Providing Peer Support to Disaster Survivors
Stephanie Frogge, Helga West  -  2007/5/29
http://ovc.ncjrs.gov/ovcproviderforum
 
 
I have seen many correlations between military losses, and disaster survivors. Is there any research to back up the corrolation?
 
1.  S. Frogge
 Thats a good question that can be looked at from a couple of different angles. If you're talking about crisis reaction following the death, my understanding of the literature is that the trauma reactions are very similar. 9/11 is a good example of a disaster trauma event that involved both military and non-military losses. Characteristics of many military losses, at least those involving combat situations, are very similar to those of disaster survivors:-Sudden loss-Traumatic circumstances-Highly publicized. As it relates to peer support, I know of research that has looked at the positive effects of peer support among military personnel who have experienced combat situations. Take a look at Larsson, Michel & Lunden. But I am not aware of completed research that has looked specifically at peer support among military survivors those whose loved ones have died while serving in the military. TAPS is involved in a project right now that will examine the effects of peer support among military survivor childrenwell be eager to share those findings when we have them; our hypothesis is that well see benefit as measured by school performance, behavior at home, and outward expressions of mourning.
 
2.  Helga West
 Your observation raises a very important point. Trauma is often a common experience for survivors of disasters and war and also violence, abuse, neglect, and terrorism. The experiences may be very different, but the impact is similar with individuals, families, and communities. Witness Justice pulled together some research regarding the science of trauma that might be helpful (see http://www.witnessjustice.org/health/trauma.cfm).Another important consideration here is that stigma and job impact can be significant barriers to accessing mental health services for military survivors. Peer support, however, offers a non-threatening approach to addressing the silent wounds.
 
 
How do we implement a peer support program for disaster survivors? Is it a program we should have at the ready, in the event of a mass violence event?
 
1.  Helga West
 Preparation is key and, if things are planned well in advance, the support can be mobilized very quickly. There is a disaster-specific peer support model in development that will be helpful. See After the Crisis (www.gainscenter.samhsa.gov/atc/peer_support.html).Another interesting approach, that also honors anonymity in a peer support context, is to offer peer support online. With so many different approaches listserves, facilitated list discussions, blogs, message boards, and more they are a number of options for connection. While we are working to assess efficacy for each of these avenues for connection, it will be essential that the online support model be trauma-informed, survivor driven, and also managed in a way to ensure that the meeting place remains safe.
 
 
How do you determine when a survivor is ready to offer support to other survivors?
 
1.  S. Frogge
 Great question! And one all practitioners struggle with in programs that use survivor volunteers. How do we know when someone is ready to mentor others? When we look at someone taking on somewhat of a leadership or specialized role as it relates to peer support we examine three issues: Can the survivor listen to another survivor's story without needing to tell their own? Second, can the survivor companion the other survivor which means not feeling the need to fix things or offer advice based on their own experience. Third, it's important to know that a survivor can listen to someone else's story without being revisited to a significant degree by their own pain and trauma. Those are the three primary issues that I take a look at. Of course simply sharing ones own story with other survivors is a peer support experience and someone may be ready to do that much earlier in their own journey. For survivors who want to come to some kind of a peer support event as a participant I would be primarily concerned only that being exposed to the pain of others wouldnt be so overwhelming to them that it would hurt more than it would help. For those who are still extremely vulnerable to the pain of others, individual counseling would be more appropriate initially.
 
 
Are there any trainings available on this topic?
 
1.  Helga West
 There are a few peer support, trauma-intervention models with related training that I am aware of: 1) Addiction and Trauma Recovery Integration Model (ATRIUM) (http://www.dustymiller.org), 2) the Essence of Being Real (http://www.sidran.org), and 3) Peer Companion Training (this one pays particular attention to cultural competency issues - http://www.bpsos.org/node/289). There is also a peer support model specifically designed for disasters that is currently being developed by the After the Crisis initiative (learn more at www.gainscenter.samhsa.gov/atc/peer_support.html).More general trauma training is available at no or low cost to publicly-funded programs and services through the US Department of Health and Human Service, CMHSs National Center for Trauma-Informed Care (www.mentalhealth.samhsa.gov/nctic). They also offer information about trauma-specific interventions and related training (see http://mentalhealth.samhsa.gov/nctic/trauma.asp#intervention).
 
 
Can peer support programs be used in lieu of counseling/therapy?
 
1.  Helga West
 Peer support does not replace traditional services but instead, offers an alternative to individuals who feel alienated from the mental health system or have other access barriers. Every individual heals differently and finding the right path is a personal decision. So much depends on what support system is in place for the survivor. What works for one person may not be what works for another. For the long-term, peer support offers helpful connection and understanding that can be particularly helpful in managing triggers or retraumatization.
 
2.  S. Frogge
 I think peer support should be considered an adjunct to professional counseling although the two don't have to be simultaneous. Regardless of what's desirable from a clinical perspective however, folks will seek out what they think is beneficial and or most comfortable and some people won't see a counselor...or go to a support group...or won't seek help until they get to a particular point on their own journey. We should keep in mind, though, that peer support doesn't necessarily equate to a support group setting but happens anytime you put two people who have had similar experiences together. TAPS hosted its annual survivor seminar this weekend and we had 300+ people in Washington, DC. Believe me, there was peer support going on at the swimming pool, in the bar, in the bathrooms, and on the bus! Interestingly, the PTSD literature suggests that a combination of interventions is more effective than any single intervention. That might be another indicator that peer support can be an effective adjunct to other kinds of interventions.
 
 
What are the benefits to peer support programs?
 
1.  Helga West
 Peer support is an effective way to overcome stigma barriers that might prevent a survivor from reaching out to service providers. Since peer support should take place in a mutually supportive environment, greater openness and expression can take place without fear of being evaluated or assessed. It is easier to address cultural issues in a peer support environment, given that participants live with this knowledge and dont require being taught to be culturally competent. Online peer support is also becoming increasingly popular. Ease to access, anonymity, instant connections and other benefits have made it an effective means of support. This doesn't work well in the immediate aftermath of a disaster due to potential damage to infrastructure, but it can be very helpful for long-term support or when triggers arise.
 
2.  S. Frogge
 Different researchers use different language to describe the value but fundamentally, I like Jacobson and Greenley's take on it, that peer support creates opportunities for us to bear witness to one another.But others note that there's value from an emotional perspective, from the perspective of shared information and tools, and social support.
 
 
What key concepts lay the groundwork for peer support programs?
 
1.  Helga West
 The core principles of effective peer support include: it should be peer run and offer mutual support, it should be trauma-informed, it should be culturally competent, it should offer referral or paths to needed services, it should facilitate support beyond the group (i.e. with the family), if appropriate, and it should be available long-term.
 
 
Are the same principles applied to a peer support group for disaster survivors as it is for another type of victimization, such as homicide?
 
1.  Helga West
 The core principles of any peer support environment are: it should be peer run and offer mutual support, it should be trauma-informed, it should be culturally competent, it should offer referral or paths to needed services, it should facilitate support beyond the group (i.e. with the family), if appropriate, and it should be available long-term. Peer support can promote the healing process for many different experiences. One of the most important aspects in peer support efficacy is ensuring that it is done in a trauma-informed context. That means, the peer support program is based on an understanding of the vulnerabilities or triggers of trauma survivors so that the program can be more supportive and avoid re-traumatization. Programs that are trauma-informed should also account for differences in experiences and sensitivity issues around that.
 
 
Helga, can you tell us a little more about the Survivors Taking Action program?
 
1.  Helga West
 Survivors Taking Action (www.survivorsaction.org) is an advocacy initiative launched by Witness Justice in April 2007. It provides a platform for ALL survivors of trauma (violence, abuse, neglect, diaster, terrorism, and war) to come together to speak collectively about the nature and impact of trauma and the support needed for long-term health and wellness. There often is great emphasis placed on crisis intervention, but many survivors also need intermediate and long-term support. Survivors Taking Action will advocate for changes at the national and state levels to ensure this happens - and to do so in a trauma-informed context.
 
 
The nature of a disaster is that they usually happen very quickly. If you don't already have a program in place, is it still possible to assist in this way?
 
1.  Helga West
 Preparation is key and, if things are planned well in advance, the support can be mobilized very quickly. There is a disaster-specific peer support model in development that will be helpful. See After the Crisis (www.gainscenter.samhsa.gov/atc/peer_support.html). With some thought and planning, bringing survivors together in a trauma-informed environment to support and promote healing can take place. There are a number of models and training opportunities to help. Please see earlier posting for more info.
 
 
This is the first I've heard of peer support programs. Are these programs common practice?
 
1.  S. Frogge
 I would suggest they're not only very common but from a historical standpoint, a fundamental part of the development of the victim rights and services movement in the U.S. Unlike many other countries, it was survivors of violence speaking out about their experiences (and naming their perpetrators) that provided the early impetus for the development of programs that are common place today. In the 60s we called it consciousness raisingtoday we call it peer support! In addition, because of various influences, many programs were started and then run by volunteers who were motivated by their own victimization. That grassroots philosophy continues to influence the movement today.
 
 
Are peer support programs effective for all ages?
 
1.  C. Mitchell
 What would you recommend on starting up a peer support group for young children and adolescents? What types of topics would you recommend?
 
2.  S. Frogge
 Yes, the research has looked at peer support programs for children...I've seen work relating to child victims of sexual violence, children impacted by 911 and children exposed to community violence. All have found some (or much) positive effect of peer support. I would echo Helga's point in an earlier answer about the importance of a trauma context in peer support initiatives. Although just sitting around and talking about what's happened to us and comparing notes can, in fact, be beneficial for some under some circumstances, it can also be harmful if the experience fails to offer coping tools. Some of the child-related research has actually shown mixed results and I think some of the less positive effects can be traced back to the absence of trauma context support.
 
 
Can you talk about the Pennsylvania model DCSN? What are the components and has it been tested/evaluated? Can it be replicated in a community like New Orleans?
 
1.  Helga West
 Here's some information... The Mental Health Association of Southeastern Pennsylvania, in conjunction with the Center for Mental Health Policy and Services Research at the University of Pennsylvania, is responsible for the development of the Disaster Community Support Network (DCSN) model. Informed by experiences in Philadelphia, PA, the DCSN is an example of a model that facilitates recovery among individuals and communities affected by traumatic events. The DCSN model focuses on strengthening the capacity of a community to support self-help and mutual aid services following a disaster through the work of local leadership (e.g. elected officials, the local business community, mental health and other human services agencies) or through mental health advocates. The mission of the DCSN is to establish the groundwork for community mobilization in the event of national, State, or local disasters that impact, either directly or indirectly, Philadelphians and their communities. For more, see http://gainscenter.samhsa.gov/html/eNews/articles/11_06_ATC.html
 
2.  S. Frogge
 I'm not familiar with it either. Sounds like something to take a closer look at.
 
3.  Helga West
 Sorry - I am not familiar with that model.
 
 
In your experience, what are the challenges experienced by these types of support programs?
 
1.  Helga West
 Peer support can present some challenges. Some of the language, labels, actions, and stories of participants could be triggering for other participants. Again, if the environment is trauma-informed, and when survivors have an active role in their recoverytherapy, there is great context for healing while also lessening some of the risks or challenges.
 
2.  S. Frogge
 In my experience a number of things. Sustaining interest and participation can be difficult. Time-specific programs and/or topic orientated programs can help overcome that a bit. Another caution is not being fully prepared for people with signficant issues that are beyond the scope of a peer program. Peer support, in my opinion, should still be monitored, if not facilitated by a trained mental health professional.
 
 
I believe in peer support wholeheartedly and especially its ability to cut through a victim's isolation, but sometimes it's difficult to get victims to see that there is a real benefit and much value in meeting others. Any creative suggestions?
 
1.  S. Frogge
 Helga's response reminded me of something that happened this weekend during the course of the TAPS Survivor Seminar. Some of those in attendance asked that we consider having a scrapbook initiative at next year's seminar - both someone to talk about the benefits as well as an opportunity for those who are interested to actually bring pictures to share with one another and to place in scrapbooks. I would never have thought of scrapbooking as a peer support initiative...but by giving those in attendance this year a chance to provide input as to next year's agenda, I suspect it will be something very well received.
 
2.  Helga West
 We've found that letting survivors drive the support program helps to foster the greatest connection and openness. Asking survivors for their ideas on discussion, activities, etc. can be helpful in determining how to facilitate in a helpful way. You may want to look into some of the peer support models I mentioned in an earlier posting.
 
3.  S. Frogge
 You raise a very important issue. This is not a case of if we build it, they will come. They might not for the very reasons you raise! One of the things I've seen is that some of the most successful support groups peer support initiatives are those that didnt actually call themselves support groups. Potlucks, meet-and-greets, volunteer nights, special topic discussions, etc. seemed to attract more people and more enthusiastic participation than a support group even though in many cases the set up was pretty much the same.
 
 
What about training group leaders in a series of topics to bring up at groups that follow a format, and then helping the facilitator recognize when the person needs more help and be able to offer other resources?
 
1.  Helga West
 Knowing when to seek help is unique to every survivor, so conveying info to those who need help might help. You might find this information helpful - http://www.witnessjustice.org/health/knowingwhen.cfm
 
2.  S. Frogge
 Absolutely. As Helga has mentioned there are trauma-informed models already developed that can be used or modified as needed. I've done support groups and certainly following a model was easier in some respects for me as a facilitator. A good training will include handling referrals and people who are not appropriate for a peer support program. This also supports my position that peer support programs, although survivor driven, should be at least monitored by trained mental health professionals who, by virtue of their specialized training, have some skill in dealing with potential challenges.
 
3.  Helga West
 There are a few peer support, trauma-intervention models with related training that take the group through a series of progressive activities and many models also offer guidance regarding management of participants that need additional outside assistance and also the concern of vicarious trauma. Some of these models include: 1) Addiction and Trauma Recovery Integration Model (ATRIUM) (http://www.dustymiller.org), 2) the Essence of Being Real (http:www.sidran.org), and 3) Peer Companion Training (this one pays particular attention to cultural competency issues - http:www.bpsos.org/node/289). There is also a peer support model specifically designed for disasters that is currently being developed by the After the Crisis initiative (learn more at www.gainscenter.samhsa.gov/atc/peer_support.html).
 
 
What guidelines do you provide concerning peer support volunteers becoming friends with victims they assist and joining in activities together?
 
1.  Helga West
 The models mentioned earlier offer some information regarding this important issue in facilitating peer support.
 
2.  S. Frogge
 Oh my gosh...this is an issue that is raised constantly - especially in the context of grassroots programs. The survivor that you provide services for today may well be your board president in another year or two. Melissa Hook has codified many of the ethical principles that were actually developed by the field under the leadership of OVC in her book, Ethics in Victim Services. It does provide some excellent guidance but this is not a clear-cut issue.
 
 
How does the peer support model compare with something like Psychological First Aid (PFA)? In terms of a Crisis Counseling Program (CCP) such as Project Liberty that was established in New York after September 11th, what would be the difference in these approaches, if any?
 
1.  Helga West
 PFA is an evidence-informed modular approach for assisting people in the immediate aftermath of disaster and terrorism: to reduce initial distress, and to foster short and long-term adaptive functioning. It is for use by mental health specialists including first responders, incident command systems, primary and emergency health care providers, school crisis response teams, and faith-based organizations. To my knowledge, it typically is not used in peer settings. Peer support is longer-term and helps to overcome some of the barriers like stigma and discrimination. Project Liberty offered a Disaster Mental Health Toolkit (see http://www.projectliberty.state.ny.us/educational.htm)that was very effective in the aftermath of 9-11.
 
2.  S. Frogge
 Good question! I'm not extremely familiar with Project Liberty but I do know that the model reflects many of the prefered practices that Helga and I have raised. Project Liberty is flexible enough to be applied to a variety of community issues and needs and allows for survivor input in terms of developing community-specific support.
 
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