Turkey

UN/UNICEF-ITC as Prime Subcontractors: Mamara Earthquake-Turkey 1999-2004

Psychosocial Support – Children and Adults-Turkey

ITC (formerly known as the Center for Trauma Psychology) in partnership with the Center for Crisis Psychology in Bergen, Norway were deployed to manage the psychosocial response to the Mamara earthquakes in Turkey in 1999. ITC worked with the Ministry of National Education (MONE) to install the largest development assistance program for youth ever undertaken post earthquake between 1999 and 2004 with the CBI reaching over 44,000 youth and 10,000 adults and changing the core value and curriculum dissemination of the Turkish school system and public health system.

The following text is from the UNICEF report. The full report is available athttp://www.unicef.org/turkey/lf/ep1d.html and UCDR has attached a PDF of the report as well.

During the course of field assessments following the first tremor at Gölcük, UNICEF psycho-social consultants interviewed many children and their families. The children displayed a number of post-traumatic symptoms, their parents reporting that they were unable to close their eyes and sleep, or that they were unable to remain asleep, fearful of a recurrence of the disaster. Other typical reactions included the recurrence of intrusive, distressing thoughts and images of the disaster, numbness, a sense of detachment, general irritability and nervousness. Some parents reported feelings of anger towards their children. Grief was profound among the many who had been bereaved. Such reactions can be overwhelming and, if not dealt with, may cause long-term psychological problems. It was plainly apparent that a psycho-social intervention programme was required to meet the needs of the children and that their parents and those who represented points of reference in the children’s lives, such as teachers, should be included within the scope of the programme. In addition to school teachers, Turkey has a number of school counsellors per province who are co-ordinated by the General Directorate of Special Education and Counselling Services (GDSECS), at central level, and the provincial Guidance and Research Centres (GRCs) ofMONE. Consultants had to design a project that would be effective in reaching up to a quarter of a million children — a challenge not only by dint of the number of children involved but also because of the intrinsic problem of their distribution over a large geographical area. It was decided to adopt the cascade model of training as being the fastest, most efficient course to take in implementing the project. A core group of experts would train a larger group of counsellors who would then debrief the teachers who would subsequently offer the intervention to the children.

Acting on the findings of the field mission, UNICEF initiated an emergency response programme with four main components; Health and Nutrition; Water and Environmental Sanitation; Education and the Psycho-social School Project. MONE had plans for a psycho-social school programme of their own at the time, immediately established a close relationship with UNICEF for the development and implementation of the fourth component.

At the beginning of September, consultants from the Center for Crisis Psychology in Bergen, Norway held the first seminar on trauma psychology and debriefing techniques in Ankara (ITC was deployed to structure and assess seminars and develop culturally effective methods of debriefings or coping groups). Eighty-five academicians from the universities of Ankara, Gazi, Hacettepe and Kocaeli attended along with executives from MONE. ( ITC was the keynote speaker at these series.) Sessions lasted up to three hours and the meetings were also used as a medium to identify those teachers who needed extra psychological support. Consultations with local authorities in the Marmara region followed and, with the supervision and support ofMONE and UNICEF, a National Expert Team (NET) was formed. The NET consisted of sixty-two counsellors, psychologists and psychiatrists, divided into project groups of eight, each group being responsible for the support of an affected province.

Less Fearful, More Active: The Psycho-social School Project

Cascade model for the training and debriefing of counsellors. © UNICEF Turkey 2001

Strategy

A key point of the project was to strengthen both governmental and non-governmental resources at local and national levels. This would be achieved through a programme of continuous and gradually more intensive training by international authorities on trauma psychology. Eventually, selected school counsellors and members of NET would become trainers in different components of the programme. To this end, the psychology Department at Ankara University designed a pre- and post-evaluation study and reported on the project in the Spring of 2001.

The first essential step, required the setting up of a network of facilitators: the Teachers Debriefing (TD) would show teachers how to cope better themselves, thus helping to re-establish educational/support activities for the children they work with.

The second step, Classroom Based Intervention (CBI) would be implemented by school counsellors using expressive-behavioural therapy methods to help the children cope with the after effects of the disaster.

The third step, seven sessions of Group Counselling (GC) would follow up on CBI in the case of those children who would be identified as being moderately-to-severely traumatised.

A fourth component, Psycho-education (PE), was planned as seven sessions to be implemented in classrooms, reaching out to children, their teachers and parents who could not be involved in the more specialised activities.

Originally planned to run for six months, from September 1999 to February 2000, it was decided after the first term to extend the project to June. Following an evaluation in June, it was decided to extend it for a further school year.

Activities For Children And Parents

While the initial Teachers’ Debriefing phase was in progress, the second, more complex, phase was planned in three parallel components which aimed to reach the children through a comprehensive range of services. The primary component, referred to as the Classroom Based Intervention (CBI), was designed to reach children directly in the classroom. The second component, Group Counselling (GC) complemented the first and was designed to provide further in-depth support to the more seriously affected children identified during the CBI sessions. The third component, known as Psycho-education (PE) encompassed teachers and parents as well the children themselves, providing basic training about the normal reactions for those who have lived through an abnormal event.

Classroom Based Intervention

Conceived and developed at ITC (formerly the Boston Trauma Centre) specifically for the children who survived the Turkish earthquakes, Classroom Based Intervention (CBI) was implemented through school counsellors trained in CBI techniques by a team of ITC trauma psychologists from Boston. Two three-day training sessions were held between the 6th and 11th of March for school counsellors where a total of three hundred and twenty attended.

We were sleeping when the earthquake struck and as soon as we felt the tremors we ran from the house. My father went to help the neighbours and I went with him. As I watched him trying to help a man from under the rubble, I thought I heard a deep voice crying for help from under some rubble nearby.

I was shocked and stunned. I couldn’t speak. I wasn’t able to tell the others that I had heard a voice beneath the rubble. After that, I couldn’t get over the feeling of guilt. I kept thinking that I might have saved that man. But, through CBI, I have been able to understand that my reaction was normal and finally to overcome this feeling of guilt.

G (boy) 7th grade, Orhangazi Primary School, Sakarya

The primary objectives of the CBI were to stabilise traumatic stress responses, to facilitate normal school activities, to engage the children in creative activities which would enlighten their perception of traumatic experiences (thereby helping them to cope more efficiently) and to show them that such experiences can be safely studied, expressed and understood by trusted care-taking adults within the classroom context.

At Kaynaşlı Primary School, in Düzce, a school counsellor was taking the class for What have I lost and what has changed? One girl had drawn a female figure which she said was her mother who had lost her life during the earthquake. She said she wanted to share her picture. Then she began to cry. Soon the rest of the children were in tears.

The counsellor managed to collect herself and said I believe your mother is an angel now, above us, and that she is watching down on you.

This calmed the girl somewhat but the tears continued to flow. She said that she hadn’t even been able to say ‘goodbye’ to her mother. At this point, the counsellor asked her if she would like to say ‘goodbye’ now. The girl nodded ‘yes’ and the counsellor asked her whether or not she would like to do so with her friends. Again, the girl nodded ‘yes’. The counsellor invited the whole class to close their eyes and to imagine the girl’s mother.

Altogether they said ‘goodbye’ to her. During the course of the next class, the counsellor noticed that the same girl was drawing a bicycle and she asked her about it. The girl said it was her bicycle which she had lost during the earthquake — a healthy sign that she had completed the process of grieving for her mother and had begun to grieve for the other things she had lost.

From the first CBI implementation, Spring 2000

Where MONE had been cautious to make changes to the national curriculum in the past, many alterations and adjustments were made, often in the space of a day, in order to facilitate urgent need for the intervention. The training manual and intervention methods were refined during the Winter recess to suit the Turkish context and, afterwards, at a meeting in Ankara, MONE and UNICEF finalised arrangements with NET and established the future course of the programme.

The Structure Of The CBI Sessions

The programme was structured so that the children were guided step by step through each session by a routine of three stages: opening circle, central activities and games and the closing circle. An important feature of the sessions was the single voice principle whereby no one, child or counsellor, could be interrupted when speaking. Neither was laughter or any other distracting behaviour permitted to interfere when a participant spoke. Through this simple discipline, the children would learn self-control, self-confidence and self-assertion, to externalise their feelings and develop mutual respect for one another within the group.With the resumption of school activities, it became rapidly apparent that parents and teachers had become over-indulgent towards the children, perhaps compensating for the disturbance of the earthquakes. To start with, there was chaos in the classrooms. School counsellors had to learn to communicate with their charges more effectively. One counsellor, working with the 7th and 8th grades noted that his pupils had great difficulty obeying the rules:

I could not make myself heard. However, in the CBI we kept reminding them of the rules. We never raised our voices and simply held our patience. Eventually the children settled down. They became less aggressive. Where they used to get together in cliques and make fun of the activities, with time, they learned to trust and now they generally participate without making fun.

Evaluating Classroom Based Intervention

Before and after the intervention, a survey of symptom measures was collected from six hundred and forty-four students above the age of twelve and seven hundred and eighty-nine parents of children below that age. Comparisons were made between students participating in the CBI and those of a similar age in a Wait-List Comparison Group (WL). It was generally understood by all parties concerned that students in both groups identified as being at risk should be referred for treatment immediately. Although the authorities were asked not to introduce systematic or formal psycho-social interventions in any of the WL schools, it was impossible to control interventions delivered by teachers of their own accord or delivered outside of school.

There was the very interesting case of a boy in primary school at Adapazarı who had been withdrawn and generally reluctant to take play with his classmates even before the earthquake. When CBI sessions began at his school, his attitude was not surprisingly to remain disinterested, unwilling to join in the group activities, despite efforts to engage him with the others.

The counsellor was advised to leave him be and allow him the space to become more relaxed about what was happening. After two sessions, the counsellor and also — it should be said — his classmates were pleasantly surprised to observe him joining hands with others in the circle.

From that day, he has ceased to be withdrawn and continues to take part in all classroom activities. It would appear that, in this little boy’s case, the CBI reached further beyond the effects of the earthquake to mitigate a more deep-rooted problem.
From the first CBI implementation, Autumn 2000

Activities commenced in the first week of April with the collection of pre-intervention symptom measures. The programme utilised many proven methods of processing the often fragmented memories and physical fears surrounding a traumatic event. Sessions were spread over a period of six weeks and utilised movement, silent story telling, music therapy, art therapy and highly structured confidence building games to encourage the children to express their fears. The objective was to rebuild their self-esteem and trust in the environment. Each week would feature a specific theme such as: information; safety and stabilisation; awareness; control and self-esteem; thoughts and reactions during and after the earthquake; resource identification; coping skills; resource installation and future planning. A number of props such as beach balls, fabric dyes, frisbees, paints and an innovative particoloured parachute were used to enhance activities, often to musical accompaniment.

Post-intervention symptom measures were collected simultaneously one week after the completion of the last CBI session. Comparisons of the students’ symptoms before and after the CBI showed that the programme was most effective in reducing anxiety, depression and the physical side-effects of trauma in the more distressed children. Distressing symptom clusters such as these, common to the survivors of traumatic events, are damaging to the everyday functioning of the child and therefore their reduction can only be viewed in a positive light. The programme seemed to have had little effect on less distressed adolescents who may have had little room to improve within the brief span of the study. Neither did the programme have any obvious effect on the symptoms of post-traumatic stress disorder (PTSD) although it should be emphasised that it is extremely unlikely counsellors could address PTSD in a classroom setting in any way that would be helpful or that the children would accept. That said, results of the study suggest that CBI would be best targeted at adolescents with higher levels of PTSD. When used as a first step towards post-trauma normalisation, the intervention can reduce the impact of PTSD on other aspects of their emotional functioning.

I had been very happy before the earthquake. Then I lost my brother, my sister, my aunt, my uncle, my grandmother and cousins when it happened. I felt that my life was over.

Then you came and showed me how to love life all over again.
GA (girl) 6a Cumhuriyet Primary School, Spring 2000

Results were apparent by the second or third session, and by the end of the sixth week, children were showing signs of improvement and an eagerness to take part in more sessions. Counsellors reported reduced externalisation of fear, less aggressive behaviour increased attention and a general improvement in performance at school. There were significant reductions in disturbances of sleep, digestive problems and elimination, improved peer and adult relationships, self care and play behaviour, a sense of safety, a sense of self-control and a sense of the future. Preliminary results from the evaluation study indicated significant changes in those children who received psycho-social intervention during the previous school year.

In many cases, children said they had learned to associate certain problems with the disaster and to view their reactions to them as normal. They were beginning to develop friendships, to listen to each other, to share their problems and to look for solutions to those problems together. One child observed that:

Following the rules has taught me to be less fearful, more active.

Between April 2000 and June 2001, twenty-eight thousand children took part in the CBI and five thousand parents were reached through follow-up meetings.