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The last two decades of neuroscientific research have led to new understandings of how the brain and body are affected by crises. In response to this new research, I propose an alternative approach to crisis intervention in schools. The approach engages the oldest, wisest part of our brain, the brain stem, through the language of sensations for two reasons: first, because the core of the crisis experience is processed by the brain stem, and second, because the language of this more primitive brain is sensations.

After a crisis event, activity of the brain stem needs to be brought into greater balance with the rest of the triune brain - the limbic mid-brain and the neocortex. When all three parts of the brain are realigned with one another and the nervous system is thus brought back into greater balance through a process of gentle discharge (more later), the likelihood of problematic reactions emerging later is greatly decreased (Levine, 1997). Self-regulation is restored. Students regain their physiological capacity to move through frightening situations without becoming debilitated by them. The nervous system is then able to naturally move in and out of stress unburdened by an ongoing, sometimes accumulating amount of stress.

Psycho-physiological first aid is intended for use immediately after a crisis event. It does not require the waiting period of other approaches of up to seventy-two hours. Students do not have to be "ready to talk" about the event because discussing what happened is not required. Students do not have to be out of shock or no longer numb from the experience - a stipulation of other interventions - because those feelings and sensations are what get worked through and resolved with psycho-physiological first aid. With other approaches, resolution of shock and numbness is needed before implementation can begin. However, for some people, shock and numbness do not go away in the hours, days, even weeks after a crisis. Without psycho-physiological first aid, these natural responses to trauma can last for weeks or months, even years.

Although psycho-physiological first aid is a unique response to crises, it includes elements from other programs that are useful and empirically supported. For instance, from the research conducted examining Jeffrey Mitchell's model, we learned that intervention that occurred without delay resulted in fewer and less severe symptoms (Campfield & Hill, 2001). We also learned that debriefing reduced distress when it was lengthened for up to three hundred minutes and combined with either post-group psychoeducation (Chemtob, Thomas, Law, & Cremniter, 1997) or an integrated stress management system with individual support (Richards, 2001).

From developmental approaches, it is helpful to retain an understanding of the developmental age and stage of the students we serve knowing that regressive states will also appear. Meeting students where they are is the challenge. If adolescents present behaviors more commonly seen in preschoolers, we need to intervene with them at that level, and reassure them as we would a preschooler. From solution-focused approaches, it is useful to highlight students' strengths and abilities, what is working, and how they can manage and cope with stress.

Stephen Brock's approach emphasizes the need to consider the different phases of the crisis and intervene at each phase accordingly. His GCI model is cost-efficient and productive overall because of the number of students that can be served at one time. Relatively healthy students with available resources and little or no remarkable history of trauma may be well suited to this particular group-wide approach.

Each of these valuable contributions to crisis intervention has been included in the development of the model of psycho-physiological first aid. Additionally, recent research has informed us that the best approach to crisis intervention and trauma resolution is one that understands and intervenes with physiology. In the International Journal of Emergency Mental Health, for example, in a study of the use of mental health services following 9-11, the authors stated that peri-event physiological reactions, and psychological perceptions of physiological responses, were important factors determining subsequent psychopathology (Boscarino, Galea, Ahern, Resnick, & Vlahov, 2002). It is psycho-physiological first aid, uniquely, that provides a model in which such reactions and responses can be understood and quickly resolved.

Phases of Psycho-physiological First Aid

While useful and empirically supported elements of other crisis intervention approaches are included, much of the model being proposed here is the result of the work of Dr. Peter Levine. Over the past three decades, Dr. Levine has traveled the world in response to global crises, studying and healing children and adults who have experienced life-altering events.

Psycho-physiological first aid involves four phases: needs assessment, intervention (small group, large group, individual), psychoeducation, and follow up.

Needs Assessment

This first phase is invaluable. The school's crisis response team meets as a group, clarifies their roles, and determines who will do what. The team gathers as many of the facts as possible regarding what went on during the event. Knowing the magnitude of the crisis helps the team decide how to intervene first. If the scope of the event was relatively small and a whole class or large group of students was not involved or impacted, then group-wide models would not be needed, nor would they be helpful. Group crisis interventions are reserved for homogeneous groups (Brock & Jimerson, 2002; Mitchell & Everly, 1996a) of students who have all been exposed to the event to about the same degree, and who display a manageable amount of difficulty due to the event.

Homogeneity of groups is a difficult qualifier in the case of trauma. Most students will each have their own individual responses based on their own previous experiences with trauma, their closeness to the event and/or victim, and their available resources before, during, and after the event. The crisis response team may find that, unless a significant number of effected students make a large group intervention necessary, small groups and individual support are more appropriate.

The goal of the first phase of psycho-physiological first aid is to decide what the needs are, whether large group, small group, or individual intervention - and which team member will respond to what need. If a large group intervention is needed then Brock's GCI model may be helpful when the team is committed to spotting those in the group who need immediate removal and individual intervention in the form of psycho-physiological first aid. A trained eye is needed to observe any early signs of physiological or emotional overwhelm in order to prevent such responses. Education and training is required in order to readily see these signs.

Should the large group approach be necessary, there would likely be a delay in the crisis response due to the time it takes to assemble the group's participants. At such times, it is helpful for certain members of the team to immediately seek out the students directly involved or impacted by the event due to exposure or closeness to the victim. Rather than wait for the larger intervention with these particular students, it is best to administer psycho-physiological first aid with each of them on an individual basis as soon as possible.

If we are not able to be at the scene right away or help the students involved immediately after the event, we need not be overly concerned. The energy mobilized by the trauma is always there. It is in the body waiting to be discharged. As Dr. Peter Levine discovered through his research, trauma is an interrupted process naturally inclined to complete itself whenever possible. As soon as we create the opportunity, [students] will complete the healing process and avoid the debilitating effects of trauma (Levine, 1997).

The needs assessment includes attention to what the crisis counselors themselves may need before offering their assistance to students. Our own physical and emotional responses require acknowledgment. Just as we are instructed to do on an airplane in times of crisis, we must assist ourselves first. We must sense the feelings going on inside our own body, and utilize stress management skills and the camaraderie of our colleagues to calm ourselves before we try to do anything else. If we feel upset, we need to ground and center through deep breaths, connection with the floor, the room and the people around us. If we do not take the time necessary to calm ourselves, students will pick up on, and react to, our fear or confusion. Students are very sensitive to the physical and emotional states of their teachers and other adults.

There are three possible outcomes of the needs assessment: large group, small group, or individual psycho-physiological first aid.

Large Group Intervention

Like with other approaches, dissemination of facts, dispelling of rumors and psychoeducation involving normalization of responses are important steps to take at the intervention phase of psycho-physiological first aid. Unique to this approach is an emphasis on normalizing physiological responses, taking into account that crises happen to the whole person, body as well as mind. Students should be made aware that their body may respond to the event through involuntary trembling, shaking, heat, cold, and/or crying. They need to know that not only are these responses normal, they are important. Such responses are the body's way of moving through the experience. Allowing the natural physical expression of distress to continue until it stops or levels out on its own is the key to preventing residual problems later.

An emphasis on resources is important. Unique to this approach is a greater focus on resources than on sharing stories or reactions to the event. Doing so in the large group particularly can cause unnecessary arousal for the person telling the story as well as for the people hearing it. In fact, if students begin to tell their story in the large group, they should be stopped gently and encouraged to notice their feet planted on the ground as they look around the room and see the people there supporting them.

Do not be concerned that you are stopping a process when you distract a student from engaging in narrative about the event and instead have them focus on something around them that helps them feel more grounded and centered. This is an important protective service you are providing them that will prevent an experience of overwhelm in the nervous system. Some students may not be easily discouraged from telling the story. They may seem to have a compulsion to speak out about what they saw or what happened to them. These are the students to refer for individual support. At later stages of the process, students will have a chance to tell their story. The first concern, however, is to ground and center students, allowing their body to naturally move through the initial physiological reactions of the experience. Once the nervous system is balanced, telling the story will not have the same power to re-traumatize.

Containment must be provided. In a large group situation, it is important to have as many calm adults as possible in and around the room, so that students feel a strong sense of support. We know from Dr. Bruce Perry's research on the brain that relationship and close physical proximity actually changes neural activity (Perry, 2003). Studies have found greater neural activity, a healthy indicator, when people are in the presence of, and connected to, others as opposed to when they are alone. Elevated levels of heart rate and blood pressure decrease when we are in physical proximity to others and feel the containment and support of their presence.

Students benefit from becoming involved in creative activities as a group. Have them draw pictures, write letters, read poems, or design murals that help them express their thoughts and feelings about the event. Educate students about the need to focus on their resources when they leave the group. Direct them to connect with friends, family, pets, and nature as much as possible. Let them know that it is important for them not to get together with friends or family to talk about the event, especially repeatedly or in a ruminating way. Rather, they need simply to feel the support of their loved ones and enjoy their company through games, rituals or activities.

Make sure students know to turn the television off, especially the news or any shows or commercials that are frightening or violent. We are learning more and more about the impact television viewing has on the nervous system. One study completed after the Oklahoma City bombing indicated that simply viewing the images of the explosion on television accounted for more variance of posttraumatic stress responses than knowing someone who experienced the crisis or actually seeing or hearing the blast (Pefferbaum, Nixon, Tivis, Doughty, Pynoos, Gurwithch, & Foy, 2001). Have students instead get involved with, or return to, sports, a martial art, or a creative activity that helps them express themselves.

Reassure students that they are not alone, that we are right here with them and for them. Encourage students to seek out the help of school personnel anytime they need to.

Small Group Intervention

Whether meeting in a large or small group, the above steps are necessary to bring the students' nervous system back into balance. In both groups, it is important to keep a vigilant eye on who may be becoming too physiologically aroused to be in the group. Some will likely need to be seen individually and provided with first aid.

Small group exercises that are helpful during times of crisis involve grounding. This is especially important for students who are too upset to stay in the large group. To help these overwhelmed students become calmer and better balanced internally, encourage them to remain seated and guide them verbally to feel their feet planted on the ground. Have them sense the connection they have to the earth as well as the people around them.

Encourage them to look around the room, see the others there with them, and feel their presence and support. Guide them to feel the support of the chair behind their back and underneath them. Have them really sink into the chair and sense that it is holding them. Have students call out the colors they see as they look around the room, blues, reds, and yellows. Have them describe something they see outside the window or in the room. This is how we call in external resources to develop an inner resource, a greater sense of calm and balance in the nervous system.

Without using the word "relax" with students, conduct a progressive relaxation exercise for grounding. Encourage the students to move their attention from their toes all the way up to the top of their head, tightening each small muscle group, holding it for a few seconds, and then gently releasing it.

Individual Psycho-physiological First Aid

Create a sense of safety for students by keeping things quiet and calm. Keep students as still and warm as possible and simply encourage them to rest. This is important when students show signs of shock, such as pale complexion, shallow or rapid breathing, glazed eyes, shaking or trembling, or looking disoriented as though they are walking through a dream. They may have a dazed or spacey quality about them. They may seem shut down or frozen. On the other end of the spectrum, students may be overly emotional. Whatever their state, it is our job as crisis counselors to provide them with a safe environment, monitoring our own internal responses as well as theirs. By taking full, deep breaths, grounding ourselves, and staying as calm as possible, we are better able to help students settle and rest.

Provide physical connection and support by gently putting your hand in the center of the students' upper back, behind the heart (I ask permission from them to do so). As good as our intentions may be when we excessively rock or pat students when they are in distress, this is actually a disruptive response and not helpful. Simply placing a hand on the back in a gentle way can be soothing as it gives the student a sense of connection and containment. Allow time for that glazed look or excessive emotion to dissipate. Gently remind students they are not alone and you are right there with them.

Gently guide the students' attention to the physical experiences they are having in their body by asking them about sensations. Speak quietly and calmly allowing a moment between each question. Reflect the students' answers back to them to help focus their attention and feel the presence of another. The brief conversation may go something like this:

What do you notice inside your body?

It hurts.

It hurts inside.

Yes.

Can you point to, or tell me, where?

My head.

Can you describe the hurt for me?

It feels like it's going to explode.

Like it's going to explode.

Yes.

Does it feel hot in there, or tight? What is that explosion feeling like?

It's tight. It hurts. It's pinching down on me.

It's tight and feels like it's pinching down on you.

Yes.

I would like you to focus on those sensations that you just described - that tight, pinching feeling. I'm right here with you. Just watch and see what happens next.

Allow a moment or two of silence so the sensations can move through without the distraction of another question. Look for signs that the sensations are changing such as a full breath or shift in eye contact or emotion. You will notice that as students continue to focus on sensations within the container of your presence, they will experience a shift or change in the quality of the sensation. They may experience a discharge of the energy and chemicals mobilized during the incident that involves trembling, gentle crying, yawning, heat or facial flushing. Check back with the student.

How does your head feel now?

It doesn't hurt as much.

Just notice now that the hurt has lessened.

Another cycle may follow during which students feel another uncomfortable sensation and the process would continue until the overall sense of discomfort goes away.

Keep the focus on sensation, discharge, and rest through gentle containment. This is not the time for discussion about the event. Opportunities at another phase of the process will be available to students. They will have the chance later to draw, color, and/or tell stories about what happened.

Normalize the students' physical reactions. Let them know how involuntary crying, trembling, feeling heat, and yawning are all natural, healthy responses after a frightening event. Simply make statements like, "That's it. Just let your body do what it needs to do." Keeping your hand gently on their back can be helpful when offering such reassurance.

The body may want to move in a particular way. This is normal. Students may begin to feel the impulse to run, kick, or hit. These are fight or flight behaviors, often thwarted at the time of a crisis due to shock, freeze, extreme fear, or simply the inability to fight or flee. Let the movement happen only when it can be kept very slow. The brain stem is not sophisticated enough to move through these powerful experiences quickly. The intervention, if it is going to be effective, must occur slowly.

You can slow students down if they begin to give into their impulses too quickly. Just stay calm and use a firm, quiet voice to let them know how important it is that the body may want to move, and that is okay, but it is absolutely critical that the movements do not happen quickly. An excellent alternative to having the students slowly engage in the actual movements is to encourage them to imagine themselves, in their mind's eye, giving into the impulse and moving in the way the body wants to move.

Make sure the discharge process is not disrupted. For example, you may notice an urge to stop what is happening. Do not. (The only time to stop is when too much is happening too quickly and the student is becoming overwhelmed.) Notice your own reactions and ground yourself through deep, full breaths and connection to the chair beneath you. The successful completion of the process requires that you trust yourself to observe and provide safe containment, and that you trust the body to complete these natural responses. Do not worry about whether or not you are doing this the "right way." Simply know that things will happen naturally as they are intended.

Watch for signs of completion. Students may be complete after one cycle of noticing an uncomfortable sensation and then experiencing its completion through a gentle discharge involving trembling or heat. Other students may cycle several times between pleasant and unpleasant sensations. One clear way of knowing that they have completed a discharge is orientation back to the room, to you, or to the external world in general.

Make time for students to express their feelings about the event through art, drawing, coloring, or storytelling with an emphasis on highlighting resources, coping, and empowerment. Continue to normalize what they are feeling and expressing. Tell stories of heroism, about other students or adults who experienced a frightening event and then went on to do great things.

If at any point during this process students seem overwhelmed or stuck in unpleasant sensations too long (more than three or four minutes), introduce a resource to them, such as a grounding exercise. You may simply orient them to the room by asking them to find something on the wall that catches their eye, or make a connection with them by having them look into your eyes. Alternatively, you could ask them to imagine their best friend is there with them, giving them support.

Psychoeducation for Parents

Once we have intervened with students, it is important to educate their caregivers about what to expect and how they can be helpful at home. Let parents know about the potential impact a crisis event has on the nervous system. Empower them by giving them a clear sense of the kind of presence they can be for their children that will be most helpful to return the nervous system back to normal. "Building mutual support for the family to surmount this tragedy together" has proven to be very helpful (Walsh, 2003, p. 403).

Parents can be a container for their children at home by providing an overall sense of safety and calm. Reassurance can be provided through simple statements such as, "You are not alone. I am right here with you." Talking too much is not helpful.

Let parents know how important it is that their children do not watch the news or any programs that involve frightening or violent themes.

Tell them about the signs of anxiety and upset that may signal the need for physical proximity and connection with nature, pets, and loved ones. It is precisely these kinds of external resources that will help reinstate calm and balance in the nervous system. When working with the families of students who have experienced a crisis, one of the most important things we can do is identify and fortify key processes for resilience (Walsh, 2003).

Parents need to know that offering quiet connection through gentle holding can help facilitate the letting go of anxiety and stress. When holding their children, or offering any kind of physical support, parents may notice their children trembling, shaking, giving off heat or sweating, even yawning excessively. Let them know that these responses should not be interrupted but simply watched and validated through brief statements like, "That's it. That's okay. Just let that happen. I'm right here with you."

In whatever way parents can promote their children's competencies will be an invaluable part of helping them overcome a traumatic event. Getting them involved in activities they are good at, that they derive a sense of pride from, is very useful.

Emphasize to parents that talking about the event may not be helpful. If their children bring it up and seem to really need to talk about it, it is most important for parents to point out their children's resources. As children tell the story, parents can highlight the parts of the story involving who and what helped them get through the event.

Psychoeducation for Teachers

It is important to let teachers know what is helpful and what is harmful in the classroom after a student has experienced a crisis.

Harmful

Having a presence, tone of voice, or body language that is in any way threatening or provocative to the student is harmful. Some students will have had previous traumas and/or few resources before, during, or after the event. As a result, they may become significantly impacted by the crisis and may go in and out of freeze states, even fight or flight states, depending on two things: how they responded during the trauma and how well they are currently able to meet the demands of the classroom.

Researchers have found that students who were negatively impacted by trauma have difficulty meeting the demands of their classroom because of the residual effects of the event(s) on the nervous system. Rather than having the ability to simply go with the flow of the classroom and the teacher's directives, they may respond to demands by not responding. Their nervous system may no longer have the ebb and flow, fluidity and flexibility that is essential to making transitions, complying with requests, and persevering in the face of increasing challenges. There is a greater sense of inflexibility about these students, even opposition. This is when teachers are in danger of engaging in threatening stances. Of course, we want the students to comply and do what they need to do. However, becoming harsh, threatening, or provocative in order to exert power over these students is a very bad idea.

Helpful

Having firm boundaries that are reasonable and flexible is helpful. Understanding where students are coming from is the first step. We need to truly appreciate that this is not a compliance issue. This is a capacity issue. Traumatized students do not have the fluid capacity to respond immediately in the moment. Some need ample warning of transitions, such as the daily schedule taped to their desk as mentioned in chapter eight. Others benefit from the simple intervention of a longer response time when demands are made. This requires extra patience as well as flexibility in the limits and boundaries of the classroom. Flexibility should not lead to abandoning limits and boundaries, however. These are needed for structure and containment. The stability of functioning of students who have been traumatized depends upon the safety and predictability that firm yet flexible limits and boundaries provide.

Harmful

Banning these students to a time-out area or the office over a capacity issue that only appears to be a compliance issue is a mistake. We have to know the difference between capacity and compliance. Of course there need to be consequences for any student engaging in problematic behavior, but these students are helped by such consequences when they are held in place with compassion. We do not want to instill in them a deeper sense of hopelessness, shame or collapse.

Helpful

Use time-out areas as a resource to students where they can go to take a break, a deep breath, and conjure a calming thought or image to bring the nervous system back into balance. Help students un-do the damage of their actions or inaction by helping them apologize, correct their previous response with a new more adaptive one, and validate them for that. Remind them that everyone makes mistakes and that what is most important is the repair we do after a mistake to restore peace and a sense of well-being.

Harmful

According to an article written after the nightclub fire in Rhode Island, school psychologists Torem and DePalma indicated that while not speaking of the tragedy would be unnatural, spending too much time in discussion could be counterproductive (Torem & DePalma, 2003). They also stated that while scheduled tests should be postponed, the daily schedule should not be veered from too dramatically.

Helpful

Torem and DePalma reported that teachers should be reminded that art, music, and writing activities can be helpful in reducing stress levels, and that simply reassuring students with facts is enough (Torem & DePalma, 2003). Also helpful was support given to teachers so they could model appropriately calm and reassuring responses to their students. After-school support groups for teachers were utilized and found to be effective.

Follow-up

Let us briefly review the first three phases of psycho-physiological first aid. First, as a crisis response team, we meet and conduct a needs assessment that considers the scope of the event. Once this is complete, we know what we need to do for our second phase: A large or small group intervention, an individual approach, or some combination of two or more of these. Whether we work in a large or small group, or individually, there is a unique emphasis on educating students about their natural physiological responses to threat and how to move through these with ease. At the third phase of psycho-physiological first aid, it is important to provide psychoeducation to parents and teachers.

Once the first three phases are complete we enter the fourth and final stage, follow-up. At this stage, we assess for the potential need for greater assistance, at or outside of school. Some students will need to be seen more than once. A small number may require individual sessions to completely work through the event. An even smaller number may need therapy outside of what can be provided at school. The need for greater assistance, and how intense that help should be, will depend upon the students' previous history of trauma, their pre-event level of functioning, and/or their lack of available resources before, during, or after the event.