This psycho-social-educational manual is a result of the founders’ combined years of direct experience of working with child survivors of war and disaster, and their teachers and carers in diverse cultures. In May 1998, six people, Patrick Smith, Atle Dyregrov, William Yule, Sean Perrin, Rolf Gjestad and Leila Gupta, who had been working in former Yugoslavia and other war areas were brought together. They brainstormed what was known about effective-evidence-based methods to boost children’s capacity to cope with the psychological aftermath of war. The aim was to produce a manual that could be used with minimal training and supervision by people responsible for the well-being of children affected by war and disasters.
The aim was not to “cure” symptoms but rather to give children better coping strategies so that they would feel sufficiently more in control of their reactions and so be able to benefit from the support of their families and the opportunities available in schools. This resulted in the Teaching Recovery Techniques (TRT).
TRT was developed by Patrick Smith, Atle Dyregrov, William Yule in collaboration with Leila Gupta, Sean Perrin and Rolf Gjerstad. The accompanying workbook was developed by colleagues Ayuse Yalin, Bergin Levent and Nazan Kaya in association with UNICEF following the earthquake in Turkey in 1999 to accompany the war manual. It was intended as a thorough guide and easy reference guide.
The manual teaches children skills which help them cope with difficulties and prepare for possible future difficulties, and is designed to prevent the need for later treatment. Children who have learned and practised the techniques will be less likely to need specialist treatment services in the future.
TRT have been designed to be used with children aged 8 years and older, and work best with groups of less than 15 children. It works across cultures.
To date, TRT is available in two versions: war and disaster. Both manuals are accompanied by a workbook.
TRT versions are available in
- Bahasa Malaysian
- S American Spanish
How it works
The programme’s consists of five sessions (1 ½ hour long). An additional section contains guidelines for running two parallel parent sessions. An essential element of the package is the meetings for parents to explain the intervention and give suggestions on how to help their children in the aftermath of a traumatic incident.
The sessions help children deal with intrusive thoughts and feelings (bad memories, nightmares and flashbacks), childrens’ arousal (their difficulties in relaxing, concentrating, and sleeping ie) and avoidance (childrens’ fears, and difficulties in facing up to reminders of the disaster). Children are taken through various warm-up exercises and helped to adopt a problem-solving and group-sharing approach to these difficulties. They practice various imagery techniques to demonstrate that they can gain some control over the intrusive images that may have troubled them. They are introduced to distraction techniques, so-called dual attention techniques (similar to some EMDR techniques) and how to manage frightening, repetitive dreams.
Children learn how to identify their reactions and are taught how to relax at will. They are encouraged to make use of their own techniques to induce relaxation and where possible bolster these by breathing exercises and muscle relaxation. They are helped to schedule their activities, to look at better sleep patterns and develop and practice coping self-statements. They are taught to conquer their fear and shown how they can approach and control painful reminders and situations they fear. The children are also encouraged to draw, write and talk about the incidents and above all to look to the future rather than the past (avoidance).
Results so far
Teaching Recovery Techniques manual was first used in 1999 in Greece and Turkey following the big earthquake of 1999. Working in a child mental health service in Athens, Giannopolou demonstrated that the techniques were easy to use with small groups of children and that the measures showed significant improvement (Giannopolou et al 2006).
In Turkey, it was first tried out with about 300 children and then rolled out to help many others. Unfortunately, to date the results have not been formally published although the data we have seen are again very positive.
The most exciting use of the manual has been in Iran, following the earthquake in Bam, Iran in 2003. The Iranian Director of Mental Health, Dr Yasamy, had asked for help after an earlier, less devastating earthquake, and through UNICEF had arranged for training in the manual through colleagues from the Center for Crisis Psychology. When the Bam earthquake happened, they trained a further 400 psychologists and psychiatrists, and 1,380 teachers to use the manual and a variant of it with over 42,500 survivors in the first 7 months after the earthquake. They measured distress before and after the intervention and found that around 85% of survivors greatly benefited. This is currently being written up for publication but must rank as one of the largest mental health interventions in history, and the manual was at the centre of it.
In addition to this it has been used following the earthquake in China in 2008 and in various other disaster and war situations, including the 2004 tsunami and in Sri Lanka during the warfare there.
The manual has also formed the basis for interventions with young refugees seeking asylum in the UK. Sessions in schools helped reduce the adolescents’ distress, although the effects were not as marked as in the post-disaster studies, probably because of the complexities of the pupils’ lives and the uncertainty surrounding their future (Ehntholt et al 2005).
In Finland Kirsti Pekkarinen, Raija-Leena Punamäki and Soili Poijula have used it with a group of boys who were sexually abused by the same perpetrator. The results show that there was a significant reduction of posttraumatic symptoms when measured by the Children’s Impact of Event Scale (CRIES-13).
Format of training
Depending on the level of prior experience, we use different training formats. For those without a formal mental heath education we suggest a three day training (four days to secure proper follow-up). The training format is found here. For those with a mental health background we have a two-day format. This can be found here. We expect that a stronger focus on the parent/caretaker will make us move to a three-day training in the future.