Program Profile: Enhancing Resiliency Amongst Students Experiencing Stress-Prosocial (ERASE-Stress–Prosocial) in Israel

This is a universal, school-based intervention for Jewish-Israeli students who are exposed to the ongoing Israeli–Palestinian conflict. It combines the original ERASE-Stress program with six additional modules focused on topics related to prosocial orientation, and aims to reduce PTSD, enhance resiliency, and develop prosocial skills. The program is rated Promising. The program was shown to statistically significant reduce 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–Prosocial (ERASE-Stress–Prosocial [ESPS]) is designed to reduce symptoms of posttraumatic stress disorder (PTSD), including anxiety, somatic complaints, and functional problems, among students in third through eighth grades who are experiencing ongoing war-related violence. ESPS is a skill-oriented, teacher-delivered program that uses cognitive–behavioral, somatic, and narrative stress-reduction strategies in combination with mindfulness, compassion-cultivating strategies, and prosocial orientation. The target population includes Jewish-Israeli students who are exposed to violence and acts of terror associated with the Israeli–Palestinian conflict and who suffer from PTSD symptomatology. 

The program is a combination of the original ERASE-Stress (ES) program, with six additional prosocial-orientation modules that focus on perspective taking, empathy training, and dealing with stereotyping and prejudice. ESPS aims not only to reduce youths’ stress and enhance resiliency, but also to help them develop prosocial skills.

Services Provided

ESPS consists of 16 classroom sessions, 90 minutes each, which are conducted weekly by students’ homeroom teachers. The ESPS intervention incorporates 10 sessions from the original ES program (Gelkopf and Berger 2009). View the profile and rating for the original ES program.

In addition, ESPS also includes six sessions based on the Pro-Social and Civil Virtue program (Berger and Zimbardo 2009), which includes topics such as exploring group biases, identifying stereotypes and prejudices toward the other, cultivating independent and critical thinking, and developing prosocial orientation. Contemplative practices based on mindful self-compassion are also incorporated into ESPS. 

Topics covered in each of the ESPS sessions are as follows:

Session 1—Getting Started: Presenting an overview of the program and setting ground rules for the students. Describing the “stress continuum” (from daily stress to traumatic stress) and the various emotional, cognitive, and behavioral impacts of these stressors. Students learn the function of these symptoms and how to normalize them (same as Session 1 from ES). 

Session 2—Resourcing: Identifying students’ personal resource profiles and providing them with new coping skills. Students learn how to enhance their coping repertoire by identifying seven domains of resources, including sensory-motor, spiritual–ideological, affective, social, imagery, cognitive, and behavioral (same as Session 2 from ES).

Session 3—Empowering Your Body: Learning the role of the body and its function during stress. Students develop awareness of somatic reactions pertaining to stress by using guided imagery and somatic-experiencing exercises. They learn to develop sensory-motor strategies to control their bodies during stressful situations (same as Session 3 from ES).

Session 4—Giving Freedom to Your Feelings: Enhancing students’ emotional awareness, identifying and clarifying feelings, and becoming aware of the connections between sensations and feelings (based on the BEST model). Students learn different modalities to express feelings (same as Session 4 from ES). 

Session 5—Controlling Your Feelings With Your Mind: Exploring relationships among sensations, feelings, and thoughts. Students learn cognitive–behavioral techniques to modify negative, unproductive, and rigid thought patterns through techniques such as challenging automatic thoughts and distractions, thought stopping, and flexing thoughts (same as Session 5 from ES). 

Session 6—Developing Empathy Toward Yourself and Others: Exploring the complexity and richness of the self and the similarities and differences between the self and others. Students learn to accept and respect their difficulties and limitations and those of others. This work is based on practices borrowed from compassion-focused therapy and contemplative self-compassion exercises. 

Session 7—Cultivating Your Independent and Critical Thinking: Becoming aware of injustice and forming independent opinions. Students are introduced to a story about a family that was mistreated by its community and explore, via role-playing, how to productively challenge those who mistreated the family. They learn problem-solving skills and practice productive challenging. 

Session 8—Knowing Your Group Biases and Prejudices: Exploring the ways individuals form attitudes and identifying stereotypes and prejudices toward others. This is done by inviting students to relate stories where they either experienced prejudicial attitudes from peers or exhibited prejudicial attitudes toward others. Students learn to adopt an open attitude and to develop tolerance toward others. 

Session 9—Overcoming Your Fears: Normalizing fears and exploring new ways to deal with them by using behavioral strategies such desensitization and mindfulness. Students practice fear-management techniques by using imagery techniques (same as Session 6 from ES).

Session 10—Dealing With Your Anger and Rage: Confronting anger and rage and expressing them in a controlled manner. Students learn to identify their anger somatically and to express it through body-oriented, expressive exercises. They acquire assertiveness skills and practice them through role-playing situations (same as Session 7 from ES). 

Session 11—Coping With Your Grief and Loss: Exploring and normalizing grief and loss reactions. Providing students with an opportunity to express feelings of sadness and grief and create an inner place of safety (same as Session 8 from ES). 

Session 12—Boosting Your Self-Esteem: Exploring students’ self-image and the way it impacts their coping styles through body drawing. Students learn to accept deficits, acknowledge strengths, and practice self-compassion strategies (same as Session 10 from ES).

Session 13—Building Your Social Shield: Exploring students’ social needs and interpersonal relationships by creating a social map that represents their current social network and the social network that they desire. Students learn how to ask for help and how to become sensitive to the needs of others (same as Session 9 from ES).

Session 14—Developing a Prosocial Orientation: Developing individual accountability, exploring civic engagement, learning interpersonal skills, and practicing helping behaviors. 

Session 15—From Darkness to Light–Developing Hopefulness: Exploring hopes and dreams and setting realistic future goals. Through “Future Perspective Imagery,” students project a class reunion in the future. They learn how to develop a positive perspective and identify and overcome obstacles on their way to achieving their goals. 

Session 16—Putting It All Together: Reviewing briefly the skills learned in the program and identifying difficulties in applying them. This session ends with a closure ritual. that symbolizes the entire process. Students are encouraged to practice the new skills they learned in class and at home and to implement their pro-social projects.

Program Theory

The program is based on the idea 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, the negative psychological impact may not be short-lived (Dyregrov, Gjestad, and Raundalen 2002). In addition, the program supports the idea that for children to become more accepting and less prejudicial toward others, they need to develop empathy and compassion for self and others (Gilbert 2010).

Study

Berger and colleagues (2016) conducted a randomized controlled trial to examine the impact of Enhancing Resiliency Amongst Students Experiencing Stress–Prosocial (ERASE-Stress–Prosocial [ESPS]) on measures of posttraumatic stress disorder (PTSD) such as severity, anxiety, somatic complaints, and function problems in third through sixth-grade students in Israel. The study was conducted in a Jewish public elementary school in Ofakim, a southern Israeli town that was subjected to intense rocket fire during the 2008 Gaza War.

The study sample consisted of 200 students, of which 99 received the ESPS intervention, and 101 received a social skills (SS) program. Assignment to the treatment and comparison groups was randomized. The treatment group was 45 percent male, with a religious demographic breakdown of 45 percent secular, 43 percent traditional, and 10 percent religious. Additionally, 23 percent of the treatment group were third graders, 22 percent were fourth graders, 27 percent were fifth graders, and 27 percent were sixth graders. Sixty-three percent reported relatively high levels of PTSD before the intervention.

The comparison group was 46 percent male, and 40 percent were secular, 50 percent were traditional, and 10 percent were religious. Of this group, 22 percent were third graders, 26 percent were fourth graders, 23 percent were fifth graders, and 30 percent were sixth graders. Fifty-six percent reported relatively high levels of PTSD before the intervention. No statistically significant differences were found between the control and treatment groups prior to the implementation of the program.

The treatment group received the ESPS intervention. The comparison group received the SS program for 90 minutes each week. The SS program focused on interpersonal relationships with peers and parents. Additionally, the SS program focused on learning how to use social skills, including nonverbal cues, active listening, becoming assertive, resolving conflict, and negotiating effectively. While no homework was assigned in the SS program, teachers encouraged students to practice what they had learned between sessions.

PTSD symptoms were measured prior to and 2 months following the intervention. Posttraumatic symptomology outcomes were assessed using the 17-item Child Posttraumatic Symptom Scale (CPSS; Foa et al. 2001). The functional problems outcome was measured using seven items of the DISC Predictive Scales (DPS; 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. The somatic complaint outcome was assessed using six items from the DPS (Lucas et al. 2001) and included questions regarding physiological stress reactions such as stomach and respiratory problems, headaches, sleeping problems, and excessive eating or appetite loss. Anxiety items were pulled from the Screen for Child Anxiety Related Emotional Disorders (SCARED), which assesses generalized anxiety symptoms (Birmaher et al. 1997).

A random time ANCOVA was used to analyze the results of the outcome measures in which the effects of the experimental group (ESPS versus SS), time (before and after), and time on group interaction were estimated as fixed and random effects. There were no subgroup analyses conducted. 

In the study by Berger and colleagues (2016), each of the eight homeroom teachers in the intervention participated in a 25-hour training, which was led by an experienced therapist familiar with the Enhancing Resiliency Amongst Students Experiencing Stress–Prosocial (ERASE-Stress–Prosocial [ESPS]) program. The training included a 2-day, intensive summer workshop (16 hours) and three, 3-hour sessions (9 hours) during the academic year. Five, 2-hour supervisions (10 hours) were also provided by the trainers during the implementation of the program. During the training, the teachers were exposed to the full program, including psychoeducational information, experiential exercises, and skills practice. Classroom simulations were conducted throughout the training, during which dissemination techniques and skills were practiced and evaluated. During the application of the program with the students, the teachers received supervision sessions in which issues of implementation were raised and solutions were offered by the group and the trainer.  

Fidelity to the intervention was monitored through teacher observations, and each teacher was observed four times. Teacher adherence to the program and the 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. 2016).

Subgroup Analysis

The effect of the ESPS intervention on measures of stereotyping and discriminatory tendencies toward white, Arab, and Ethiopian children was also evaluated. These outcomes were not scored in determining the final program rating; however, there was a statistically significant reduction in stereotyping and discriminatory tendencies among those in the treatment group, compared with the control group (Berger et al. 2016).

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

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

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 Marc Gelkopf. 2009. “School-Based Intervention for the Treatment of Tsunami-Related Distress in Children: A Quasi-Randomized Controlled Trial.” Psychotherapy and Psychosomatics 78:364 –371.

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.

Berger, Rony and Philip Zimbardo. 2009. Enhancing Resiliency Among Students and Promoting Pro-Social Behavior & Civic Virtue: A Manual for Educators. Tel Aviv, Israel: Natal, Trauma Center for Victims of Terror and War.

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.

Foa, Edna B., Kelly M. Johnson, Norah C. Feeny, and Kimberli R.H. Treadwell. 2001. “The Child PTSD Symptom Scale: A Preliminary Examination of its Psychometric Properties.” Journal of Clinical Child Psychology 30:376–84.

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." Journal of Child Psychology and Psychiatry 50:962–971.

Gilbert, Paul. 2010. Compassion Focused Therapy: The CBT Distinctive Features Series. London, UK: Routledge.

Lucas, Christopher P., Haiying Zhang, Prudence Fisher, David Shaffer, Darrel A. Regier, and William E. Narrow, et al. 2001. “The DISC Predictive Scales (DPS): Efficiently Screening for Diagnosis.” Journal of the American Academy of Child & Adolescent Psychiatry 40:443–49.