTSD symptoms on educational tasks and other daily life events. Such structuredsupport groups can promote resiliency and promote constructive coping with problems.

Depending on training and supervision, the school psychologist might also engage in therapiesvalidated for the treatment of PTSD. These therapies are reviewed in the section on community-basedtherapy. Time and other constraints often make outside referral necessary.

Bibliotherapy

Bibliotherapy may also be useful following a disaster. A particularly useful resource for chil-dren 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 chil-dren’s feelings that often emerge in the aftermath of a disaster, and offer useful techniques to helpyoung people cope with them.

Another technique in which the child is an active participant in the creation of a book aboutpersonal experiences is called the resolution scrapbook (Lowenstein, 1995). Here the child is guidedthrough a set of experiences and activities designed to help the child reprocess traumatic experiencesand place completed work in a scrapbook. Evidence for the effectiveness of this technique is largelyanecdotal to date.

Other Adults in Crisis

An important feature of a traumatic event is the fact that the adults in the school as well asthe children are affected. The teachers, administrators, and guidance staff would be as traumatizedas children by an earthquake, terrorism, or an airplane crashing into the school. They will needassistance 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 entirecommunity deal with disaster and mayhem associated with violence.

Community-based Psychotherapy

Cognitive behavior therapy. There are many treatments being studied for their effectiveness inthe 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 onthe premise that thoughts and behaviors can cause negative emotions and patterns of interactionswith 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 associatedwith anxiety with behavioral techniques—such as relaxation, imaginal or in vivo exposure, and roleplaying—that are known to be useful in the reduction of anxiety (Cook-Cottone, 2004).



Another protocol for dealing with treating PTSD is eye movement desensitization and repro-cessing (EMDR). It includes many of the same elements as CBT, with the exception of in vivoexposure, and includes rhythmic eye and other tracking exercises (Greenwald, 1998). It has beensuccessfully used with school-age populations (Chemtob, Nakashima, & Carlson, 2002).

Play and art therapy. Play and art therapy are also being studied to determine their effectivenesson 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 environmentand 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. Oftenthe symptoms of anxiety or depression that have resulted from exposure to a traumatic experi-ence are treated. Selective serotonin reuptake inhibitors (SSRIs) in particular are often prescribedto treat the symptoms of anxiety and depression, including sertraline, paroxetine, and fluoxetine (Foa,Davidson, & Frances, 1999). In the adult population, antipsychotic, antiepileptic, and otherpsychotropic medications have been explored and may be effective depending on the symptomsof the individual (Davis, Frazier, Williford, & and Newell, 2006). If medications are prescribed toa student, it is important that there be a liaison between the school and the treating physician orpsychiatrist to monitor effectiveness and deleterious side effects.

CONCLUSIONS

School psychologists are often the contacts in schools when there is a traumatizing event.School psychologists should be ready to administer psychological first aid that is individualized anddevelopmentally and culturally appropriate. By intervening and facilitating coping processes and thegrieving process, it may be possible to prevent or minimize the development of PTSD. School-basedprotocols have been developed to respond to children in crisis. When students are referred to otherpsychological, psychiatric, or medical services, it is important to designate a liaison between theschool and other professionals to maximize optimal treatment and care.

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Crisis counseling: An overview