Psychoanalytically based workbooks to help children cope with disaster
by Gilbert Kliman, MD
Published in The Journal of the American Psychoanalytic Association, Volume 55, Issue 1, p.279-282
My own disaster work goes back to crises such as helping schoolchildren deal with the death of a president. As a clinical analyst, I learned from my individual child patients at the time and reported on Oedipal themes I observed being activated among them. However, it was a formative experience to realize I learned even more of practical public health value from a psychoanalytically informed behavioral survey of teacher observations about the behaviors of 800 schoolchildren. Through that study, it was learned that on the fateful afternoon of John F. Kennedy’s death, teachers and administrators who avoided immediate discussion of the assassination with their in-school pupils experienced behavioral deterioration in their classroom populations as measured by behavioral checklists. The pupils of teachers who initiated discussion with their children had markedly better classroom behavioral outcomes.
I kept applying this knowledge about the value for children of adult leadership during times of crisis. Adult-augmented ego executive function and use of adult superego modeling could be essential factors. This clue proved useful in later systematic population-based research I undertook with foster children. Controlled studies of a pro-active approach to having foster children create written narratives about their personal life histories led to a significant public health breakthrough. The method produced a sharp reduction of a psychologically malignant phenomenon already vulnerable children bouncing among foster homes.
Questions arise which can help in future crises: What are the psychoanalytic principles that make a difference; why is it that creating a written narrative of a foster child’s life, one that is authored by the child with the aid and input of a network of current caregivers, results in a statistically significant lowering of bouncing to another foster home and in a qualitatively improved experience of life for the child?
Since Kennedy’s death, many large scale crises have provided the impetus to produce psychoanalytically-informed guided activity workbooks for children, families, and teachers, similar to those that helped foster children. My colleagues and I have authored workbooks concerning the Loma Prieta earthquake, the first and second Gulf Wars, the attack on America, floods, fire storms, the Kosovo refugee experience, terror attacks in Israel, and we are starting one for Lebanese children who have been caught in the war in Lebanon. A Guatemalan mudslide book was produced with the leadership of Leah Fisher. A tsunami workbook is being developed with Sombat Tapaya in Thailand.
Evaluation of Effectiveness
Research is underway to help determine what is helpful about psychoanalytic resources of this type in the aftermath of a disaster. When Hurricane Katrina made landfall in New Orleans on August 29 2005, causing extensive flooding, immense destruction, and human suffering, Mercy Corps and the San Francisco-based Children’s Psychological Health Center began collaborating on production and distribution of a new guided activity workbook within a week after the disaster.
To evaluate the effectiveness of the intervention, the American Psychoanalytic Foundation and Mercy Corps jointly funded a study of the resource. The objective of the resource was to decrease post-traumatic symptoms in several hundred among the evacuated fifth to eighth grade children attending a displaced school, temporarily based in Houston. The formerly New Orleans student population was 100 percent African American, the majority (82 percent) from impoverished areas of New Orleans that were widely devastated by Katrina. The University of California at Los Angeles Child Post-Traumatic Stress Disorder Reaction Index (PTSD-RI) was administered to the children prior to beginning work on the Hurricane Workbook and again after three months of working with the specially designed psycho-analytically informed workbooks.
My Personal Story About Hurricanes Katrina and Rita:A Guided Activity Workbook for Children, Families and Teachers was given to each child. Each worked on it in class for 30 minutes weekly for three months. Post-traumatic symptom level scores among 100 twice-tested adolescents declined sharply. The improvement was statistically highly significant (p=.000 1). It confirmed compelling clinical observations that even classes of highly agitated and overactive inner city children quickly grew very calm when using the activity workbooks. My Personal Story About Hurricanes Katrina and Rita appears to have contributed to decreasing PTSD symptoms.
Reports of post-Katrina mental health symptoms in other studies generally contrast with this one showing increases of pathology over time. According to the most comprehensive survey yet completed of mental health among Hurricane Katrina survivors from Alabama, Louisiana, and Mississippi, the proportion of people with a serious mental illness doubled in the months after the hurricane compared to a survey carried out several years before the hurricane. We await, however, controlled and random assignment studies, which we have conducted so far only with foster children. We also await with great interest studies of cognitive functions such as IQ which have been shown to improve when other supportive expressive methods are used in social networks, particularly the Cornerstone Therapeutic Preschool Method [now known as Reflective Network Therapy].
Alas, there will never be a time when children are exempt from disasters. The creation and use of psychoanalytically informed public health measures, as well as further study in this area, are essential. We have some tentative hypotheses about the reasons children improve through use of such adult-recommended measures. The use of guided activity workbooks shows children that honestly facing the disaster is supported rather than avoided by their teachers and families. The use of drawings and encouragement of narrative writing advances a sublimative and witnessing process in which the child feels respected and useful within the child’s human network. The child’s personal locus of control and sense of personal history are enhanced. These factors all can easily be absent in a disaster. Current and future research will augment our understanding of how psychoanalytically-based resources make an important difference.