Mental Health Field Guide

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A F I E L D G U I D E

M E N TA L H E A LT H R E S P O N S E T O MASS VIOLENCE AND TERRORISMM E N TA L H E A LT H R E S P O N S E T O MASS VIOLENCE AND TERRORISM

Dis

aste

rResponse

D i s a s t e rP l a n n i n g

U.S. DEPARTMENT OF JUSTICEOffice of Justice ProgramsOffice for Victims of Crimewww.ojp.usdoj.gov/ovc

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A F I E L D G U I D E

U.S. Department of Health and Human ServicesSubstance Abuse and Mental Health Services Administration

Center for Mental Health Services2005

M E N TA L H E A LT H R E S P O N S E T O MASS VIOLENCE AND TERRORISM

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This publication was produced under Interagency Agreement#RA00C5400A between the U.S. Department of Justice (DOJ),Office for Victims of Crime (OVC), and the Center for MentalHealth Services (CMHS), the Substance Abuse and Mental HealthServices Administration (SAMHSA). DOJ provided funds for thedevelopment of the document; SAMHSA provided funds for theediting, design, and layout of the publication; and the FederalEmergency Management Agency (FEMA) provided the funds forprinting. The document was written by Deborah J. DeWolfe, Ph.D.,M.S.P.H., and reviewed by a group of experts on mass violenceand mental health response. The SAMHSA Disaster TechnicalAssistance Center (DTAC), ESI, under contract with CMHS, editedthe document and designed the cover and layout for thispublication.

DisclaimerThe content in this publication is solely the responsibility of theauthor and does not necessarily represent the position of U.S.DOJ, OVC; SAMHSA or its centers. This publication is a com-panion piece for Mental Health Response to Mass Violence andTerrorism: A Training Manual (SAMHSA Publication No. SMA3959), and all material referenced in the Field Guide is cited in theTraining Manual, References and Additional Reading section.

Public Domain NoticeAll material appearing in this publication is in the public domainand may be reproduced or copied without permission fromSAMHSA or CMHS. Citation of the source is appreciated. However,this publication may not be reproduced or distributed for a feewithout the specific, written authorization of the Office ofCommunications, SAMHSA, Department of Health and HumanServices (DHHS).

ACKNOWLEDGMENTS

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Electronic Access and Copies of PublicationThis publication can be accessed electronically through the following Internet connections: www.samhsa.gov andwww.ncjrs.org. For additional free copies of this document, please contact SAMHSAs National Mental Health InformationCenter, and ask for Publication No. SMA 4025, at 1-800-789-2647, 1-866-889-2647 (TDD); or contact the OVCResource Center, and ask for Publication No. NCJ 205452, at 1-800-851-3420, 1-877-712-9279 (TTY).

Recommended CitationU.S. Department of Health and Human Services. Mental HealthResponse to Mass Violence and Terrorism: A Field Guide. DHHS Pub.No. SMA 4025. Rockville, MD: Center for Mental Health Services,Substance Abuse and Mental Health Services Administration,2005.

Originating OfficeSubstance Abuse and Mental Health Services Administration1 Choke Cherry Road, Rockville, Maryland 20857DHHS Publication No. SMA 4025Printed 2005

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Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii

Key Principles for Mental Health Intervention . . . . . . . . . . . . . . . . . .1

Survivors and Families Immediate Needs . . . . . . . . . . . . . . . . . . . . .5

Psychological First Aid and Counseling Skills . . . . . . . . . . . . . . . . . .7

Establishing Rapport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

Active Listening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

Some Possible Dos and Definite Donts . . . . . . . . . . . . . . . . . . . .9

Psychological First Aid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Problem Solving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..12

A Word of Caution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

Confidentiality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

When to Refer for Mental Health Services . . . . . . . . . . . . . . . . . . . .15

Populations with Special Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

Age Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

Table 1: Reactions to Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

Highly Impacted Survivors and Families . . . . . . . . . . . . . . . . . .24

Cultural, Ethnic, and Racial Groups . . . . . . . . . . . . . . . . . . . . . . .24

People with Serious and Persistent Mental Illness . . . . . . . . .26

Human Service, Criminal Justice, and Emergency Response Workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

Stress Prevention, Management, and Intervention . . . . . . . . . . . .27

Table 2: Organizational Approaches . . . . . . . . . . . . . . . . . . . . . .29

Table 3: Individual Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . .30

Internet Sites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

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TABLE OF CONTENTS

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This Field Guide is intended for mental health and disasterworkers; first responders; government agency employees; andcrime victim assistance, faith-based, healthcare, and other serviceproviders who assist survivors and families during the aftermathof mass violence and terrorism. All who come in contact withvictims and families can contribute to restoring their dignity andsense of control by interacting with sensitivity, kindness, andrespect. This Field Guide provides the basics of responding tothose in crisis.

Human-caused events such as mass shootings, bombings, riots,exposure to biohazards, and acts of terrorism are deliberatelyplanned and perpetrated for political, sociocultural, revenge-motivated, or hate-based reasons. Acts of mass violence andterrorism target a building, neighborhood, particular site, or event.Those confronted with life threat, mass casualties, overwhelmingterror, and human suffering may experience severe psychologicalstress and trauma. Survivors, families, and the affected com-munities cope not only with the resulting deaths, injuries, anddestruction but also with the horrific knowledge that their losseswere caused by intentional human malevolence. When rescueand recovery efforts extend over weeks and months, familymembers endure prolonged uncertainty and an ongoing threat ofpossible future attacks, which contribute to heightened anxietyand a sense of vulnerability. These traumatic realities also impactfirst responders, media personnel, government officials, andothers whose job-related responsibilities bring them in contactwith the disasters tragic impact.

Because disasters caused by mass violence and acts of terrorismare also crimes, law enforcement and the criminal justice systemfill primary roles. When the underlying motivation is terrorism,Federal criminal justice agencies are responsible for the investi-gation and prosecution. The disasters impact zone becomes a

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INTRODUCTION

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secured crime scene. Crime victims and their families have thelegal right to receive information about criminal justice activities,participate in the criminal justice process, and receive protectionfrom intimidation and harassment. They may apply for benefitsand compensation for crime-related expenses. This interplay ofemergency response, criminal justice, and disaster relief andrecovery systems is a defining feature of the response to massviolence and terrorism.

This Field Guide includes essential information about survivorsand family members reactions and needs, with specific sugges-tions for assisting children, adolescents, adults, and older adults.It describes basic helping skills with indicators for when to refersomeone to a licensed mental health professional. The lastsection presents strategies for worker* stress prevention andmanagement.

This Field Guide draws from material contained in Mental HealthResponse to Mass Violence and Terrorism: A Training Manual andhighlights practical approaches. The Training Manual providesindepth and comprehensive information, and references foradditional reading.

*In this Field Guide, the term worker refers to service providers andothers who assist survivors and families.

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Workers assisting survivorsand family members mayfind the following keyprinciples helpful, as theyfrequently are used byseasoned crime victimassistance and disastermental health professionals:

No one who witnessesthe consequences ofmass criminal violence isunaffected by it.

Mass violence andterrorism result in twotypes of human impactindividual andcommunity.

Mental health, crime vic-tim assistance and otherhuman services must beuniquely and individuallytailored to the communi-ties they serve. Culturalcompetence is essential.

While most traumaticstress and grief reactionsare normal responses toextraordinary circum-stances, a significantminority of survivorsexperience serious, long-term psychologicaldifficulties.

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KEY PRINCIPLESFOR MENTAL HEALTH

INTERVENTION

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Most survivors and families respond to active, genuine interestand concern. However, some will reject services of all kinds.

Mental health assistance is practical, flexible, empowering, andrespectful of survivors needs to pace their exposure to harshrealities resulting from the event. First and foremost, providersmust do no harm when intervening.

Procedures and protocols used by emergency services, lawenforcement, medical examiners offices, and the criminaljustice system can confuse and distress survivors. Clear,sensitive explanations are helpful.

Support from family, friends, and the community helpssurvivors and families cope with trauma and loss.

When mass violence occurs, innocent and unsuspecting peopleare caught by surprise in the course of their daily routines. Thesepeople usually are well-functioning and resilient. They have thecapacity to cope with the profound psychological demands andlosses they experience. Communities, families, and social supportsystems pull together to comfort and support those mostimpacted.

Workers providing emotional support take a practical, down-to-earth approach. They reach out to survivors and respectfully offerreassurance, a listening ear, a warm beverage, concrete informa-tion about what will happen next, and practical assistance withimmediate tasks. Survivors and families may gather at designatedsites such as community centers, schools, employment settings,local places of worship, and disaster relief centers. They may notthink they need psychological counseling or mental healthservices but may welcome genuine concern and help to copewith the stress. Mental health support can even take place overa cup of coffee.

Communities vary in their cultural, racial, and ethnic com-positions including: the presence of refugee or immigrant groups,

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the primary languages spoken, and demographic and socio-economic characteristics. A particular group may have been the target of violence due to prejudice or hate. If the allegedperpetrators are from a particular country or group, U.S. citizensand residents with similar physical characteristics or origins maybe at risk for harassment and retaliatory violence. Crisis mentalhealth support must help each affected group in the community.


Tailor Support to Community Needs

Be culturally sensitive.

Provide information and services in theappropriate language.

Understand the disasters specific impact onaffected cultural groups.

Collaborate and consult with trusted organizationsand community leaders to serve all members ofthe community.


SURVIVORSAND FAMILIES

IMMEDIATE NEEDS

Experiencing an act ofterrorism or mass violenceinvolving exposure to masscasualties, extreme trauma,and threats causes pre-dictable human reactions.Most survivors and familieshave the same initialconcerns and needs. They accept relief effortsmore readily when firstresponders, emergencymanagers, law enforcementpersonnel, human servicesworkers, and governmentofficials consider thefollowing:

Physical need forwarmth, safety, rest,fluids, and food.

Emotional need forprotection, comfort,control, reassurance, anda listening ear.

Fear and anxiety aboutthe safety and well-beingof loved ones, friends,and coworkers.

Need for connection withloved ones and supportsystems.



Desire for frequent updates regarding the status of rescue andrecovery efforts, criminal investigations, potential threats, andwhat is going to happen next.

Need for clear, sensitive explanations of: emergency medicalprocedures; medical examiners office procedures andprotocols; the criminal justice process; the rationale for high-impact operational decisions; and immediately availableservices, benefits, grants, and assistance.

Need for death notification conducted in a straightforward,clear, and compassionate manner.

Normal trauma reactions such as fearfulness, numbness,jumpiness, sleep and concentration problems, and replayingtraumatic images and sounds.

In the days and weeks following mass violent victimization, initialshock gives way to the realization of personal losses. The life-changing implications of death, the destruction of home andcommunity, serious injuries, and the loss of a sense of safety andsecurity in the world become increasingly apparent. Other conse-quences such as loss of employment, and relocation of home,school, or place of worship exacerbate disruption and grieving.Survivors and families psychologically pace themselves accordingto individual timeframes and personal coping styles.

Survivors and families often face numerous logistical andpractical issues that can seem overwhelming. Workers mayfacilitate assistance with transportation, child care, locating amissing loved one or pet, funeral arrangements, findingtemporary housing, filling prescriptions, replacing eyeglasses, and providing healthy foods and beverages. They also may helpfacilitate filling out the necessary paperwork for obtaining crimevictim compensation and benefits, a death certificate, disaster-related unemployment, insurance benefits, and financialassistance. Through helping with practical tasks, workers oftenearn survivors trust and the privilege to support them when theyexpress their pain, fear, sorrow, and anger.




PSYCHOLOGICALFIRST AID AND

COUNSELING SKILLS

Workers should approachsurvivors and familymembers with compas-sion and regard for theirhumanity and dignity.This includes honoringfamilies and survivorswishes to be left alone or deal privately with their suffering. Workersenhance survivors sense of control over theirsituation through recog-nizing and reinforcingtheir coping strengths,providing clear informa-tion, and offering choiceswhen appropriate. Whensurvivors feel more secureand in control, they canbetter address immediatechallenges. Crisis supportinvolves guiding, listening,reassuring, and providingpractical assistance. Thefollowing section providesnuts-and-boltssuggestions.


Establishing Rapport

When making initial contact, workers should introduce them-selves and briefly explain their roles. They may ask permission tosit down, since standing over people when they are seated mayseem intimidating. Workers convey genuine interest and concernthrough eye contact, the assurance of safety, offering a warmbeverage, and a calm presence. They provide comfort, support,and nonjudgmental response to expressed immediate needs.Trust and safety are enhanced when workers listen to whatdistressed survivors and family members choose to discuss andavoid asking intrusive questions.

Active Listening

Workers listen most effectively when they absorb informationthrough their ears, eyes, and hearts. Some tips for effectivelistening are:

Support personal pacingMany survivors and familymembers want to talk about their traumatic experiences.Putting terrifying and tragic experiences into words and havingthem heard while receiving emotional support can contributeto the healing process. Others may choose to focus on concretetasks or seemingly inconsequential matters, temporarilyavoiding direct discussion of their trauma and loss. Workersshould look for cues regarding comfort levels, coping style, andappropriate pacing, and allow survivors and family members totake the lead with personal sharing.

Allow silenceSilence can give a person time to reflect andbecome aware of feelings. Silence may help survivors identifywhat is most important to them at the moment, or be a promptfor elaboration on thoughts and reactions. Simply being withthe survivor or family member can be supportive.

Attend nonverballyEye contact, head nodding, caring facialexpressions, and being at the same physical level (e.g., sitting,




standing) let the person know that the worker is listening.Observing and heeding cultural differences with regard to non-verbal communication conveys cultural sensitivity and canenhance acceptance of help.

ParaphraseThe worker conveys understanding, interest, andempathy by repeating portions of what the person has said.Paraphrasing also checks for accuracy, clarifies misunderstand-ings, and lets the person know that he or she is being heard.Good lead-ins are: So you are saying that..., It sounds likeyou..., or I have heard you say that.... Paraphrasing may seemawkward at first, but is an effective tool for building trust.

Reflect feelingsThe worker may notice that the personstone of voice or nonverbal gestures suggest emotions such asanger, sadness, or fear. Possible responses are, You seemafraid of spending the night at home alone. Is that true? Thishelps the person to identify and articulate emotions and needs.

Allow expression of emotionsCommunicating intenseemotions through tears or venting is an important part of heal-ing. It often helps the survivor or family member work throughfeelings so that he/she can better address the immediate tasksat hand. Workers should stay relaxed and let the person knowthat it is okay to feel and express emotions. [Suggestions in theStress Prevention, Management, and Intervention sectionmay be helpful.]

Some Possible Dos and Definite Donts

Do say:

You have temporarily lost your sense of safety and security.You will feel better over time.

It is understandable that you feel this way.



This is your bodys and minds way of dealing with what hashappened to you. Your reactions are normal.

Feeling intense emotions and having thoughts that you havenever had before is normal. You are not going crazy.

You didnt do anything wrong. It wasnt your fault. You did thebest you could.

Things will never be the same as they were, but you willgradually feel better.

Dont say:

It could have been worse. Youre lucky that.

Its best if you just stay busy.

You should count your blessings, it will make you feel better.

I know just how you feel.

He/she is in a better place now.

You need to get on with your life.

While the human desire is to try to fix the survivors or familymembers painful situation or to make them feel better, hearingcomments in the preceding Dont Say, however, can make aperson feel discounted, judged, misunderstood, or more alone.Workers may find it difficult not to overidentify with survivors andfamilies. They should allow survivors and families the space fortheir own experiences, feelings, and perspectiveswhatever theyare. Simply listening with respect, concern, and calmness cancomfort them.



Psychological First Aid

During and immediately after an act of mass violence or terror-ism, those most affected may experience shock, confusion, fear,numbness, panic, and anxiety. They may shut down.

Witnessing or suspecting the death of loved ones or friends canbe emotionally overwhelming. Some people may be locked in dis-belief. When the perpetrators have not been apprehended or theevent is considered terrorism, all may experience a sense of con-tinued threat and danger. Workers have seven immediate tasksand purposes:

1. Identify those in need of medical attention for intensestress reactions.

2. Provide protection from further harm, and assistance to asafe environment.

3. Ensure that survivors are warm/cool enough and are beinggiven fluids and food.

4. Promote a sense of security through orienting andreassurance.

5. Connect survivors with family, friends, and loved ones.

6. Provide information about the crime scene and perpetra-tors, status of rescue efforts, and what will happen next.

7. Connect survivors and family members with resources forimmediate help (e.g., voluntary agencies, crime victimassistance, systems for locating missing persons,emergency shelter and food, faith-based resources, anddisaster mental health and psychiatry).



Problem Solving

Stress resulting from trauma, crime victimization, and suddenbereavement often causes disorganized thinking, concentrationproblems, and difficulty planning and making decisions. Somepeople react by feeling overwhelmed and may become eitherimmobilized or unproductively overactive. Workers canencourage survivors and family members to participate in simpleconcrete tasks to help them focus and assume a more active rolein coping. Also, workers can guide individuals through thefollowing problem-solving steps to help prioritize and addressimmediate issues.

Identify current priority needs and problems andpossible solutions

Describe the problems/challenges that you are facing right now.

Selecting one solvable problem and then successfullyaddressing it can help restore a sense of control and capability.Avoid picking a complex problem first. Support the person inidentifying a task that is easily completed.

Assess functioning and coping

How are you doing? How do you feel about how you arecoping?

How have you handled stressful life events in the past?

Through observation, gently asking questions, and reviewingthe magnitude of the persons problems and loss, the workerdevelops an impression of the persons capacity to addresscurrent challenges. Based on this assessment, the worker may



point out coping strengths, facilitate the persons engagementwith social supports, or make referrals. The worker may alsoseek consultation from a medical or mental healthprofessional.

Evaluate available resources

Who might be able to help you with this task/problem?

What resources and options might be helpful?

Explore existing sources of assistance and support such asimmediate and extended family, loved ones, friends, neighbors,coworkers, religious leaders, and healthcare providers. Connectthe survivor or family member with the appropriate commu-nity, crime victim assistance, and disaster relief resources andassess if he/she is able to make the calls and complete therequired paperwork. Assist with accessing resources whennecessary.

Develop and implement a plan

What steps will you take to address this problem?

Encourage the survivor or family member to say out loud whatthey plan to do and how. Offer to check in for support and tosee how he/she is doing. If the worker has agreed to perform atask or get information, it is very important to follow through. Aplan may focus on a very short timeframe or limited actions.For example, a plan could be to make two phone calls. Beingreliable and following up, even when there is no new informa-tion, helps survivors gain control. Workers should promise onlywhat they can do, not what they would like to do.


A Word of Caution

When confronted with a survivors or family members seeminglyoverwhelming and heart-wrenching needs, workers can feel theunderstandable impulse to help in every way possible. Workersmay become over-involved and do too much for the survivor orgrieving family, which is usually not in the survivors or familysbest interest. While being helpful and available, workers shouldalso convey their confidence in the individuals coping abilitiesand resilience. When survivors and families are empowered toaddress their own problems, they feel more capable to tackle thenext challenge.

Confidentiality

The privilege of helping others carries ethical responsibilities.Helping people in need involves learning their problems,concerns, fears, and anxietiessometimes with very personaldetails. This sharing must be done with a sense of trust, builtupon mutual respect, and the understanding that all discussionsare confidential. No persons situation or case should bediscussed elsewhere without the consent of the person beinghelped, except in extreme situations when the worker believes theperson might harm him/herself or others. Under those circum-stances, workers should report concerns to their supervisors sothat the appropriate authorities may be contacted.

Workers should avoid discussing information in public places,such as restaurants, that might give the impression that privacy isnot being protected. Only by maintaining the trust and respect ofthe survivor or family member can the privilege of helpingcontinue.




WHEN TO REFERFOR MENTAL

HEALTH SERVICES

Workers should makereferrals to mental healthand other healthcare pro-fessionals when theyencounter survivors andfamily members withsevere physical or emo-tional reactions. Somemay have preexistingphysical or psychiatricconditions that have wors-ened because of traumaticstress. The following reac-tions, behaviors, andsymptoms signal a needfor the worker to consultwith his or her supervisorand, in most cases, referthe person for assessmentand more specializedassistance. In all instances,when in doubt, consult.

Disorientation: Theperson is dazed andunable to give date ortime, location, andevents of the past 24hours, or understandwhat is happening.

Anxiety andHyperarousal: The per-son is highly agitated,restless, jumpy, and onedge; is unable to sleep;has frequent disturbing



nightmares, flashbacks, and intrusive thoughts; or broods overcircumstances surrounding the event.

Dissociation: The person exhibits pronounced emotionaldisconnection, an incomplete awareness of the traumaticexperience, a sense of seeing him/herself from anotherperspective, a perception that the environment is unreal or thattime is distorted.

Depression: The person exhibits pervasive feelings ofhopelessness and despair; unshakeable feelings of worth-lessness, guilt, or self-blame; frequent crying for no apparentreason; withdrawal from others; or inability to engage inproductive activity.

Mental Illness: Symptoms include hearing voices, seeingthings or people that are not there, delusional thinking,appearing out of touch with reality, and excessive pre-occupation with an idea or thought.

Inability to Care for Self: The person does not eat, bathe, orchange clothes; is apathetic, isolated from others, and unableto manage activities of daily living.

Suicidal or Homicidal Thoughts or Plans: The personmakes statements like I cant go on, I just want to end thisterrible pain Im feeling, I wish that I had died, I want to joinmy husband in heaven, or Im going to get even. The personfeels pervasive self-blame or sense of responsibility for anotherpersons death.

Problematic Use of Alcohol or Drugs: The person makesreferences to getting drunk, getting high, or not being able tostop drinking; blocks out pain with mood-altering substances;relapses from previous abstinence; misses work or otherobligations due to alcohol or drug use; or expresses concernabout a family members substance use.

Domestic Violence, Child Abuse, or Elder Abuse: Theperson mentions instances of inappropriate anger or violencetoward family members.



POPULATIONS WITHSPECIAL NEEDS

Terrorism and massviolence inevitably touchall who are in their zone ofimpact. This zone mayinclude people of differentages and economic means;people of various cultural,racial, and ethnic back-grounds; people with dif-ferent sexual orientationsand family configurations;people who speak foreignlanguages; people frommany occupational groups;and people who have rolesin emergency responseand recovery efforts.

The basic human need forsurvival, safety, protection,connection with lovedones, and accurate infor-mation are shared, whileadditional needs may bemore specific to a particu-lar group. Workers aremost effective when theyare informed about,respectful of, and respon-sive to the various groupsin the affected community.Special considerationshould be given to the fol-lowing groups as well asothers with special needs:


Age groups (e.g., children, teenagers, older adults);

Highly impacted survivors and families;

Cultural, ethnic, and racial groups;

People with serious and persistent mental illness;

Human service, criminal justice, and emergency responseworkers.

Age Groups

Each age group is vulnerable in unique ways to the stress oftrauma, victimization, and sudden bereavement. Some of thereactions listed in Table 1 may be immediate, while others mayappear months later. Table 1 describes possible behavioral,physical, and emotional reactions of different age groups andoptions for helpful intervention.




Clinging toparents orfamiliar adults

Helplessnessand passivebehavior

Resumption ofbed wetting orthumb sucking

Fear of the dark

Avoidance ofsleeping alone

Increased crying

REACTIONS TO TRAUMA ANDSUGGESTIONS FOR INTERVENTIONT A B L E 1 :

C o n t i n u e d o n n e x t p a g e

1-5 Loss of appetite

Stomach aches

Nausea

Sleepproblems,nightmares

Speechdifficulties

Tics

Anxiety

Generalizedfear

Irritability

Angry outbursts

Sadness

Withdrawal

Give verbalreassurance andphysical comfort

Clarify miscon-ceptions repeatedly

Provide comfortingbedtime routines

Help with labels foremotions

Avoid unnecessaryseparations

Permit child to sleepin parents roomtemporarily

Demystify reminders

Encourageexpression regardinglosses (deaths, pets,toys)

Monitor mediaexposure

Encourageexpression throughplay activities

Ages Behavioral Physical Emotional Intervention Options



Decline in schoolperformance

Schoolavoidance

Aggressivebehavior athome or school

Hyperactive orsilly behavior

Whining,clinging, actinglike a youngerchild

Increasedcompetition withyounger siblingsfor parentsattention

Traumatic play andreenactments

6-11 Change inappetite

Headaches

Stomach aches

Sleepdisturbances,nightmares

Somaticcomplaints

Give additionalattention andconsideration

Relax expectations ofperformance at homeand at schooltemporarily

Set gentle but firmlimits for acting outbehavior

Provide structuredbut undemandinghome chores andrehabilitationactivities

Encourage verbaland play expressionof thoughts andfeelings

Listen to childsrepeated retelling oftraumatic event

Clarify childsdistortions andmisconceptions

Identify and assistwith reminders

Develop schoolprogram for peersupport, expressiveactivities, educationon trauma and crime,preparednessplanning, identifyingat-risk children

REACTIONS TO TRAUMA ANDSUGGESTIONS FOR INTERVENTION


Fear of feelings

Withdrawal fromfriends, familiaractivities

Reminderstriggering fears

Angry outbursts

Preoccupationwith crime,criminals,safety, anddeath

Self-blame

Guilt

C o n t i n u e d f r o m p r e v i o u s p a g e

T A B L E 1 :



Decline inacademicperformance

Rebellion athome or school

Decline inpreviousresponsiblebehavior

Agitation ordecrease inenergy level,apathy

Delinquentbehavior

Risk-takingbehavior

Socialwithdrawal

Abrupt shift inrelationships

Use of alcohol orillegal drugs

12-18 Appetitechanges

Headaches

Gastrointestinalproblems

Skin eruptions

Complaints ofvague achesand pains

Sleep disorders

Give additionalattention andconsideration

Relax expectations ofperformance at homeand schooltemporarily

Encouragediscussion ofexperience of traumawith peers, significantadults

Avoid insistence ondiscussion of feelingswith parents

Address impulse torecklessness

Link behavior andfeelings to event

Encourage physicalactivities

Encourageresumption of socialactivities, athletics,clubs, etc.

Encourage partici-pation in communityactivities and schoolevents

Develop schoolprograms for peersupport anddebriefing, at-riskstudent supportgroups, telephonehotlines, drop-incenters, and identifi-cation of at-risk teens



Loss of interestin peer socialactivities,hobbies,recreation

Sadness ordepression

Anxiety andfearfulnessabout safety

Resistance toauthority

Feelings ofinadequacy andhelplessness

Guilt, self-blame, shameand self-consciousness

Desire forrevenge

T A B L E 1 :

C o n t i n u e d o n n e x t p a g e



Sleep problems

Avoidance ofreminders

Excessiveactivity level

Protectivenesstoward lovedones

Crying easily

Angry outbursts

Increasedconflicts withfamily

Hypervigilance

Isolation,withdrawal,shutting down

Increased use ofalcohol or illegaldrugs

Adults Nausea

Headaches

Fatigue,exhaustion

Gastrointestinaldistress

Appetitechange

Somaticcomplaints

Worsening ofchronicconditions

Protect, direct, andconnect

Ensure access toemergency medicalservices

Provide supportivelistening andopportunity to talkabout experience andlosses

Provide frequentrescue and recoveryupdates andresources forquestions

Assist with prioritizingand problem solving

Assist family tofacilitate communi-cation and effectivefunctioning

Provide informationon traumatic stressand coping, childrensreactions, and tips forfamilies

Provide informationon criminal justiceprocedures, roles ofprimary respondergroups

Provide crime victimservices

Assess and referwhen indicated

Provide informationon referral resources



Shock, disorien-tation, andnumbness

Depression,sadness

Grief

Irritability, anger

Anxiety, fear

Despair,hopelessness

Guilt, self-doubt

Mood swings

T A B L E 1 :

C o n t i n u e d f r o m p r e v i o u s p a g e



Withdrawal andisolation

Reluctance toleave home

Mobilitylimitations

Relocationadjustmentproblems

OlderAdults

Worsening ofchronicillnesses

Sleep disorders

Memoryproblems

Somaticsymptoms

Increasedsusceptibility to hypo andhyperthermia

Physical andsensorylimitations(sight, hearing)interfere withrecovery

Provide strong andpersistent verbalreassurance

Provide orientinginformation

Ensure physicalneeds are addressed(water, food, warmth)

Use multipleassessment methodsas problems may beunderreported

Assist withreconnecting withfamily and supportsystems

Assist in obtainingmedical and financialassistance

Encouragediscussion oftraumatic experience,losses, andexpression ofemotions

Provide crime victimassistance



Depression

Despair aboutlosses

Apathy

Confusion,disorientation

Suspicion

Agitation, anger

Fears ofinstitution-alization

Anxiety withunfamiliarsurroundings

Embarrassmentabout receivinghandouts

T A B L E 1 :


Highly Impacted Survivors and Families

Research has shown that those who directly experience violentvictimization and mass traumatization, witness the serious injuryand physical mutilation of others, or suffer the murder of a lovedone have a likelihood of intense and prolonged emotional, behav-ioral, and physical reactions. They are likely to suffer high levels ofdistress during the immediate response phase and may have peri-ods of difficulty for years to come. Critical events that occurthroughout the criminal justice process, such as trials, sentencinghearings, and appeals, are especially significant to this group andare often linked to restimulation of psychological wounds.

Workers support these survivors and family members by provid-ing respectful and practical assistance, making needed informa-tion reliably available, and supporting the multiple pathways forcoming to terms with overwhelming trauma and loss. Religiousand cultural traditions; spiritual practices; community, family, andpersonal rituals; and symbolic gestures can soothe survivorsanguish and assist them with finding meaning and the courage tocontinue living. At different points during the process of comingto terms with loss and trauma, activities and interventions suchas counseling, support groups, medication, spiritual guidance,social activism, helping others, artistic expression, and symbolichealing rituals may be helpful.

Cultural, Ethnic, and Racial Groups

Workers must respond sensitively and specifically to the variouscultural groups affected by mass violence. The death of a lovedone, community trauma, and mass victimization are interwovenwith cultural overlays. Rituals surrounding death, the appropriatehandling of physical remains, funerals, burials, memorials, andbelief in an afterlife are all deeply embedded in culture and reli-gion. The serious injury of a family member brings families fromdifferent cultures into contact with Western medicine and the




healthcare delivery system. The situation may be even more chal-lenging when English is not the familys primary language.

Cultural and ethnic groups with histories of violent oppression,terrorism, or war in their countries of origin may interpret com-munity violence in the United States through their experiences ofprior traumatization. Those who have suffered from politicaloppression and abuses of military power may find the prominentvisibility of uniformed personnel highly distressing or even trau-matizing. Some survivor groups may live in a context of poverty,discrimination, or marginalization and face high rates of violentcrime in their neighborhoods, potentially making them more vul-nerable to disaster impact.

Workers convey cultural sensitivity when they provide informa-tional briefings, notifications, and applications for services andbenefits in primary spoken languages. Workers must learn abouteach affected groups cultural norms, practices, and traditions;views regarding mental health, trauma, and grieving; and thegroups local history and community politics. Establishing work-ing relationships with trusted organizations, service providers,and community leaders often facilitates increased acceptance.

Workers communicate cultural sensitivity when they:

Use culturally accepted courteous behavior (e.g., greetings,physical space, know who is considered family);

Describe their role in culturally relevant terms;

Take time to establish rapport;

Provide information and services in appropriate languages;

Ask about cultural practices when they are unsure;

Value diversity and respect differences;

Develop and adapt approaches and services to fit specialgroup needs.



People with Serious and Persistent Mental Illness

Many survivors with mental illness function fairly well following acommunity disaster, especially if essential services and supportnetworks have not been interrupted. Most have the same capacityas the general population to rise to the occasion and performheroically during the immediate response period. However, thosewho are directly involved and traumatized by the event may needadditional mental health support services, medications, or hospi-talization to regain stability. For survivors previously diagnosedwith posttraumatic stress disorder (PTSD), emergency responsestimuli (e.g., sirens, helicopters, mass casualties) may trigger anexacerbation due to associations with prior traumatic events.

The range of support services designed for the general populationis equally beneficial for survivors and family members withmental illness. As with all special population groups, workersneed to be aware of how people with mental illness perceive dis-aster assistance and services, and build bridges that facilitateaccess.

Human Service, Criminal Justice, andEmergency Response Workers

Workers in all aspects of emergency response and disaster reliefexperience considerable demands to meet the needs of survivors,families, and the community. Depending on their role, workersmay be exposed to human suffering, fatalities, people with seriousphysical injuries, family demands and anguish, community anger,and other difficulties. They may experience physical stresssymptoms or show signs of stress overload. Indicators includeirritability, over-involvement with and inability to leave theoperation, difficulty focusing, being unproductive, feelingdepressed, or feeling emotionally overwhelmed. Workers mayintervene by suggesting or using the strategies described in thenext section.



STRESSPREVENTION,

MANAGEMENT, ANDINTERVENTION

Workers must cope with arange of challengingstressors. The devastatinglosses, casualties, destruc-tion of property, and emo-tional pain of survivors andbereaved loved ones touchproviders in powerful andpersonal ways. The emer-gency response workingenvironment often involvesphysical hardship, unclearroles and responsibilities,limited resources, rapidlychanging priorities,intrusive media attention,and long work hours.

Despite the inevitablestress associated withcommunity crisis response,workers experiencepersonal gratificationusing their skills to assistfellow humans in need.Active engagement in thedisaster response can bean antidote to feelings ofvulnerability, powerless-ness, and outrage com-monly experienced by thecommunity.



A proactive stress management plan focuses on two criticalcontexts: the organizational and the individual. Adopting apreventive approach allows managers and workers to anticipatestressors and manage potential crises rather than simply reactingto them after they occur.

When stress prevention and management strategies are built intooperations and the organizational culture, providers feel valuedand supported as they engage in this emotionally demandingwork. Suggestions for organizational stress prevention, manage-ment, and intervention are presented in Table 2, and suggestionsfor individual stress prevention, management, and interventionare presented in Table 3.



EffectiveManagementStructure andLeadership

Clear chain of command and reporting relationships

Available and accessible leads and clinical supervisors

Use of managers experienced in emergency response and community trauma

ORGANIZATIONAL APPROACHES FOR STRESSPREVENTION, MANAGEMENT, AND INTERVENTIONT A B L E 2 :

Clear Purpose,Goals, andTraining

Clearly defined intervention goals and strategies appropriate to differentassignment settings (e.g., crisis intervention, community memorial)

Training and orientation for all workers

FunctionallyDefined Roles

Staff who are oriented and trained according to written role descriptions foreach assignment setting

When setting is under jurisdiction of another agency (e.g., Mayors Office,Medical Examiners Office, American Red Cross), staff are informed of mentalhealth providers role, contact people, and mutual expectations

AdministrativeControls

Shifts no longer than 12 hours with 12 hours off

Rotation between high, mid, and low-stress tasks

Breaks and time away from the assignment

Necessary supplies (e.g., paper, forms, pens, educational materials)

Communication tools (e.g., mobile phones, radios)

Delegating regular workload so workers do not attempt disaster response and usual job

Team Support Buddy system for support and monitoring stress reactions

Positive atmosphere of support, mutual respect, and tolerance

Clinical support, consultation, and supervision processes built on trust, safetyand respect

Attention to workers functioning and stress management

Floating through work areas to observe signs of stress

Education about signs and symptoms of worker stress and coping strategies

Intervention plan incorporating elements from Table 3

Exit plan for workers leaving the operation

Plan for StressManagement

Dimension Intervention




Management of Workload

Setting task priority levels with realistic work plans

Recognizing that not having enough to do or waiting is an expected part ofdisaster mental health response

INDIVIDUAL APPROACHES FOR STRESSPREVENTION, MANAGEMENT, AND INTERVENTION

Dimension Intervention

T A B L E 3 :

BalancedLifestyle

Eating nutritious food and staying hydrated, avoiding excessive caffeine,alcohol, and tobacco

Getting adequate sleep and rest, especially on longer assignments

Getting physical exercise when possible

Maintaining contact and connection with primary social supports

StressReductionStrategies

Reducing physical tension by using familiar personal strategies (e.g., takingdeep breaths, gentle stretching, meditation, washing face and hands,progressive relaxation)

Pacing self between low and high-stress activities

Using time off to decompress and recharge batteries (e.g., getting a goodmeal, watching TV, exercising, reading a novel, listening to music, taking abath, talking to family)

Talking about emotions and reactions with coworkers during appropriate times

Self-Awareness Recognizing and heeding early warning signs for stress reactions

Accepting that one may not be able to self-assess problematic stressreactions

Recognizing that over-identification with or feeling overwhelmed by victimsand families grief and trauma may signal a need for support and consultation

Understanding the differences between professional helping relationships andfriendships to help maintain appropriate roles and boundaries

Examining personal prejudices and cultural stereotypes

Recognizing when ones own experience with trauma or ones personal historyinterfere with effectiveness

Being aware of personal vulnerabilities and emotional reactions and theimportance of team and supervisor support


American Academy of Child and Adolescent Psychiatryhttp://www.aacap.org

American Psychiatric Associationhttp://www.psych.org

American Psychological Associationhttp://www.apa.org

American Red Crosshttp://www.redcross.org

Federal Emergency Management Agencyhttp://www.fema.gov

International Society for Traumatic Stress Studieshttp://www.istss.org

Mothers Against Drunk Drivers (MADD)http://www.madd.org

National Center for Post-Traumatic Stress Disorder/U.S. Department of Veteran Affairs

http://www.ncptsd.org

National Child Traumatic Stress Networkhttp://www.nctsnet.org

Office for Victims of Crime/U.S. Department of Justicehttp://www.ojp.usdoj.gov/ovc/

Office for Victims of Crime Resource Centerhttp://www.ncjrs.org

Substance Abuse and Mental Health Services Administration

http://www.samhsa.gov


INTERNET SITES


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U.S. Department of Health and Human ServicesSubstance Abuse and Mental Health Services

AdministrationCenter for Mental Health Services1 Choke Cherry RoadRockville, MD 20857DHHS Publication No. SMA 4025Printed 2005

U.S. Department of JusticeOffice of Justice ProgramsOffice for Victims of Crime810 Seventh St., NWWashington, DC 20531DOJ Publication No. NCJ 205452


Documents

Mental Health Field Guide