# PSYCHOLOGICAL FIRST AID![](media/image1.png){width="0.85in" height="0.47847222222222224in"}

**Field Operations Guide**

**Medical Reserve Corps**

**National Child Traumatic Stress Network**

**National Center for PTSD**

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**Acknowledgements**

This Medical Reserve Corps Adaptation of the Psychological First Aid
(PFA) Field Operations Guide is derived from the original PFA Guide
developed by the National Child Traumatic Stress Network and the
National Center for PTSD. Members of the National Medical Reserve Corps
Mental Health Work Group, the National Child Traumatic Stress Network
and the National Center for PTSD, as well as other individuals involved
in coordinating and participating in disaster response, have contributed
to the current document.

The principal authors from the National Child Traumatic Stress Network
and National Center for PTSD (in alphabetical order) included: Melissa
Brymer, Anne Jacobs, Chris Layne, Robert Pynoos, Josef Ruzek, Alan
Steinberg, Eric Vernberg, and Patricia Watson.  Medical Reserve Core
principal authors (in alphabetical order) included: Abbe Finn, Jack
Herrmann, John Hickey, Edward Kantor, Patricia Santucci, and James
Shultz.

Special contributors included: Steve Berkowitz, Jessica Hamblen, Julian
Ford, Laura Gibson, Robin Gurwitch, Anne Jacobs, Robert Macy, William
Saltzman, Janine Shelby, Merritt Schreiber, Betty Pfefferbaum, Cynthia
Whitham, Bonita Wirth, and Bruce Young.

If you use these guidelines to provide training to your Medical Reserve
Corps team, please notify Patricia Santucci (<santucci@pol.net>) or John
Hickey (<drjohnkhickey@optonline.net>), co-chairs of the National MRC
Mental Health Work Group, so that we may gain further input and feedback
for future revisions to the Guide.

**Psychological First Aid**

**TABLE OF CONTENTS**

Introduction and Overview

Preparing to Deliver Psychological First Aid

Core Actions

> 1\. Contact and Engagement
>
> 2\. Safety and Comfort
>
> 3\. Stabilization
>
> 4\. Information Gathering: Current Needs and Concerns
>
> 5\. Practical Assistance
>
> 6\. Connection with Social Supports

# 

# 7. Information on Coping 

> 8\. Linkage with Collaborative Services
>
> 9\. Appendix A: MRC Service Delivery Sites and Settings
>
> 10\. Appendix B: Position Statement on Psychological Debriefing
>
> 11\. Appendix C: Missing Persons: Bereavement, Death Notification, and
> Body
>
> Identification
>
> 12\. Appendix D: Resources

13. Appendix E: Handouts

14. Appendix F: Working with Older Adults

**[Introduction and Overview]{.smallcaps}**

**[Psychological First Aid in Medical Reserve Corps
Setting]{.smallcaps}**

**The Medical Reserve Corps Edition of PFA**

The Medical Reserve Corps (MRC), one of the newest organizations in the
disaster response community, has evolved rapidly since its creation in
2002, by the Office of the Surgeon General, United States Public Health
Service (USPHS). Now with more than 400 individual units and over 73,000
members, MRCs are rapidly becoming the most prominent vehicle for
pre-registering, credentialing and training health and mental health
professional volunteers in disaster response.

As the program evolved, it became clear that individual MRC units were
seeking assistance in interpreting best practices and developing
response guidelines across a host of operational areas. Taking this
feedback, the national Program Director, Commander Rob Tosatto, USPHS,
initiated several work groups to help identify some common guidelines
and standard tools for MRC units to consider, while at the same time
respecting the local autonomy of the individual unit. One of these areas
of focus is disaster mental health.

The National MRC Mental Health Work Group has examined the field of
disaster mental health and reviewed a host of issues with the intent of
providing guidance to local MRC units on areas of core competence, the
availability of existing training curricula, voids in service delivery
and controversies in the field. As one of its first actions, the
National MRC Mental Health Work Group is recommending 'Psychological
First Aid' as a standard model of mental health intervention in early
response to disasters and other traumatic events. We believe this Guide
and direction helps to fill a major gap in the field by helping to
standardize and clarify the concepts of 'Psychological First Aid', one
of the few evidence-driven intervention strategies in disaster mental
health response.

**[What is Psychological First Aid?]{.underline}**

Psychological First Aid is an evidence-informed[^1] modular approach to
assist children, adolescents, adults, and families in the immediate
aftermath of disaster and terrorism.[^2] Psychological First Aid is
designed to reduce the initial distress caused by traumatic events, and
to foster short- and long-term adaptive functioning and coping.
Principles and techniques of Psychological First Aid meet four basic
standards. They are: (1) consistent with research evidence on risk and
resilience following trauma; (2) applicable and practical in field
settings; (3) appropriate to developmental level across the lifespan;
and (4) culturally informed and adaptable. Psychological First Aid does
not presume all survivors will develop severe psychopathology, but
instead fosters an understanding that disaster survivors, and others
impacted by such events, will experience a broad range of reactions
(e.g. physical, psychological, cognitive, spiritual). Some of these
reactions will cause sufficient distress for the individual and may be
alleviated by support from compassionate and caring disaster responders.
Psychological First Aid is an intervention strategy that can be woven
into the basic disaster response mechanisms for MRC units.

**Who is Psychological First Aid For?**

Psychological First Aid intervention strategies are intended for use
with children, adolescents, parents/caretakers, families, and adults.
Other populations include healthcare workers, law enforcement officers,
firefighters, emergency medical service professionals, and other first
responders and disaster relief workers.

**Who Delivers Psychological First Aid?**

Psychological First Aid is designed for delivery by a variety of
response units. All members of the MRC who provide acute assistance as
part of the organized disaster response effort should be trained in the
basics of providing PFA. These providers may be imbedded in a variety of
response units, including first responder teams, incident command
systems, primary and emergency health care providers, school crisis
response teams, faith-based organizations, Community Emergency Response
Teams (CERT), Medical Reserve Corps, the Citizens Corps, and disaster
relief organizations.

**When Should Psychological First Aid Be Used?**

PFA is a supportive behavioral intervention for use in the immediate
aftermath of disasters and other traumatic events. It is intended to
blend into the general MRC response structure early in disaster
stabilization and recovery efforts.

**Where Should Psychological First Aid Be Used?**

Psychological First Aid is designed for delivery in diverse settings.
Medical Reserve Corps members may be called upon to provide PFA in
general population shelters, special needs shelters, field hospitals and
medical triage areas, acute care facilities (e.g., Emergency
Departments), staging areas or respite centers for first responders or
other relief workers, emergency operations centers, crisis hotlines or
phone banks, feeding locations, disaster assistance service centers,
family reception and assistance centers, homes, businesses, and other
community settings. Following weapons of mass destruction (WMD) events
or other such public health emergencies, Psychological First Aid may be
delivered in fatality collection points and in locations providing
decontamination or mass prophylaxis services. For information on the
challenges of providing PFA in some of these service sites, see Appendix
A.

**Strengths of Psychological First Aid**

-   Psychological First Aid includes basic information-gathering
    techniques to help mental health specialists make rapid assessments
    of survivors' immediate concerns and needs and how to implement
    supportive activities in a flexible manner.

-   Psychological First Aid relies on field-tested, evidence-informed
    strategies that can be provided in a variety of disaster settings.

-   Psychological First Aid emphasizes developmentally and culturally
    appropriate interventions for survivors of various ages and
    backgrounds.

-   Psychological First Aid includes important elements of risk
    communication and education via the use of materials and handouts
    that provide information for youth, adults, and families for their
    use over the course of recovery in contending with post-disaster
    reactions and adversities.

**[Basic Objectives of Psychological First Aid]{.underline}**

-   Establish a human connection in a non-intrusive, compassionate
    manner.

-   Enhance immediate and ongoing safety, and provide physical and
    emotional comfort.

-   Calm and orient emotionally-overwhelmed or distraught survivors.

-   Help survivors to articulate immediate needs and concerns, and
    gather additional information as appropriate.

-   Offer practical assistance and information to help survivors address
    their immediate needs and concerns.

-   Connect survivors as soon as possible to social support networks,
    including family members, friends, neighbors, and community helping
    resources.

-   Support positive coping, acknowledge coping efforts and strengths,
    and empower survivors; encourage adults, children, and families to
    take an active role in their recovery.

-   Provide information that may help survivors to cope effectively with
    the psychological impact of disasters.

-   Facilitate continuity in disaster response efforts by clarifying how
    long the Psychological First Aid provider will be available, and
    (when appropriate) linking the survivor to another member of a
    disaster response team or to indigenous recovery systems, mental
    health services, public-sector services, and organizations.

**Delivering Psychological First Aid**

**Professional Behavior**

-   Operate only within the framework of an authorized disaster response
    system.

-   Model sound responses; be calm, courteous, organized, and helpful.

-   Be visible and available.

-   Maintain confidentiality as appropriate.

-   Remain within the scope of your expertise and your designated role.

-   Make appropriate referrals when additional expertise is needed or
    requested by the individual.

-   Be knowledgeable and sensitive to issues of culture and diversity.

-   Pay attention to your own emotional and physical reactions, and
    actively manage these reactions.

**Guidelines for Delivering Psychological First Aid**

-   Politely observe first, don't intrude. Then ask simple respectful
    questions, so as to be able to discuss how you may be of help.

-   Initiate contact only after you have observed the situation and the
    person or family, and have determined that contact is not likely to
    be an intrusion or disruptive.

-   Be prepared to be either avoided or flooded with contact by affected
    persons, and make brief but respectful contact with each person who
    approaches you.

-   Speak calmly. Be patient, responsive, and sensitive.

-   Speak in simple, concrete terms; don't use acronyms or responder
    'jargon'. If necessary, speak slowly.

-   If survivors want to talk, be prepared to listen. When you listen,
    focus on learning what they want to tell you and how you can be of
    help.

-   Acknowledge the positive features of what the person has done to
    keep safe and reach the current setting.

-   Adapt the information you provide to directly address the person's
    immediate goals and clarify answers repeatedly as needed.

-   Give information that is accurate and age-appropriate for your
    audience, and correct inaccurate beliefs. If you don't know, tell
    them this and offer to find out.

-   When communicating through a translator or interpreter, look at and
    talk to the person you are addressing, not at the translator or
    interpreter.

-   Remember that the goal of Psychological First Aid is to reduce
    distress, assist with current needs, and promote adaptive
    functioning, not to elicit details of traumatic experiences and
    losses.

**Working With Children and Adolescents**

-   Sit or crouch at a child's eye level.

-   Help children verbalize their feelings, concerns and questions;
    provide simple labels for common emotional reactions (e.g., mad,
    sad, scared, worried). Match the children's language to help you
    connect with them, and to help them to feel understood and to
    understand themselves. Do not increase their distress by using
    extreme words like "terrified" or "horrified."

-   Match your language to the child's developmental level. Children 12
    years and under typically have much less understanding of abstract
    concepts and metaphors compared to adults. Use direct and simple
    language as much as possible.

-   Adolescents often appreciate having their feelings, concerns and
    questions addressed as adult-like, rather than child-like responses.

-   Reinforce these techniques with the child's parents to help them
    provide appropriate emotional support to their children.

**Some Behaviors to Avoid**

-   Do not make assumptions about what the person is experiencing or
    what they have been through.

-   Do not assume that everyone exposed to a disaster will be
    traumatized.

-   Do not pathologize. Most acute reactions are understandable and
    expectable given what people exposed to the disaster have personally
    experienced. Do not label reactions as 'symptoms,' or speak in terms
    of "diagnoses," "conditions," "pathologies," or "disorders."

-   Do not talk down to or patronize the survivor, or focus on their
    helplessness, weaknesses, mistakes, or disability. Focus instead on
    what the person has done that is effective or may have contributed
    to help others in need, both during the disaster and in the present
    setting.

-   Do not assume that all survivors want to talk or need to talk to
    you. Often, being physically present in a supportive and calm way
    helps affected people to feel safer and more able to cope.

-   Do not "debrief" by asking for details of what happened.

-   Do not speculate or offer erroneous or unsubstantiated information.
    If you don't know something that you are asked, do your best to
    learn the correct facts.

-   Do not suggest fad interventions or present uninformed opinion as
    fact.

**[Preparing to Deliver Psychological First Aid]{.smallcaps}**

In order to be of assistance to disaster-affected communities, the
provider must be knowledgeable about the nature of the event, the
post-event circumstances, and the type and availability of relief and
support services.

**Pre-planning and Preparation**

Pre-planning and preparation becomes particularly important when working
as an MRC member. The uniqueness of the MRC in regard to the variety of
units' roles and response duties provides for a flexible resource, but
pose potential communication problems unless thought about and resolved
ahead of time. Prior knowledge of professional competencies
(expectations and limitations), agreed upon response guidelines,
organizational control, incident command structure and working
guidelines of other 'partner' agencies is critical to a cooperative and
functional MRC response. As MRC members, we can look to our local
leadership for pre-event exercises and interagency drills to help bridge
these important differences. Flexibility, open-mindedness and
cooperation will be highly regarded skills early in the response.

[]{.mark}

**Entering the Setting**

####### Psychological First Aid begins when a disaster mental health specialist enters an emergency management setting in the aftermath of a disaster (See Appendix A for examples of various service delivery sites). Successful entry involves working within the framework of an authorized Incident Command System (ICS) in which roles and decision-making are clearly defined. It is essential to establish communication and coordinate all activities with authorized personnel or organizations that are managing the setting. Effective entry also involves orienting yourself to the setting (e.g., leadership, organization, policies and procedures, security, psychiatric support) and available services. As you provide Psychological First Aid, you need to have accurate information about what is going to happen, what services are available, and where services can be found. This information needs to be gathered as soon as possible, given that providing such information is often critical to reducing distress and promoting adaptive coping.

[]{.mark}

**Providing Services**

In some settings, Psychological First Aid may be provided in designated
areas. In other settings, Psychological First Aid providers may
circulate around the facility to identify those to be approached for
assistance. Focus your attention on how people are reacting and
interacting in the setting. Individuals who may need assistance include
those showing signs of acute distress. This includes individuals who
are:

-   Disoriented

-   Confused

-   Frantic

-   Panicky

-   Extremely withdrawn, apathetic or "shut down"

-   Extremely irritable or angry

-   Individuals who are exceedingly worried

Decide who may need assistance or would benefit most from contact with
you, and plan for how to contact them within the time and constraints of
the setting.

[]{.mark}

# Maintain a Calm Presence

# People take their cue from how others are reacting. By demonstrating calmness and clear thinking, you can help survivors feel that they can rely on you. Others may follow your lead in remaining focused, even if they do not feel calm, safe, effective, or even hopeful. Psychological First Aid providers often model the sense of hope that affected persons cannot always feel while they are still attempting to deal with what happened and current pressing concerns.

**Be Sensitive to Culture and Diversity**

Sensitivity to culture and ethnic, religious, racial, and language
diversity is central to providing Psychological First Aid. It is
critical to both outreach efforts and service provision. Providers
should be aware of their own values and prejudices, and how these may
coincide or differ with those of the community being served. Helping to
maintain or reestablish customs, traditions, rituals, family structure,
gender roles, and social bonds is important to helping survivors cope
with the impact of a disaster. Information about the community being
served, including how emotions and other psychological reactions are
expressed, attitudes towards governmental agencies, and receptivity to
counseling, should be gathered with the assistance of community cultural
leaders who represent and best understand local cultural groups.

**Be Aware of At-Risk Populations**

Individuals that are at special risk after a disaster include:

-   children (especially children whose parents have died, were
    significantly injured or are missing)

-   those who have had multiple relocations and displacements

-   medically frail adults

-   the elderly

-   those with serious mental illness

-   those with physical disabilities or illness

-   adolescents who may be risk-takers

-   adolescents and adults with substance abuse problems

-   pregnant women

-   mothers with babies and small children

-   professionals or volunteers who participated in disaster response
    and recovery efforts

-   those who have experienced significant loss of their possessions
    (e.g., home, pets, family memorabilia, etc.)

-   those exposed first hand to grotesque scenes or extreme life threat

The prevalence of exposure to pre-disaster trauma may be higher among
economically disadvantaged populations. As a consequence, minority and
marginalized communities may have higher rates of pre-disaster
trauma-related mental health problems, and are at greater risk for
developing problems following disaster. Mistrust, stigma, fear (e.g.,
fear of deportation), and lack of knowledge about disaster relief
services are important barriers to seeking, providing, and receiving
services for these populations. Those living in disaster-prone regions
are more likely to have had prior disaster experiences, although having
dealt well with a disaster in the past may be helpful in the current
situation.

**[Psychological First Aid Core Actions]{.smallcaps}**

**1**. **Contact and** **Engagement**

[Goal]{.underline}**:** To respond to contacts initiated by affected
persons, or initiate contacts in a non-intrusive, compassionate, and
helpful manner.

**2**. **Safety and Comfort**

[Goal]{.underline}: To enhance immediate and ongoing safety, and provide
physical and emotional comfort.

**3**. **Stabilization** (if needed) **1**

# [Goal]{.underline}: To calm and orient emotionally-overwhelmed/distraught survivors.

**4. Information Gathering: Current Needs and Concerns**

# [Goal]{.underline}: To identify immediate needs and concerns, gather additional information, and tailor Psychological First Aid interventions.

**5. Practical Assistance**

[Goal]{.underline}: To offer practical help to the survivor in
addressing immediate needs and concerns.

**6. Connection with Social Supports**

# [Goal]{.underline}: To help establish brief or ongoing contacts with primary support persons or other sources of support, including family members, friends, and community helping resources.

# 

# 7. Information on Coping

[Goal]{.underline}: To provide information (about stress reactions and
coping) to reduce distress and promote adaptive functioning

**8. Linkage with Collaborative Services**

[Goal]{.underline}: To in form and link survivors with available
services needed at the time or in the future.

These core goals of Psychological First Aid constitute the basic
objectives of providing early assistance (e.g., within days or weeks
following an event) and will need to be addressed in a flexible way,
using strategies that meet the specific needs of children, families and
adults. The amount of time spent on each goal will vary from person to
person, and with different circumstances according to need.

**1. Contact and Engagement**

**[Goal]{.underline}: To respond to contacts initiated by affected
persons, or initiate contacts in a non-intrusive, compassionate, and
helpful manner.**

The first contact with a survivor is important. If managed in a
respectful and compassionate way, it can help establish an effective
helping relationship and increase the person's receptiveness to further
help. Your first priority should be to manage contacts with persons who
seek you out, especially if a number of people approach you
simultaneously. Make contact with as many individuals as you can. Often
this will be very brief, but even a brief look of interest and calm
concern from another person can be grounding and helpful to people who
are feeling detached or overwhelmed.

  -----------------------------------------------------------------------
  ***Culture Alert:* The type of physical or personal contact that is
  appropriate may vary from person to person and across cultures and
  social groups, for example, how close to stand to someone, how much eye
  contact to make or how acceptable it is to touch someone. You should
  look for clues to a survivor's need for "personal space," and be
  informed about cultural norms through community cultural leaders who
  best understand local customs.**

  -----------------------------------------------------------------------

Others will not seek your help but may benefit from assistance. When you
identify such persons, timing is important. Do not interrupt
conversations. You may try to make nonverbal contact first (e.g., by
returning eye contact). *Do not assume* that people will respond to your
assistance with immediate positive reactions. It may take time for some
survivors or bereaved persons to feel some degree of safety, confidence
and trust. If an individual declines your offer of help, respect his/her
decision and indicate when and where Psychological First Aid providers
will be available later on.

**Introduce Yourself/Ask about Immediate Needs**

Introduce yourself with your name and title, and describe your role. Ask
for permission to talk to them, and explain your objective of finding
out whether there is anything you can do to make things easier, or
helping with ways to help themselves feel better. Unless given
permission to do otherwise, address adult survivors using last names.
Invite the person to sit, try to ensure some level of privacy for the
conversation, and give the person your full attention. Speak softly and
calmly. Refrain from looking around or being distracted. Find out
whether there is any pressing problem that needs *immediate attention*.
Immediate medical concerns have the utmost priority.

  ------------- ------------------------------------------------------------
  Adult/        Hello. My name is \_\_\_\_\_\_\_\_\_\_\_. I work with
  Caregiver     \_\_\_\_\_\_\_\_\_\_. I'm checking in with people to see how
                they are doing, and to see if I can help in any way. Is it
                okay if I talk to you for a few minutes? May I ask your
                name? Mrs. Williams, before we talk, is there something
                right now that you need, like some water or fruit juice?

  Adolescent/   And is this your daughter? (Get on child's eye level, smile
  Child         and greet the child, using her/his name and speaking
                softly.) Hi Lisa, I'm \_\_\_\_\_\_\_\_\_\_\_ and I'm here to
                try to help you and your family. Is there anything you need
                right now? There is some water and juice over there, and we
                have a few blankets and toys in those boxes.
  ------------- ------------------------------------------------------------

When making contact with children or adolescents, it is good practice to
make a connection with a parent or accompanying adult to explain your
role and seek permission. When speaking with a child in distress when no
adult is present, it is important to find a parent or caregiver to let
them know about your conversation.

**2. Safety and Comfort**

[]{.mark}

**[Goal]{.underline}: Enhance immediate and ongoing safety, and provide
physical and emotional comfort.**

Restoration of a sense of safety is an important goal in the immediate
aftermath of disaster. Comfort and a sense of safety can be supported in
many ways. Some strategies to accomplish this include:

-   Do things that are active (rather than passive waiting), practical
    (using available resources), and familiar (drawing on well-learned
    behaviors that do not require new learning) can increase a sense of
    control over the situation.

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-   Get current accurate and up-to-date information, while avoiding
    exposure to inaccurate or re-traumatizing information via media,
    official updates, and informal conversations.

-   Get connected with immediate practical resources (ways to connect
    with loved ones).

-   Get information that is focused on how responders are making the
    situation safer.

-   Be connected with others who have shared similar experiences.

**Ensure Immediate Physical Safety**

Make sure that individuals and families are physically safe to the
extent possible in the situation at hand. If necessary, re-organize the
immediate environment to increase *physical* and *emotional* safety. For
example:

-   Find the appropriate officials who can resolve safety concerns that
    are beyond your ability to control, such as threats, weapons, etc.

-   Remove broken glass, sharp objects, furniture, spilled liquids and
    other objects that could cause people to trip and fall.

-   Place barriers to prevent intrusions by unauthorized persons.

-   Make sure that persons who may be at risk for falling (i.e,
    physically frail individuals) are in areas that don't require the
    use of stairs or are located in lower levels of the shelter.

If there are medical concerns requiring urgent attention, contact the
appropriate unit leader or medical support immediately. Remain with the
affected person or find someone to stay with the affected person until
help can be obtained. Other safety concerns involve:

-   *Threat of harm to self or others* - Look for signs that persons may
    hurt themselves or others (e.g., expresses intense anger towards
    self or others, exhibit extreme agitation). If so, seek immediate
    support for containment and management by medical, EMT assistance,
    or a security team.

-   Shock - If an individual is showing signs of shock (pale, clammy
    skin, weak or rapid pulse, irregular breathing, dull or glassy eyes,
    unresponsive to communication, lack of bladder or bowel control,
    restless or agitated), seek immediate medical support.

**Enhance Sense of Predictability, Control, Comfort, and Safety**

Information can help to re-orient and comfort children and families, and
can include information about:

-   What to do next

-   What is being done to assist them

-   What is currently known about the unfolding event

-   Available services

-   Stress reactions

-   Self-care, family care, and coping

In providing information:

-   Use your judgment as to [whether]{.underline} and [when]{.underline}
    to present information. Does the individual appear able to
    comprehend what is being said, and is he or she ready to hear the
    content of the messages?

-   The most useful information is that which provides assistance in
    addressing immediate needs, reduces fears, answers pressing
    questions, addresses current concerns, and supports coping efforts.

-   Use clear and concise language, while avoiding technical jargon.

**Provide Simple Information about Disaster Response Activities and
Services**

Ask survivors if they have any questions about what is going to happen,
and give simple accurate information about what they can expect. *Be
sure to ask about concerns regarding current danger and safety in their
new situation*. Try to connect survivors with information that addresses
these concerns. If you do not have specific information, *do not* guess
or invent information in order to provide reassurance. Instead, develop
a plan with the person for ways you and he/she can gather the needed
information. Examples of what you might say include:

  ------------ ------------------------------------------------------------
  Adult/       From what I understand, we will start transporting people to
  Caregiver/   the shelter at West High School in about an hour. There will
  Adolescent   be food, clean clothing, and a place to rest. Stay in this
               area. A member of the team will look for you here when we
               are ready to go.

  Child        Here's what's going to happen next. You and your mom are
               going to go together soon to a place called a shelter, which
               really is just a safe building with food, clean clothing,
               and a place to rest Stay here close to your mom until people
               are ready to go.
  ------------ ------------------------------------------------------------

***Do not*** reassure people that they are safe *unless you have
definite factual information that this is the case*. Also do not
reassure people of the availability of goods or services (e.g., toys,
food, medicines, etc.) unless you have definite information that such
goods and services will be available. For example, you may say:

+---------+------------------------------------------------------------+
| Adult/  | Mrs. Williams, I want to assure you that you are in good   |
|         | hands. The fire has been contained, and you and your       |
| Ca      | family are not in danger from the fire. Do you have any    |
| regiver | concerns about your family's safety right now?             |
+---------+------------------------------------------------------------+
| Ado     | We're working hard to make you and your family safe. Do    |
| lescent | you have any questions about what happened, or what is     |
|         | going to be done to keep everyone safe?                    |
+---------+------------------------------------------------------------+
| Child   | Your mom and dad are here, and many people are all working |
|         | hard together so that you and your family will be safe. Do |
|         | you have any questions about what we're doing to keep you  |
|         | safe?                                                      |
+---------+------------------------------------------------------------+

**Attend to Physical Comfort**

Look for simple ways to make the physical environment more comfortable.
If possible, consider things like temperature, lighting, air quality,
access to furniture, and how the furniture is arranged. In order to
reduce feelings of helplessness or dependency, encourage affected
persons to participate in getting things needed for comfort (e.g., offer
to walk over to the supply area with the person rather than retrieving
supplies for them). Help them regain or exercise their ability to soothe
and comfort themselves and others around them. For children, toys like
soft Teddy Bears that they can hold and take care of, can help them to
soothe themselves (Note: avoid offering such toys if there are not
enough to go around to all children who may request them) . You can help
them learn how to take care of themselves by explaining how they can
"care" for their toy, (e.g., "Remember that she needs to drink lots of
water and eat three meals a day -- and you can do that too.")

**Promote Social Engagement**

Facilitate proximity to other people as appropriate. It is generally
soothing and reassuring to be near other people who seem to be coping
adequately with the situation. On the other hand, it is upsetting being
near others who appear very agitated and emotionally overwhelmed. If
they have heard worrying information from others or circulating rumors,
help to clarify these and correct misinformation.

Children, and to some extent adolescents, are particularly likely to
look to adults for cues about safety and appropriate behavior. When
possible, place children near adults or peers who appear relatively calm
given the circumstances, and shield them from close proximity to highly
distressed individuals. Offer brief explanations to children and
adolescents who have observed extreme reactions in other survivors.

  ------------ ------------------------------------------------------------
  Child/       "That man is so upset that he can't calm down yet. Someone
  Adolescent   from our team is trying to help him calm down."

  ------------ ------------------------------------------------------------

As appropriate, encourage people who are coping adequately to talk with
others who are currently distressed or not coping as well. Those coping
adequately may have concerns about being burdened by others' fears and
anger. However, you can reassure them that talking to people, especially
if the conversation focuses on things that people hold in common (for
example, coming from nearby neighborhoods or sharing new information),
can help them support one another. This often reduces a sense of
isolation and helplessness in both parties. If feasible, provide access
to age-appropriate materials that foster soothing activities. For
children, encourage social activities like reading out loud, doing a
joint art activity, and playing cards, board games, or sports.

# Attend to Children Who Are Separated from their Parents

Parents play a crucial role in children's perceived sense of safety
following disasters. In the event that children are separated from their
parents, helping them reconnect quickly is a priority. Try to help
create a sense of security for children while their parents are being
located or during periods of time where parents may become emotionally
overwhelmed and are thus not emotionally accessible to their children.

For children separated from parents, help to create a designated
child-friendly space. This can be a corner or room, ideally separate
from rescue activities, warm, and with one door to control those who
come in and out. Pre-prepared kits with toys, paper and markers, books,
etc. are helpful. Examples of calming, soothing, reassuring activities
that have been found to be useful are playing with Legos or other basic
building materials, using play dough, doing cut-outs or other simple art
projects that keep the hands busy, and working on coloring books
(containing neutral scenes of flowers, rainbows, trees, or cute
animals). Arrange for this space to be staffed with providers who are
known and respected, who can help supervise activities that foster
engagement, active interaction, and education at the appropriate
developmental level. That person should be able to promote calmness
among those children. Older children may be engaged as mentors/role
models for younger children, as appropriate. Do not make any promises
that you may not be able to keep, such as promising that they will be
with their parents soon. Do provide accurate information in
easy-to-understand terms so that the children will know who will be
supervising them and what activities to expect next.

In addition to securing the children's physical safety, it is also
important to protect them from exposure to additional traumatic stimuli
including sights, sounds, or smells that may be frightening. One
psychologist working with a fire department described how responders
would use their big yellow coats to help shield the child from traumatic
sights while leading them to a safe place. The "big coat" analogy is an
important one to keep in mind, as you will temporarily become that cover
for the child. Use this time to find out the children's names, state
your understanding of the situation, and reassure them that you are
taking them to a safe place while adults work to connect them with their
families.

In selecting a safe place for the children to rest while family members
are located, think again about shielding them with a 'big coat'. Try to
find a place that is out of high-traffic areas. Even if you are
positioned away from the injured and dead, children are likely to become
distressed watching adults rush around in their rescue efforts. Finding
rooms or structures to serve as walls can protect children from
traumatic stimuli as well as help them focus on calming and reassuring
activities.

**Protect from Additional Traumatic Experiences and Trauma Reminders**

Protect survivors from unnecessary exposure to additional trauma and
trauma reminders (e.g., reduce exposure to the suffering of others).
Psychological First Aid providers should look for ways to minimize
additional distressing experiences. When necessary, try to shield
survivors from reporters, other media professionals, onlookers or
attorneys. Help protect their privacy.

If survivors have access to media coverage (e.g., television or radio
broadcasts), point out that excessive viewing of such coverage can be
highly upsetting, especially for children and adolescents. Encourage
parents to monitor and limit their children's exposure to the media, and
discuss their children's concerns after such viewing. Parents can let
their children know that they are keeping track of information from the
media, and that children can get this information from them so that they
don't need to watch television. Remind parents to be careful about what
they say in front of their children, and to clarify things that might
have upset them.

  ------------ ------------------------------------------------------------
  Adult/       "You've been through a lot, and it's a good idea to shield
  Caregiver    yourself and your children from further frightening or
               disturbing sights and sounds as much as possible. Even
               televised scenes of the disaster can be very disturbing to
               children. Sometimes children worry that the disaster is
               happening all over again. You may find that your children
               feel better if you limit their television viewing of the
               disaster. It doesn't hurt for adults to take a break from
               all the media coverage, too."

  Child and    "You've been through a lot already. People often want to
  Adolescent   watch TV or look for information on the internet after
               something like this, but this can be pretty scary. It's best
               to stay away from TV or radio programs that show this stuff.
               You can also tell your mom or dad if you see something that
               bothers you."
  ------------ ------------------------------------------------------------

[]{.mark}

[]{.mark}

###### 3. Stabilization (if needed)

# 

# [Goal]{.underline}: To calm and orient emotionally-overwhelmed or disoriented survivors.

Most individuals affected by a disaster or other traumatic incident will
not require stabilization. Expressions of strong emotions, even muted
emotions (e.g., numb, indifferent, spaced-out, or confused), are
expectable reactions to disaster, and do not of themselves signal the
need for additional intervention beyond ordinary supportive contact.

**Stabilize Emotionally-Overwhelmed Survivors**

Observe individuals for signs of being disorientated or overwhelmed.
Signs include:

[]{.mark}

-   Looking glassy eyed and vacant -- unable to find direction

-   Unresponsiveness to verbal questions or commands

-   Disorientation (e.g., engaging in aimless disorganized behavior)

-   Exhibiting strong emotional responses, uncontrollable crying,
    hyperventilating, rocking or regressive behavior

-   Experiencing uncontrollable physical reactions (shaking, trembling)

-   Exhibiting frantic searching behavior

-   Feeling incapacitated by worry

-   Engaging in risky activities

If the person is too upset, agitated, withdrawn, or disoriented to talk,
or shows extreme anxiety, fear, or panic, the Psychological First Aid
provider should consider:

-   Is the person alone or in the company of family and friends? If
    family or friends are present, it may be helpful to enlist their aid
    in comforting or providing emotional support to the distressed
    person. Alternatively, you may take a distressed individual aside to
    a quiet place, or speak quietly with that person while
    family/friends are nearby.

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-   What is the person experiencing? Is he/she crying, panicking,
    experiencing a "flashback" or imagining that the event is taking
    place again? When intervening, address the person's primary
    immediate concern or difficulty, rather than simply trying to
    convince the person to "calm down" or to "feel safe" (neither of
    which tend to be effective).

For children or adolescents, consider:

-   Is the child or adolescent with his/her parents? If so, briefly
    assess the situation to make sure that the adult is coping. Focus on
    empowering the parents in their role of calming their children. Do
    not move in and supplant the parents, and be careful to avoid making
    any comments that may undermine the parents' authority or ability to
    handle the situation. Let them know that you are available to assist
    in any way that they find helpful.

-   If emotionally-overwhelmed children or adolescents are separated
    from their parents or if their parents are not coping well, refer
    below to the options for stabilizing distressed persons.

Options for stabilizing distressed persons include:

-   Respect the person's privacy, and give him/her a few minutes alone.
    Tell them that you will be available if they need you or that you
    will check back with them in a few minutes to see how they are doing
    and if there's anything you can do to help at that time.

-   Remain present, and offer a drink or chair, rather than trying to
    talk directly to the person, as this may contribute to
    cognitive/emotional overload. Make small talk, talk to other persons
    in the vicinity, do some paperwork, or in other ways demonstrate
    that you are occupied with other tasks but available should the
    person need or wish to receive further practical or emotional help.

-   Offer support and help him or her focus on specific manageable
    feelings, thoughts, and goals.

**Talking Points for Emotionally-Overwhelmed Survivors**

***Adults or Caregivers***

-   Intense emotions may come and go like waves.

-   Shocking experiences trigger strong and healthy, but often
    upsetting, self-protective "alarm" reactions in the body.

-   Sometimes the best way to recover is to take a time-out (e.g.,
    breathe deeply, go for a walk).

-   Friends and family are very important sources of support to help you
    calm down.

***Children and Adolescents***

-   These feelings come and go like waves in the ocean. When you feel
    really bad, that's a good time to talk to your mom and dad to help
    you calm down.

-   Even adults need help at times like this.

-   Many adults are working together to respond to the disaster and to
    help people who were affected.

-   Staying busy can help you deal with your feelings and start to make
    things better.

-   Caution adolescents about doing something quickly just to feel
    better, without discussing it with a parent or trusted adult.

+----------+-----------------------------------------------------------+
| Ado      | "Is there anyone who helps you feel better when you talk  |
| lescent/ | to them? Maybe I can help you get hold of them."          |
| Child    |                                                           |
|          | "You are doing a great job of letting grown-ups know what |
|          | you need. It is important to keep letting people know how |
|          | they can help you."                                       |
+----------+-----------------------------------------------------------+

If the person appears extremely agitated, shows a rush of speech, seems
to be losing touch with the surroundings, or is experiencing ongoing
intense crying, it may be helpful to:

-   Ask the individual to listen to you and look at you.

-   Find out if they know who they are, where they are, and what is
    happening.

-   Ask him/her to describe the surroundings, and say where both of you
    are.

-   Clarify what has happened and the order of events (without graphic
    details).

A technique to help stabilize agitated children and adults is called
'grounding.' You can introduce grounding by saying:

"After a frightening experience, you can sometimes find yourself
overwhelmed with emotions or unable to stop thinking about or imagining
what happened." You can use a method called "grounding" to feel less
overwhelmed. Grounding works by turning your attention from your
thoughts to the outside world. Here's what you do...."

-   Sit in a comfortable position with your legs and arms uncrossed.

-   Breathe in and out slowly and deeply.

-   Look around you and identify five non-distressing things that you
    can *see*. Name each thing in your mind, for example you could say,
    "I see the floor, I see a shoe, I see a table, I see a chair, I see
    a person."

-   Breathe in and out slowly and deeply.

-   Next, identify five sounds you can *hear*. Name each thing in your
    mind. For example you could say, "I hear a woman talking, I hear
    myself breathing, I hear a door close, I hear someone typing, I hear
    a cell phone ringing."

-   Breathe in and out slowly and deeply.

-   Next, identify five things you can *feel*. Name each thing in your
    mind. For example, you could say, "I can feel this wooden armrest
    with my hands, I can feel my toes inside my shoes, I can feel my
    back pressing against my chair, I can feel the blanket in my hands,
    I can feel my lips pressed together."

-   Breathe in and out slowly and deeply.

If none of these interventions aids in emotional stabilization,
consultation with mental health colleagues and/or psychiatric
consultation for medication may be indicated.

**4. Information Gathering: Needs and Current Concerns**

# 

# [Goal]{.underline}: To identify immediate needs and concerns, gather additional information, and tailor Psychological First Aid interventions. 

Gathering and clarifying information begins immediately after contact,
and is ongoing throughout Psychological First Aid (as appropriate). As
immediate needs and concerns are identified and addressed, it is useful
to gather and clarify additional information. Remember that in most
Psychological First Aid service delivery contexts, time, survivors'
needs and priorities, and other factors will limit information
gathering. However, although a formal assessment is not appropriate, the
provider may ask pertinent questions to obtain and clarify a variety of
issues that can inform decisions about:

-   Need for Immediate Referral

-   Need for Additional Services

-   Offering a Follow-up Meeting

-   Using Components of Psychological First Aid that may be helpful

It may be especially useful for the provider to ask some questions to
clarify the following:

***Nature and severity of experiences during the disaster***

Children, adolescents and adults who have had the most serious forms of
exposure to direct life-threat to self or loved ones, injury to self, or
witnessing injury or death may likely experience more severe and
prolonged distress. Those who felt extremely terrified and helpless may
also have more difficulty in recovering.

Information about this may be elicited with questions like:

+---------+------------------------------------------------------------+
| Child   | "I know that you've been through a lot of difficult        |
| and     | things. Would it be helpful to talk about any of what you  |
| Ado     | have been through?                                         |
| lescent |                                                            |
|         | Where were you during the hurricane?                       |
|         |                                                            |
|         | Did you get hurt?                                          |
|         |                                                            |
|         | Did you see anyone get hurt?                               |
|         |                                                            |
|         | How afraid were you?                                       |
+---------+------------------------------------------------------------+

> ***Provider Alert:* In clarifying disaster-related traumatic
> experiences, the Psychological First Aid provider should avoid asking
> for in-depth description of traumatic experiences, as this may provoke
> unnecessary additional distress. It is especially important to follow
> the lead of the survivor in discussing what happened during the event.
> Individuals should [not]{.underline} be pressed to disclose details of
> any trauma or loss. On the other hand, if individuals are anxious to
> talk about their experiences, let them know politely and respectfully
> that what would be most helpful now is to get some [basic]{.underline}
> information to be able to help with what is currently needed and plan
> for future care. Let them know that the opportunity to discuss their
> experiences in a proper professional setting can be arranged for the
> future.**

For people with these experiences, provide information about
post-disaster reactions, information about coping, and offer a follow-up
meeting.

***Death of a family member or close friend***

Loss of loved ones under traumatic circumstances is devastating, and
over time can greatly complicate the grieving process.

Information about loss may be elicited with a question like:

  ----------- ------------------------------------------------------------
  Adult/      "Did someone close to you get hurt or die as a result of the
  Caregiver   hurricane? What happened?"

  ----------- ------------------------------------------------------------

For those with loss, provide emotional comfort, information about
coping, information about social support, information on traumatic grief
and offer a follow-up meeting.

***Concerns about immediate post-disaster circumstances and ongoing
threat***

Especially in regard to complicated emergencies, concerns over immediate
and ongoing danger can be a major source of distress.

Information about this may be elicited with questions like:

+---------+------------------------------------------------------------+
| Adult/  | Do you need any information to help you better understand  |
| Ca      | what has happened?                                         |
| regiver |                                                            |
|         | Do you need information about how to keep you and your     |
|         | family safe?                                               |
|         |                                                            |
|         | Do you need information about what is being done to        |
|         | protect the public?                                        |
+---------+------------------------------------------------------------+

For those with these concerns, help with obtaining risk-related
information.

***Separations from or concern about the safety of loved ones***

Separation from loved ones, and concern over their safety, constitute
additional sources of distress in the aftermath of disaster. If not
earlier addressed, information may be elicited with questions like
these:

+---------+------------------------------------------------------------+
| Adult/  | Are you worried about anyone close to you right now?       |
| Ca      |                                                            |
| regiver | Do you know where they are?                                |
|         |                                                            |
|         | Is there anyone especially important like a family member  |
|         | or friend who is missing?                                  |
+---------+------------------------------------------------------------+

For survivors with these concerns, provide practical assistance to help
locate and reunite family members, or develop a strategy for seeking
information about persons of concern.

***Physical illness and need for medications***

Pre-existing medical conditions and need for medications constitute
additional sources of post-disaster distress and adversity. Immediate
medical concerns need to be given a high priority.

Information about this may be elicited with questions like:

+---------+------------------------------------------------------------+
| Adult/  | Do you have any physical or medical condition that needs   |
| Ca      | attention?                                                 |
| regiver |                                                            |
|         | Do you need any medications that you don't have?           |
|         |                                                            |
|         | Do you need to have a prescription filled?                 |
+---------+------------------------------------------------------------+

For those with medical conditions, provide practical assistance in
obtaining medical care and medication. Connect with additional services
if needed.

***Losses incurred as a result of the disaster (home, school,
neighborhood, business, personal property, or pets)***

Extensive material losses and their associated post-disaster adversities
can significantly interfere with recovery, and are often be associated
with feelings of depression, demoralization, and hopelessness over time.

Information about this may be elicited with questions like:

+---------+------------------------------------------------------------+
| Adult/  | Was your home badly damaged or destroyed?                  |
| Ca      |                                                            |
| regiver | Did you lose other important personal property?            |
|         |                                                            |
|         | Did a pet die or get lost?                                 |
|         |                                                            |
|         | Was your business, school, or neighborhood badly damaged   |
|         | or destroyed?                                              |
+---------+------------------------------------------------------------+

For those with losses, provide emotional comfort, practical assistance
to help link with available resources, information about coping, and
information about social support.

***Extreme feelings of guilt or shame***

These extreme negative emotions can be very painful, difficult and
challenging, especially for children and adolescents. Remember that
children and adults may be ashamed to discuss these feelings. One
approach would be to listen carefully for signs of these emotions in
their comments, then make clarifying comments such as:

+---------+------------------------------------------------------------+
| Adult/  | It sounds like you are being really hard on yourself about |
| Ca      | what happened.                                             |
| regiver |                                                            |
|         | It seems like you feel that you could have done more.      |
+---------+------------------------------------------------------------+

For those with these negative emotions, provide emotional comfort and
information about coping.

***Thoughts about causing harm to self or others***

Disasters can evoke overwhelming feelings of grief, anxiety, depression,
and anger. Getting a sense of whether an individual is having thoughts
about causing harm to self or others should be handled sensitively.

Information about this may be elicited with questions like:

+---------+------------------------------------------------------------+
| Adult/  | Sometimes situations like these can be very overwhelming   |
| Ca      | for individuals.                                           |
| regiver |                                                            |
|         | Have you had any thoughts about harming yourself?          |
|         |                                                            |
|         | Have you had any thoughts about harming someone else?      |
+---------+------------------------------------------------------------+

[]{.mark}

For those with these thoughts, escort them to medical services.

***Lack of adequate supportive social network***

Lack of adequate family and community support can greatly interfere with
the ability to cope with distress and post-disaster adversity.

Information about this may be elicited with questions like:

  ----------- ------------------------------------------------------------
  Adult/      Are there family members, friends, or community agencies
  Caregiver   that you can rely on for help in dealing with problems you
              are facing as a result of the disaster?

  ----------- ------------------------------------------------------------

For those in this situation, provide linkage with available resources
and services, information about coping, information about social
support, and offer a follow-up meeting.

***Prior alcohol or drug use***

> ***Provider Alert*: In clarifying prior history of substance use,
> prior trauma and loss, and prior mental health problems (as in the
> sections below) the Psychological First Aid provider should be
> sensitive to the immediate needs of the survivor, avoid asking for a
> history if not appropriate, and avoid asking for in-depth description.
> It may be helpful to link the questions to clear reasons for asking
> (for example, "Sometimes events like this can remind individuals of
> previous bad times\..." "Sometimes individuals who use alcohol to cope
> with stress will notice an increase in drinking following an event
> such as this...").**

Exposure to trauma and post-disaster adversities can exacerbate ongoing
substance use, cause relapse of past substance abuse, or lead to new
abuse.

Information about this may be elicited with questions like:

+---------+------------------------------------------------------------+
| Adult/  | Do you tend to use alcohol, prescription medications, or   |
| Ca      | drugs as a way to cope with stress?                        |
| regiver |                                                            |
|         | Have you had any problems in the past with alcohol or drug |
|         | use?                                                       |
+---------+------------------------------------------------------------+

For those with potential substance use problems, provide information
about coping, information about social support, link to appropriate
services and offer a follow-up meeting.

***Prior exposure to trauma and loss***

Those with a history of exposure to trauma or loss may experience more
severe and prolonged post-disaster reactions, and a "rekindling" of
prior trauma reactions.

Information about this may be elicited with questions like:

+---------+------------------------------------------------------------+
| Adult/  | Sometimes events like this can remind individuals of       |
| Ca      | previous bad times.                                        |
| regiver |                                                            |
|         | Have you ever been in a hurricane or other disaster        |
|         | before?                                                    |
|         |                                                            |
|         | Has some other bad thing happened to you in the past?      |
|         |                                                            |
|         | Have you ever had someone close to you die?                |
+---------+------------------------------------------------------------+

For those with prior exposure, provide information about post-disaster
reactions, information about coping, and offer a follow-up meeting.

***Prior psychological problems***

Those with a history of psychological problems may experience an
exacerbation of these problems and more severe and prolonged
post-disaster reactions.

Information about this may be elicited with a question like:

+---------+------------------------------------------------------------+
| Adult/  | Sometimes events like this can make existing psychological |
| Ca      | problems worse.                                            |
| regiver |                                                            |
|         | Have you ever had any treatment or taken medication for a  |
|         | mental health problem?                                     |
+---------+------------------------------------------------------------+

For those with prior psychological problems, provide information about
post-disaster reactions, information about coping, information about
social support, link with appropriate services, and offer a follow-up
meeting.

***Specific youth, adult, and family concerns over developmental
impact***

Interference with anticipated developmental activities and opportunities
resulting from disaster and post-disaster circumstances may cause
distress and concern.

Information about this may be elicited with questions like:

  ----------- ------------------------------------------------------------
  Adult/      Were there any special things or events (birthday,
  Caregiver   graduation, beginning of the school year, vacation) coming
              up that were disrupted by the hurricane?

  ----------- ------------------------------------------------------------

For those with developmental concerns, provide information about coping
and link with appropriate services.

It is also useful to ask a general open-ended question to make sure that
you have not missed any important information.

  ------------ -----------------------------------------------------------
  Adult/       Is there anything else we have not talked about that is
  Caregiver/   important for me to know?
  Child        

  ------------ -----------------------------------------------------------

The Psychological First Aid provider will need to use judgment about how
to gather this information, how much information to gather, and to what
extent to ask questions, while remaining sensitive to the needs of the
person. If the survivor identifies multiple concerns, summarize these
and help to identify which issue is most pressing.

**5. Practical Assistance**

**[Goal]{.underline}: To offer practical help to the survivor in
addressing immediate needs and concerns.**

Assisting the survivor with current or anticipated problems is a central
component of Psychological First Aid. Ongoing adversities and continuing
problems resulting from a disaster can add significantly to the stress
level of the survivor, distract from self-care, and help maintain
distress reactions. Also, survivors may welcome a pragmatic focus on a
current problem that is uppermost in their mind. Often, it is important
to help them with problem-solving in regard to important problems.

Discussion of immediate needs occurs throughout a Psychological First
Aid contact, and as much as possible, you should help the affected
individual address those needs. Assistance may be helpful because
problem-solving may be more difficult for the survivor under conditions
of stress and adversity.

**Identify the Most Immediate Need(s)**

If several needs or current concerns have been mentioned by the
survivor, it will be necessary to focus on them one at a time. For some
needs there will be immediate solutions (e.g., getting something to eat,
phoning a family member to reassure them that the survivor is OK). It
will not be possible to rapidly solve other needs (e.g., locating a lost
loved one, returning to previous routines, securing insurance for lost
property, acquiring caregiving services for family members), but it may
be possible to take concrete action steps that address the problem
(e.g., completing a missing persons report or insurance form, applying
for caregiving services).

As you collaborate with the survivor, help him or her to select issues
requiring immediate help. For example you might say:

  ----------- -----------------------------------------------------------
  Adult/      "I understand from what you're telling me, Mrs. Williams,
  Caregiver   that your main goal right now is to find your husband and
              make sure he's okay. Not knowing that he's safe and not
              being able to talk to him is very upsetting. We need to
              focus on helping you get in contact with him. In order to
              do that, let's make a plan on how to go about getting this
              information.

  ----------- -----------------------------------------------------------

**Clarify the Need**

Talk with the survivor to specify the problem. If the problem is
understood and clarified, it will be easier to identify practical steps
that can be taken to address it.

**Discuss an Action Plan**

Discuss what can be done to address the individual's need or concern.
The survivor may indicate what he or she would like to be done, or you
can offer a suggestion. Knowing what services are available ahead of
time will ensure that appropriate assistance can be provided about
services related to obtaining food, clothing, shelter, medical, mental
health, spiritual care services, financial assistance, help in
determining the location of missing family members or friends, and
volunteer opportunities for those who feel a need to contribute to
relief efforts. Inform survivors about what they can realistically
expect in terms of potential resources and support, qualification
criteria, and application procedures.

**Act to Address the Need**

Follow through in making an active response. For example, help the
person make contact or set an appointment with a needed service, or
assist them in completing paperwork.

**6. Connection with Social Supports**

# 

# [Goal]{.underline}: To help establish brief or ongoing contacts with primary support persons or other sources of support, including family members, friends, and community helping resources.

**Enhance Access to Primary Support Persons (Family and Significant
Others)**

An immediate concern for most affected persons is being able to
communicate with individuals with whom they have a primary relationship
(e.g., spouse/partner, children, parents, other family members, close
friends, clergy). Social support can play a strong role in recovery from
trauma. Therefore, an important Psychological First Aid objective is to
take practical steps to enable the person to make contact (in person, by
phone, by e-mail) with individuals for whom the person feels the
greatest concern (e.g., a child or frail elderly parent from whom the
person has been separated) or the greatest need to be with right now at
that moment.

**Encourage Use of Immediately Available Support Persons**

If individuals are disconnected from their social support network,
encourage them to make use of immediately available sources of social
support (i.e., yourself, other relief workers, other affected persons),
while being respectful of individual preferences. For example, it can
help to offer adults reading materials (e.g., magazines, fact sheets)
and discuss the material with them. When people are in close proximity
to each other, ask them, as a group, if they have questions or requests
with which you can help. These group discussions can help provide a
starting point for further conversations and encourage social
connectedness.

It can be helpful to bring similar-age children together in a shared
activity - as long as they are not separated from their adult
caregivers. Providing art materials, coloring books, or building
materials can help younger children engage in soothing, familiar
activities. Older children and adolescents can be helpful in encouraging
the younger children to participate. Children may have suggestions of
songs to sing or classroom games that they have played at school during
recess. Several activities can be done with only paper and a pencil:

-   Tic-tac-toe

-   Folding "fortune tellers"

-   Air hockey: wad up a piece of paper and have children try to blow it
    across the table into the other teams goal (Bonus: can be used to
    practice deep breathing exercises)

-   Group drawing: have children sit in a circle, the first child begins
    a drawing. After 10 seconds, that child passes the drawing to the
    child on their right. Continue until everyone has added to the
    drawing. Then show the group the final picture. Suggest that the
    children draw something positive (not pictures of the disaster),
    something that promotes a better sense of protection and safety.

-   Scribble game: pair up youth, one person makes a scribble on the
    paper, their partner has to add to the scribble to turn it into
    something

**Discuss Support-Seeking and Giving**

You can help survivors understand the value of social support, and how
to be supportive to others. For instance, you can share that experts
recommend that connection with others is an important factor in recovery
from a disaster. Let them know that there are differences between normal
stress and traumatic stress, which can cause people to want to avoid
traumatic memories, or feel flooded by the memories. Let them know that,
following trauma, some people choose not to talk about traumatic
experiences at all, or not until a later time when they feel secure
enough re-visit the experience. And when a person feels comfortable
talking, they may need to discuss the event on numerous occasions.
Spending time with people one feels close to and accepted by, without
having to talk, can feel good. For example, your message might be:

+----------+-----------------------------------------------------------+
| Adult/   | "When you're able to leave the Assistance Center you may  |
| C        | just want to be with the people you feel close to. You    |
| aregiver | may find that talking some about what each of you has     |
|          | been through can be helpful. You can decide when and what |
|          | to talk about. You don't have to talk about everything    |
|          | that occurred; only what you choose to share with each    |
|          | person. It's good not to rush the talking, but also not   |
|          | to wait if it would help you or them to talk."            |
+----------+-----------------------------------------------------------+
| Ad       | "When something really upsetting like this happens, even  |
| olescent | if you don't feel like talking, be sure to ask for what   |
|          | you need. Also, you might find that you will feel better  |
|          | if you try to help other people."                         |
+----------+-----------------------------------------------------------+
| Child    | "You are doing a great job of letting grown-ups know what |
|          | you need. It is important to keep letting people know how |
|          | they can help you."                                       |
|          |                                                           |
|          | "You're doing some great things to help the grown-ups     |
|          | too, like keeping an eye on your little brother and       |
|          | talking with these other kids who are scared."            |
|          |                                                           |
|          | "The more help you get, the more you can make things      |
|          | better. Even grown-ups need help at times like this."     |
+----------+-----------------------------------------------------------+

As a helper, you can model positive supportive responses, such as:

> [Reflective comments:]{.underline}
>
> \"It sounds like...\"
>
> \"From what you\'re saying, I can see how you would be....\"
>
> \"It sounds like you\'re saying....\"
>
> \"You seem really....\"

Make sure your reflections are correct by using sentences like:

> "Tell me if I'm wrong ... it sounds like you ..."
>
> "Am I right when I say that you ..."
>
> [Supportive comments]{.underline}
>
> \"No wonder you feel..."
>
> \"It sounds really hard...\"
>
> \"It sounds like you\'re being hard on yourself...\"
>
> \"It is such a tough thing to go through something like this.\"
>
> \"I\'m really sorry this is such a tough time for you.\"
>
> \"We can talk more tomorrow if you\'d like...\"
>
> [Empowering Comments and Questions:]{.underline}
>
> \"What have you done in the past to make yourself better when things
> got difficult?\"
>
> \"Are there any things that you think would help you to feel better?\"
>
> \"I have an information sheet with some ideas about how to deal with
> difficult situations. Maybe there is an idea or two here that might be
> helpful for you....\"
>
> \"People can be very different in what helps them to feel better. When
> things get difficult, for me, it helped me to..... Would something
> like that work for you?\"

If appropriate, distribute handouts such as those provided in
***Appendix E.*** These handouts are intended for adults and older
adolescents. Discuss the following points:

If an individual is reluctant to seek support, there may be many
reasons, including:

-   Not knowing what they need (an perhaps feeling that they should
    know)

-   Feeling embarrassed or weak because of needing help

-   Feeling guilty about receiving help when other are in greater need

-   Not knowing where to turn for help when everyone else also needs
    help

-   Worrying that they will be a burden or depress others

-   Fearing that they will get so upset that they'll lose control

-   Doubting that such support will be helpful

-   Preferring to avoiding thinking or having feeling about what
    happened

-   Telling themselves that "no one can understand what I'm going
    through"

-   Having tried to get help and felt that help wasn't there (feeling
    let down or betrayed)

-   Fearing the people they ask will be angry at them or make them feel
    guilty for needing help

**When Support is [Not]{.underline} Working:**

You may need to inform individuals that if someone they care about is
showing *extreme social isolation or withdrawal*, they can help the
person choose specific ways to be involved with other people in a way
that they feel will be helpful. A friend or loved one may need to also
know that there are other people who can listen if more help is needed
(i.e., primary care doctor, chaplain, support group, or counselor). Let
them know that positive social support, in any way that is acceptable to
them, is one of the most crucial factors in recovery from a disaster.
They can enlist help from others in their social circle so that they all
take part in supporting the person. They can also encourage their
friend/loved one to get involved in a support group with others who have
had similar experiences, or accompany them in seeking professional help.

**7. Information on Coping**

[]{.mark}

**[Goal]{.underline}: To provide information (about stress reactions and
coping) to reduce distress and promote adaptive functioning.**

Disasters can be disorienting, confusing, and overwhelming. Various
types of information can help to re-orient children and adults to their
situation. Such information includes:

-   What is currently known about the unfolding event

-   What is being done to assist them

-   What services are available

-   Post-disaster reactions and how to manage them

-   Self-care, family care, and coping

Psychological First Aid providers should use judgment as to when to
present information, and provide the type of information that is most
pertinent and useful. The most useful information provides assistance in
addressing immediate needs, reducing distress, addressing current
concerns, and supporting positive coping efforts.

**Provide Basic Information about Stress Reactions**

If appropriate, it may be useful to briefly discuss common stress
reactions being experienced by the survivor. Stress reactions may be
alarming for survivors. Some will be frightened or otherwise distressed
by their own responses to an event; some may view their reactions in
negative and distressing ways (e.g., my reactions mean "There's
something wrong with me," or "I'm weak"). Therefore, individuals may
benefit from explanations about reactions that they are experiencing,
and understanding that these reactions are normal and expectable**.**
Some important considerations in the process of educating survivors
about their reactions include:

-   Build any discussion around their individual reactions.

-   Take care to avoid pathologizing survivor responses; don't use terms
    like "symptoms."

-   Distribute the appended handouts consistent with content areas. This
    will allow a way for survivors to review these materials after your
    meeting. Remember that stress may interfere with the ability to
    understand and remember information.

  -----------------------------------------------------------------------
  **[Provider Alert]{.underline}: While it may be helpful to describe
  common stress reactions and note that intense reactions are common but
  often diminish over time, it is also important to avoid providing
  "blanket" reassurance that stress reactions will disappear. This may
  set up unrealistic expectations, resulting in negative views of self if
  reactions persist.**

  -----------------------------------------------------------------------

**Review Common Psychological Reactions to Traumatic Experiences and
Losses**

Especially for individuals who have had significant exposure to trauma
and have sustained significant losses, provide basic psycho-education
about common distress reactions. The Psychological First Aid provider
can review these, again emphasizing that such reactions are
understandable and expectable. Inform survivors that if these reactions
continue to interfere with their ability to function adequately for over
a month, psychological services should be considered.

Many individuals who have had traumatic experiences suffer from ongoing
reactions that are distressing and can lead to difficulties in daily
life.

  -----------------------------------------------------------------------
  **[Provider Alert]{.underline}: The following basic information is
  presented as an overview for the Psychological First Aid provider so
  that issues arising from survivors' past experiences and post-disaster
  reactions can be selectively discussed as appropriate.**

  -----------------------------------------------------------------------

There are three types of posttraumatic stress reactions:

***Intrusive reactions*** are ways in which the traumatic experience
comes back to mind. These reactions include distressing thoughts or
images of the event (e.g., picturing what one saw), or dreams about what
happened. Among children, bad dreams can occur that may not be
specifically about the disaster. Intrusive reactions also include
upsetting emotional or physical reactions to reminders of the
experience. Some people may act like one of their worst experiences is
happening all over again. This is called "a flashback."

***Avoidance and withdrawal reactions*** are ways people use to keep
away from, or protect against, intrusive reactions. These reactions
include efforts to avoid talking, thinking and having feelings about the
traumatic event, and to avoid any reminders of the event, including
places and people connected to what happened. Emotions can become
restricted, even numb, to protect against distress. Feelings of
detachment and estrangement from others may lead to social withdrawal.
There may be a loss of interest in usually pleasurable activities.

***Physical arousal reactions*** are physical changes that make the body
react as if danger is still present. These reactions include constantly
being \"on the lookout\" for danger, startling easily or being jumpy,
irritability, or experiencing outbursts of anger, difficulty falling or
staying asleep, and difficulty concentrating or paying attention.

It is also useful to discuss the role of trauma reminders, loss
reminders, and hardships in contributing to distress.

***Trauma Reminders*** can be sights, sounds, places, smells, specific
people, times of the day, situations, or even feelings, like being
afraid or anxious. Trauma reminders can evoke upsetting thoughts and
feelings about what happened. Examples include the sound of wind, rain,
helicopters, screaming or shouting, and specific people who were present
at the time. Reminders are related to a specific type of event, such as
hurricane, earthquake, flood, tornado or fire. Over time, avoidance of
reminders can make it hard for people to do what they normally do or
need to do.

***Loss Reminders*** can also be sights, sounds, places, smells,
specific people, the time of day, situations, or feelings. Loss
reminders bring to mind the absence of a loved one. Missing the deceased
can bring up strong feelings, like sadness, feeling nervous, feeling
uncertain about what life will be without them, feeling angry, feeling
alone or abandoned, or feeling hopeless. Examples include seeing a
picture of a lost loved one, or seeing their belongings, like their
clothes. Loss reminders can also lead to avoiding things that people
want to do or need to do.

***Change Reminders*** can be things (people, places, things,
activities, or hardships) that remind us of how our lives have changed
from what they used to be as the result of a disaster. This can be
something as simple as waking up in a different bed in the morning, or
going to a different school, or being in a different place. Even nice
tings can remind us of how things have changed, and make us miss what we
had before.

***Hardships*** often follow in the wake of disasters, and can make it
more difficult to recover. Hardships place additional strains on
children and families, and can contribute to feelings of anxiety,
depression, irritability, uncertainty, and mental and physical
exhaustion. Examples of hardships include: loss of home or possessions,
lack of money, shortages of food or water, separations from friends and
family, medical or physical health problems, the process of obtaining
compensation for losses, school closures, being moved to a new area, and
lack of fun things for children to do.

Other kinds of reactions include grief reactions, depression and
physical reactions.

***Grief Reactions*** will be prevalent among those who survived the
disaster but have suffered many types of losses -- including loss of
loved ones, home, possessions, pets, schools, and community. Loss may
lead to feelings of sadness and anger, guilt or regret over the loss,
missing or longing for the deceased, and dreams of seeing the person
again. These grief reactions are normal, vary from person to person, and
can last for many years after the loss. There is no single "correct"
course of grieving. Importantly, personal, family, religious and
cultural factors affect the course of grief. Although grief reactions
may be painful to experience, especially at first, they are healthy
reactions and reflect the ongoing significance of the loss. Over time,
grief reactions tend to include more pleasant thoughts and activities,
such as positive reminiscing or finding positive ways to memorialize or
remember a loved one.

***Traumatic Grief*** occurs when children and adults have suffered the
[traumatic loss]{.underline} of a loved one, and often makes grieving
more difficult. In traumatic death, there is a tendency for the mind
stay focused on the circumstances of the death, including preoccupations
with how the loss could have been prevented, what the last moments were
like, and issues of accountability. Traumatic grief reactions include
intrusive, disturbing images of the manner of death that interfere with
positive remembering and reminiscing, delay in the onset of healthy
grief reactions, retreat from close relationships with family and
friends, and avoidance of usual activities because they are reminders of
the traumatic loss. Traumatic grief changes the course of mourning,
putting individuals on a different time course than may be expected by
other family members. Often, traumatic grief reactions can clash with
the timing of religious rituals and other cultural expressions of
mourning.

***Depression*** can be an additional major concern. Depression is
associated with prolonged grief reactions and strongly related to the
accumulation of post-disaster adversities. Reactions include: persistent
depressed or irritable mood; loss of appetite; sleep disturbance, often
early morning awakening; greatly diminished interest or pleasure in life
activities; fatigue or loss of energy; feelings of worthlessness or
guilt; feelings of hopelessness; and sometimes thoughts about suicide.
Demoralization is a common response to unfulfilled expectations about
improvement in post-disaster adversities, and resignation to adverse
changes in life circumstances.

***Physical Reactions*** may be commonly experienced, even in the
absence of any underlying physical injury or illness. These reactions
include: headaches; dizziness; stomachaches; muscle aches; rapid heart
beating; tightness in the chest; loss of appetite; and bowel problems.

These handouts may be useful and can be found in **Appendix E**.

-   ***Handout: When Terrible Things Happen*** describes common
    reactions and positive/negative coping

-   ***Handouts: Tips for Helping Preschool Age children; Tips for
    Helping School Age Children; and Tips for Helping Adolescents*** are
    intended to be given to parents and caregivers. These describe
    common reactions for children in different age groups (6 years old
    and younger, 6-12 years old, adolescents), and give suggestions on
    ways for parents/caregivers to help their children adjust.

**Provide Basic Information on Ways of Coping**

## It may also be appropriate and helpful to discuss various ways of coping.

## 

## ***Adaptive coping actions*** are those that help to reduce anxiety, lessen other distressing reactions, and improve the situation. In general, coping methods that are likely to be helpful include:

-   Talking to another person for support

-   Getting adequate rest, diet, exercise

-   Engaging in positive distracting activities (sports, hobbies,
    reading)

-   Trying to maintain a normal schedule to the extent possible

-   Scheduling pleasant activities

-   Eating healthy meals

-   Taking breaks

-   Spending time with others

-   Participating in a support group

# Using relaxation methods

# Using calming self talk

-   Exercising in moderation

-   Seeking counseling

-   Keeping a journal

***Maladaptive coping actions*** tend to perpetuate problems. Such
actions include:

-   Using alcohol or drugs to cope

-   Withdrawing from activities

-   Withdrawing from family or friends

-   Working too many hours

-   Getting angry or violent

-   Blaming others

-   Overeating

-   Watching too much TV or playing too many computer games

-   Doing risky or dangerous things

-   Not taking care of oneself (sleep, diet, exercise, etc.)

The aim of discussing positive and negative forms of coping is to:

-   Help survivors consider coping options

-   Identify and acknowledge their coping strengths

-   Explore the negative consequences of maladaptive coping actions

-   Encourage survivors to make conscious choices about how to cope

-   Enhance a sense of control over coping and adjustment

As noted above, ***Handout*: *When Terrible Things Happen*** reviews
positive and negative coping for survivors in general. This handout can
be found in **Appendix E**.

**Demonstrate Simple Relaxation Techniques**

Breathing exercises help reduce feelings of over-arousal and physical
tension. Simple exercises such as these can be taught in a brief period.
Children and adolescents can use these techniques also, and it may be
helpful for parents to prompt their children (or vice versa) to use
these techniques several times a day.

***Handout: Basic Relaxation Exercises*** can be provided to reinforce
the use of relaxation techniques and can be found in **Appendix E**.

+----------+-----------------------------------------------------------+
| Adult/   | Inhale slowly (one-thousand one; one-thousand two;        |
| Ca       | one-thousand three) through your nose and comfortably     |
| regiver/ | fill your lungs all the way down to your belly.           |
| Ad       |                                                           |
| olescent | Silently and gently say to yourself, \"My body is filling |
|          | with calm.\" Exhale slowly (one-thousand one,             |
|          | one-thousand two, one-thousand three) through your mouth  |
|          | and comfortably empty your lungs all the way down to your |
|          | abdomen.                                                  |
|          |                                                           |
|          | Silently and gently say to yourself, \"My body is         |
|          | releasing tension.\"                                      |
|          |                                                           |
|          | Repeat five times slowly and comfortably.                 |
+----------+-----------------------------------------------------------+
| Child    | Let's practice a different way of breathing that can help |
|          | calm our bodies down. Put one hand on your stomach, like  |
|          | this \[demonstrate\]. Okay, we are going to breathe in    |
|          | through our noses. When we breathe in, we are going to    |
|          | fill up with a lot of air and our stomachs are going to   |
|          | stick out like this \[demonstrate\].                      |
|          |                                                           |
|          | Then, we will breathe out through our mouths. When we     |
|          | breathe out, our stomachs are going to suck in and up     |
|          | like this \[demonstrate\].                                |
|          |                                                           |
|          | We are going to breathe in really slowly while I count to |
|          | three. I'm also going to count to three while we breathe  |
|          | out really slowly. Let's try it together. Great job!      |
+----------+-----------------------------------------------------------+

Engaging ways to practice deep breathing:

-   Blow bubbles with a bubble wand and dish soap

-   Blow bubbles with chewing gum

-   Blow paper wads or cotton balls across the table -- make a game of
    it!

**For Parents or Caregivers, Review Special Considerations for
Children**

For parents or caregivers, ***Handouts: Tips for Helping Preschool
Children; Tips for Helping School Age Children; and Tips for Helping
Adolescents*** provide specific information about age-related reactions,
and strategies for addressing these to assist in children's recovery.
They address children 5 years old and younger, children 6-12, and
adolescents. These information sheets should be provided to parents or
caretakers for their use over the next weeks and months. These handouts
can be found in **Appendix E**.

Establishing family routines *to the extent possible* after a disaster
is important for family recovery. It is especially important to
encourage parents and caregivers to try to maintain family routines such
as meal times, bedtime, wake time, reading time, and play time. This can
be done in a shelter or transitional housing.

Encourage youth and family members to pay special attention to taking
care of their *[physical health]{.underline}*. This includes getting
enough sleep, proper nutrition (including fluid intake), proper
exercise, good hygiene, and setting aside time for enjoyable activities.

It is especially important to assist family members in developing a
mutual understanding of their different experiences, reactions and
course of recovery, and to help develop a family plan for communicating
about these differences. For example, a provider might say:

  ----------- -----------------------------------------------------------
  Adult/      Often, due to differences in their experiences during and
  Caregiver   after a disaster, family members will have different
              reactions and different courses of recovery. These
              differences can be difficult for family members to deal
              with, and can lead to difficulties like not feeling
              understood, getting into arguments, or not supporting each
              other. For example, one family member may be more troubled
              by a trauma or loss reminder than other family members.

  ----------- -----------------------------------------------------------

The Psychological First Aid provider should encourage family members to
be understanding, patient, and tolerant of differences in their
reactions, and to talk about things that are bothering them so the
others will know when and how to support them. People can support and
help each other in a number of ways, like listening and trying to
understand, comforting with a hug, doing something thoughtful like
writing a note, or getting their mind off things by playing a game.
Parents need to pay special attention to how their children may be
troubled by reminders and hardships because they can strongly affect how
their children appear and behave. For example, a child may look like he
is having a temper tantrum when actually he has been reminded of a
friend who was hurt or killed.

***Assist with Developmental Issues***

Children, adolescents, adults and families go through stages of
physical, emotional, cognitive and social development. The many stresses
and adversities in the aftermath of a disaster may result in key
interruptions, delays or reversals in developmental progression. The
loss of developmental opportunities or achievements can be experienced
as a major consequence resulting from the disaster. Developmental
progression is often measured by milestones.

+-------------+--------------------------------------------------------+
| **Examples  |                                                        |
| of          |                                                        |
| De          |                                                        |
| velopmental |                                                        |
| M           |                                                        |
| ilestones** |                                                        |
+-------------+--------------------------------------------------------+
| Young       | -   becoming toilet trained                            |
| Children    |                                                        |
|             | -   entering preschool                                 |
|             |                                                        |
|             | -   riding a tricycle                                  |
+-------------+--------------------------------------------------------+
| School Age  | -   learning to read and do arithmetic                 |
| Children    |                                                        |
|             | -   being able to play by rules in a group of children |
|             |                                                        |
|             | -   handling themselves safely in a widening scope of  |
|             |     unsupervised time                                  |
+-------------+--------------------------------------------------------+
| Early       | -   having friends of the opposite sex                 |
| Adolescents |                                                        |
|             | -   pursuing organized extracurricular activities      |
|             |                                                        |
|             | -   striving for more independence and activities      |
|             |     outside of the home                                |
+-------------+--------------------------------------------------------+
| Older       | -   learning to drive                                  |
| Adolescents |                                                        |
|             | -   getting a first job                                |
|             |                                                        |
|             | -   dating                                             |
|             |                                                        |
|             | -   going to college                                   |
+-------------+--------------------------------------------------------+
| Adults      | -   starting or changing a job or career               |
|             |                                                        |
|             | -   getting engaged or married                         |
|             |                                                        |
|             | -   having a child/having children leave home          |
+-------------+--------------------------------------------------------+
| Families    | -   buying a new home or moving                        |
|             |                                                        |
|             | -   going through a separation or divorce              |
|             |                                                        |
|             | -   experiencing the death of a grandparent            |
+-------------+--------------------------------------------------------+
| All Ages    | -   graduations                                        |
| (De         |                                                        |
| velopmental | -   birthdays                                          |
| Events)     |                                                        |
|             | -   special events                                     |
+-------------+--------------------------------------------------------+

In responding to needs and concerns after a disaster, even though
attention will be paid to those that are immediate, children and
families should also be given an opportunity to attend to the disaster's
impact on development. It can be useful to help children and families
identify any of these issues by asking directly.

+----------+-----------------------------------------------------------+
| Parent/  | Are there any special events that the family was looking  |
|          | forward to? Was anyone looking forward to doing something |
| C        | important, like starting school, graduating from high     |
| aregiver | school, or entering college?                              |
+----------+-----------------------------------------------------------+
| Adult    | Are there any goals you were working towards that this    |
|          | disaster has, or might, interfere with?                   |
+----------+-----------------------------------------------------------+
| Child/   | Were there things before the hurricane that you were      |
|          | looking forward to doing? Like a birthday, something fun  |
| Ad       | at school, or going somewhere with a friend.              |
| olescent |                                                           |
+----------+-----------------------------------------------------------+

The Psychological First Aid provider should try to increase appreciation
of family members to these issues, so that they understand the challenge
to each individual, as well as the whole family. Help find alternative
ways for family members to handle the interruption or delay. In helping
to develop a plan to help with these concerns, consider whether:

-   the event can be postponed to a later date

-   the event can be relocated to a different place

-   changes in expectations need to take place so that the family
    members are able to tolerate the postponement

-   steps can be taken to put these changes in place

**Assist with Anger Management**

In post-disaster situations, with stress and adversity, including
difficulty sleeping, some individuals may be irritable and have
difficulty managing their anger. When appropriate, the Psychological
First Aid provider can discuss the following anger management issues.

-   Discuss how the anger is affecting the person's life (e.g.,
    relationship with family members and friends, including effects on
    parenting).

-   Normalize the experience of anger, and discuss specifically how
    anger could increase conflict, push others away, or lead to
    violence.

-   Ask the person to identify changes he/she would like to make.

Some anger management skills that you can suggest include:

-   Taking a "time out" or "cool down"

-   Reminding yourself that being angry will not help you achieve what
    you want, and may harm important relationships.

-   Increasing exercise or other tension-reducing activities

-   Talking to a friend about what's angering you

-   Remembering that when you are feeling particularly angry or
    irritable, have another family member temporarily supervise your
    children's activities

If anger appears uncontrollable, or leads to violence, seek immediate
medical attention, and contact security.

**Address Highly Negative Emotions (e.g., guilt and shame)**

In the aftermath of disasters, survivors may think about what caused the
event, how they reacted, and what the future holds. Some of these
beliefs may add to their distress, especially attributing excessive
blame to themselves. The Psychological First Aid provider should listen
for such negative beliefs, and help survivors to identify alternatives
to the negative beliefs that are causing distress. Some questions that
can facilitate this process are:

-   How else could you look at the situation that would be less
    upsetting and more helpful? What's another way of thinking about
    this?

-   How might you respond if a good friend was talking to
    himself/herself like this? What would you say to them? Can you say
    the same things to yourself?

It may be helpful for the individual to hear that just because he or she
*thinks* she is at fault does not mean that this is true. If the
individual is receptive, you can offer some alternative ways of looking
at the situation. An important role for the Psychological First Aid
provider in this effort is to attempt to clarify misunderstandings,
rumors, and distortions that exacerbate distress, unwarranted guilt, or
shame.

**Help with Sleep Problems**

Sleep difficulties are very common following a disaster or other trauma.
Ask questions to assess the individual's sleep routines and
sleep-related habits. Problem-solve ways of improving sleep, including:

-   Go to sleep at the same time and get up at the same time each day

-   Reduce alcohol consumption: alcohol disrupts sleep

-   Eliminate consumption of caffeinated beverages (e.g., coffee, soft
    drinks) in the afternoon or evening

-   Increase regular exercise, though not too close to bedtime

-   Relax before bedtime by doing something calming, like listening to
    soothing music, or praying.

-   Limit daytime naps to 15 minutes and not napping later than 4pm

-   Discuss that worry over immediate concerns and exposure to daily
    reminders can make it more difficult to sleep, and that being able
    to discuss these and get support from others can improve sleep over
    time.

**Address Alcohol and Substance Use**

When use of alcohol and other substances is a concern:

-   Educate the individual regarding the tendency for many people who
    experience stress reactions to drink or use medications or drugs to
    reduce their bad feelings.

-   Ask the individual to identify what they see as the "pro's and
    con's" of using alcohol or drugs to cope.

-   Discuss and mutually agree on abstinence or a safe pattern of use.

-   Discuss anticipated difficulties in making change.

-   If appropriate and acceptable to the person, make a referral for
    substance abuse counseling.

-   If the individual has previously received treatment for substance
    abuse, encourage him or her to once again seek treatment to get
    through the next few weeks and months.

The ***Handout: Alcohol and Drug Use after Disasters*** gives an
overview of this information, and is intended for adults and older
adolescents who indicate concerns in this area. This handout can be
found in **Appendix E**.

**8. Linkage with Collaborative Services**

**[Goal]{.underline}: To in form and link individuals with available
services needed at the time or in the future.**

**Provide Direct Link to Additional Needed Services**

Providing information should be accompanied by a discussion about which
of the survivor's needs and current concerns require additional
information or services. If the survivor is interested in additional
services, do what is necessary to insure effective linkage with those
services (e.g., walk the survivor over to an agency representative who
can provide a service; set up a meeting with a community representative
who may provide appropriate referrals).

When making a referral:

-   First summarize your discussion with the person about their needs
    and concerns

-   Check for accuracy of your summary

-   Describe the option of referral, including how this may help and
    what will take place if the individual goes for further help

-   Ask about reaction to suggestion of referral

-   Give written referral information, or if possible, make an
    appointment then and there

**Promote Continuity in Helping Relationships**

A secondary, but important concern for many affected persons is being
able to keep in contact with helpers and other persons whom they feel
have been or could be helpful as they continue to deal with the
immediate situation.

[]{.mark}

In most cases, continuing contact between affected survivors and you
will **not** be possible because the affected persons will leave triage
sites or family assistance centers and go to other sites for continuing
services. However, contacts made during the acute aftermath of disasters
can lead to a sense of abandonment or rejection if the Psychological
First Aid provider seems to just "vanish." Therefore, Psychological
First Aid should include the use of strategies for creating a
psychological sense of continuity of care, such as:

-   Give the name(s) and contact information for the local public health
    and public mental health service providers in the community. There
    may also be other local providers or recognized agencies who have
    volunteered to provide post-disaster follow up services for the
    community. (Be wary of referring to unknown volunteer providers. )
    -- Such information may not be known for several hours or days, but
    once available, it can be considerably helpful to disaster
    survivors.

-   Introduce the survivor to other mental health, health care, family
    service, or relief workers so that they know several helpers by name
    rather than only you.

Sometimes, survivors feel as if they are meeting a never-ending
succession of helpers, and that they have to go on explaining their
situation and telling their story to each one in turn. To the extent
possible, this should be minimized. If you are leaving a response site,
it is important to let the survivor know this and to ensure a direct
"hand-off" to another provider, and if possible, one who will be in a
position to maintain an ongoing helping relationship with the person.
Orient the new provider to what he or she needs to know about the
person, and provide an introduction if at all possible.

  ------------ ------------------------------------------------------------
  Adult/       "I'll be here tomorrow and for the rest of the week and will
  Caregiver/   look for you -- if you're here or want to stop by, would you
  Adolescent   look for me and let me know how you and your family/friends
               are doing?"

  Child        "Thanks for staying with your brother, I know that's a big
               help to your parents while they're figuring out how to make
               sure you're all safe. I'll keep checking on you while I'm
               here, and if you have a chance and would like to make a
               drawing that I could keep to remember you, I'd really like
               that. I'll try to say goodbye if I have to go."
  ------------ ------------------------------------------------------------

# Appendix A: MRC Service Delivery Sites and Settings

**Service Site Challenges in Delivering Psychological First Aid**

Medical Reserve Corps members can face many challenges in providing PFA
to disaster survivors and relief personnel. These challenges are often
related to the specific disaster characteristics (e.g. natural vs. human
caused, size, location) and those of the individuals involved (e.g.
populations of special consideration-elders, physically challenged,
youth, disadvantaged groups, individuals with pre-existing psychiatric
illness). Of considerable challenge can be the settings in which medical
reserve corps members are assigned. The following information will be
helpful in anticipating and understanding the unique challenges of some
disaster related service sites.

**General Population Shelters**

When it is determined that a community or area of the community must be
evacuated because of dangerous or threatening conditions, *General
Population Shelters* are opened for the temporary housing of
individuals. General Population Shelters are usually located in schools,
community and recreation centers, or in other large facilities. Shelters
usually have limited space for people to sleep and eat as well as an
area for meals to be served. Typical challenges include establishing
shelter rules (e.g. lights out, regulated use of showers when in limited
supply, feeding hours), addressing the socio-cultural and ethnic issues
that arise when bringing diverse populations together, managing public
health issues (e.g. sanitation, medication dispensing, isolating the
sick) and resolving the inevitable disputes that arise between shelter
residents and each other or between shelter residents and staff.

**Respite Centers**

*Respite Centers* are locations where first responders can rest and
obtain food and clothing and other basic support services. The decision
to open a Respite Center is usually determined if there is evidence that
prolonged rescue and recovery efforts are necessary. Respite Centers are
usually located in close proximity to the direct impact of a disaster.
Typical challenges include limited interaction with responders given the
usual frenetic pace of the response in the early aftermath of disaster,
the urgency on behalf of the responders to continue working, especially
if the response is still in the 'rescue' mode, and in many cases, the
responders need to emotionally 'distance' themselves can create
significant barriers for MRC personnel in providing PFA activities.

**Hospital-Hospital Emergency Room Settings**

During a mass casualty incident, survivors that are triaged on site and
listed as "immediate" will be brought to a hospital. In addition, many
others will self transport to the hospital wanting to be seen in the
Emergency Room. This is likely to create a surge on medical resource
capacity. Psychological causalities, as well as medical causalities, may
arrive in large numbers, as well as those who have combined
psychological and physical symptoms.

One important goal is to facilitate the treatment of injured survivors
by removing individuals who do not require immediate medical care from
the patient flow. However, increased physical symptoms have frequently
been reported after disasters, particularly among those who witness
injury and death, and those who may have had toxic exposure to a
chemical or biological attack. As a result, differential diagnosis may
at times be difficult, since signs and symptoms may be nonspecific
and/or status may change over time. News or rumors of such an attack may
generate thousands who fear they have been exposed, and rapidly
overwhelm the system. Along with a system of triage, hospitals may set
up a "support center" where PFA providers can refer those in need to a
spectrum of psychological, behavioral and pharmacological interventions.

Depending on the incident or numbers, the Emergency Room may experience
a "shut down." While awaiting bed availability, those who are in need of
medical care or who have been decontaminated may be placed in holding
areas for observation. These survivors will benefit from Psychological
First Aid.

If survivors are admitted to the hospital, the integration of medical
care and PFA for medical-surgical casualties is imperative. In addition,
family members, friends and co-workers will come to the hospital, some
of them searching for missing friends and loved ones, others awaiting
news of progress. These individuals may also benefit from PFA.

**Service Centers**

*Service Centers* may be opened by a local or federal governmental
agency or by disaster relief organizations to meet the initial needs of
disaster survivors. These centers typically offer assistance with
locating temporary housing or providing for the immediate personal needs
of disaster survivors, such as food, clothing, and clean-up materials.
Depending on the size and magnitude of the disaster, MRC personnel may
encounter large numbers of survivors seeking services, anger and
frustration expressed by survivors who perceive assistance is not
reaching them in a timely or efficient manner, and aggressive or
hoarding behaviors in those survivors who perceive inadequate supplies
to go around.

**Emergency Operation Center**

On-going mental health support services may also be requested at the
county's *Emergency Operation Center* (EOC). In the aftermath of a
large-scale disaster, the EOC is a chaotic and stressful environment as
county, and other organizational disaster planners and managers are
preparing the disaster relief response.

**Community Outreach Teams**

*Community Outreach Teams* are usually established in the event of
disasters that affect a large geographic area and/or a significant
percentage of the population. These teams are often necessary to avoid
long lines at Service Centers or when transportation services for the
general population are limited. The teams usually represent two (2) or
more individuals that can provide comprehensive services to disaster
survivors. For example, a disaster mental health or spiritual care
professional may be teamed up with a representative from the American
Red Cross who can provide assistance in meeting the survivors' food,
clothing, and shelter needs.

**Emergency First Aid Stations**

*Emergency First Aid Stations* provide basic medical services to
disaster survivors as well as responders who may suffer minor injuries
in the rescue and recovery efforts following a disaster. They are
usually located in close proximity to the direct impact of a disaster.
In the event of a disaster resulting in mass casualties, makeshift
emergency first aid stations may be set up in close proximity of your
healthcare facility in an effort to relieve the burden of emergency room
services and ensure that such high level care is available to the
seriously injured.

**Phone Banks and Hotlines**

Communities and healthcare systems may wish to set up a *Phone Bank* to
address and respond to numerous calls with questions that typically
arise after a disaster. These Phone Banks are likely to be overwhelmed
in the first few hours or days with many questions or concerns regarding
such issues as locating missing or injured family members or healthcare
concerns or issues. Community hotlines may encounter similar questions
and address additional information such as the availability of shelter
locations, mass food distribution sites and other disaster relief
services.

**Points of Dispensing (POD) Centers**

PODs might be established by local, state, or federal public health
agencies in the event of a public health emergency. These centers may be
established to provide mass distribution of medications or vaccinations
in an effort to prevent or mitigate the spread of any communicable
disease or other public health risk. Healthcare facilities may open PODs
with the goal of vaccinating or distributing necessary medications to
its own personnel or to reduce the burden on the community POD sites.

**Volunteer Staging Area**

In the event of large-scale disasters requiring significant volunteer
resources, a *Volunteer Staging Area* may be established by a particular
disaster relief agency, by a local, state, or federal government agency,
or by a healthcare system for its own personnel. Typically, activities
in the Volunteer Staging Area include the registering of volunteers for
duty and the credentialing of those involved in duties requiring
specific skill sets such as mental health or health services. It is
important for you to understand that you will be assigned to a service
site where you are needed most. While you may have a preference for one
site over another, the response needs will require you to be flexible.
Survivors and relief personnel are equally important in our response to
providing mental health and spiritual care.

**Family Reception Centers (FRC)**

*Family Reception Centers* are typically opened in the immediate
aftermath of a disaster involving mass casualties or fatalities. There
is a common recognition that after such disasters, individuals may be
trying to locate family or other loved ones specifically involved in the
disaster or estranged during the evacuation process. Often these are
temporary holding sites until a more structured and operational Family
Assistance Center can be opened. Family Reception Centers may be
established in close proximity to the immediate disaster scene where
individuals arrive in search of family and other loved ones involved in
the incident or in healthcare facilities where the injured have been
transported.

**Family Assistance Centers (FAC)**

*Family Assistance Centers* are commonly opened in the event of a
disaster involving mass casualties or fatalities. These centers usually
offer a range of services in an effort to meet the needs of individuals
under these circumstances. Mental health services, spiritual care,
catering, and crime victims' services, as well as the services of law
enforcement, the medical examiner, disaster relief agencies, and other
local, state, and federal agencies are also offered on site. Family
Assistance Centers are usually located away from the immediate disaster
site, though it is important to note that many times, family members
will request visits to the affected site or memorial services will be
planned, and thus the FAC should be close enough to facilitate those
activities.

**First Responder and Disaster Relief Personnel Units**

Individuals belonging to First Respond units[^3] or other disaster
relief response groups may experience a range of reactions as a result
of in the aftermath of their disaster response. These reactions do not
typically result in severe psychological dysfunction and rarely require
extensive mental health intervention. In fact, most reactions will cause
minor distress for the individual and will remit over a relatively short
period of time. A small minority of workers will require more
significant mental health intervention for their reactions, typically
administered later in the individual's recovery.

For many first responder units, a mandated (or strongly encouraged or
entirely voluntary) group intervention in the aftermath of a disaster or
other critical incident has become part of their unit's post-disaster
routine. Often these group interventions, which focus on the goal of
mitigating future psychological distress in those exposed to such
events, follow a prescribed, structured process, known as a
demobilization, defusing, or a critical incident stress debriefing. On
occasion MRC units, or their members, are invited to facilitate these
structured group interventions or act as co-facilitators or 'mental
health consultants' when internal or external peer group facilitators
are used.

Given the MRC's position statement on psychological debriefing and
similarly structured interventions that include the detailed recounting
of one's disaster experience (see Appendix B), special caution and
consideration must be given to these requests for assistance.

All efforts should first be made to support the provision of
Psychological First Aid individually to unit members. If a group process
is advised, consider using a psychoeducational format. That is, provide
group participants with information regarding the common or anticipated
stress reactions typically identified in responder groups following
disaster and specific methods for engaging stress relief or self-care
activities. It is also advisable to provide participants with
information that assists them in identifying reactions that may require
or necessitate additional mental health assistance and the local mental
health resources available to provide such services.

**Appendix B: Position Statement and Guidance for MRC Units on
Psychological Debriefing**

Medical Reserve Corps

National Disaster Mental Health Work Group

April 2006

The National MRC Mental Health Work Group has developed this position
statement on the use of ***psychological debriefing*** as an early
mental health intervention in the aftermath of disasters. This position
statement is intended to assist individual MRC units and the response
community in the development of policy and practice as they relate to
the provision of acute mental health services for disaster survivors and
MRC personnel.

***Recommendation:***

*Because of the possibility of psychological harm to individual
participants, 'Psychological Debriefing' should NOT be a part of the
standard mental health response to crisis and disaster situations.*

*Mandatory or 'required' psychological interventions should not be
universally applied to survivors or responders following disaster.*

**Rationale**

Major controversy has evolved over the use of psychological debriefing
as an early intervention strategy for individuals or responders exposed
to disasters or other major traumatic events. Additionally, considerable
ambiguity surrounding the term 'debriefing' and inconsistencies in how
debriefings are conducted have added to this controversy and confusion
in the field.

Mental health experts, professional organizations and a number of
federal and state task forces have consistently advised and recommended
that psychological debriefing not be utilized as a standard early
intervention technique.

This has come about, in part, due to research that suggests:

> **There is no convincing evidence that psychological debriefing
> prevents PTSD or other trauma-related mental disorders.**[^4]
>
> **Some individuals may be harmed by debriefing, with the "systemic
> ventilation of feelings" as the potentially most harmful phase.**[^5]
>
> **An individual sense of control or mastery is important in (one's)
> recovery.**[^6]

**Background**

The Medical Reserve Corps (MRC), as one of the newest organizations in
the disaster response community, has evolved rapidly since its creation
in 2002, by the Office of the Surgeon General, United States Public
Health Service (USPHS). With more than 400 individual units and over
70,000 members, MRCs have become a prominent vehicle for
pre-registering, credentialing and training health (and mental health)
professional volunteers in disaster response.

As the MRC program evolved, it became evident that individual MRC units
were seeking assistance in interpreting best practices and developing
response guidelines across a host of operational areas. In response, the
MRC National Program Director, Commander Robert Tosatto, USPHS,
initiated several work groups to help identify some common guidelines
and policy objectives for MRC units to consider, while at the same time
respecting the local autonomy of each individual unit. One of these
focus areas is Disaster Mental Health.

The MRC Mental Health Work Group was convened to provide guidance to
local MRC units specifically in the areas of disaster mental health
where to date, no standard approach exists and response strategies
remain unclear. Upon examination of the field the MRC Mental Health Work
Group identified a host of issues pertinent to MRC policy and field
operations that need to be addressed. These issues include:

-   establishing professional core competencies to insure a consistent,
    well-trained workforce;

-   identifying existing training curricula or developing new curricula
    that embrace these competencies;

-   identifying and resolving gaps in service delivery;

-   clarifying and resolving controversies related to the provision of
    MRC-related disaster mental health interventions in the field.

While each of the above issues is critical to establishing a highly
skilled volunteer workforce, most at issue is the current controversy
surrounding psychological debriefing.

**Overview and Clarification of the Term Debriefing**

Debriefing as a concept has evolved over the years into an ambiguous
term. Even among emergency services and disaster operations personnel,
there is *no uniform application* of the term. It is extremely important
to understand these different meanings to ensure that we are
communicating the correct message and providing appropriate care to
those exposed to traumatic events, including victims, their families and
response personnel.

*Operational debriefing* is an organizational process and is *not*
considered a psychological intervention. An operational debriefing is
typically implemented shortly after a major event or training exercise
to review the process of the response and identify successes and
failures of the activity.

The primary intent of *operational debriefing* is to gather information
about an event for leadership and to convey important "lessons learned"
to the participants. Operational debriefings also allow the opportunity
to problem-solve current response needs and identify potential sources
of support for response personnel. The operational debriefing process
has been used extensively by military and civilian agencies for
intelligence gathering and informational purposes, providing an
evaluative or quality improvement component to response activities and
field operations.

"*Operational debriefing,* in first responder settings, **is not a
psychological intervention** but a collection of shared information
(minus emotional processing), and may be helpful in allowing the
construction of a more coherent, shared narrative of the incident among
those who have worked together or have a shared support system,"[^7].

*Psychological Debriefing* is a technique of early intervention employed
after a traumatic event with the intent of helping an individual process
the event and its linked emotional content. One of the more commonly
used *psychological debriefing* techniques is Critical Incident Stress
Debriefing (CISD). CISD, a component of Critical Incident Stress
Management (CISM), has been widely embraced by first responder
populations (police, fire, and EMS) as a mechanism for supporting
personnel in the aftermath of potentially psychologically distressing
events.

In 2001 the National Institute of Mental Health (NIMH) convened a group
of disaster mental health experts to explore the efficacy of early
psychological interventions and attempt to clarify the controversy
surrounding *psychological debriefing*. These consensus findings were
also intended to provide some guidance for the provision of mental
health intervention in the early aftermath of mass violence and other
disasters. The group's findings in relation to debriefing were as
follows:

> *There is **some** Level 1 evidence (Level 1 evidence is considered
> the most reliable type of evidence in most cases) suggesting that
> early intervention in the form of **a single one-on-one recital of
> events and expression of emotions** evoked by a traumatic event (as
> advocated in **some forms** of psychological debriefing) **does not
> consistently reduce risks** of later developing PTSD or related
> adjustment difficulties.*
>
> *Some survivors (e.g., those with high arousal) may be put **at
> heightened risk for adverse outcomes** as a result of such early
> interventions*[^8]*.*

Over the past five years mental health experts have continued to review
the literature on the efficacy of psychological debriefing and have
found similar conclusions. Ørner, Kent, Pfefferbaum, Raphael, and
Watson, reaffirmed the NIMH psychological debriefing findings and
stated:

> ***There is currently no empirical evidence to support any
> intervention that utilizes components of trauma remembrance and
> emotional processing in the early phases following mass
> violence....***
>
> ***The most positive results from early interventions are usually for
> those that mobilize community support and address survivors' human
> affiliation needs (e.g. helping survivors establish contact with
> relatives) rather than interventions that focus on individual
> psychological reactions.***[^9]

**Summary and Recommendations**

It is becoming clear across all emergency and disaster mental health
disciplines\--there is no "one size fits all" approach to addressing and
responding to the mental health consequences of disasters. It is
critical that those responsible for community planning and response
begin to develop an integrated and flexible mental health response plan
that is guided by the evidence\-- when evidence exists.

Because the findings (cited previously in this Position Statement and
those included in the endnotes of this appendix) suggest that
*psychological debriefing* does not prevent trauma-related mental health
problems and puts some exposed persons at risk of adverse outcomes, it
is the recommendation of this work group that *psychological
debriefing*, or *techniques that include trauma remembrance and
emotional processing*, should *NOT* be part of the routine MRC mental
health response to disaster or other crisis situations.

The disaster mental health response begins long before a disaster occurs
and should be an integral part of the overall community disaster plan.
Ideally, plans will include an early focus on community education,
discussions of realistic expectations following events, risk
communication methods and content, triage and screening-both on the
scene and in hospitals, as well as post-event availability of
psychoeducational informaiton, community resilience activities,
individual and group crisis counseling and more definitive mental health
treatment, when indicated for those more severely affected by disaster.

Further, the responsibility for providing supportive interventions
during disaster can and should extend beyond just the mental health
professional alone. Educating and training all disaster responders in
the concepts of Psychological First Aid (PFA) or other supportive
problem- solving and comfort care activities, strengthens the overall
disaster response and ensures that those individuals impacted by
disaster and its aftermath have a greater opportunity to have their
practical and psychosocial needs addressed early on, and as a result,
potentially minimize long- term psychological consequences.

MRC Psychological Debriefing Position Statement Work Group: Jack
Herrmann, John Hickey, Edward M. Kantor, Patricia Santucci, James M.
Shultz, and Alan Steinberg.

**Additional Resources**

Bisson J, Jenkins P, Alexander J, Bannister C. (1997). Randomised
controlled trial of psychological debriefing for victims of acute burn
trauma. *Br J Psychiatry*, 171, 78-81.

Carlier IVE, Lamberts RG, van Uchelen AJ, Gersons BPR. (1998). Disaster
related post-traumatic stress in Police Officers: A field study of the
impact of debriefing. Stress Medicine, 14, 143-148.

Carr VJ, Lewin TJ, Webster RA, Kenardy JA. (1997). A synthesis of the
findings from the quake impact study: a two-year investigation of the
psychosocial sequelae of the 1989 Newcastle earthquake. *Int J Soc
Psychiatry Psychiatr Epidemiol*, 32, 123-136.

Litz, B., Gray, M., Bryant, R., Adler, A. (2005). Early Intervention for
Trauma: Current Status and Future Directions. Retrieved April 3, 2006,
from
<http://www.ncptsd.va.gov/facts/disasters/fs_earlyint_disaster.html>

MacFarlane AC. (1998). The longitudinal course of posttraumatic
morbidity: the range of outcomes and their predictors. *J Nerv Ment
Disorders,* 176, 30-39.

Mitchell J. (1983). When disaster strikes . . . the critical incident
stress debriefing procedure. *J Emerg Med Serv*, 8, 36-39.

Raphael B, Meldrum L, McFarlane A. (1995). Does debriefing after
psychological trauma work? *BMJ*, 310, 1479-1480.

Raphael B, et al. (2000). Critical incident stress management and
critical incident stress debriefings: evolutions, effects and outcomes.
In B. Raphael and J. Wilson (Eds.), *Psychological Debriefing: Theory,
Practice and Evidence* (pp71-90). London: Cambridge University Press.

Small R, Lumley J, Donohue L, Potter A, Waldenström U. (2000).
Randomised controlled trial of midwife led debriefing to reduce maternal
depression after operative childbirth. *BMJ*, 321, 1043-1047.

Wessely, S., Rose, S., & Bisson, J. (1998). *A systematic review of
brief psychological interventions (\"debriefing\") for the treatment of
immediate trauma related symptoms and the prevention of posttraumatic
stress disorder* \[CD-ROM\]. Oxford, UK: Update Software, Inc.

**Appendix C: Missing Persons, Bereavement, Death Notification, and Body
Identification**

**The PFA provider may lend support and practical assistance to
children, adults and families in the following post-disaster
circumstances:**

-   When a family member or friend is missing

-   When a family member or close friend has died

-   When death notification is made

-   When body identification is requested

-   When body recovery is likely to be delayed

  -----------------------------------------------------------------------
  ***Culture Alert:* Beliefs and attitudes about death, funerals, and
  expressions of grief are strongly influenced by family, culture,
  religious beliefs, and rituals related to mourning. You should inform
  yourself about cultural norms with the assistance of community cultural
  leaders who best understand local customs. Even within cultural and
  religious groups, belief and practices can vary widely. Do not assume
  that all members of a given group will believe or behave similarly. It
  is important for families to engage in their own traditions, practices,
  and rituals to provide mutual support, seek meaning, manage a range of
  emotional responses and death-related adversities, and honor the
  death.**

  -----------------------------------------------------------------------

# When a Family Member is Missing

Worry about a missing loved one is extremely distressing. Family members
may experience a number of different feelings: worry, hope, anger,
turmoil, shock, gratitude, or guilt. They may alternate between
certainty that the person is alive - even in the face of contradictory
evidence - and hopelessness and despair. They may blame authorities for
perceived ineptitude or delays. They may also feel vengeful against
those that they consider responsible for their presumed loss and may be
frustrated by what they consider to be inadequate efforts or resources
devoted to locating their missing relative or friend.

An important way that you can assist family members who have a missing
relative, friend or neighbor is to help them obtain updated information
about the missing person(s). You should be familiar with the local
post-disaster system and locations for updated "debriefings," and
methods for connecting/reuniting survivors. If registries or other
mechanisms are available, have family members place their own names in
the registry, as well as use it to search for missing loved ones. The
wait to register or receive new information is filled with anxiety and
apprehension.

The PFA provider, if possible, may want to take extra time with
survivors worried over a missing family member. Just being there to
listen to their hopes and fears, and being honest in giving information
and answering questions is often deeply appreciated.

In assisting family members who may be preoccupied with concerns over a
missing loved one, the PFA provider should help to insure that care is
taken to prevent young children from wandering away in what may be a
strange environment. Family members should be encouraged to make sure
that they and their children get enough nourishment and sleep.

The PFA provider can review with the family any pre-disaster plans for
post-disaster contact, including:

-   School or workplace evacuation plans, plans for tracking transport
    of students or co-workers for medical care, and locations set up for
    reunification

-   Out-of-state telephone numbers to be used by schools, workplaces, or
    families in case of emergency

-   Pre-arranged or likely meeting places (including homes of relatives)
    families may have established, both within and outside the disaster
    perimeter

As local cell phones may not operate after a disaster, if available in
the setting, help family members gain access to working cellular phones
to locate a missing loved one or to contact relatives who may be worried
about them.

Some family members may want to leave a safe area to attempt to find or
rescue a missing loved one. As this may not be advisable, the PFA
provider should know about the current circumstances in the search area.
This includes the specific dangers of such a search, needed precautions,
and other options, including telling survivors about the efforts of
first responders and when updated information may be available. Those
who may feel most urgent about leaving a safe area include:

-   Adults with missing elderly parents

-   Parents/caregivers of missing children

-   Adolescents with a missing parent or close friend

It may comfort some family members to keep a small personal item and or
photograph of the missing person with them. When it is feasible, this
may be encouraged as an alternative to leaving a safe area when it is
not advisable. It is helpful to discuss specific concerns they may have
(e.g., an elderly parent who recently had hip surgery, or a child who
needs special medications) and offer to inform first responder teams.

In some cases, authorities may ask survivors to give information or
provide other evidence to help the search. Authorities may have family
members file a missing persons report or provide information about when
and where the person was last seen, who else was there, and what he or
she was wearing. It is best to limit the exposure of younger children to
this process.

It can be disturbing and confusing for a child to be present at a
caregiver's interview with authorities or to hear adult speculations
about what might have happened to the person. Authorities may ask a
family member to collect DNA from a loved one's personal effects, for
example, hair from a hairbrush. Observing this can also be disturbing to
a young child. It is extremely important to reassure children that the
family, police, and other experts are doing everything possible to find
the missing loved one.

In rare cases, a child may need to be interviewed because he/she was the
last one to see the person. A mental health or forensic professional
trained to interview children should conduct the interview or be
present. A supportive family member should always accompany the child.
Children should be told about the interview in simple and honest
language.

  ------------- -----------------------------------------------------------
  Adolescent/   Uncle Mario is missing. Everyone is working very hard to
  Child         find out what happened. The police need to ask you some
                questions. It's okay if you do not remember something. Just
                tell them that you don't remember. Not remembering
                something will not hurt (name). Your mom will stay with you
                while they ask the questions, and I can stay too, if you
                want. Do you have any questions?

  ------------- -----------------------------------------------------------

A very young child may provide more useful information if first asked to
draw what he/she remembers and then talk about the picture.

Forensic experts may seek permission to swab the inside of a family
member's cheek to match DNA. When DNA must be collected from a family
member, usually it is taken from the nearest living maternal-line
relative. All efforts are made to avoid collecting DNA from a child.
However, if a child is the closest living maternal-line relative, and
the family chooses to participate, authorities might need to swab the
inside of the child's cheek to collect cells or even take blood. If this
must be done, it should: (1) be explained to the child in simple, honest
language; (2) be demonstrated on an adult family member; and (3) done
gently and slowly, with continuing simple explanations to the child.

In assisting children, adults and families, the PFA provider should
repeat and reinforce the information already provided to the family.

## When a Family Member or Close Friend has Died

  -----------------------------------------------------------------------
  ***Acute Grief Reactions*** are likely to be intense and prevalent
  among those who have suffered the loss of a loved one or close friend:
  sadness and anger over the loss, guilt or regret over not having been
  able to prevent the death, provide comfort, or have a proper
  leave-taking, missing or longing for the deceased, and strong desires
  for reunion (including dreams of seeing the person again). Grief
  reactions vary from person to person and in intensity for years after
  the loss. There is no single "correct" course of grieving. Importantly,
  personal, family, religious and cultural factors affect the expression
  and course of grief. Although painful to experience at first, grief
  reactions are healthy reactions that reflect the significance of the
  loss. Over time, grief reactions tend to include more pleasant thoughts
  and activities, such as telling positive stories about a loved one and
  finding constructive ways to memorialize or remember him/her. Remember
  that grief puts people at risk for abuse of over-the-counter
  medications, increased smoking, and consumption of alcohol. Survivors
  should be made aware of these risks and the importance of self-care and
  the availability of professional help.

  -----------------------------------------------------------------------

Treating acutely bereaved children and adults with dignity, respect and
compassion is the overriding principle. In working with children and
families who have experienced the death of a family member or close
friend, the PFA provider can communicate the following to adults,
caretakers, and children:

-   Family members and friends will each have their own special set of
    reactions.

-   No particular way of grieving is right or wrong.

-   Do not expect that there is a "normal" period of time for all types
    of grief.

-   Discuss with family members and friends how culture or religious
    beliefs influence how you grieve, and especially how the rituals may
    or may not match current feelings of each family member.

-   Keep in mind that children may only show their grief for short
    periods of time each day, and even though they may play or engage in
    other positive activities, their grief can be just as that of any
    other family member.

-   Young children often need more than one honest and clear talk about
    death.

-   What is most helpful for family members and friends is to respect
    and understand how each may be experiencing their own course of
    grief.

-   Some children and adolescents will not have words to describe their
    feelings of grief and may resist talking with others about how they
    feel.

-   For some children, distracting activities will be more calming
    rather than conversation, e.g., drawing, listening to music,
    reading, etc.

-   Some adolescents may wish to be alone. If safe, provide them with
    some privacy.

  -----------------------------------------------------------------------
  **The PFA provider should keep in mind that grief is influenced by: 1)
  the way that the person died; 2) the kind of supports available from
  family and friends; 3) prior relationship with the deceased; 4) age and
  experience with loss; and 5) the felt consequences of the loss for that
  child, adult or family.**

  -----------------------------------------------------------------------

Someone who has lost a family member or close friend may want to talk
about the loved one. The PFA provider should listen carefully---and with
sympathy---for what they have experienced. Do not feel that you have to
talk a lot. Do not probe. Use the deceased person's name, rather than
referring to him/her as "the deceased."

***Don't say:***

-   I know how you feel.

-   It was probably for the best.

-   He is better off now.

-   It was her time to go.

-   At least he went quickly.

-   Let's talk about something else.

-   You should work towards getting over this.

-   You are strong enough to deal with this.

-   You should be glad s/he passed quickly.

-   That which doesn't kill us makes us stronger.

-   You'll feel better soon.

-   You did everything you could.

-   You need to grieve.

-   You need to relax.

-   It's good that you are alive.

-   It's good that no one else died.

-   It could be worse; you still have a brother/sister/mother.

-   Everything happens for the best according to a higher plan.

-   We are not given more than we can bear.

-   (To a child) You are the man/woman of the house now.

-   Someday you will have an answer.

If a person who has lost a loved one says any of the above things, you
can respectfully *acknowledge* the feeling or thought (for example,
"It's helpful for you to know that he didn't suffer, even though you
really wish he could have survived"). Just don't *initiate* these
statements yourself.

***Do:***

-   Reassure grieving individuals that what they are experiencing is
    understandable and expectable.

-   Let them know that they will most likely continue to experience
    periods of sadness, loneliness or anger.

-   Tell them that if they continue to experience feelings of depression
    beyond three to six months, talking to a member of the clergy or to
    a counselor who specializes in grief is advisable.

-   If they have a prior history of significant depression, let them
    know that they may wish to consult with someone at even an earlier
    time.

-   Tell them that their doctor should be able to refer them to a
    counselor. They can also contact their city or county department of
    mental health or local hospital for a referral to appropriate
    services.

  -----------------------------------------------------------------------
  **Physical Touching: Many cultures have strict rules about physical
  space between people, eye contact, and the appropriateness of physical
  touching, especially of the opposite sex. Until you become familiar
  with the rules for the culture of the family, you should not approach
  too closely, make prolonged eye contact, or touch. In working with
  family members, it is important for the PFA provider to find out who is
  the spokesperson for the family.**

  -----------------------------------------------------------------------

### Talking to Children and Adolescents about Death and Loss

Children's understanding of death varies depending on age and prior
experience and is strongly influenced by family, religious, and cultural
values.

-   Pre-school children may not understand that death is permanent, and
    may believe that if they wish it, the person can return. They need
    help to confirm the physical reality of a person's death---that
    he/she is no longer breathing, moving or having feelings---and has
    no discomfort or pain. They may be concerned about something
    happening to another family member.

-   School-age children may understand the physical reality of death,
    and think of death as a monster or skeleton. In longing for his/her
    return, they may experience upsetting feelings of the "ghostlike"
    presence of the lost person, but not tell anyone.

-   Adolescents understand that death is irreversible. Losing a family
    member or friend can trigger rage and impulsive decisions, (quitting
    school, running away, or abusing substances). These issues need
    prompt attention by the family or school.

  -----------------------------------------------------------------------
  **Losing a parent or guardian affects children differently depending on
  their age. When a toddler loses a parent/caregiver, he/she needs
  consistent care and a predictable daily routine as soon as possible.
  Toddlers are easily upset by change: food prepared differently, their
  special blanket missing, or being put into bed at night without the
  usual person or in a different way. Caregivers (including the surviving
  parent) should ask the child if they are doing something differently or
  something "wrong," (e.g., Am I not doing this the way Mommy did?). A
  school-age child loses not only their primary caretaker, but also loses
  the person who would normally be there to comfort him/her and help with
  daily activities. Other caretakers should try, as best they can, to
  assume these roles. Children may be angry at a substitute caregiver,
  especially when disciplined. Caregivers should acknowledge that the
  child is missing his family member or friend, and then provide extra
  comfort. A teenager whose parent, sibling, or close friend has died may
  have an intense sense of unfairness, and protest over the loss. They
  may have to take on greater responsibilities within their family, and
  resent not being able to have more independence. Over time, caregivers
  should discuss with teens how to balance these different needs.**

  -----------------------------------------------------------------------

When assisting parents in talking with their children about death, keep
the following in mind:

-   Be at the child's eye level when talking with them.

-   Assure children that they are loved and will be cared for.

-   Watch for signs that the child may be ready to talk about what
    happened.

-   Do not make the child feel guilty or embarrassed about wanting to
    talk.

-   Do not push children to talk.

-   Give short, simple and honest age-appropriate answers to their
    questions.

-   Listen carefully to their feelings without judgment.

-   Reassure them that they did not cause the death, and that it was not
    a punishment for anything that anyone did "wrong."

-   Answer questions honestly about funerals, burial, prayer, and other
    rituals.

-   Be prepared to discuss the same things again and again.

-   Do not be afraid to say that you don't know the answer to a
    question.

The PFA provider should give information to parents/caretakers and
children about reactions they might experience. Children's overt
reactions to the loss may be intense and immediate, or appear only after
several days or weeks. Clarifying that each family member should be
sensitive to each other's unique experience of grief, and that some may
need special attention. Families should know that remembering and
reminiscing are, and will be an important part of grieving.

When speaking to parents/caretakers, the PFA provider can say:

  ----------- -----------------------------------------------------------
  Parent/     "Although feelings about the loss may be there all the
  Caregiver   time, there may be moments when you feel it very strongly.
              Some of these moments everyone will share in common, and it
              is a good time to give each other extra support and
              comfort. Some of these moments will be very private for
              each family member. It is okay to take some time for
              yourself, but it is often good to let others in the family
              know when this happens and how they can be of help."

  ----------- -----------------------------------------------------------

The PFA provider can also add:

+----------+-----------------------------------------------------------+
| Parent/  | "It can be helpful to think about times when your         |
| C        | children will particularly miss their family member, like |
| aregiver | at mealtime or bedtime. If you say something like, 'It is |
|          | hard not to have daddy here with us right now,' you can   |
|          | ease the discomfort everyone is feeling, make children    |
|          | feel less alone, and help them to better handle these     |
|          | difficult times."                                         |
|          |                                                           |
|          | "When you see a sudden change in your child---looking     |
|          | kind of lost or sad or even angry---and you suspect       |
|          | he/she is missing the family member, let him/her know     |
|          | that you, too, have times when you feel that way. Say     |
|          | something like, 'You seem really sad, I'm wondering if    |
|          | you are thinking about your dad. Sometimes I feel very    |
|          | sad about dad too. It's ok to tell me when you are        |
|          | feeling bad so maybe I can help.' Help by giving them     |
|          | some time alone with those feelings, sitting quietly with |
|          | them, and giving them a hug."                             |
+----------+-----------------------------------------------------------+

Let family members know that there may be differences in how much each
wants to talk about the lost loved one. You can say:

+----------+-----------------------------------------------------------+
| Adult/   | "Each of you may have different ways to deal with the     |
|          | death right now. Sometimes you will want to talk about    |
| Ad       | person. Other times you will feel like being by yourself  |
| olescent | and quiet. Family members need to respect what each is    |
|          | feeling so that you do not get upset with each other over |
|          | differences in how each family member is responding."     |
+----------+-----------------------------------------------------------+

Children and adolescents sometimes feel guilty that they have survived
while other family members have not. They may believe that they caused
the death is some way. Families need to help dispel children's sense of
responsibility, and assure them that in events like this, they are not
to blame for what happened. For example, you may suggest that a
caregiver say:

+----------+-----------------------------------------------------------+
| Parent   | "We all did what we could to try to save everybody. Daddy |
| to       | would be so happy that we are all okay. You did not do    |
| Ado      | anything wrong."                                          |
| lescent/ |                                                           |
| Child    | Saying this once may not be enough; feelings of guilt may |
|          | come up again and again, and caretakers need to be able   |
|          | to provide constant assistance with the child's ongoing   |
|          | worries and confusion about guilt.                        |
+----------+-----------------------------------------------------------+

In the immediate aftermath of loss of a loved one, encourage family
members to rely on one another for comfort in the weeks and months
ahead.

***Grief and Spiritual Issues***

  -----------------------------------------------------------------------
  **Many times during disaster situations, well-meaning religious people
  seek out survivors in order to proclaim their own religious beliefs
  about salvation or damnation. If you become aware of activities like
  this, do not try to intervene; instead notify security personnel or
  others in charge.**

  -----------------------------------------------------------------------

In order to assist families with spiritual needs, the PFA provider
should become familiar with clergy who may be part of the disaster
response team on-site, and ways to obtain contact information for clergy
of local religious groups that you can use for referral purposes.

It is common for families to rely on religious and spiritual
beliefs/practices as a way to cope with traumatic events. Survivors may
use religious language to talk about what is happening or want to engage
in prayer or other religious practices. It is not necessary for the PFA
provider to share these beliefs in order to be supportive. You are not
required to do or say anything that violates your own beliefs. Often,
simply listening and attending is all that is required. Things to keep
in mind include:

-   A good way to broach this topic is to ask, "Do you have any
    religious or spiritual needs at this time?" This question is not
    meant to lead to a theological discussion or to the PFA provider
    engaging in spiritual counseling. If requested, you can refer them
    to a pastoral care professional or offer to call a clergyperson or
    chaplain of their choice.

-   Do not contradict or try to "correct" what a person says about their
    religious beliefs, even if you disagree and think that it may be
    causing them distress.

-   Do not try to answer religious questions like, "Why was this allowed
    to happen?" These questions represent expressions of emotion rather
    than real requests for an answer. Often listening and attending is
    enough and all that is required.

-   Do not be drawn into a discussion of religion or put forth your own
    religious views (i.e., "Everything happens for the best according to
    a higher plan.").

-   If a person is clearly religious, ask if he/she wants to see a
    clergy member of their faith. Do not assume that a person wants to
    see a clergy person.

-   Many people rely on religious objects such as prayer beads, statues,
    or sacred texts that they may have lost or left behind. Locating an
    object like this can help to increase their level of security and
    sense of control. A local clergy person can be of help in providing
    these items.

-   Survivors may want to pray alone or in a group. You may help by
    finding a suitable place for them to do so. For some people, facing
    in the proper direction while praying is important. You can help to
    orient them.

-   You may also provide information to officials in charge regarding
    space and religious items needed for religious observances.

-   If you are asked to join in prayer, you may decline if you feel
    uncomfortable. Keep in mind that joining may only involve standing
    in silence while they pray. If you are comfortable joining in at the
    end with an "Amen," this can help your relationship with the person
    and the family.

-   Many people routinely light candles or incense when they pray. If
    not allowed in the setting, explain this to the person, and assist
    them in finding a nearby place where an open flame would be allowed.

-   Some people believe in miracles. A survivor may voice hope for a
    miracle, even in the face of virtual certainty that their loved one
    has died. Do not take this as evidence that he/she has lost touch
    reality or has not heard what has been said, but the survivor's way
    of continuing to function in devastating circumstances.

-   Every religion has specific practices around death, particularly in
    regard to the care of dead bodies. Ask survivors about their
    religious needs in this area. They may want a clergyperson to advise
    them.

-   In some cultures, expressions of grief can be very loud and may seem
    out of control. It may be helpful to move families to a more private
    space to prevent them from upsetting others. If the behavior is
    upsetting to you, you should find someone else to assist the family.

If a survivor expresses anger associated with his/her religious beliefs
(a sign of spiritual distress) do not judge or argue with him/her. Most
people are not looking for an "answer," but a willing, non-judgmental
listener. If spiritual concerns are contributing to significant
distress, guilt or functional impairment, you can ask if he/she would
like a referral to a pastoral counselor.

***Casket and Funeral Issues***

Local laws often govern the preparation of a body for burial and rules
regarding caskets or internment. Sometimes exceptions are made for
members of particular religious groups. In many jurisdictions, the law
requires autopsies for any victim of a traumatic death or when the cause
of death is not clear. This requirement may be upsetting, especially to
members of religious groups that normally prohibit autopsies. In some
jurisdictions, autopsy requirements can be waived by a Medical Examiner.
Families who do not want an autopsy should be helped to find out about
the local law.

When a body has been significantly disfigured, you may suggest that---if
it is in keeping with the religious tradition of the family---survivors
place a photograph of the deceased on the casket in order to allow
mourners to remember the person and pay their respects.

## *Children's Attendance at a Funeral*

The PFA provider can assist family members with their questions about
whether children should attend the funeral, memorial service, or
gravesite. In responding to questions, keep the following in mind:

-   It can be helpful to a child to attend a funeral. Even if
    emotionally challenging, funerals help children accept the physical
    reality of the death that is part of grieving. If not offered to be
    included, children can feel left out of something important to the
    family.

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-   Parents/caregivers should give children a choice as to whether they
    want to attend. They may encourage, but not pressure them.

    -   Before asking them to choose, tell them what to expect if they
        attend, including letting them know that adults may be upset and
        crying. Explain that there will be a special area for the family
        if that is to be arranged. Let them know about things that will
        happen during the service.

    -   Give them an opportunity to help chose a person they feel close
        to, who can pay appropriate attention to them during the
        service.

    -   Always provide children a way to leave with that person, even
        temporarily, if the event becomes overwhelming.

    -   Tell children about alternative arrangements if they do not wish
        to attend, for example that they can stay with a neighbor or
        friend of the family.

    -   If they chose not to attend, offer to say something or read
        something on their behalf, and explain how they can participate
        in a memorial activity at a later time.

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-   If possible, bring younger children to the location early so that
    they can explore the space. Describe the casket and, if they wish,
    join them in approaching it. Caution should be exercised in regard
    to allowing young children to view or touch the body. A young child
    can use a photograph of the person to help them say goodbye.

-   For younger children, reinforce that the family member is not in
    distress.

The PFA provider may be asked to attend funerals or events. You may feel
that in attending, you can further assist a family member or child.

### 

### Traumatic Grief

  -----------------------------------------------------------------------
  **Alert: Disaster survivors, who have experienced extreme life threat
  or witnessed the death of their loved one, can become preoccupied with
  traumatic details of how the person died. This preoccupation, which has
  been referred to as Traumatic Grief, can change the course of
  bereavement. Survivors with traumatic grief may not appear to be
  acutely grieving, but do not confuse a lack of crying or sadness with
  not caring. Help family members understand that each of them will
  experience his/her own type---and course---of grief reactions depending
  on the experience of the disaster and the death. Do not delve into the
  traumatic details of the death, but instead, inform family members that
  different types of disaster-related experiences can affect grief. The
  PFA provider can help to promote a family milieu of understanding and
  tolerance that helps to avoid conflict and estrangement.**

  -----------------------------------------------------------------------

After traumatic death, survivors tend to stay focused on the
circumstances of the death, including being preoccupied with how the
loss could have been prevented, what the last moments were like, and who
was at fault. Traumatic grief reactions include:

-   Intrusive, disturbing images of the manner of death that interfere
    with positive remembering and reminiscing

-   Delay in the onset of healthy grief reactions

-   Retreat from close relationships with family and friends

-   Avoidance of usual activities because they are reminders of the
    traumatic loss

Traumatic grief changes mourning, often putting individuals on a
different time course than may be expected or experienced by other
family members. Traumatic grief reactions can clash with the timing of
religious rituals and other cultural expressions of mourning. To address
issues of traumatic grief with a family, the PFA provider might say:

+----------+-----------------------------------------------------------+
| Adult/   | "It is important to know that what each of you            |
|          | experienced during the disaster may affect how you        |
| Ad       | express your grief. Some of you may not be able to cry,   |
| olescent | while others might cry a lot. You should not feel badly   |
|          | about this or think there is something wrong with you.    |
|          | Each of you will feel your loss differently. What is most |
|          | important is to respect the different ways each of you    |
|          | will feel or show your grief and help each other in the   |
|          | days and weeks ahead."                                    |
+----------+-----------------------------------------------------------+

You may want to speak privately to a family member who was present at
the time of the death in order to advise them about the extra burden of
witnessing the death. Let him/her know that talking to a mental health
professional or clergy may be very helpful. For example, the provider
might say:

+----------+-----------------------------------------------------------+
| Adult/   | "It is awful to have been there when Joe died. Other      |
|          | family members may want to know details about what        |
| Ad       | happened, but there may be some details that you think    |
| olescent | will be too upsetting for them. Discussing what you went  |
|          | through with a professional can help you decide what to   |
|          | share with your family and also help you with your        |
|          | grief."                                                   |
+----------+-----------------------------------------------------------+

#### [Death Notification]{.underline}

Although it is unlikely that the PFA provider will be asked to notify a
family member of a death, the PFA provider may assist family members who
have been informed of the high probability, or confirmation, of a death.
The PFA provider may be asked by police, FBI, hospital personnel or
D-Mort team members to be present at the time of death notification. You
should be aware that in some catastrophic situations, for example
airline crashes, the news media may report that there were no survivors
of the accident. This news is often released before family members have
been officially notified that a relative has died. Sometimes incorrect
information is circulated by the media or other survivors---caution
family members to wait for official confirmation from the authorities.

After learning of the death of a family member or close friend, people
may have psychological and physiological reactions that vary from
hyperarousal to numbness. At the same time, they must cope with the
continuing stress of still being in the disaster environment. In
providing support, the PFA provider should keep the following in mind.

-   Don't rush. Family members need time to process the news and to ask
    questions.

-   Allow for initial strong reactions to horrible news concerning the
    sudden death of a loved one. Consider these to be normal reactions
    to a highly abnormal situation, and expect that they will recede
    over time. If medically necessary, ask for assistance from an
    Emergency Medical Technician (EMT). If family members become highly
    agitated, get help from authorities to protect them from hurting
    themselves or others. Family and friends are critical in these
    intense situations. Prior to, during and after death notification,
    the PFA provider should try to assure that these social supports are
    in place.

-   Try to work with individuals and small family units. Even when
    officials are addressing large crowds, it is better to have family
    members assembled at their own tables with the PFA provider present.
    Potentially traumatic activities ---such as reviewing passenger
    manifests, ticket lifts, morgue photos, etc.,---should be done in
    small family groups, in a private location, with the appropriate
    authorities, and a PFA provider present.

-   There may be a need for immediate decision-making or action
    following the tragic news. The PFA provider can assist family
    members in clarifying what needs to be done, and what options are
    available. Getting accurate information is crucial. Those who have
    been traumatized and are acutely bereaved may have difficulty in
    recalling information. Help family members by restating information
    as needed.

-   When talking about a person who is a confirmed fatality, use the
    word "died", not "lost" or "passed away."

-   Remember that family members do not want to know how you feel
    (sympathy); they want to know you are trying to understand how THEY
    feel (empathy).

-   If you go with family members to a hospital emergency department,
    ICU or morgue, prepare them for what they are going to see, hear,
    smell, etc. If you have already established a supportive
    relationship with the family, accompanying them can help them cope
    with the immediate trauma as well as assist them with other tasks to
    come.

-   If possible, try to have the most physically and emotionally stable
    family member make a body identification, or assist family members
    who must make the identification.

-   Encourage the family to minimize children's exposure to any
    photographs, artifacts, or remains of the deceased.

#### [Body Identification]{.underline}

When bodies or partial remains have been recovered, family members may
be asked to gather medical records, x-rays, dental records and articles
containing the relative's DNA (a hair brush, tooth brush etc.) and bring
them to a designated location. Under such circumstances, family members
may be asked for a sample of their DNA (usually obtained by swabbing the
lining of the cheek) provided at a location established for this
purpose. A mental health responder is usually present at these DNA
stations.

Where identifiable bodies have been recovered and family members have
been asked to assist in the identification process, authorities may take
family members to a private location to view photographs of persons who
have been brought to the morgue. Once a person is tentatively recognized
by photo, a family member may be asked to view the body in the morgue.
The body may be behind a glass partition, mostly covered by a sheet. If
the relative has died in the hospital, identification may be made at a
designated location in the hospital. Many forensic authorities try to
reduce the traumatic effect of seeing a loved one's body in the morgue
by using a videotape or still photographs. This also protects family
members from the strong odor, which can be highly disturbing.

Some may feel that they must see the body before they can accept that
the person is dead. Adolescents and older children might ask to be
present when the body is identified; however, in most cases, mental
health professionals discourage allowing children to be present.
Children may not understand the extent to which the body has
deteriorated or changed and may find seeing the body extremely
disturbing. This can be upsetting for adults as well. Parents can say to
the child:

  ------------- -----------------------------------------------------------
  Parent to     "You know, Uncle Bobby wouldn't want you to see him that
  Adolescent/   way. He'd want you to remember him looking alive and
  Child         healthy. I'm going to go and make sure that it's him, but I
                don't feel you should go and see the body."

  ------------- -----------------------------------------------------------

When the body found is too disfigured for family members to be able to
identify it, it is natural for families to want to know when and where
the body was found, and what the person experienced before dying. Family
members may be more disturbed by the unanswered questions, than by
having those questions answered.

  -----------------------------------------------------------------------
  **The physical confirmation of the death can provoke a range of grief
  reactions, including shock, numbness, fainting, vomiting, trembling,
  screaming, or hitting something or someone. Some individuals may be
  unresponsive, while others may become outraged, cursing about how the
  person died. You should expect a wide range of reactions, many of which
  will be quite brief.**

  -----------------------------------------------------------------------

### 

### Confirming Body Identification to a Child or Adolescent

After a family member has identified the body of a loved one, a parent
or closely related caregiver should convey this to related children. You
may sit in to provide support and assistance. Since young children don't
understand that death is final, a family member should make it very
clear that the missing loved one's body has been found, and that he/she
is dead. If the identification was made through forensic methods, it is
important to explain the certainty of the identification in simple
direct language. The family's belief about death and an afterlife will
often be part of this conversation. Parents should reassure the child
that the loved one is not suffering, that the child was very loved by
him/her, and that the child will be taken care of. Allow the child to
ask questions, and---if an answer is not readily available­---let him/her
know that the parent or PFA provider will try to get some additional
information. The PFA provider should caution parents or caretakers about
giving disturbing details of the physical appearance of the body. If the
child asks about the appearance, a parent can say:

  ------------- -----------------------------------------------------------
  Parent to     "It was not easy to see Uncle Jack, and he would want us to
  Adolescent/   remember him alive, and to think about the nice times we
  Child         spent together. I remember going on hikes and going
                fishing. You can pick any memory of Uncle Jack that you
                want to, too. Then we'll both have good ways to think about
                him."

  ------------- -----------------------------------------------------------

Young children may have a range of responses to being told of the death.
They may act as if they did not hear; they may cry or protest the news.
They may be angry with the person who told them of the death. Children
need a comforting presence, reassurance that the loved one is not
physically suffering, and confirmation that they were loved. The PFA
provider may suggest that the parent or caretaker to say something like:

  ------------- -----------------------------------------------------------
  Parent to     "It is awfully hard to hear that Aunt Julia is really dead.
  Adolescent/   It's okay if you want to cry or if you don't want to cry.
  Child         Anytime you want to talk about her and what happened, I'm
                going to be here for that. You'll see me have lots of
                feelings too. Don't be worried; we can all help each
                other."

  ------------- -----------------------------------------------------------

Family members should address children's immediate questions about their
living circumstances and who will take care of them. In assisting, the
PFA provider may suggest that separation of siblings be avoided, if at
all possible.

The PFA provider can help parents or other family members talk with
their adolescent children. Parents should be told that, after
experiencing a traumatic loss, it is important to caution teens about
doing something risky, like storming off, driving while overwhelmed with
such news, staying out late, being tempted to use alcohol or other
drugs, or acting in some other reckless way. Parents or caretakers
should also understand that an adolescent's anger can turn to rage over
the loss, and they should be prepared to tolerate some amount of
expression of rage. However, they should also be firm in addressing any
behavioral risks. Expression of any suicidal thought should be taken
seriously, and appropriate additional assistance should be immediately
sought. Expressions of revenge should also be taken seriously.
Adolescents should be cautioned to think about the consequences of
revenge, and be encouraged to consider different constructive ways to
respond to their feelings.

  -----------------------------------------------------------------------
  **The process leading to the confirmation of a relative's sudden death
  is extremely intense and challenging. Psychological, social and
  practical support in these situations is critical. In these
  circumstances, the PFA provider should take cues from the family in
  regard to how they wish to spend this time. They may want to sit in
  silence, pray, read sacred text, or distract themselves by talking
  about totally unrelated matters. Distracting activities like games or
  talking about lighter subjects can be an adaptive way of not focusing
  on their grief.**

  -----------------------------------------------------------------------

***When a Child has seen a Dead Body (Outside of a Ritual Setting)***

In the case of terrorism and disaster, children are sometimes exposed to
dead bodies of strangers or of their loved ones. Parents/caretakers
should be encouraged to explain to a child why a dead body looks
different from a living person. For example, a body that has been
submerged under water looks bloated and discolored. If not explained,
the child may come to his/her own even more disturbing conclusions.

##### When Body Recovery is Delayed

Sometimes days or weeks after a person has disappeared with no recovery
of the body, the evidence will strongly suggest that the person is dead.
Parents/caregivers should not assume that it is better for a child to
keep hoping that the person is alive, but instead honestly share this
information with the child. Parents should explain to the child, without
providing too much detail, that it looks like the loved one has died,
and that this is what you and the authorities believe has happened.

+-----------------------------------------------------------------------+
| **In some religious and cultural groups, mourning or moving on with   |
| life is prohibited until a body is recovered and a funeral held. This |
| practice can cause difficulties for families where the recovery of    |
| the body is delayed or never occurs. When the recovery of the body is |
| seriously delayed for a family with these beliefs, the PFA provider   |
| should assist the family in consulting with their religious leader.** |
|                                                                       |
| **Not being able to perform burial and other religious rituals can    |
| complicate the grief process and increase a family's distress. When   |
| there is no body to bury, it is important for families and            |
| communities to create other kinds of rituals or memorial observances. |
| Having a place to visit that memorializes their loved one is often    |
| comforting to families. Parents should include children in these      |
| rituals.**                                                            |
+-----------------------------------------------------------------------+

# Appendix D: Resources[^10]

**Training Resources**

**Advanced Disaster Medical Response: A Manual for Providers**

> Briggs, S.M., & Brinsfield, K.H., (editors). Harvard Medical
> International, Inc., 2003.
>
> **http://www.amazon.com/gp/product/0972377204/002-8489036-2108026?v=glance&n=283155**

**Behavioral Health Awareness Training for Terrorism and Disasters**

Shultz JM, Espinel Z, Cohen RE, Shaw JA, Flynn BW, Ursano RJ.

Center for Disaster Epidemiology & Emergency Preparedness (DEEP Center),
University of Miami School of Medicine, 2005 (first edition 2003).

> **http://deep.med.miami.edu**

**Community-based Psychological Support: A Training Manual**

> Published by the International Federation of Red Cross and Red
> Crescent Societies, 2003.
>
> **http://www.ifrc.org/what/health/psycholog/manual.asp**

**Disaster Behavioral Health: All Hazards Training**

Shultz JM, Espinel Z, Cohen RE, Smith RG, Flynn BW.

> Center for Disaster Epidemiology & Emergency Preparedness (DEEP
> Center), University of Miami School of Medicine, 2006.
>
> **http://deep.med.miami.edu**

**Disaster Behavioral Health OPERATIONS Training for Health Care
Professionals**

Shultz JM, Espinel Z, Cohen RE, Shaw JA, Flynn BW, Watson PJ, Hick JL,
Schreiber M.

> Center for Disaster Epidemiology & Emergency Preparedness (DEEP
> Center), University of Miami School of Medicine, 2005.
>
> **http://deep.med.miami.edu**

**Disaster Mental Health: A Critical Response. A Training for Mental
Health Professionals in Community Settings**

> Herrmann, J. University of Rochester. 2005

[**http://www.centerfordisastermedicine.org/community_setting/**](http://www.centerfordisastermedicine.org/community_setting/)

**Disaster Mental Health: A Critical Response. A Training for Mental
Health and Spiritual Care Professionals in Healthcare Settings**

> Herrmann, J. University of Rochester. 2006

**<http://www.centerfordisastermedicine.org/healthcare_setting/>**

**Disaster Mental Health Training: Guidelines, Considerations, and
Recommendations**

> Young, B.H., Ruzek, J.I., Wong, M., Salzer, M.S., and Naturale, A.J.
> In Interventions Following Mass Violence and Disasters: Strategies for
> Mental Health Practice. Edited by Elspeth Cameron Ritchie, Patricia
> J.Watson, and Matthew J. Friedman. New York: Guilford Publications,
> 2006.
>
> **http://www.istss.org/guilfordDMH.pdf**

**Disaster Mental Health Response Handbook: An Educational Resource for
Mental Health Professionals Involved in Disaster Management**

> Centre for Mental Health, NSW Health and NSW Institute of Psychiatry.
> New South Wales, Australia State Health Publication No: (CMH) 00145,
> 2000.
>
> **http://www.nswiop.nsw.edu.au/Resources/Disaster_Handbook.pdf**

**Disaster Mental Health Services: A Guidebook for Clinicians and
Administrators**

> Young, B.H., Ford, J.D., Ruzek, J.I., Friedman, M.J., & Gusman, F.D.
> The National Center for Post-Traumatic Stress Disorder, Education &
> Clinical Laboratory, VA Palo Alto Health Care System, Menlo Park,
> California 94025; Executive Division, VA Medical & Regional Office
> Center, ,White River Junction, Vermont 05009, 1998.
>
> **http://www.ncptsd.va.gov/publications/disaster/**

**Field Manual for Mental Health and Human Service Workers in Major
Disasters**

> DeWolfe, D. J. (author). Nordboe, D. (editor). Department of Health
> and Human Services, Substance Abuse and Mental Health Services
> Administration (SAMHSA), Center for Mental Health Services DHHS
> Publication No. ADM 90-537, 2000.
>
> **http://www.mentalhealth.samhsa.gov/publications/allpubs/ADM90-537/Default.asp**

**Grief Counseling Resource Guide**

Published by the New York State Office of Mental Health (OMH), 2004.

> **http://www.omh.state.ny.us/omhweb/grief/**

**Helping to Heal: A Training on Mental Health Response to Terrorism
Manual (2004)**

> Community Resilience Project of Northern Virginia. Commonwealth of
> Virginia Department of Mental Health, Mental Retardation and Substance
> Abuse Services, January 2004.
>
> **http://www.dmhmrsas.virginia.gov/CWD-HelpingToHeal.htm**

**Mental Health Response to Mass Violence and Terrorism: A Training
Manual**

> U.S. Department of Health and Human Services. DHHS Pub. No. SMA 3959.
> Rockville, MD: Center for Mental Health Services, Substance Abuse and
> Mental Health Services Administration, 2004.
>
> **http://www.mentalhealth.samhsa.gov/media/ken/pdf/SMA-3959/MassViolenceAndTerrorism.pdf**

**National Disaster Mental Health Training Program**

> U.S. Department of Veterans Affairs, National Center for Post
> Traumatic Stress Disorder (NCPTSD)
>
> **http://www.ncptsd.org/about/training/ndmh_training.html**

**Psychological First Aid: A Field Operation Guide**

> Terrorism and Disaster Branch, National Child Traumatic Stress
> Network, National Center for Post Traumatic Stress Disorder. 2005

[**http://www.ncptsd.va.gov/pfa/PFA.html**](http://www.ncptsd.va.gov/pfa/PFA.html)

**Psychological Intervention for Victims of Mass Terrorism and Trauma**

> Buetler, L. National Center on the Psychology of Terrorism, Pacific
> Graduate School of Psychology.

[**http://www.terrorismpsychology.org**](http://www.terrorismpsychology.org/)

**SURGE, SORT, SUPPORT: Disaster Behavioral Health Awareness Training
for Health Care Professionals**

Shultz JM, Espinel Z, Cohen RE, Smith RG, Flynn BW.

Center for Disaster Epidemiology & Emergency Preparedness (DEEP Center),
University of Miami School of Medicine, 2005 (first edition 2004).

> **http://deep.med.miami.edu**

**Training Manual for Mental Health and Human Service Workers in Major
Disasters**

> DeWolfe, D. J. (author). Nordboe, D. (editor). Department of Health
> and Human Services, Substance Abuse and Mental Health Services
> Administration (SAMHSA), Center for Mental Health Services DHHS
> Publication No. ADM 90-538, 2000.
>
> **http://www.mentalhealth.samhsa.gov/publications/allpubs/ADM90-538/Default.asp**

**Triumph Over Tragedy, 2nd Ed. A Community Response to Managing Trauma
in Times of Disaster and Terrorism**

> Evans, G.D., & Wiens, B.A., (editors). National Rural Behavioral
> Health Center, Department of Clinical & Health Psychology, P.O. Box
> 100165, Gainesville, FL 32610, January 2004.
>
> **http://www.nrbhc.org**

**Issues and Populations of Special Consideration**

**An ADA Guide for Local Governments: Making Community Emergency
Preparedness and Response Programs Accessible to People with
Disabilities (2005)**

> U.S. Department of Justice, Civil Rights Division, Disability Rights
> Section

[**http://www.usdoj.gov/crt/ada/emergencyprep.htm**](http://www.usdoj.gov/crt/ada/emergencyprep.htm)

**Assuring Cultural Competence in Disaster Response**

> The Florida Center for Public Health Preparedness

**http://www.fcphp.usf.edu/courses_listings.htm**

**Developing Cultural Competence in Disaster Mental Health Programs:
Guiding Principles and Recommendations**

> U.S. Department of Health and Human Services. Developing Cultural
> Competence in Disaster Mental. Health Programs: Guiding Principles and
> Recommendations. DHHS Pub. No. SMA 3828. Rockville, MD: Center for
> Mental Health Services, Substance Abuse and Mental Health Services
> Administration, 2003.
>
> **http://www.mentalhealth.samhsa.gov/media/ken/pdf/SMA03-3828/CulturalCompetence_FINALwithcovers.pdf**

**Disaster Mental Health: Crisis Counseling Programs for the Rural
Community (1999)**

> U.S. Department of Health and Human Services, Substance Abuse and
> Mental Health Services Administration (SAMHSA), Center for Mental
> Health Services. DHHS Publication No. SMA 99-3378. Printed in 1999.
>
> **http://www.mentalhealth.org/publications/allpubs/sma99-3378/default.asp**

**Disaster Preparedness for People with Disabilities**

> American Red Cross national headquarters: Disaster Services, Health
> and Safety, Services, National Office of Volunteers, Office of General
> Counsel, and Risk, Management Division.
>
> **http://www.redcross.org/services/disaster/beprepared/disability.pdf**

**Helping Children after a Disaster**

> American Academy of Child & Adolescent Psychiatry, No. 36. Updated
> July 2004.

**www.aacap.org/publications/factsfam/disaster.htm**

**Mental Health Care for Ethnic Minority Individuals and Communities in
the Aftermath of Disasters and Mass Violence**

> Norris, F.H., & Alegria, M. CNS Spectrums. February 2005. Vol. 10, No.
> 2. p. 132-140.
>
> **http://www.cnsspectrums.com/pdf/art_637.pdf**

**Psychosocial Issues for Children and Families in Disasters: A Guide
for the Primary Care Physician**

> U.S. Department of Health and Human Services, Public Health Service,
> Substance Abuse and Mental Health Services Administration (SAMHSA),
> Center for Mental Health Services.
>
> **http://www.mentalhealth.samhsa.gov/publications/allpubs/SMA95-3022/default.asp**

**Psychosocial Issues for Older Adults in Disasters**

> U.S. Department of Health and Human Services, Substance Abuse and
> Mental Health Services Administration (SAMHSA), Center for Mental
> Health Services. DHHS Publication No. ESDRB SMA 99-3323
>
> [**http://media.shs.net/ken/pdf/SMA99-3323/99-821.pdf**](http://media.shs.net/ken/pdf/SMA99-3323/99-821.pdf)

**Disaster Relief Organizations, Agencies and Programs**

**American Association of Marriage and Family Therapy (AAMFT)**

> **http://www.aamft.org**

**American Mental Health Counselors Association**

> **http://www.amhca.org**

**American Nurses Association**

> **http://www.nursingworld.org/news/disaster**

**American Psychiatric Association**

> **http://www.psych.org**

**American Psychological Association (APA)**

> **http://www.apa.org**

**American Red Cross Disaster Services (ARC)**

> **http://www.redcross.org/services/disaster**

**Center for Mental Health Services (CMHS)**

> **http://www.mentalhealth.samhsa.gov/cmhs**

**Department of Health and Human Services (DHHS)**

> **http://www.dhhs.gov**

**Department of Homeland Security (DHS)**

> **http://www.dhs.gov**

**Department of Veterans Affairs (VA)**

> **http://www.va.gov/about_va/history**

**Disaster Psychiatry Outreach (DPO)**

> **http://www.disasterpsych.org**

**Federal Emergency Management Agency (FEMA)**

> **http://www.fema.gov**

**International Society for Traumatic Stress Studies (ISTSS)**

> **http://www.istss.org**

**Medical Reserve Corps (MRC)**

> **http://www.medicalreservecorps.gov**

**National Association of Social Workers**

> **http://www.naswdc.org**

**National Center for Post-Traumatic Stress Disorder (NCPTSD)**

> **http://www.ncptsd.org**

**National Child Traumatic Stress Network (NCTSN)**

> **http://www.nctsn.org**

**National Disaster Medical System (NDMS)**

> **http://www.ndms.dhhs.gov**

**National Organization for Victims Assistance (NOVA)**

> **http://www.dhs.gov**

**National Voluntary Organizations Active in Disaster (VOAD)**

> **http://www.nvoad.org**

**New York Disaster Interfaith Services (NYDIS)**

> **http://www.nydis.org**

**New York State Emergency Management Office (SEMO)**

> **http://www.nysemo.state.ny.us**

**Office of Victims of Crime (OVC)**

> **http://www.ojp.usdoj.gov/ovc**

**Project Liberty**

> **http://www.projectliberty.state.ny.us**

**Substance Abuse and Mental Health Services Administration (SAMHSA)**

> **http://www.samhsa.gov**

**Planning Tools and Technical Resources**

**A Guide to the Disaster Declaration Process and Federal Disaster
Assistance**

> Department of Homeland Security, Emergency Preparedness and Response
> Directorate, Office of Legislative Affairs, 202-646-4500.
>
> **http://www.fema.gove/pdf/rrr/dec_proc.pdf**

**An ADA Guide for Local Governments: Making Community Emergency
Preparedness and Response Programs Accessible to People with
Disabilities**

> U.S. Department of Justice, Civil Rights Division, Disability Rights
> Section, 2005.
>
> **http://www.usdoj.gov/crt/ada/emergencyprep.htm**

**CDC Public Health Emergency Response Guide for State, Local, and
Tribal Public Health Directors**

> Department of Health and Human Services, Centers for Disease Control
> and Prevention, 2004.
>
> **http://www.bt.cdc.gov/planning/pdf/cdcresponseguide.pdf**

**Community Guidelines for Developing a Spontaneous Volunteer Plan**

> Illinois Terrorism Task Force Committee on Volunteers and Donations
>
> **http://www.illinoishomelandsecurity.org/pdf/spontvol.pdf**

**Crisis Counseling Assistance and Training Program**

> **http://www.mentalhealth.samhsa.gov/cmhs/emergencyservices/progguide.asp**

**Disaster Nursing and Emergency Preparedness for Chemical, Biological,
and Radiological Terrorism and Other Hazards**

> Veenema, T.G., (editor). New York: Springer Publishing Company, Inc.,
> 2003.
>
> **http://www.springerpub.com/prod.aspx?prod_id=21438**

**Disaster Technical Assistance Center**

> U.S. Department of Health and Human Services, Substance Abuse and
> Mental Health Services Administration (SAMHSA), Center for Mental
> Health Services
>
> **http://www.mentalhealth.samhsa.gov/dtac**

**Disaster Mental Health Training: Guidelines, Considerations, and
Recommendations**

> Young, B.H., Ruzek, J.I., Wong, M., Salzer, M.S., and Naturale, A.J.
> In Interventions Following Mass Violence and Disasters: Strategies for
> Mental Health Practice. Edited by Elspeth Cameron Ritchie, Patricia J.
> Watson, and Matthew J. Friedman. New York: Guilford Publications,
> 2006.
>
> **http://www.istss.org/guilfordDMH.pdf**

**Federal Family Assistance Plan for Aviation Disasters**

> Prepared by the National Transportation Safety Board, August 1, 2000.
>
> **http://www.ntsb.gov/publictn/2000/SPC0001.pdf**

**Mental Health All-Hazards Disaster Planning Guidance**

> U.S. Department of Health and Human Services. DHHS Pub. No. SMA 3829.
> Rockville, MD: Center for Mental Health Services, Substance Abuse and
> Mental Health Services Administration, 2003.
>
> **http://media.shs.net/ken/pdf/SMA03-3829/All-HazGuide.pdf**

**Mental Health and Mass Violence: Evidence-Based Early Psychological
Intervention for Victims/Survivors of Mass Violence**

> National Institute of Mental Health. NIH Publication No. 02-5138,
> Washington, D.C.: U.S. Government Printing Office, 2002.
>
> **http://www.nimh.nih.gov/publicat/massviolence.pdf**

**National Incident Management System**

> Published by the U.S. Department of Homeland Security, March 1, 2004.
>
> **http://www.fema.gov/pdf/nims/nims_doc_full.pdf**

**National Memorial Institute for the Prevention of Terrorism**

> **http://www.mipt.org**

**National Response Plan**

> **http://www.dhs.gov/dhspublic/interapp/editorial/editorial_0566.xml**

**New York State County Disaster Mental Health Planning and Response
Guide: A Guide for County Directors of Mental Health and Community
Services**

> Herrmann, J., University of Rochester, 2005.
>
> **http://www.centerfordisastermedicine.org**

**Pandemic Influenza**

> **http://pandemicflu.gov/**

**Preparing for the Psychological Consequences of Terrorism: A Public
Health Strategy**

> Butler, A.S., Panzer, A.M., & Goldfrank, L.R., (editors). Washington,
> DC: The National Academies Press, 2003.
>
> **http://books.nap.edu/catalog/10717.html**

**Robert T. Stafford Disaster Relief and Emergency Assistance Act**

> United States Code, Title 42. The Public Health and Welfare, Chapter
> 68. Disaster Relief (As amended by Pub. L. 103-181, Pub. L. 103-337,
> and Pub. L. 106-390) Pub. L. 106-390, October 2000, 114 Stat.
> 1552-1575.
>
> **http://www.fema.gov/library/stafact.shtm**

**State Mental Health Authorities' Response to Terrorism**

> National Association of State Mental Health Program Directors,
> (NASMHPD) Medical Directors Council, 66 Canal Center Plaza, Suite 302,
> Alexandria, VA 22314, February 2004.
>
> **http://www.nasmhpd.org/general_files/publications/med_directors_pubs/Med%20Dir%20Terrorism%20Rpt%20-%20final.pdf**

**Surge Hospitals: Providing Safe Care in Emergencies**

> Published by the Joint Commission on Accreditation of Healthcare
> Organizations, 2006.
>
> **http://www.jcaho.org/about+us/public+policy+initiatives/surge_hospital.pdf**

**Terrorism and Disaster Management: Preparing Healthcare Leaders for
the New Reality**

> McGlown, K. J., (editor). Published by the Foundation of the American
> College of Healthcare. Chicago: Health Administration Press, 2004.

**Trauma and Disaster: Response and Management**

> Ursano, R., & Norwood, A.E. (editors). Review of Psychiatry Series,
> Volume 22, Number 1; Oldham, JM & Riba, M.B., (series editors).
> Washington, DC: American Psychiatric Publishing, 2003.

**Risk Communication**

**Communicating in a Crisis: Risk Communication Guidelines for Public
Officials**

> U.S. Department of Health and Human Services (SAMHSA), Substance Abuse
> and Mental Health Services Administration, 5600 Fishers Lane, Room
> 17C-26, Rockville, MD 20857, 2002.
>
> **http://www.riskcommunication.samhsa.gov/index.htm**

**Crisis & Emergency Risk Communication: By Leaders for Leaders, Course
Book and Participants Manual**

> U.S. Department of Health and Human Services (HHS) in partnership with
> the Centers for Disease Control and Prevention (CDC) Public Health
> Practice Program Office and the CDC Office of Communication (OC),
> Office of the Director (OD).
>
> **http://www.cdc.gov/communication/emergency/leaders.pdf**
>
> **http://www.cdc.gov/communication/emergency/part_man.pdf**

**Effective Media Communication During Public Health Emergencies, WHO
Handbook, Field Guide, and Wall Chart**

> Published by the World Health Organization, 2005.
>
> **http://www.who.int/csr/resources/publication**

**Terrorism and Other Public Health Emergencies: A Reference Guide for
Media**

> Office of the Assistant Secretary for Public Affairs, U.S. Department
> of Health and Human Services, Washington, D.C. September 2005.
>
> **http://www.hhs.gov/emergency/mediaguide/PDF/HHSMedisReferenceGuideFinal.pdf**

**WHO Outbreak Combination Guidelines**

> Published by the World Health Organization, 2005.
>
> **http://www.who.int/infectious-disease-news/IDdocs/whocds200528/whocds200528en.pdf**

**WHO Outbreak Communication, WHO Handbook for Journalists: Influenza
Pandemic**

> Published by the World Health Organization, 2005.
>
> **http://www.who.int/csr/don/Handbook_influenza_pandemic_dec05.pdf**

# 

# Appendix E: Handouts

The following handouts were prepared by the National Child Traumatic
Stress Network (NCTSN) and the National Center for PostTraumatic Stress
Disorder (NCPTSD) for the Medical Reserve Corps.

**ALCOHOL, MEDICATION, AND DRUG USE AFTER DISASTER**

**CONNECTING WITH OTHERS: SEEKING SOCIAL SUPPORT**

**CONNECTING WITH OTHERS: GIVING SOCIAL SUPPORT**

**TIPS FOR RELAXATION**

**WHEN TERRIBLE THINGS HAPPEN**

**TIPS FOR HELPING ADOLESCENTS AFTER DISASTERS (PART I & II)**

**TIPS FOR HELPING PRE-SCHOOL AGE CHILDREN AFTER DISASTERS (PART I &
II)**

**TIPS FOR HELPING SCHOOL AGE CHILDREN AFTER DISASTERS (PART I & II)**

**ALCOHOL, MEDICATION, AND DRUG USE AFTER DISASTER**

Some people increase their use of alcohol, prescription medications or
other substances after a disaster. You may feel that using drugs and
alcohol seem to help you escape bad feelings or physical symptoms
related to stress responses (e.g., headaches, muscle tension). However,
they can actually make these things worse in the long term because they
interrupt natural sleep cycles, create health problems, interfere with
relationships, and create potential dependence on the substance. If your
use of alcohol or drugs has increased since the disaster or is causing
problems for you, it is important for you to reduce your level of use or
seek help in gaining control over your use.

**Managing alcohol, medication, and drug use**

+---------------------------------+------------------------------------+
| -   Pay attention to any change | -   Consult with a healthcare      |
|     in your use of alcohol      |     professional about safe ways   |
|     and/or drugs.               |     to reduce anxiety, depression, |
|                                 |     muscle tension, and sleep      |
|                                 |     difficulties.                  |
+---------------------------------+------------------------------------+
| -   Correctly use prescription  | -   If you find that you have      |
|     and over-the-counter        |     greater difficulty controlling |
|     medications as indicated.   |     alcohol/substance use since    |
|                                 |     the hurricane, seek support in |
|                                 |     doing so.                      |
+---------------------------------+------------------------------------+
| -   Eat well, exercise, get     | -   If you believe you have a      |
|     enough sleep, and use your  |     problem with substance abuse,  |
|     family and others for       |     talk to your doctor or         |
|     support.                    |     counselor about it.            |
+---------------------------------+------------------------------------+
| -   If you feel like using      |                                    |
|     larger amounts of either    |                                    |
|     prescribed or               |                                    |
|     over-the-counter            |                                    |
|     medications, consult a      |                                    |
|     healthcare professional.    |                                    |
+---------------------------------+------------------------------------+

**If you have had an alcohol, medication, or drug problem in the past**

For people who have successfully stopped drinking or using drugs,
experiencing a disaster can sometimes result in strong urges to drink or
use again. Sometimes it can lead them to strengthen their commitment to
recovery. Whatever your experience, it is important to consciously
choose to stay in recovery.

+---------------------------------+------------------------------------+
| -   Increase your attendance at | -   Talk with family and friends   |
|     substance abuse support     |     about supporting you to avoid  |
|     groups.                     |     use of alcohol or substances.  |
+---------------------------------+------------------------------------+
| -   If you are receiving        | -   If you have a 12-Step sponsor  |
|     disaster crisis counseling, |     or substance abuse counselor,  |
|     talk to your counselor      |     talk to him or her about your  |
|     about your past alcohol or  |     situation.                     |
|     drug use.                   |                                    |
+---------------------------------+------------------------------------+
| -   If you have been forced to  | -   Increase your use other        |
|     move out of your local      |     supports that have helped you  |
|     community, talk to disaster |     avoid relapse in the past.     |
|     workers about helping to    |                                    |
|     locate nearby alcohol or    |                                    |
|     drug recovery groups, or    |                                    |
|     ask them to help organize a |                                    |
|     new support group.          |                                    |
+---------------------------------+------------------------------------+

**CONNECTING WITH OTHERS**

**SEEKING SOCIAL SUPPORT**

-   Making contact with others can help reduce feelings of distress

-   Children and adolescents can benefit from spending some time with
    other similar-age peers

-   Connections can be with family, friends, or others who are coping
    with the same traumatic event

## Social Support Options

+-------------------+----------------------------+---------------------+
| -   Spouse or     | -   Priest, Rabbi, or      | -   Support group   |
|     partner       |     other clergy           |                     |
+-------------------+----------------------------+---------------------+
| -   Trusted       | -   Doctor or nurse        | -   Co-worker       |
|     family member |                            |                     |
+-------------------+----------------------------+---------------------+
| -   Close friend  | -   Crisis counselor or    | -   Pet             |
|                   |     other counselor        |                     |
+-------------------+----------------------------+---------------------+

Do . . .

+-----------------+-------------------------+--------------------------+
| -   Decide      | -   Start by talking    | -   Ask others if it's a |
|     carefully   |     about practical     |     good time to talk    |
|     whom to     |     things              |                          |
|     talk to     |                         |                          |
+-----------------+-------------------------+--------------------------+
| -   Decide      | -   Let others know you | -   Tell others you      |
|     ahead of    |     need to talk or     |     appreciate them      |
|     time what   |     just to be with     |     listening            |
|     you want to |     them                |                          |
|     discuss     |                         |                          |
+-----------------+-------------------------+--------------------------+
| -   Choose the  | -   Talk about painful  | -   Tell others what you |
|     right time  |     thoughts and        |     need or how they     |
|     and place   |     feelings when       |     could help---one     |
|                 |     you're ready        |     main thing that      |
|                 |                         |     would help you right |
|                 |                         |     now                  |
+-----------------+-------------------------+--------------------------+

Don't . . .

+-----------------------------------+----------------------------------+
| ###### Keep quiet becau           | ###### Assume                    |
| se you don't want to upset others | that others don't want to listen |
+-----------------------------------+----------------------------------+
| -   Keep quiet because you're     | -   Wait until you're so         |
|     worried about being a burden  |     stressed or exhausted that   |
|                                   |     you can't fully benefit from |
|                                   |     help                         |
+-----------------------------------+----------------------------------+

##### Ways to Get Connected

+-----------------------------------+----------------------------------+
| -   Calling friends or family on  | -   Getting involved with a      |
|     the phone                     |     support group                |
+-----------------------------------+----------------------------------+
| -   Increasing contact with       | -   Getting involved in          |
|     existing acquaintances and    |     community recovery           |
|     friends                       |     activities                   |
+-----------------------------------+----------------------------------+
| -   Renewing or beginning         |                                  |
|     involvement in church,        |                                  |
|     synagogue, or other religious |                                  |
|     group activities              |                                  |
+-----------------------------------+----------------------------------+

**CONNECTING WITH OTHERS**

**GIVING SOCIAL SUPPORT**

You can help family members and friends cope with the disaster by
spending time with them and listening carefully. Most people recover
better when they feel connected and understood to others who care about
them. Some people choose not to talk about their experiences very much,
and others may need to discuss their experiences on numerous occasions.
Talking about things that happened because of the disaster can help them
seem less overwhelming. At times, just spending time with people one
feels close to and accepted by, without having to talk, can feel best.
Here are some things we know about giving social support to other people
after disasters.

## 

## Reasons Why People May Avoid Social Support

+-------------------+----------------------------+---------------------+
| -   Not knowing   | -   Not wanting to burden  | -   Wanting to      |
|     what they     |     others                 |     avoid thinking  |
|     need          |                            |     or feeling      |
|                   |                            |     about the event |
+-------------------+----------------------------+---------------------+
| -   Feeling       | -   Doubting it will be    | -   Feeling that    |
|     embarrassed   |     helpful, or that       |     others will be  |
|     or "weak"     |     others won't           |     disappointed or |
|                   |     understand             |     judgmental      |
+-------------------+----------------------------+---------------------+
| -   Feeling they  | -   Having tried to get    | -   Not knowing     |
|     will lose     |     help and felt that it  |     where to get    |
|     control       |     wasn't there before    |     help            |
+-------------------+----------------------------+---------------------+

Good Things to Do When Giving Support

+-----------------+-------------------------+--------------------------+
| -   Show        | -   Show respect for    | -   Talk about           |
|     interest,   |     individuals'        |     expectable reactions |
|     attention,  |     reactions and ways  |     to disasters, and    |
|     and care    |     of coping           |     healthy coping       |
+-----------------+-------------------------+--------------------------+
| -   Find an     | -   Acknowledge that    | -   Believe that the     |
|                 |     this type of stress |     other is capable of  |
|   uninterrupted |     can take time to    |     recovery             |
|     time and    |     resolve             |                          |
|     place to    |                         |                          |
|     talk        |                         |                          |
+-----------------+-------------------------+--------------------------+
| -   Be free of  | -   Help brainstorm     | -   Offer to talk or     |
|                 |     positive ways to    |     spend time together  |
|    expectations |     deal with their     |     as many times as is  |
|     or          |     reactions           |     needed               |
|     judgments   |                         |                          |
+-----------------+-------------------------+--------------------------+

Things That Interfere with Giving Support

+----------------------------------+-----------------------------------+
| #                                | #                                 |
| ##### Rushing to tell someone th | ##### Acting like someone is weak |
| at he or she will be okay or tha |  or exaggerating because he or sh |
| t they should just "get over it" | e isn't coping as well as you are |
+----------------------------------+-----------------------------------+
| -   Discussing your own personal | -   Giving advice without         |
|     experiences without          |     listening to the person's     |
|     listening to the other       |     concerns or asking the person |
|     person's story               |     what works for him or her     |
+----------------------------------+-----------------------------------+
| -   Stopping the person from     | -   Telling them they were lucky  |
|     talking about what is        |     it wasn't worse               |
|     bothering them               |                                   |
+----------------------------------+-----------------------------------+

##### When Your Support is Not Enough...

+-----------------------------------+----------------------------------+
| -   Let the person know that      | -   Encourage the other to talk  |
|     experts think that avoidance  |     with a counselor, clergy, or |
|     and withdrawal are likely to  |     medical professional, and    |
|     increase distress, and social |     offer to accompany them      |
|     support helps recovery        |                                  |
+-----------------------------------+----------------------------------+
| -   Encourage the other to get    | -   Enlist help from others in   |
|     involved in a support group   |     your social circle so that   |
|     with others who have similar  |     you all take part in         |
|     experiences                   |     supporting the other         |
+-----------------------------------+----------------------------------+

**TIPS FOR RELAXATION**

Tension and anxiety are common after disasters. Unfortunately, they can
make it more difficult to cope with the many things that must be done to
recover. There is no easy solution to coping with post-disaster
problems, but taking time during the day to calm yourself through
relaxation exercises may make it easier to sleep, concentrate, and have
energy for coping with life. These can include muscular relaxation
exercises, breathing exercises, meditation, swimming, stretching, yoga,
prayer, exercise, listening to quiet music, spending time in nature, and
so on. Here are some basic breathing exercises that may help:

**FOR YOURSELF:**

1.  Inhale slowly (one-thousand one; one-thousand two; one-thousand
    three) through your nose and comfortably fill your lungs all the way
    down to your belly.

2.  Silently and gently say to yourself, \"My body is filled with
    calmness.\" Exhale slowly (one-thousand one, one-thousand two,
    one-thousand three) through your mouth and comfortably empty your
    lungs all the way down to your abdomen.

3.  Silently and gently say to yourself, \"My body is releasing the
    tension.\"

4.  Repeat five times slowly and comfortably.

5.  Do this as many times a day as needed.

**FOR CHILDREN:**

Lead a child through a breathing exercise:

1.  "Let's practice a different way of breathing that can help calm our
    bodies down.

2.  Put one hand on your stomach, like this \[demonstrate\].

3.  Okay, we are going to breathe in through our noses. When we breathe
    in, we are going to fill up with a lot of air and our stomachs are
    going to stick out like this \[demonstrate\].

4.  Then, we will breathe out through our mouths. When we breathe out,
    our stomachs are going to suck in and up like this \[demonstrate\].

5.  We are going to breathe in really slowly while I count to three. I'm
    also going to count to three while we breathe out really slowly.

6.  Let's try it together. Great job!"

Make a game of it:

-   Blow bubbles with a bubble wand and dish soap

-   Blow bubbles with chewing gum

-   Blow paper wads or cotton balls across the table

-   Tell a story where the child helps you imitate a character who is
    taking deep breaths (i.e., the three little pigs)

-   

![](media/image5.wmf){width="0.9375in" height="10.183333333333334in"}

**Tips for Helping Adolescents After Disasters (Part I)**

+-----------------------+-----------------------+----------------------+
| **Reactions**         | **Responses**         | **Examples of things |
|                       |                       | to do and say**      |
+-----------------------+-----------------------+----------------------+
| #                     | ►Provide a safe time  | ► "Many kids---and   |
| [Detachment, shame, a | to discuss with your  | adults---feel like   |
| nd guilt]{.underline} | teen the events and   | you do, angry and    |
|                       | their feelings.       | blaming themselves   |
|                       |                       | that they couldn't   |
|                       | ►Emphasize that these | do more. You're not  |
|                       | feelings are common,  | at fault---remember; |
|                       | and correct excessive | even the             |
|                       | self-blame with       | firefighters said    |
|                       | realistic             | there was nothing    |
|                       | explanations of what  | more we could have   |
|                       | actually could have   | done."               |
|                       | been done.            |                      |
+-----------------------+-----------------------+----------------------+
| [Self-consc           | ►Help teens           | ► "I was feeling the |
| iousness]{.underline} | understand that these | same thing. Scared   |
| about their fears,    | feelings are common.  | and helpless. Most   |
| sense of              | ►Encourage            | people feel like     |
| vulnerability, fear   | relationships with    | this when a disaster |
| of being labeled      | family and peers for  | happens, even if     |
| abnormal              | needed support during | they look calm on    |
|                       | the recovery period.  | the outside."        |
|                       |                       |                      |
|                       |                       | ► "My cell phone is  |
|                       |                       | working again, why   |
|                       |                       | don't you see if you |
|                       |                       | can get a hold of    |
|                       |                       | Pete to see how he's |
|                       |                       | doing."              |
|                       |                       |                      |
|                       |                       | ► "And thanks for    |
|                       |                       | playing the game     |
|                       |                       | with your little     |
|                       |                       | sister. She's much   |
|                       |                       | better now."         |
+-----------------------+-----------------------+----------------------+
| [Acting out           | ►Help teens           | ► "Many teens---and  |
| b                     | understand that       | some adults---feel   |
| ehavior]{.underline}; | acting out behavior   | out of control and   |
| using alcohol and     | is a dangerous way to | angry after a        |
| drugs, sexual acting  | express strong        | disaster like this.  |
| out, accident-prone   | feelings (like anger) | They think drinking  |
| behavior.             | over what happened.   | or taking drugs will |
|                       |                       | help somehow. It's   |
|                       | ►Limit access to      | very normal to feel  |
|                       | alcohol and drugs.    | that way---but it's  |
|                       |                       | not a good idea to   |
|                       | ►Talk about the       | act on it."          |
|                       | danger of high-risk   |                      |
|                       | sexual activity.      | ► "It's important    |
|                       |                       | during these times   |
|                       | ►On a time-limited    | that I know where    |
|                       | basis, have them let  | you are and how to   |
|                       | you know where they   | contact you." Assure |
|                       | are going and what    | them that this extra |
|                       | they're planning to   | checking-in is       |
|                       | do.                   | temporary, just      |
|                       |                       | until things have    |
|                       |                       | stabilized.          |
+-----------------------+-----------------------+----------------------+
| # [Fears of recurren  | ►Help to identify     | ► "When you're       |
| ce and reactions to r | different reminders   | reminded, you might  |
| eminders]{.underline} | (people, places,      | try saying to        |
|                       | sounds, smells,       | yourself, 'I am      |
|                       | feelings, time of     | upset now because I  |
|                       | day) and to clarify   | am being reminded,   |
|                       | the difference        | but it is different  |
|                       | between the event and | now because there is |
|                       | the reminders that    | no hurricane and I   |
|                       | occur after it.       | am safe."            |
|                       |                       |                      |
|                       | ►Explain to teens     | ►Suggest "Watching   |
|                       | that media coverage   | the news reports     |
|                       | of the disaster can   | could make it worse, |
|                       | trigger fears of it   | because they are     |
|                       | happening again.      | playing the same     |
|                       |                       | images over and      |
|                       |                       | over. How about      |
|                       |                       | turning it off now?" |
+-----------------------+-----------------------+----------------------+

**Tips for Helping Adolescents After Disasters (Part II)**

+--------------------+------------------+-----------------------------+
| **Reactions**      | **Responses**    | **Examples of things to do  |
|                    |                  | and say**                   |
+--------------------+------------------+-----------------------------+
| [Abrupt shifts in  | ►Explain that    | ►Spend more time talking as |
| interpersonal      | the strain on    | a family about how everyone |
| relations          | relationships is | is doing. Say, "You know,   |
| hips]{.underline}: | expectable.      | the fact that we're crabby  |
| Teens may pull     | Emphasize that   | with each other is          |
| away from parents, | we need family   | completely normal, given    |
| family, and even   | and friends for  | what we've been through. I  |
| from peers; they   | support during   | think we're handling things |
| may respond        | the recovery     | amazingly. It's a good      |
| strongly to        | period.          | thing we have each other."  |
| parent's reactions |                  |                             |
| in the crisis.     | ►Encourage       | ►You might say, "I          |
|                    | tolerance for    | appreciate your being calm  |
|                    | different family | when your brother was       |
|                    | member's courses | screaming last night. I     |
|                    | to recovery.     | know he woke you up too."   |
|                    |                  |                             |
|                    | ►Accept          | ►"I want to apologize for   |
|                    | responsibility   | being irritable with you    |
|                    | for your own     | yesterday. I am going to    |
|                    | feelings.        | work harder to stay calm    |
|                    |                  | myself."                    |
+--------------------+------------------+-----------------------------+
| # [Radic           | ►Explain that    | ► "We are all under great   |
| al changes in atti | changes in       | stress. When people's lives |
| tude]{.underline}  | people's         | are disrupted this way, we  |
|                    | attitudes after  | all feel more scared,       |
|                    | a disaster are   | angry---even full of        |
|                    | common, but will | revenge. It might not seem  |
|                    | return back to   | like it, but we all will    |
|                    | normal over      | feel better when we get     |
|                    | time.            | back to a more structured   |
|                    |                  | routine."                   |
+--------------------+------------------+-----------------------------+
| [Wanting premature | ►Encourage       | ► "I know you're thinking   |
| entrance into      | postponing major | about quitting school and   |
| adult              | life decisions.  | getting a job to help out.  |
| hood]{.underline}: | Find other ways  | But it's important not to   |
| (e.g., wanting to  | to make the      | make big decisions right    |
| leave school, get  | adolescent feel  | now. A crisis time is not a |
| married)           | more in control  | great time to make major    |
|                    | over things.     | changes."                   |
+--------------------+------------------+-----------------------------+
| # [Concern for oth | ►Encourage       | ►Help teens to identify     |
| er victims and fam | constructive     | projects that are           |
| ilies]{.underline} | activities on    | age-appropriate and         |
|                    | behalf of        | meaningful (e.g., clearing  |
|                    | others, but do   | rubble from school grounds, |
|                    | not burden with  | collecting money or         |
|                    | undo             | supplies for those in       |
|                    | responsibility.  | need).                      |
+--------------------+------------------+-----------------------------+

+----------------------------+-------------+--------------------------+
| **Reactions/Behavior**     | **          | **Examples of things to  |
|                            | Responses** | do and say**             |
+----------------------------+-------------+--------------------------+
| [Helplessness and          | ►Provide    | ►Give your child more    |
| Passivity]{.underline}:    | comfort,    | hugs, hand holding, or   |
| Young children know they   | rest, food, | time in your lap.        |
| can't protect themselves.  | water, and  |                          |
| In a disaster they feel    | op          | ►Make sure there is a    |
| even more helpless. They   | portunities | special safe area for    |
| want to know their parents | for play    | your child to play with  |
| will keep them safe. They  | and         | proper supervision.      |
| might express this by      | drawing.    |                          |
| being unusually quiet or   |             | ►In play, a four year    |
| agitated.                  | ►Provide    | old keeps having the     |
|                            | ways to     | blocks knocked down by   |
|                            | turn        | hurricane winds. Asked,  |
|                            | spontaneous | "Can you make it safe    |
|                            | drawing or  | from the winds?" the     |
|                            | playing     | child quickly builds a   |
|                            | from        | double block thick wall  |
|                            | traumatic   | and says, "Winds won't   |
|                            | events to   | get us now." A parent    |
|                            | include     | might respond with,      |
|                            | something   | "That wall sure is       |
|                            | that would  | strong" and explain,     |
|                            | make them   | "We're doing a lot of    |
|                            | feel safer  | things to keep us safe." |
|                            | or better.  |                          |
|                            |             |                          |
|                            | ► Reassure  |                          |
|                            | your child  |                          |
|                            | that you    |                          |
|                            | and other   |                          |
|                            | grownups    |                          |
|                            | will        |                          |
|                            | protect     |                          |
|                            | them.       |                          |
+----------------------------+-------------+--------------------------+
| [General                   | ►Be as calm | ► Be aware when you are  |
| Fearfulness]{.underline}:  | as you can  | on the phone or talking  |
| Young children may become  | with your   | to others, that your     |
| more afraid of being       | child. Try  | child does not overhear  |
| alone, being in the        | not to      | you expressing fear.     |
| bathroom, going to sleep,  | voice your  |                          |
| or otherwise separated     | own fears   | ►Say things such as, "We |
| from parents. Children     | in front of | are safe from the        |
| want to believe that their | your child. | hurricane now, and       |
| parents can protect them   |             | people are working hard  |
| in all situations and that | ►Help       | to make sure we are      |
| other grownups, such as    | children    | okay."                   |
| teachers or police         | regain      |                          |
| officers, are there to     | confidence  | ►Say, "If you start      |
| help them.                 | that you    | feeling more scared,     |
|                            | aren't      | come and take my hand.   |
|                            | leaving     | Then I'll know you need  |
|                            | them and    | to tell me something."   |
|                            | that you    |                          |
|                            | can protect |                          |
|                            | them.       |                          |
|                            |             |                          |
|                            | ►Remind     |                          |
|                            | them that   |                          |
|                            | there are   |                          |
|                            | people      |                          |
|                            | working to  |                          |
|                            | keep        |                          |
|                            | families    |                          |
|                            | safe, and   |                          |
|                            | that your   |                          |
|                            | family can  |                          |
|                            | get more    |                          |
|                            | help if you |                          |
|                            | need to.    |                          |
|                            |             |                          |
|                            | ►If you     |                          |
|                            | leave,      |                          |
|                            | reassure    |                          |
|                            | your        |                          |
|                            | children    |                          |
|                            | you will be |                          |
|                            | back. Tell  |                          |
|                            | them a      |                          |
|                            | realistic   |                          |
|                            | time in     |                          |
|                            | words they  |                          |
|                            | understand, |                          |
|                            | and be back |                          |
|                            | on time.    |                          |
|                            |             |                          |
|                            | ►Give your  |                          |
|                            | child ways  |                          |
|                            | to          |                          |
|                            | communicate |                          |
|                            | their fears |                          |
|                            | to you.     |                          |
+----------------------------+-------------+--------------------------+
| [Confusion about the       | ►Give       | ►Continue to explain to  |
| danger being               | simple,     | your child that the      |
| over]{.underline}: Young   | repeated    | hurricane has passed and |
| children can overhear      | e           | that you are away from   |
| things from adults and     | xplanations | the flooded area         |
| older children, or see     | as needed,  |                          |
| things on TV or just       | even every  | ►Draw, or show on a map, |
| imagine that it is         | day. Make   | how far away you are     |
| happening all over again.  | sure they   | from the disaster area,  |
| They believe the danger is | understand  | and that where you are   |
| closer to home, even if it | the words   | is safe. "See? The       |
| happened further away.     | you are     | hurricane was way over   |
|                            | using.      | there, and we're way     |
|                            |             | over here in this safe   |
|                            | ►Find out   | place."                  |
|                            | what other  |                          |
|                            | words or    |                          |
|                            | e           |                          |
|                            | xplanations |                          |
|                            | they have   |                          |
|                            | heard and   |                          |
|                            | clarify     |                          |
|                            | in          |                          |
|                            | accuracies. |                          |
|                            |             |                          |
|                            | ►If you are |                          |
|                            | at some     |                          |
|                            | distance    |                          |
|                            | from the    |                          |
|                            | danger, it  |                          |
|                            | is          |                          |
|                            | important   |                          |
|                            | to tell     |                          |
|                            | your child  |                          |
|                            | that the    |                          |
|                            | danger is   |                          |
|                            | not near    |                          |
|                            | you.        |                          |
+----------------------------+-------------+--------------------------+

**Tips for Helping Preschool-Age Children After Disasters (Part I)**

**Tips for Helping Preschool-Age Children After Disasters (Part II)**

**Tips for Helping School-Age Children After Disasters (Part I)**

+-----------------------+-----------------------+-----------------------+
| **Reactions**         | **Responses**         | **Examples of things  |
|                       |                       | to do and say**       |
+-----------------------+-----------------------+-----------------------+
| [Confusion about what | ►Give clear           | ► "I know other kids  |
| happened]{.underline} | explanations of what  | said that more        |
|                       | happened whenever     | hurricanes are        |
|                       | your child asks.      | coming, but we are    |
|                       | Avoid details that    | now in a place that   |
|                       | would scare your      | is safer from         |
|                       | child. Correct any    | hurricanes."          |
|                       | information that your |                       |
|                       | child is unclear or   | ►Continue to answer   |
|                       | confused about        | questions your        |
|                       | regarding if there is | children have         |
|                       | a present danger.     | (without getting      |
|                       |                       | irritable) and to     |
|                       | ►Remind children that | reassure them the     |
|                       | there are people      | family is safe.       |
|                       | working to keep       |                       |
|                       | families safe and     | ►Tell them what's     |
|                       | that your family can  | happening, especially |
|                       | get more help if      | about issues          |
|                       | needed.               | regarding school and  |
|                       |                       | where they will be    |
|                       | ►Let your children    | living.               |
|                       | know what they can    |                       |
|                       | expect to happen      |                       |
|                       | next.                 |                       |
+-----------------------+-----------------------+-----------------------+
| [Feelings of being    | ►Provide              | ►Take your child      |
| resp                  | opportunities for     | aside. Explain that,  |
| onsible:]{.underline} | children to voice     | "After a disaster     |
| School-age children   | their concerns to     | like this, lots of    |
| may have concerns     | you.                  | kids---and parents    |
| that they were        |                       | too---keep thinking   |
| somehow at fault, or  | ►Offer reassurance    | 'What could I have    |
| should have been able | and tell them why it  | done differently?' or |
| to change what        | was not their fault.  | 'I should have been   |
| happened. They may    |                       | able to do            |
| hesitate to voice     |                       | something.' That      |
| their concerns in     |                       | doesn't mean they     |
| front of others.      |                       | were at fault."       |
|                       |                       |                       |
|                       |                       | ► "Remember? The      |
|                       |                       | firefighter said no   |
|                       |                       | one could save Pepper |
|                       |                       | and it wasn't your    |
|                       |                       | fault."               |
+-----------------------+-----------------------+-----------------------+
| [Fears of recurrence  | ►Help child to        | ►When they recognize  |
| of the event and      | identify reminders    | that they are being   |
| reactions to          | (people, places,      | reminded, say, "Try   |
| r                     | sounds, smells,       | to think to yourself, |
| eminders]{.underline} | feelings, time of     | 'I am upset because I |
|                       | day) and to clarify   | am being reminded of  |
|                       | the difference        | the hurricane because |
|                       | between the event and | it is raining, but    |
|                       | the reminders that    | now there is no       |
|                       | occur after it.       | hurricane and I am    |
|                       |                       | safe."                |
|                       | ►Reassure them, as    |                       |
|                       | often as they need,   | ► "I think we need to |
|                       | that they are safe.   | take a break from the |
|                       |                       | TV right now."        |
|                       | ►Protect children     |                       |
|                       | from seeing media     |                       |
|                       | coverage of the event |                       |
|                       | as it can trigger     |                       |
|                       | fears of the disaster |                       |
|                       | happening again.      |                       |
+-----------------------+-----------------------+-----------------------+
| [Retelling the        | ►Permit the child to  | ► "I notice you're    |
| event]{.underline} or | talk and act out      | drawing a lot of      |
| playing out the event | these reactions. Let  | pictures of what      |
| over and over         | them know that this   | happened. Did you     |
|                       | is normal. ►Encourage | know that many        |
|                       | positive              | children do that?"    |
|                       | problem-solving in    |                       |
|                       | play or drawing.      | ► "It might help to   |
|                       |                       | draw about how you    |
|                       |                       | would like your       |
|                       |                       | school to be rebuilt  |
|                       |                       | to make it safer."    |
+-----------------------+-----------------------+-----------------------+

**Tips for Helping School-Age Children After Disasters (Part II)**

**Appendix F: Working with Older Adults**

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  **Older adults have areas of strength as well as vulnerability. Many
  elderly individuals can be highly resilient, having acquired effective
  coping skills through a lifetime of experience in dealing with
  adversity. Alternatively, some may be more vulnerable to stress due to
  a variety of age-related impairments.**

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Factors contributing to strength in the elderly include:

-   Having effective coping skills (mature perspective, patience, faith,
    interpersonal skills)

-   Having a supportive network of family, friends, neighbors, community
    groups, and organizations

Factors that may increase vulnerability to stress in the elderly
include:

-   Health problems such as: physical illness; problems with blood
    pressure, fluid and electrolyte balance; frailty (increased
    susceptibility to falls, minor injuries and bruising)

-   Age-related sensory loss:

    -   Visual loss, which can limit awareness of surroundings and add
        to confusion

    -   Hearing loss, resulting in gaps in understanding of what others
        are saying

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-   Cognitive problems, such a difficulty with attention, concentration
    and memory

-   Dependency on prescription or other medications

-   Being on a fixed or low income

-   Social isolation, separation from close family members and friends

-   Lacking mobility and/or transportation

In working with older adults, the PFA provider should keep the following
in mind:

-   Talk at eye level, allowing him/her to see your lips when you speak

-   Speak clearly and in a low pitch

-   Don't make assumptions based only on physical appearance or age,
    such as that a confused elder is senile. Reasons for apparent
    confusion may include: disaster-related disorientation due to change
    in surroundings; poor vision or hearing; poor nutrition or
    dehydration; sleep deprivation; a medical condition or problems with
    medications; social isolation; and feeling helpless or vulnerable

-   Speak to the elderly person, unless direct communication is
    difficult

-   In general, take the word of a person who claims to have a
    disability, even if the disability is not obvious or familiar to you

-   When you are unsure of how to help, ask, "What can I do to help?"
    and trust what the person tells you

-   Where possible, enable the person to be self sufficient

-   An elderly person with a psychiatric or emotional disability may be
    more upset or confused in unfamiliar surroundings. If you identify
    such an individual, help to make arrangements for a mental health
    consultation or referral.

To provide effective assistance, you can:

-   *Safety:* Help to make the physical environment safer, (for example,
    try to insure adequate lighting, and protect against slipping,
    tripping and falling.

-   *Sensory:* Ask specifically about his/her needs for eyeglasses,
    hearing aids, or other medical devices.

-   *Assistance with Physical Tasks:* Ask whether the elder needs help
    with health-related issues or daily activities (e.g., assistance
    with dressing, use of bathroom, daily grooming, meals; supportive
    clothing; walker, cane).

-   *Medications and Medical Equipment:* Inquire about medications---ask
    if he/she has a list of current medications or where this
    information can be obtained. Make sure he/she has a readable copy of
    this information to keep during the post-disaster period. Ask about
    whether he/she needs medical equipment or supplies (for example,
    medications, oxygen and wheelchairs). Try to insure that all
    essential aids are kept with the person.

-   *Advocacy/Monitoring:* If available, contact relatives to insure
    safety, nutrition, medications and rest.

-   Make sure that the authorities are aware of any daily needs that are
    not being met.

-   *Housing/Discharge:* Help with plans for an elder who is going home
    or needs access to alternative housing. Make sure the elder has
    referral sources for the following, if needed:

[^1]: PFA has received considerable support from disaster mental health
    experts in the field as the 'acute intervention of choice' when
    responding to the psychological, psychosocial, and psychospiritual
    needs of individuals impacted by disaster. It is important to note,
    however, no model of PFA to date has been empirically validated or
    rigorously tested and thus, the efficacy of this supportive
    intervention and its resultant outcomes are unknown. Because many of
    the components of PFA have emanated from other theoretical models of
    support that have been tested and validated, there is consensus
    among experts at this time that these components when administered
    to disaster survivors and workers individually should, at worse
    produce no harm, and at best, provide effective ways for individuals
    to manage post-disaster stress and identify those who may require
    additional psychological support.

[^2]: While this guide primarily focuses on the use of PFA in a disaster
    survivor population, this support intervention may also be used with
    disaster workers and other relief personnel.

[^3]: While traditionally thought of as police, fire, and EMS
    responders, other individuals or groups may be considered. These
    include: search and rescue teams, salvage teams, DMORT and medical
    examiner's staff, DNA and forensic specialists, media personnel,
    spiritual care providers, hospital personnel, hotel food service and
    janitorial staff, CERT volunteers, and transportation crews.

[^4]: Kenardy JA, Webster RA, Lewin TJ, Carr VJ, Hazell PL, Carter GL.
    Stress debriefing and patterns of recovery following a natural
    disaster. *J Trauma Stress* 1996; 9: 37-4.

[^5]: Ørner RJ, Kent AT, Pfefferbaum BJ, Raphael B, and Watson PJ.
    (2006). The Context of Providing Immediate Postevent Intervention.
    In: EC Ritchie, PJ Watson, & MJ Friedman (eds.), *Interventions
    Following Mass Violence and Disasters*. New York: The Guilford
    Press.

[^6]: Watson P, Ritchie EC, Demer J, Bartone P, Pfferbaum BJ. (2006).
    Improving Resilience Trajectories Following Mass Violence and
    Disaster. In: EC Ritchie, PJ Watson, & MJ Friedman (eds.),
    *Interventions Following Mass Violence and Disasters*. New York: The
    Guilford Press.

[^7]: Ørner RJ, Kent AT, Pfefferbaum BJ, Raphael B, and Watson PJ.
    (2006). The Context of Providing Immediate Postevent Intervention.
    In: EC Ritchie, PJ Watson, & MJ Friedman (eds.), *Interventions
    Following Mass Violence and Disasters*. New York: The Guilford
    Press.

[^8]: National Institute of Mental Health (2002). *Mental Health and
    Mass Violence: Evidence-Based Early Psychological Intervention for
    Victims/Survivors of Mass Violence. A Workshop to Reach Consensus on
    Best Practices*. NIH Publication No. 02-5138, Washington, D.C.: U.S.
    Government Printing Office.

[^9]: Ørner RJ, Kent AT, Pfefferbaum BJ, Raphael B, and Watson PJ.
    (2006). The Context of Providing Immediate Postevent Intervention.
    In: EC Ritchie, PJ Watson, & MJ Friedman (eds.), *Interventions
    Following Mass Violence and Disasters*. New York: The Guilford
    Press.

[^10]: Adapted from: Herrmann J. *Disaster Mental Health: A Critical
    Response. A Training Curriculum for Mental Health and Spiritual Care
    Professionals in Healthcare Settings*. University of Rochester,
    2006.