Program Profile: Enhancing Resiliency Amongst Student Experiencing Stress (ERASE-Stress) in Israel

This intervention is a universal, school-based intervention for Jewish-Israeli students who are exposed to the ongoing violence of the Israeli–Palestinian conflict. The program aims to reduce participants’ posttraumatic stress symptoms. The program is rated Promising. The program was shown to be statistically significant in reducing PTSD severity, functional problems, anxiety, and somatic complaints.

A Promising rating implies that implementing the program may result in the intended outcome(s).

A Promising rating implies that implementing the program may result in the intended outcome(s).

Program Goals/ Target Population

Enhancing Resiliency Amongst Students Experiencing Stress [ERASE-Stress (ES)] is a 12-session program that was designed to reduce symptoms of posttraumatic stress disorder (PTSD), such as anxiety, somatic complaints, and functional problems, among seventh- and eighth-grade students who experience ongoing war-related violence. For the first study in this review, which evaluated the original ES program, the target population of the program included male, Jewish-Israeli students who were exposed to violence and acts of terror associated with the Israeli–Palestinian conflict and suffered from PTSD symptomatology (Gelkopf and Berger 2009).

Extended ERASE-Stress (EES) is an extended version of the ES program, which was intended to accommodate the teachers who delivered the original program who felt they needed more time to spend on each of the session modules. The extended version contains four additional sessions, expanding the 12-session program to a 16-session program. The target population for the second study in this review, which evaluated the EES program, comprised both male and female Jewish-Israeli students who were exposed to violence and acts of terror associated with the Israeli–Palestinian conflict and suffered from PTSD symptomatology (Berger et al. 2012).

Services Provided

ES consists of 12 and EES consists of 16 classroom sessions. The sessions last 90 minutes each and are conducted weekly by students’ homeroom teachers. The sessions focus on developing students’ coping skills and use cognitive–behavioral, somatic, and narrative stress-reduction techniques in combination with mindfulness, compassion-cultivating strategies, and prosocial orientation. 

Each meeting contains a warm-up exercise, experiential work, psychoeducational knowledge, a contemplative practice, learning a skill, and homework assignments. Parental involvement is incorporated by inviting parents to school for two sessions and motivating them to help their children with homework.

The original ES program includes the following sessions:

• Session 1 – Getting Started: Introducing group leaders, participants, and the program; presenting an overview of the program and setting ground rules; and describing the stress continuum in an interactive format.
• Session 2 – Strengthening Your Personal Resources: Identifying students’ personal resource profiles and providing them with new coping skills, so that they learn how to enhance their coping repertoire through a resourcing model (the M-O-S-T B-A-S-I-C model).
• Session 3 - Inhabiting Your Body: Learning the role of the body and its function during stress, becoming aware of somatic reactions pertaining to stress, and developing sensory-motor strategies to control the body during stressful situations.
• Session 4 – Knowing Your Feelings: Enhancing students’ emotional awareness; identifying and clarifying feelings, and becoming aware of the connections between sensations and feelings; and learning various modalities to express feelings.
• Session 5 – Controlling Your Emotions with Your Mind: Exploring relationships among sensations, thoughts, and feelings; and learning cognitive coping skills.
• Session 6 - Dealing with Fears: Normalizing fears and learning new ways to deal with them, and creating an inner sense of safety.
• Session 7 – Dealing with Anger and Rage: Confronting anger and rage and expressing them in a controlled manner, and learning and practicing assertiveness.
• Session 8 – Coping with Grief and Loss: Exploring grief and loss experiences and providing an opportunity to express these feelings within a safe context.
• Session 9 – Building a Social Shield: Exploring social needs and ways to strengthen support systems, learning to ask for help, and becoming more empathic.
• Session 10 – Boosting Your Self Esteem: Exploring self-image and the way it impacts coping styles, and learning to accept deficits and acknowledge strengths.
• Session 11 – Turning Crisis into an Opportunity: Becoming aware of negative thought patterns and learning how to reframe them positively.
• Session 12 –Seeking a Better Future: Exploring future dreams and fantasies, learning how to build a plan toward achieving them, reviewing the program, and providing an opportunity for closure.

The EES program added additional sessions to the original ES program. EES uses the same 12 sessions described above, and added four additional sessions, including a session on affect-modulation strategies (where students learn strategies and techniques to control the body during stressful situations); a session focused on self-affirmations (where students practice strategies and techniques learned in Session 6); a practice session on combating fears with behavioral and cognitive strategies; and a session that focuses on learning more social skills (where students explore their “social map” and work toward redesigning their relationships according to their wishes). In addition, in the EES program, religious and spiritual practices were further emphasized, using biblical stories, meditative prayers, and spiritual narratives.  

Program Theory

The program is based on the perspective that strengthening children’s coping skills and developing their resiliency strategies helps them deal better with stressful situations. Further, for youths who are exposed to traumatic conditions, research suggests the negative psychological impact may not be short-lived (Dyregrov, Gjestad, and Raundalen 2002). Therefore, the ES and EES programs were designed to support youths who live under conditions of war and terrorism, to enhance their resiliency and reduce their risk of developing long-term PTSD symptoms (Gelkopf and Berger 2009).

Study

Gelkopf and Berger (2009) used a quasi-experimental design to measure the effectiveness of the Enhancing Resiliency Amongst Students Experiencing Stress [ERASE-Stress (ES)] program. The program is a universal, school-based intervention to help reduce posttraumatic symptomatology, depression, and somatic symptoms and functional problems among seventh and eighth graders. The study was conducted in an all-male, religious public secondary school located in Beersheba, the largest southern city in Israel, from January to March 2006. The study location had been at the center of several terror attacks since the year 2000.

The study consisted of 114 seventh and eighth graders who were randomly assigned to the ES intervention or the wait-list (WL) control group. A total of five classes were used for the study, and each class consisted of 28 to 31 children. One of the seventh-grade classes was assigned to the ES group and one class to the WL group. Two of the eighth-grade classes were assigned to the ES group and one to the WL group. Assignment to the treatment and control groups was done randomly by coin flip. The treatment group (n = 58) received 12, 90-minute classroom sessions on a weekly basis. Children received homework review, warm-up introduction, experiential exercises, psychoeducational material, skill learning, and a closure exercise. The topics included dealing with stress, anger, rage, and fear, and coping mechanisms.

In terms of students’ exposure to terror attacks, 3 students (2.8 percent) reported that they had planned to be in the place where a terrorist attack had occurred; 19 (9.3 percent) reported having been in the location just before or just after an attack; 13 (12.1 percent) reported having been close to a terrorist attack when one occurred; 2 (1.9 percent) reported having been present during an attack; 14 (13.1 percent) reported having known someone who was hurt in an attack; 11 (10.3 percent) reported having known someone who died in a terrorist incident; and none reported being personally hurt during a terrorist attack. In other words, 25.3 percent of the students reported personal exposure, 24.2 percent reported near-miss exposure, and 50.5 percent reported no exposure of any kind. There were no differences in age and exposure variables between groups.

Outcomes were measured before and 3 months following the intervention. The study authors used a number of questionnaires to measure exposure to terrorism, posttraumatic stress disorder (PTSD) symptomatology, functional impairment, somatic complaints, and fear. Exposure levels were measured using an objective and subjective exposure questionnaire (Pat-Horenczyk 2007). PTSD levels were assessed using the 17-item, self-report UCLA PTSD Index for DSM-IV Child Version (Rodriguez et al. 1999). Functional impairment was assessed using the 7-item Functional Impairment Questionnaire, which is based on the Disc Predictive Scales (DPS). Somatic complaints related to terrorism were assessed using five categorical items based on the DPS. To assess depression, the Brief Beck Depression Inventory (Beck and Beck 1972) was used. The study authors used an ANOVA mix design to assess the treatment effect. There were no subgroup analyses conducted. 

Study

Berger and colleagues (2012) conducted a randomized controlled trial to examine the effectiveness of Extended ERASE-Stress (EES) program on measures of PTSD severity, anxiety, somatic complaints, and function problems among Jewish-Israeli seventh and eighth graders. The study was conducted in a Jewish public secondary school in Sderot, Israel. Sderot is a multiethnic development town in southern Israel and has been subjected to ongoing and intense war-related threats, including daily rocket attacks and mortar shelling from the adjacent Gaza region.

The intervention was administered from the last week of November 2007 to the middle of March 2008. The study sample consisted of 154 students, with 107 students in the treatment group and 47 students in the comparison group. Assignment to the treatment or comparison group was done by picking paper slips out of a bag. Four of the six seventh- and eighth- grade classes (two in each grade level) were assigned to the treatment group, and the other two (one in each grade level) were assigned to the comparison group. Both groups were from lower-middle-class socioeconomic backgrounds. The age range for the entire sample was between 11 and 13 years. Most of the students had been exposed to rocket attacks. No statistically significant differences were observed between the control and treatment groups prior to the intervention program.

The treatment group received the 16-week, EES intervention for 90 minutes each week, with the topics focused on stress reduction, mindfulness, and compassion, or on prosocial behavior. The version of the program implemented focused on religious and spiritual practices. The average age of the EES group was 12.9 years, and the majority (56 percent) were female.

Individuals in the comparison group were assigned to the wait- list (WL) condition. The average age of the comparison group was 12.8 years, and almost half (48.9 percent) were female. Comparing the EES and control groups, the study authors found no statistically significant differences for gender, age, level of exposure, and posttraumatic symptoms and related distress.

Outcomes were measured prior to and 1 month following the intervention. The posttraumatic symptoms outcome was assessed using the 17-item basic version of the UCLA PTSD Index for DSM-IV Child Version (Goenjian et al. 1995; Rodriguez et al. 1999). Functional problems outcomes were measured using four items of the Child Diagnostic Interview Schedule (Lucas et al. 2001). This measure asked participants to indicate whether they had experienced functional impairment due to terrorist attacks in social relationships, school performance, family relationships, and afterschool activities. Somatic complaint outcomes were assessed using six items from the DISC Predictive Scales (Lucas et al. 2001) and included questions regarding physiological stress reactions, stomach and respiratory problems, headaches, sleeping problems, and excessive eating or appetite loss. Generalized anxiety was assessed through eight items, and separation anxiety assessed through seven items from the Screen for Child Anxiety-Related Emotional Disorders Inventory (Birmaher et al. 1997). A repeated measures analysis of variance was used to analyze the results of the outcome measures. There were no subgroup analyses conducted.

The ERASE-Stress (ES) program demonstrated promising effects within the context of political violence, terrorism, and domestic violence and has also been applied to youths in the aftermath of natural disasters (i.e., earthquakes and tsunami). The program has been translated into 12 languages and implemented in 14 countries. The 12 sessions are manualized; however, components of the program may be adapted based on cultural context (Gelkopf and Berger 2009).

The Extended ERASE-Stress (EES) teacher training comprised eight, 3-hour sessions conducted by two experienced EES therapists. The teachers underwent a teaching-oriented experiential version of the original intervention. Additionally, classroom simulations were conducted throughout the training, in which dissemination techniques were practiced. During the implementation of the program, the teachers received six, 2-hour group supervision sessions from the trainers.

Fidelity to the intervention was monitored through teacher observations, with each teacher being observed four times. Teacher adherence to the program and training manual was measured on how 1) the teacher adhered to the topics, 2) the exercises were followed, 3) the class members participated actively in the session, 4) the homework was discussed, and 5) the philosophical orientation of the manual was upheld. Ratings of 0 to 5 were used, with 5 being the highest level of fidelity. All rating scores were either 4 or 5 on all domains and in all classes, confirming a high fidelity to the program manual (Berger et al. 2012).  

These sources were used in the development of the program profile:

These sources were used in the development of the program profile:

Beck, Aaron T., and Roy W. Beck. 1972. "Screening Depressed Patients in Family Practice." Postgraduate Medicine 52(6): 81–85.

Berger, Rony. 2002. An Ecological Model for Community-Based Intervention During Traumatic Stress: A Manual. Tel Aviv, Israel: Natal, Trauma Center for Victims of Terror and War.

Berger, Rony., and N. Manasra. 2005. Enhancing Resiliency Among Students Experiencing Stress (ERASE-STRESS CHERISH): A Manual for Teachers. Tel Aviv, Israel: Natal, Trauma Center for Victims of Terror and War.

Berger, Rony, Ruth Pat-Horenczyk, and Marc Gelkopf. 2007. “School-Based Intervention for Prevention and Treatment of Elementary-Students’ Terror-Related Distress in Israel: A Quasi-Randomized Controlled Trial.” Journal of Traumatic Stress 20:541–551.

Birmaher, Boris, Suneeta Khetarpal, David Brent, Marlane Cully, Lisa Balach, Joan Kaufman, and Sandra Mckenzie Neer. 1997. “The Screen for Child Anxiety Related Emotional Disorders (SCARED): Scale Construction and Psychometric Characteristics.” Journal of the American Academy of Child & Adolescent Psychiatry (36):545–53. 

Dyregrov, Atle, Rolf Gjestad, and Magne Raundalen. 2002. “Children Exposed to Warfare: A Longitudinal Study.” Journal of Traumatic Stress 15:59–68.

Gelkopf, Marc, and Rony Berger. 2009. “A School-Based, Teacher-Mediated Prevention Program (ERASE-Stress) for Reducing Terror-Related Traumatic Reactions in Israeli Youth: A Quasi-Randomized Controlled Trial.” The Journal of Child Psychology and Psychiatry (50)8:962–71.

Goenjian, Armen K., Robert S. Pynoos, Alan M. Steinberg, Louis M. Najarian, Joan R. Asarnow, Ida Karayan, Micheline Ghurabi, and Lynn A. Fairbanks. 1995. “Psychiatric Co-Morbidity in Children After the 1988 Earthquake in Armenia.” Journal of the American Academy of Child & Adolescent Psychiatry (34):1174–84.

Pat-Horenczyk, Ruth, Osnat Peled, Ayala Daie, Robert Abramovitz, Daniel Brom, and Claude M. Chemtob. 2007. "Adolescent Exposure to Recurrent Terrorism in Israel: Posttraumatic Distress and Functional Impairment." American Journal of Orthopsychiatry 77(1):76–85.

Rodriguez, Ned, Alan M. Steinberg, and Robert S. Pynoos. 1999. UCLA PTSD Index for DSM IV Instrument Information: Child Version, Parent Version, Adolescent Version. Los Angeles, Calif.: UCLA Trauma Psychiatry Services.