A TRAINING MANUAL

U.S. Department of Health and Human Services

Substance Abuse and Mental Health Services Administration

Center for Mental Health Services

2004

MENTAL HEALTH RESPONSE TO 

MASS VIOLENCE AND TERRORISM
ii

ACKNOWLEDGMENTS

This publication was produced under Interagency Agreement #RA00C5400A between the U.S.

Department of Justice (DOJ), Office for Victims of Crime (OVC), and the Center for Mental Health

Services (CMHS), the Substance Abuse and Mental Health Services Administration (SAMHSA). DOJ

provided funds for the development of the document; SAMHSA provided funds for the editing,

design, layout, and printing of the publication. The document was written by Deborah J. DeWolfe,

Ph.D., M.S.P.H., and reviewed by a group of experts on mass violence and mental health response.

The SAMHSA Disaster Technical Assistance Center (DTAC), ESI, under contract with CMHS, edited

the document and designed the cover and layout for this publication.

Disclaimer

The content in this publication is solely the responsibility of the author and does not necessarily

represent the position of U.S. DOJ, OVC; SAMHSA or its centers.

Public Domain Notice

All material appearing in this report is in the public domain and may be reproduced or copied

without permission from SAMHSA or CMHS. Citation of the source is appreciated. However, this

publication may not be reproduced or distributed for a fee without the specific, written authorization

of the Office of Communications, SAMHSA, Department of Health and Human Services (DHHS).

Electronic Access and Copies Of Publication

This publication can be accessed electronically through the following Internet connections:

www.samhsa.gov and www.ncjrs.org. For additional free copies of this document, please contact

SAMHSA’s National Mental Health Information Center, and ask for Publication No. SMA 3959, at 

1-800-789-2647, 1-866-889-2647 (TDD); or contact the OVC Resource Center, and ask for

Publication No. NCJ 205451, at 1-800-851-3420, 1-877-712-9279 (TTY).

Recommended Citation

U.S. Department of Health and Human Services. Mental Health Response to Mass Violence and

Terrorism: A Training Manual. DHHS Pub. No. SMA 3959. Rockville, MD: Center for Mental Health

Services, Substance Abuse and Mental Health Services Administration, 2004.

Originating Office

Substance Abuse and Mental Health Services Administration 

1 Choke Cherry Road, Rockville, Maryland 20857

DHHS Publication No. SMA 3959

Printed 2004
Preface...................................................................................................................vii

Chapter I. Background and Overview ...................................................................2

Purpose of the Manual ....................................................................................................................4

Overview of the Manual..................................................................................................................5

Overview of Resources ...................................................................................................................7

Glossary of Acronyms .....................................................................................................................7

Chapter II. Human Responses to Mass Violence and Terrorism.........................8

Population Exposure Model..........................................................................................................11

Population Exposure Checklist................................................................................................11

Traumatic Event and Stressor Characteristics.............................................................................12

Survivor Characteristics ................................................................................................................14

Immediate Adult Reactions to Trauma, Victimization, and Sudden Bereavement ...................16

Physical Reactions...................................................................................................................16

Behavioral Reactions...............................................................................................................16

Emotional Reactions ...............................................................................................................17

Cognitive Reactions.................................................................................................................17

Long-Term Responses of Adults...................................................................................................17

Traumatic Bereavement ..........................................................................................................18

Screening and Assessment Checklist ......................................................................................18

Model of Human Responses to Trauma and Bereavement ........................................................19

Children and Adolescents: Priority Considerations and Reactions ............................................21

Traumatic Event and Stressor Characteristics.........................................................................23

Post-Trauma and Grief Reactions ...........................................................................................23

Screening and Assessment Checklist ......................................................................................24

Older Adults: Priority Considerations and Reactions ..................................................................24

Screening and Assessment Checklist ......................................................................................25

Cultural and Ethnic Groups: Priority Considerations and Reactions..........................................26

Cultural Response Checklist....................................................................................................27

Recommended Reading ................................................................................................................28

Chapter III. Mental Health Intervention...............................................................30

Key Principles for Mental Health Intervention.............................................................................31

Mental Health Assistance Coordination ..................................................................................33

Mental Health Service Provider Groups ..................................................................................33

iii

TABLE OF CONTENTS
iv

Immediate Mental Health Intervention ........................................................................................34

Goals and Priorities.................................................................................................................34

Immediate Mental Health Interventions with Adults ..................................................................35

Psychological First-Aid ............................................................................................................35

Crisis Intervention ...................................................................................................................36

Informational Briefings ...........................................................................................................38

Crime Victim Assistance ..........................................................................................................38

Community Outreach..............................................................................................................39

Psychological Debriefing .........................................................................................................40

Psycho-Education ..................................................................................................................41

Mental Health Consultation ....................................................................................................42

Long-Term Mental Health Interventions with Adults..................................................................43

Goals and Priorities.................................................................................................................43

Crime Victim Services..............................................................................................................44

Brief Counseling......................................................................................................................46

Support Groups.......................................................................................................................47

Immediate Mental Health Interventions for Children and Adolescents.....................................48

Goals and Priorities.................................................................................................................48

Psychological First-Aid ............................................................................................................49

Play Areas................................................................................................................................49

Participation in Disaster Relief ................................................................................................49

School Interventions................................................................................................................50

Classroom Interventions .........................................................................................................50

Long-Term Mental Health Interventions for Children and Adolescents ....................................50

Goals and Priorities.................................................................................................................50

Brief Counseling......................................................................................................................51

Support Groups.......................................................................................................................52

Considerations for Immediate and Long-Term Mental Health Intervention 

With Cultural and Ethnic Groups ..............................................................................................52

Tips for Working with Interpreters ..........................................................................................53

Basic Cultural Sensitivity Checklist..........................................................................................53

Key Events with Mental Health Implications...............................................................................54

Death Notification ...................................................................................................................55

Ending Rescue and Recovery Operations................................................................................56

Applying for Death Certificates When No Identified Remains Have Been Found....................56

Events Involved in Criminal Justice Proceedings.....................................................................57

Returning to the Crime Scene and Disaster-Impacted Areas ..................................................58

Memorials and Funerals .........................................................................................................59

Determination of Formulas and Methods for Distributing Federal, State, Employer, and

Charity Funds to Victims and Families ................................................................................60

Interventions with the Community...............................................................................................60

Memorials, Rituals, and Commemorations ............................................................................60

Usual Community Gatherings.................................................................................................61

Symbolic Gestures...................................................................................................................62

Recommended Reading ................................................................................................................66
v

Chapter IV. Organizational Preparation and Response to Mass Violence and 

Terrorism and the Mental Health Role.............................................................68

Emergency Operations..................................................................................................................69

Crisis Mental Health Response .....................................................................................................71

Key Considerations for Mental Health Providers Responding to Criminal Mass Violence .......73

Crisis Mental Health Response: Future Directions ......................................................................75

Long-Term Mental Health and Crime Victim Assistance Services .............................................76

Recommended Reading ................................................................................................................77

Chapter V. Stress Prevention, Management, and Intervention.........................78

Sources of Stress ...........................................................................................................................79

Stress Prevention, Management, and Intervention.....................................................................80

Environmental Context............................................................................................................80

Individual Context ...................................................................................................................83

Compassion Fatigue and Secondary Traumatization..................................................................83

Signs and Symptoms of Worker Stress ........................................................................................86

Mental Health Provider Stress Reactions ................................................................................86

Rewards and Joys of Disaster Work .............................................................................................88

Recommended Reading ................................................................................................................88

Chapter VI. Setting Up Training ...........................................................................90

Rapid Response Training ..............................................................................................................91

Comprehensive Training...............................................................................................................92

Selection of Qualified Trainers .....................................................................................................92

Setting Up Training........................................................................................................................93

Who Should Attend? .....................................................................................................................93

Chapter VII. Comprehensive Training Course Outline........................................94

Course Overview ...........................................................................................................................95

Course Objectives..........................................................................................................................95

Overview of Comprehensive Training Course.............................................................................96

Module 1: Introduction..................................................................................................................97

Module 2: Criminal Mass Victimization .......................................................................................99

Module 3: Adult Responses to Mass Violence and Terrorism ..................................................101

Module 4: Organizational Response and Mental Health Roles ................................................104

Module 5: Community Crisis Response and Mental Health Interventions...............................106

Module 6. Children’s and Adolescents’ Reactions and Interventions ......................................110

Module 7: Cultural and Ethnic Groups: Considerations and Interventions .............................113

Module 8: Planning Workgroups ................................................................................................115

Module 9: Stress Prevention, Management, and Intervention .................................................117

Training Overheads .....................................................................................................................121

Handouts......................................................................................................................................166

Videotapes ...................................................................................................................................169
vi

Chapter VIII. Additional Training Needs and Options........................................170

Training for Paraprofessional Staff.............................................................................................171

Counseling Skill Development ..............................................................................................171

Counseling Interventions ......................................................................................................171

Self-Awareness ......................................................................................................................172

Assessment of Mental Health and Other Problems...............................................................172

Legal, Ethical, and Program Considerations.........................................................................172

Training for Human Service Workers.........................................................................................172

Topics and Considerations for In-Service Training ...................................................................173

References and Additional Reading ..................................................................175

Internet Sites ......................................................................................................184

Figures and Tables

Figure 1: Population Exposure Model ..........................................................................................11

Figure 2: Model of Responses to Trauma and Bereavement......................................................20

Figure 3: ICS Organizational Components...................................................................................70

Figure 4: ICS Unified Command ...................................................................................................71

Table 1: Comparison of Mass Violent Victimization and Natural Disasters ................................9

Table 2: Survivor Characteristics..................................................................................................15

Table 3: Reactions to Trauma and Suggestions for Intervention ...............................................63

Table 4: Environmental and Organizational Approaches for Stress Prevention 

and Management ............................................................................................................81

Table 5: Individual Approaches for Stress Prevention and Management ..................................84
vii

PREFACE

The Emergency Mental Health and Traumatic Stress Services Branch (formerly the Emergency

Services and Disaster Relief Branch) of the Center for Mental Health Services (CMHS) through the

Substance Abuse and Mental Health Services Administration (SAMHSA), and the Office for Victims

of Crime (OVC) in the Office of Justice Programs (OJP), U.S. Department of Justice (DOJ), formed a

collaboration in 1999 to provide mental health training, technical assistance, and consultation

services for professionals assisting victims of crime. As part of a formal agreement between the

two agencies, this training manual was developed to assist mental health providers in better

serving victims of terrorism and mass violence. 

CMHS has extensive experience in a number of areas surrounding disaster response, including

crisis counseling. OVC works with Federal, State, and local governments and nongovernmental

partners in promoting justice and healing for all victims of crime. Both CMHS and OVC have

drawn on their considerable experience to develop this manual and provide the most relevant and

comprehensive information available to mental health and crime victim service providers in

responding to victims of terrorism and mass violence. Through the preparation of this document,

both CMHS and OVC are furthering their goals of addressing the mental health needs of victims,

survivors, and communities in the aftermath of terrorist and mass violence crimes.

The events of September 11, 2001, the Oklahoma City bombing, and other events both in the

United States and abroad, have served as dramatic examples of the need for mental health

services in the wake of terrorism and mass violence. Because the risk of becoming a victim of

mass violence has risen dramatically in the last decade, the need for competent mental health

services following a disaster has increased significantly. This manual seeks to present mental

health and crime victim service providers with a comprehensive and informative resource for

assisting terrorism and mass violence victims and affected members of the communities in which

acts occur. To do so, it explores an array of reactions providers may encounter following an

incident. In addition, providers are presented with characteristics of the criminal justice system

and how best to support victims and survivors participating in this process. Furthermore, the

manual provides information for providers to understand and manage their own work-related

stress.

The primary goal of this manual is to enable mental health and crime victim service providers to

help victims, survivors, and the community-at-large cope and recover through outreach and

support. To further this goal, the manual includes a training course for providing mental health
viii

John W. Gillis, M.S.

Director

Office for Victims of Crime

Charles G. Curie, M.A., A.C.S.W.

Administrator

Substance Abuse and Mental 

Health Services Administration

services in the wake of a disaster. Included are field and training resources such as handouts,

overheads, and rapid field training Modules—including supplementary training for paraprofessionals. By preparing in advance, providers will be better equipped to help victims, survivors, and

affected individuals cope with the profound losses and traumatic experiences that stem from these

crimes.

The targeted audiences for this publication are mental health professionals, crime victim

assistance providers, and faith-based counselors who respond to acts of mass violence and

terrorism. However, many people affected by mass violence or a terrorist incident will turn to their

health care providers. This manual can provide valuable information to this audience as well.

The companion Field Guide may be used with this publication to assist mental health and crime

victim service providers while on site of a terrorist or mass violence incident. The Field Guide was

developed to further assist providers with the complex task of counseling victims and the

community in the wake of a disaster.

Both CMHS and OVC hope that those who receive this training find it helpful to understand the

unique mental health needs of terrorism and mass violence victims. We thank you for your

continued work on behalf of those in need.

2 • Mental Health Response to Mass Violence and Terrorism

Over the last decade, U. S.

citizens increasingly have

been the targets of mass

violence and terrorism. The

Los Angeles civil unrest

following the Rodney King

verdict in 1992, the World

Trade Center terrorist bombing

in New York City in 1993, the

Oklahoma City terrorist

bombing in 1995, the mass

shootings at Thurston High

School in Oregon in 1998 and

at Columbine High School in

Colorado in 1999, and the

terrorist attacks of September

11, 2001, in New York,

Virginia, and Pennsylvania,

have resulted in thousands of

fatalities and many more

people whose lives have been

changed forever. School

violence continues to threaten

the safety of children,

teachers, and other school

personnel. Terrorist acts

against the United States also

have been carried out

overseas—the bombing of Pan

Am Flight 103 in 1988, the

bombing of military barracks

at Khobar Towers in 1996, and

the bombing of U.S. embassies

in Kenya and Tanzania in

1998.

Each tragic event affects the

country as a whole, touches

those residing in the affected

communities, and alters the

lives of those directly

victimized. Growing evidence

suggests that terrorism and

mass violence places victims,

bereaved family members, and

CHAPTER I

BACKGROUND

AND OVERVIEW
Chapter I: Background and Overview • 3

emergency response personnel

at risk for long-term physical,

emotional, and psychological

consequences (Office for

Victims of Crime, 2000; Center

for Mental Health Services,

2000b). Each criminal act of

mass violence generates its

own sequence of criminal

justice activities—potentially

including investigations,

arrests, trials, sentencings, and

appeals—each step bringing

related challenges for families

and victims.

For more than 25 years, under

the authority of the Robert T.

Stafford Disaster Relief and

Emergency Assistance Act of

1974, the Federal Government

has provided mental health

assistance following presidentially declared disasters (P.L.

93-288 as amended). Most of

these disasters have been

nature-caused. The Federal

Government has increasingly

been called upon to assist

communities responding to

human-caused mass violence

and terrorism. Because

terrorist acts are Federal

crimes, Federal criminal justice

agencies have statutory

responsibilities related to

protecting victims’ rights and

providing support services,

including responding to the

psychological consequences.

The U.S. Department of

Justice’s (DOJ) Office for

Victims of Crime (OVC) has

developed a working definition

of “mass violence,” which is

“an intentional violent criminal

act, for which a formal investigation has been opened by the

Federal Bureau of Investigation

(FBI) or other law enforcement

agency, that results in physical,

emotional, or psychological

injury to a sufficiently large

number of people as to significantly increase the burden of

victim assistance for the

responding jurisdiction” (p.

17580, U.S. Department of

Justice, 2001). Terrorism has

been defined in the U.S.

Criminal Code as “an activity

that (a) involves a violent act

or an act dangerous to human

life that is a violation of the

criminal laws of the United

States or of any State, or that

would be a criminal violation if

committed within the

jurisdiction of the United States

or of any State; and (b) appears

to be intended to intimidate or

coerce a civilian population, to

influence the policy of a

government by intimidation or

coercion, or to affect the

conduct of a government by

assassination or kidnapping”

[18 U.S.C. 3077].

To better serve victims of

devastating attacks, an

interagency agreement

between the DOJ, OVC, and the

U.S. Department of Health and

Human Services (DHHS),

Substance Abuse and Mental

Health Services Administration

(SAMHSA), Center for Mental

Health Services (CMHS) was

signed in 1999 and concluded

in 2001. This joint effort

combined the substantial

expertise, knowledge, and field

experience of each agency.

Since 1984, the DOJ’s OVC has

assisted crime victims through

funding, direct support, and

advocacy and compensation

programs for crime-related

expenses at the State and local

levels. OVC has supported the

development and provision of

training on a range of crimerelated topics, resource

materials, and demonstration

projects—all aiming to help

victims recover from the

emotional and material effects

of crime and to ensure their

rights as they participate in the

criminal justice system. OVC

has undertaken pioneering

work to better serve victims of

rape, sexual and physical

abuse, domestic violence, hate

crimes, and homicide. OVC

developed innovative programs

and approaches to respond to

the victims and their families

of the bombing of Pan Am

Flight 103, the Oklahoma City

bombing, and the September

11, 2001, terrorist attacks.

Since 1974, SAMHSA’s CMHS

has provided technical

guidance and consultation to

State mental health authorities

to help them develop effective

mental health recovery

programs following presidentially-declared disasters.

Operating through an

interagency agreement with

the Federal Emergency
4 • Mental Health Response to Mass Violence and Terrorism

Management Agency (FEMA),

CMHS has supported and

overseen nearly 200 postdisaster mental health

recovery programs. The

majority of these programs,

known as Crisis Counseling

Programs (CCPs), have served

communities following an

array of natural disasters,

including floods, tornadoes,

hurricanes, earthquakes, and

wildfires. In addition, CMHS

has supported the

development of numerous

technical assistance

publications. In collaboration

with FEMA, CMHS has trained

administrators, managers, and

mental health providers from

all 50 States and the District of

Columbia to better prepare

them should disaster strike in

their communities. More

recently, CMHS has supported

CCPs designed to meet

specialized needs following

the Los Angeles civil unrest,

the Oklahoma City bombing,

and the September 11 terrorist

attacks.

The partnership between

SAMHSA and DOJ brings

together the breadth of skills,

experience, and perspectives

developed over years of

assisting people affected by

violent crime and natural

disasters. The combined efforts

aim to respond effectively to

the mental health needs of

individuals and communities

affected by mass violence and

terrorism and to protect the

rights of victims and families.

This manual provides orienting

information and a training

course designed to enable

human service providers to:

◆ Help victims, survivors,

and family members cope

with trauma and loss;

◆ Help victims, survivors,

and family members

participate in the criminal

justice process;

◆ Assist the community-atlarge in recovery through

education, outreach, and

support; and 

◆ Understand and manage

service providers’ own

work-related stress

responses.

Purpose of 

The Manual

This manual contains “the

basics” of what mental health

providers, crime victim

assistance professionals, and

faith-based counselors need to

know to provide appropriate

mental health support

following incidents involving

criminal mass victimization.

The manual is primarily for

mental health professionals,

yet all service providers will

find much of the material to be

useful. Program planners,

administrators, and clinical

supervisors must acquaint

themselves with the

information in this manual to

IN COLLABORATION 

WITH FEMA, CMHS 

HAS TRAINED 

ADMINISTRATORS, 

MANAGERS, AND MENTAL 

HEALTH PROVIDERS FROM 

ALL 50 STATES AND THE 

DISTRICT OF COLUMBIA 

TO BETTER PREPARE 

THEM SHOULD DISASTER 

STRIKE IN THEIR 

COMMUNITIES.
Chapter I: Background and Overview • 5

develop mental health

response programs, respond to

emerging issues and needs,

and address clinical

challenges. Psychological

support and treatment, crime

victims’ services, and spiritual

guidance and support are

essential components of a

crisis response. Mass acts of

violence and terrorism

commonly have widespread

community impacts as well.

Mental health intervention

targets affected individuals and

families as well as the larger

community.

Human service workers,

including disaster relief

volunteers, faith-based

volunteers, senior center

personnel, cultural group

social service providers, public

assistance workers, and day

care center staff, have contact

with survivors, their families,

and bereaved loved ones.

Many who are experiencing

post-event physical and

psychological symptoms seek

initial treatment and

assistance from their health

care providers. Each of these

service provider groups may

benefit from the material in

this manual and the related

training in order to better

understand and more

effectively serve survivors and

families of victims.

Mental health professionals,

crime victim assistance

providers, and faith-based

counselors responding to mass

acts of violence and terrorism

must be prepared and mobilize

rapidly. Priorities and areas of

emphasis for each group may

conflict, overlap, or leave gaps

in service. Preplanning and

post-event coordination are

essential to minimize heat-ofthe-moment misunderstandings and turf battles. The

training course outlined in

Chapter VII provides an

opportunity for these

disciplines to share their

experience and knowledge,

receive a common foundation

of information, and collaborate

in order to best respond to

community needs.

Overview of 

The Manual 

This manual includes

background information for

mental health responders,

guidance for setting up the

training course, training course

design, and recommendations

for in-service training

addressing long-term recovery

issues. The training course and

materials may be adapted for

preparedness training before a

crisis has occurred, for

immediate mental health

response training shortly after

an incident, or as part of staff

training for a long-term mental

health recovery program. A

brief description of each

chapter follows.

Chapter II: Human

Responses to Mass

Violence and Terrorism

The impact of mass criminal

victimization is widespread

and to varying degrees affects

victims, responders, and the

community-at-large. This

chapter describes characteristics of disaster events that

are likely to result in serious

and long-lasting psychological

effects. It compares the

dimensions of human-caused

and natural disasters. Survivor

risk factors that can contribute

to severe, persistent reactions

are discussed, as are characteristics related to resilience.

This chapter presents the

physical, behavioral,

emotional, and cognitive

reactions to trauma, victimization, and sudden

bereavement experienced by

adults, adolescents, and

children. Considerations for

responding to cultural, racial,

and ethnic groups also are

discussed.

Chapter III: Mental Health

Intervention

Since tragic events change not

only individual lives, but also

the sense of safety within the

entire community, this chapter

describes individual and

community-based mental

health interventions. A

discussion of key concepts for

mental health support and

intervention may assist all

service providers in dealing
6 • Mental Health Response to Mass Violence and Terrorism

with victims, survivors, and

family members. Cultural

sensitivity and competence is

essential for mental health

responders. This chapter

describes a range of immediate

and long-term mental health

interventions appropriate for

adults, children, and

adolescents. A table with

common reactions to trauma

and practical suggestions for

intervention is provided at the

end of the chapter.

Chapter IV: Organizational

Preparation and Response

To Mass Violence and

Terrorism and the Mental

Health Role

The organizational structure

for emergency response to

mass casualty criminal

incidents is complex.

Emergency medical services,

law enforcement, search and

rescue, the medical examiner’s

office, emergency

management, the criminal

justice system, and

government authorities have

key roles and responsibilities

throughout the immediate

response. Jurisdictions may

move from the local to State to

Federal levels and span

various agencies. The mental

health response supports the

primary emergency response

agencies in authority. This

chapter provides an overview

of the incident command

system and the roles,

jurisdictions, and responsibilities of these key organizations, and emphasizes the

importance of coordination

among all responder groups.

Chapter V: Stress

Prevention, Management,

And Intervention

While helping survivors and

their loved ones following

tragic events is often

meaningful and rewarding, it

can also be psychologically

demanding. This chapter

describes sources of mental

health responder stress,

including environmental and

individual factors. It presents a

range of approaches for stress

prevention, management, and

intervention. Mental health

providers engaged in crisis

response over an extended

period are at risk for

compassion fatigue and

secondary traumatization. The

chapter emphasizes critical

components of a comprehensive, multifaceted program

for staff stress prevention and

intervention.

Chapter VI: Setting Up

Training

Training may be provided as

part of preparedness activities

to orient mental health

providers joining the

immediate response and as

part of more formal mental

health program implementation. Training should be

adapted to the unique characteristics of the incident, local

issues, and community needs,

and to the service provider

groups attending the training.

Effective trainers are excellent

facilitators of adult learning

and have relevant knowledge

and experience in at least

several of the following areas:

community crisis response,

disaster mental health, trauma,

bereavement, crime victimization, crime victim advocacy,

and stress management.

Specialists in topics such as

children and trauma, cultural

competence, or the criminal

justice process, and representatives from key agencies or

programs may present

portions of the comprehensive

training.

Chapter VII: Comprehensive

Training Course Outline

The training course outline

includes nine modules with

objectives, materials,

procedures, and duration

described for each one. Each

module integrates brief

lectures with overheads, group

discussions with questions,

videotapes, and group learning

exercises. The training design

may expand or contract

depending on local needs. The

outline is not intended to be a

detailed prescriptive

curriculum, instead it

highlights necessary topics and

provides methodological

suggestions for addressing

them. Trainers may

incorporate and adapt the

materials as needed.
Chapter I: Background and Overview • 7

Chapter VIII: Additional

Training Needs and Options

Each disaster, community, and

mental health intervention

program will generate

additional training needs

beyond the course outlined in

Chapter VII. In-service training

for mental health providers

may address phase-related

issues such as acknowledgment of the 1-year

anniversary or emerging

mental health needs such as

brief counseling for traumatic

bereavement and posttraumatic stress disorder

(PTSD). Training may be

provided for paraprofessional

counselors working under the

auspices of the intervention

program or for human services

workers employed by other

agencies.

Overview of

Resources

Recommended readings and

references throughout this

manual provide more

information on research, field

experience, and sound clinical

suggestions. References cited

throughout the manual, as well

as additional resources, are

included at the end of the

manual. Recommended

videotapes for use in the

comprehensive training are

listed at the end of Chapter VII.

A list of useful Internet sites is

provided at the end of the

References section.

Glossary of Acronyms

ARC American Red Cross

AG Attorney General (Federal and State)

ATF Bureau of Alcohol, Tobacco and Firearms (Federal)

CMHS Center for Mental Health Services (Federal)

DOJ Department of Justice (Federal)

DOEd Department of Education (Federal)

DMH Department of Mental Health (State)

DMHS Disaster Mental Health Services 

EMS Emergency Medical Services

EOC Emergency Operations Center (local, State)

ESF Emergency Support Function

FBI Federal Bureau of Investigation

FEMA Federal Emergency Management Agency 

ICP Incident Command Post

ICS Incident Command System

LFA Lead Federal Agency

MOU Memorandum of Understanding

OVC Office for Victims of Crime (Federal)

PIO Public Information Officer

PTSD Post-Traumatic Stress Disorder

SAMHSA Substance Abuse and Mental Health Services 

Administration (Federal)

SMHA State Mental Health Authority

UC Unified Command

VOAD Voluntary Organizations Active in Disaster

VOCA Victims of Crime Act

VOLAGS Voluntary Agencies
8 • Mental Health Response to Mass Violence and Terrorism

Violent incidents resulting in

mass casualties and victimization send waves of shock

and trauma throughout the

community, the State, and

often across the Nation. This

chapter focuses on the

physical and psychological

effects of these tragic events

and how they are expressed

among different groups.

Because the impact of mass

violence is typically

widespread, a population

exposure model portrays the

victim, family, responder, and

community groups that may

be affected. This model may

help mental health response

managers and planners

identify priority groups for

mental health services.

Table 1 compares the

attributes and effects of mass

violent victimization and

natural disasters. This

template may provide a

structure for further inquiry

and study. Survivor characteristics—both risk factors and

resiliency factors—are

described. Risk factors

contribute to the variability in

individuals’ responses to

identical exposures to severe

trauma, particularly over time.

The section on adult reactions

to trauma, victimization, and

sudden bereavement describes

the range of potential physical,

behavioral, emotional, and

cognitive reactions

experienced by traumatized

CHAPTER II

HUMAN RESPONSES TO

MASS VIOLENCE AND

TERRORISM
Chapter II: Human Responses to Mass Violence and Terrorism • 9

Mass Violent Victimization

• Mass riots • Hostage taking • Arson 

• Terrorist bomb • Mass shooting 

• Bioterrorism • Aircraft hijacking

• Include evil human intent, deliberate sociopolitical act, human cruelty, revenge, hate or

bias against a group, mental illness.

• Event seems incomprehensible, senseless.

• Some view as uncontrollable and

unpredictable, others view as preventable.

• Social order has been violated.

• Life threat, mass casualties, exposure to

trauma, and prolonged recovery effort result

in significant physical and emotional effects. 

• There are higher rates of Post-Traumatic

Stress Disorder (PTSD), depression, anxiety

and traumatic bereavement that can last for

a longer period of time.

• Victims are suddenly caught unaware in a

dangerous, life-threatening situation. May

experience terror, fear, horror, helplessness,

and sense of betrayal and violation. 

• Resulting distrust, fear of people, or being

“out in the world” may cause withdrawal and

isolation. 

• Outrage, blaming the individual or group

responsible, desire for revenge, and demand

for justice are common.

• Assumptions about humanity are shattered;

individuals no longer feel that the world is

secure, just, and orderly. 

• Survivors confronted with the reality that evil

things can happen to good people. 

• People lose their illusion of invulnerability;

anyone can be in the wrong place at the

wrong time.

Natural Disasters

• Hurricane • Earthquake • Tornado 

• Flood • Volcanic eruption • Wildfire 

• Drought

• Is an act of nature; severity of impact may

result from interaction between natural

forces and human error or actions.

• Expectations defined by disaster type.

• Awe expressed about power and

destruction of nature. 

• Disasters with warnings increase sense of

predictability and controllability. 

• Recurring disasters pose ongoing threat.

• Property loss and damage are primary

impacts, so reactions relate to losses,

relocation, financial stress, and daily hassles. 

• Disaster traumatic stress typically resolves

over 18 months, with lower rates of

diagnosable disorders unless high number

of fatalities and serious injuries.

• Separation from family members,

evacuation, lack of warning, life threat,

trauma, and loss of irreplaceable property

and homes contribute to disaster stress

reactions. 

• Anger and blame expressed toward

agencies and individuals responsible for

prevention, mitigation, and disaster relief.

• Spiritual beliefs may be shaken (e.g., “How

could God cause this destruction?”). 

• Loss of security in “terra firma” that the

earth is “solid” and dependable. 

• People lose their illusion of invulnerability;

anyone can be in the wrong place at the

wrong time.

T ABLE 1: COMPARISON OF MASS VIOLENT VICTIMIZATION AND NATURAL DISASTERS

DIMENSION

Examples

Causation

Appraisal of

Event

Psychological

Impact

Subjective

Experience

World View/

Basic

Assumptions

Continued on next page
10 • Mental Health Response to Mass Violence and Terrorism

Mass Violent Victimization

• Some victims may come to feel humiliation,

responsibility for others’ deaths, survivor guilt,

self-blame, and unworthy of assistance, thus

assigning stigma to themselves. 

• The larger community, associates, friends,

and even family may distance themselves to

avoid confronting the idea that crime victimization can happen to anyone. 

• Well-meaning loved ones may urge victims

and bereaved to “move on,” causing them to

feel rejected and wrong for continuing to

suffer. 

• Hate crimes reinforce the discrimination and

stigma that targeted groups already

experience.

• Impact 

• Outcry

• Disbelief, shock, and denial

• Interaction with criminal justice system

• Working-through process

• Coming to terms with realities and losses

• Reconstruction

• The media shows more interest in events of

greater horror and psychological impact.

• Excessive and repeated media exposure

puts people at risk for secondary traumatization.

• Risk of violations of privacy.

• Victims’ needs may conflict with necessary

steps in the criminal justice process.

• Steps required to obtain crime victim

compensation and benefits can seem

confusing, frustrating, bureaucratic, and

dehumanizing and trigger feelings of

helplessness.

• Bias-crime victims may suffer prejudice and

blame.

• Victims may feel that the remedy or

punishment is inadequate in comparison to

the crime and their losses.

Natural Disasters

• Disasters tend to have greater impact on

people with fewer economic resources 

due to living in lower-cost, structurally

vulnerable residences in higher-risk areas. 

• Survivors from cultural, racial, and ethnic

groups; single parent families; people with

disabilities; and the elderly on fixed incomes

experience greater barriers to recovery

causing double jeopardy and potential

stigma.

• Warning, threat

• Impact 

• Rescue and heroism

• Honeymoon

• Interaction with disaster relief and recovery

• Disillusionment

• Coming to terms with realities and losses

• Reconstruction

• Short-term media interest fosters sense in

community that “the rest of the world has

moved on.”

• Media coverage can result in violations of

privacy; there is a need to protect children,

victims, and families from traumatizing

exposure.

• Disaster relief and assistance agencies and

bureaucratic procedures can be seen as

inefficient, fraught with hassles, impersonal.

• Disillusionment can set in when the gap

between losses, needs, and available

resources is realized.

• Victims rarely feel that they have been

“made whole” through relief efforts.

T ABLE 1: COMPARISON OF MASS VIOLENT VICTIMIZATION AND NATURAL DISASTERS

Continued from previous page

DIMENSION

Stigmatization of

V ictims

Phases of

Response and

Reconstruction

Media

Secondary 

Injury
Chapter II: Human Responses to Mass Violence and Terrorism • 11

and bereaved individuals. A

graphic model of human

responses to trauma and

bereavement portrays the

emotions and processes

associated with coping with

extreme trauma and loss.

Three special populations

addressed are children and

adolescents, older adults, and

cultural, racial, and ethnic

groups. A model of responses

to trauma and bereavement,

practical assessment

checklists, and tables are

included in this chapter. The

recommended reading section

at the end of the chapter

includes detailed information

on the effects of traumatic

stress and bereavement,

research reviews, screening

and assessment, and the

combined impact of crime

victimization and community

trauma.

Population

Exposure Model

Mental health providers new to

responding to community

disasters and widespread

trauma must consider a

community perspective as well

as individual psychological

effects. The collective social,

political, environmental, and

cultural impacts of community

disaster interact with

individual reactions and

coping. A public health

approach helps the provider

develop a macro-view of the

A

E

D

C

B

Population Exposure Checklist

✔ Identify direct victims and highly impacted families

✔ Identify comparable groups for A, B, C, D, E in model

✔ Identify cultural and ethnic groups and special

populations present in A, B, C, D, E

✔ Determine impact and mental health service needs for

each group (see Chapter III)

F IGURE 1: P OPULATION E XPOSURE M ODEL

A: Community victims killed and seriously injured

Bereaved family members, loved ones, close friends

B: Community victims exposed to the incident and disaster scene, but

not injured

C: Bereaved extended family members and friends

Residents in disaster zone whose homes were destroyed

First responders, rescue and recovery workers

Medical examiner’s office staff

Service providers immediately involved with bereaved families, 

obtaining information for body identification and death notification 

D: Mental health and crime victim assistance providers

Clergy, chaplains

Emergency health care providers

Government officials

Members of the media

E: Groups that identify with the target-victim group

Businesses with financial impacts

Community-at-large
12 • Mental Health Response to Mass Violence and Terrorism

entire community and the

gradations of effects and needs

across population groups

(Burkle, 1996). A concentric

circle model, in Figure 1,

depicts the spectrum of

populations affected following

large-scale disaster (Tucker et

al., 1999; Wright, Ursano, and

Bartone, 1990).

The model’s underlying

principle is that the individuals

who are most personally,

physically, and psychologically

exposed to trauma and the

disaster scene are likely to be

affected the most. This

relationship has been consistently demonstrated in

numerous research studies and

reviews (Norris et al., 2002,

Shariat et al., 1999; Young et

al., 1998; Green, 1996;

Marsella et al., 1996; Green

and Solomon, 1995; Lurigio 

et al., 1990). The model may

be used as a conceptual aid for

planning because it portrays

general trends. It is important

to remember that models are

generalizations. There will

always be individuals within

each category who suffer

severe reactions requiring

more intensive mental health

assistance. Many of these

individuals are at risk because

of pre-existing vulnerabilities,

another key consideration for

planning and screening. These

survivor-related risk factors

are addressed later in the

chapter.

Traumatic Event

And Stressor

Characteristics

As shown in Figure 1, the level

of exposure to the traumatic

event and the stressors

associated with that event are

highly correlated with mental

health outcomes especially in

“most exposed” groups.

However, not all events and

traumatic stressors are equal

in their potential for psychological impact. Eight

dimensions of traumatic

exposure associated with posttraumatic stress are:

1. Threat to life and limb;

2. Severe physical injury;

3. Receipt of intentional

injury;

4. Exposure to the

grotesque;

5. Violent/sudden loss of a

loved one;

6. Witnessing or learning of

violence to a loved one;

7. Learning of exposure to a

noxious agent;

8. Causing death or severe

injury to another.

(Green, 1993)

Most of these dimensions are

inherent in mass violence and

terrorism. The level of

community trauma is

increased when there are both

large numbers of victims

WHEN DEATH 

AND DESTRUCTION ARE 

D ELIB ERAT ELY PLANN ED 

AND CAUSED BY OTHER

PERSONS, SURVIVORS, 

F AMILY M EMB ER S , AND 

THE LARGER COMMUNITY 

ARE HORRIFIED BY THE 

TRAG ED Y, E VIL INT ENT, 

AND UNNECESSARY 

LOSSES.
Chapter II: Human Responses to Mass Violence and Terrorism • 13

relative to non-victims and

high numbers of fatalities and

serious injuries (Tierney, 2000).

A prolonged recovery effort

involving body-handling and

delayed death notifications is

related to increased posttraumatic stress in emergency

workers as well as waiting

families (Ursano and

McCarroll, 1994). The grieving

process is intensified and

complicated when a loved

one’s death is sudden, violent,

random, preventable,

mutilating, and associated with

multiple other deaths (Rando,

1996). In addition, when no

physical remains of the

deceased are identified, many

families have even more

difficulty accepting the death

and memorializing their loved

one.

When death and destruction

are deliberately planned and

caused by other persons,

survivors, family members,

and the larger community are

horrified by the tragedy, evil

intent, and unnecessary losses.

They may be both enraged and

terrified by their inherent

vulnerability to such random,

yet deliberate acts. Incessant

questioning “Why me?,” “How

could this have happened?,”

“Why my child’s school?,”

“What terrible thing is going to

happen next?” interacts with

the need to blame and demand

justice. Survivors feel

confused, out of control,

frightened, and unable to

make sense of an act that

seems incomprehensible.

Since the goal of mass murder

of innocent civilians appears

outside the bounds of rational

human behavior, the perceived

vulnerability of future attacks

causes many to live with high

levels of anticipatory anxiety

and hyper-vigilance.

Research comparing the

psychological effects of

human-caused versus natural

disasters has yielded equivocal

results (Norris et al., 2002

Green and Solomon, 1995).

Considering the consequences

of causation exclusively,

studies have not consistently

demonstrated that one type of

disaster is “worse” than the

other. When the eight

dimensions listed previously

also are considered, however,

terrorist acts and mass

violence that result in a

significant number of deaths

and serious injuries can be

expected to have profound and

long-lasting physical,

emotional, and financial

effects for many survivors and

family members (Norris et al.,

2002; Office for Victims of

Crime, 2000; Green, 1993).

Traumatic events intentionally

perpetrated through human

design “may be qualitatively

different in a psychological

sense than threat or injury

arising from nature or mishap,

since betrayal by other human

beings must be dealt with in

addition to the vulnerability

and helplessness caused by the

sudden threat” (Green, 1993).

Deliberately human-caused

disasters may be motivated by

terrorism targeting innocent

people, prejudice and hate

toward a group, revenge and a

misguided desire to “get even,”

social tensions resulting from

oppression and poverty, or by

the delusional paranoia or

obsessions of a person with

untreated or undiagnosed

mental illness. Terrorist acts

are calculated, yet are

designed to be unpredictable.

The ruthless intent underlying

terrorism is to harm and kill

defenseless people for political

or sociocultural purposes.

Terrorists seek to intimidate a

civilian population. The killing

of innocent people becomes a

vehicle for delivering a

message. When children are

among those who are killed,

the community loses its sense

of being able to protect and

provide safety for its children.

“The great threat of terrorism

is that anyone, anytime,

anywhere can be a target. No

one is immune; no one is

protected” (American

Psychological Association Task

Force, 1997).

Mass acts of violence may be

motivated by hate and may

target victims based on their

race, religion, ethnicity,

gender, sexual orientation, or

country of origin. Victims of

hate crimes are attacked due

to a core characteristic that is
immutable. Instead of feeling

they have suffered a random

act of violence or one that was

economically motivated,

victims, as well as the larger

targeted group, continue to

feel vulnerable to intentional

attacks. Victims of bias crimes

may confront institutional

prejudice as they seek medical

care or the prosecution of

criminals, causing them to feel

betrayed by the American

system (Office for Victims of

Crime, 1995).

Survivor

Characteristics

For decades, clinicians and

researchers have grappled

with why survivors, when

exposed to identical trauma

and tragedy, respond with

considerable variability,

especially over time. Some

survivors incorporate

catastrophic experiences into

their life stories and find

meaning or increased selfrespect through their suffering.

Others continue to feel

devastated and embittered,

suffer lasting psychological

problems, and fail to find a

path to resolution that allows

them to move on with their

lives. Characteristics of the

individual survivor can provide

a buffer from long-term effects

or may set the stage for great

difficulty.

In the immediate aftermath of

a large-scale, severely

traumatic event, highly

exposed survivors’ physiological and psychological

reactions primarily are linked

to the event. As time passes,

characteristics within the

individual survivor play

increasingly important roles in

alleviating or worsening

psychological reactions.

Biological, genetic, personality,

temperament, and socioeconomic factors as well as

prior traumatic life events

contribute to the survivor’s

vulnerability to traumatic

events (Shalev, 1997, 1996;

Yehuda and McFarlane, 1997).

Predictors of an increased risk

for trauma-related psychiatric

problems include a prior, preexisting, or family history of

psychiatric disorder or

substance abuse; neuroendocrine vulnerability; early and

prior traumatization; family

instability; female gender;

lower education level; and

poverty (Halligan and Yehuda,

2000). Women have a higher

prevalence of depression,

anxiety, and PTSD (Kessler et

al., 1994) and may have

increased vulnerability due to

sociocultural and biological

factors. 

In addition, pre-existing

attachment disturbances or

difficulties with separation

anxiety contribute to the

likelihood of developing

persistent traumatic grief or

experiencing complicated

bereavement (Jacobs, 1999).

Each predictor or risk factor

tips the balance of the

survivor’s vulnerability in the

direction of increased risk.

With multiple risk factors, their

accumulated weight increases

the potential for long-term

psychological consequences.

Experience in communities

following natural disasters has

shown that survivors with

serious and persistent mental

illness have many of the same

needs for social and psychological support as the general

population (Center for Mental

Health Services, 1996). When

housing, medication, and case

management services remain

stable, most people with

mental illness function

reasonably well and, at times,

heroically, following disasters.

Post-traumatic stress reactions

should not be interpreted

automatically as exacerbations

of pre-existing illness. 

Likewise, survivor resilience is

enhanced through the absence

of psychiatric or substance

abuse problems, biological and

neuroendocrine “protection,”

family stability, and financial

resources. Survivor resilience

is linked to being able to

understand, tolerate, and cope

effectively with the inevitable

aftermath of severe trauma:

intrusive thoughts, sleep

disturbances, numbness, and

anxiety (Yehuda and

McFarlane, 1997). The ability

to self-regulate emotions and

reactions is in part related to

14 • Mental Health Response to Mass Violence and Terrorism
the survivor’s cognitive

appraisal of the event and his

or her resulting trauma

symptoms (e.g., “These are

temporary, normal reactions”

versus “I’m going crazy;” “I’m

dead inside;” “My reactions

indicate I’m in real danger;”

“The disaster is over” versus

“Nowhere is safe;” “I attract

disasters.”) (Ehlers and Clark,

2000). For many survivors,

social support contributes to

resilience. The survivor must

be able to engage with family,

friends, and social support

networks to derive a sense of

connectedness and comfort

from such interactions

(Kaniasty and Norris, 1999). 

Cultural, racial, or ethnic group

affiliation may promote

resilience through social,

family, and community

support. Cultural beliefs,

traditions, and rituals may

provide mechanisms to

understand the tragedy and

move through the recovery

process. Alternatively, poverty,

violence, and family disruption

associated with disenfranchised groups can compound

the effects of overwhelming

trauma and loss. The

experience of marginalization

can deepen inner coping

strength, or it can erode the

person’s capacity to tolerate

life’s relentless challenges.

Table 2 summarizes key risk

and resiliency factors.

Assessing these risk factors in

combination with the

survivor’s degree of trauma

and loss exposure provides a

preliminary way to identify the

most vulnerable survivor

groups. These factors may be

included in a brief screening

checklist to help mental health

providers determine those in

greatest need of mental health

support.

Research following the 1995

bombing of the Alfred P.

Murrah Federal Building in

Oklahoma City provides a case

example of the significance of

survivor characteristics and

their association with psychological outcomes. North et al.

(1999) found that nearly half of

the blast survivors studied had

one or more active postdisaster psychiatric disorders,

and one-third met the criteria

for PTSD at 6 months after the

bombing. Two-thirds (66

percent) of the respondents

with a previous psychiatric

disorder at any time in their

lives suffered a psychiatric

disorder after the bombing,

compared to 29 percent with

no psychiatric history.

Conversely, when the

researchers looked at those

study participants who had

PTSD, they found that 74

percent had not experienced it

before the bombing. Similarly,

56 percent who experienced

major depression after the

bombing had no pre-disaster

history of it. Women had twice

the rate of PTSD as men, and

more than twice the rates of

depression and generalized

anxiety order.

T ABLE 2: S URVIVOR C HARACTERISTICS

SURVIVOR GROUPS’ CHARACTERISTICS

• Prior or pre-existing mental health or substance

abuse problems

• Prior traumatization or unresolved losses

• Female gender

• Low socioeconomic status, low education

• Family instability, conflict, single-parent household

• Perceived or real lack of social support, isolation

• Overuse of coping strategies such as avoidance and

blaming self or others

RESILIENCY FACTORS

• Relative mental health, absence of history of diagnosable

psychiatric problems

• Capacity to tolerate emotions and cope flexibly with

symptoms associated with trauma and bereavement

• Self-perception of having ability to cope and control

outcomes

• Higher socioeconomic status, higher educational level

• Immediate and extended family providing practical,

emotional, and financial support

• Effective use of social support systems

Chapter II: Human Responses to Mass Violence and Terrorism • 15
Immediate Adult

Reactions to

Trauma,

Victimization,

And Sudden

Bereavement

Survivors’ acute reactions

immediately after a lifethreatening violent incident

range from detached shock

and numbness to fright, panic,

and hysteria. Many survivors

experience disbelief and some

degree of disorientation. Most

are focused on communicating

with family and loved ones.

Some may require emergency

medical attention for stress

reactions and others

desperately want to help with

rescue efforts. Emotional

turmoil is common. Survivors

may go through, virtually

simultaneously, a range of

emotions such as anger that

rises to rage, fear that rises to

terror, confusion that rises to

feelings of chaos, self-blame

that evolves to profound guilt,

sorrow that evolves into grief,

and relief that is experienced

as euphoria (Young, 1989).

Each survivor’s personal

experience before, during, and

after mass violence is unique.

Even though all have gone

through the same incident, and

may experience a similar

range of post-trauma

reactions, each survivor’s

thoughts and perceptions, the

specifics of what was

witnessed, and how it touched

him/her are part of a personspecific pattern. Research

findings suggest that those

who have more extreme,

pronounced, acute reactions

are more likely to develop

long-lasting and severe posttrauma responses (Bryant and

Harvey, 2000; North et al.,

1999; Young et al., 1998).

Post-trauma reactions are

expressed through different

pathways: physical, behavioral,

emotional, and cognitive.

Complex biopsychophysical

interactions between parts of

the brain, different neurotransmitter systems, and

neurohormones play a role in

increasing or regulating

arousal symptoms associated

with traumatic stress (Halligan

and Yehuda, 2000; van der

Kolk, 1996). 

These complex internal

processes underlie the more

observable reactions listed

below. Additional research is

needed to more fully

understand these complex

interactions and their

application to clinical

assessment and intervention.

The following lists of posttrauma symptoms enumerate

the range of common survivor

reactions:

Physical Reactions

Physical reactions can include:

■ Faintness, dizziness

■ Hot or cold sensations in

body

■ Tightness in throat,

stomach, or chest

■ Agitation, nervousness,

hyper-arousal

■ Fatigue and exhaustion

■ Gastrointestinal distress

and nausea

■ Appetite decrease or

increase

■ Headaches

■ Exacerbation of preexisting health conditions

Behavioral Reactions

Behavioral reactions can

include:

■ Sleep disturbances and

nightmares

■ Jumpiness, easily startled

■ Hyper-vigilance, scanning

for danger

■ Crying and tearfulness for

no apparent reason

■ Conflicts with family and

coworkers

■ Avoidance of reminders of

trauma

■ Inability to express feelings

■ Isolation or withdrawal

from others

■ Increased use of alcohol or

drugs

16 • Mental Health Response to Mass Violence and Terrorism
Emotional Reactions

Emotional reactions can

include:

■ Shock, disbelief

■ Anxiety, fear, worry about

safety

■ Numbness

■ Sadness, grief

■ Longing and pining for the

deceased

■ Helplessness,

powerlessness, and vulnerability

■ Disassociation (disconnected, dream-like)

■ Anger, rage, desire for

revenge

■ Irritability, short temper

■ Hopelessness and despair

■ Blame of self and/or

others

■ Survivor guilt

■ Unpredictable mood

swings

■ Re-experiencing pain

associated with previous

trauma

Cognitive Reactions

Cognitive reactions can

include:

■ Confusion and disorientation

■ Poor concentration and

memory problems

■ Impaired thinking and

decision making

■ Complete or partial

amnesia

■ Repeated flashbacks,

intrusive thoughts and

images

■ Obsessive self-criticism

and self-doubts

■ Preoccupation with

protecting loved ones

■ Questioning of spiritual or

religious beliefs

Long-Term

Responses 

Of Adults

Early mental health

intervention efforts focus on

normalizing post-trauma

reactions and informing

survivors that their reactions

are normal responses to

abnormal events. The majority

of survivors experience a

gradual reduction in the

intensity and pervasiveness of

their post-traumatic symptoms,

taking months to years

depending on the level of

exposure and the presence of

vulnerability risk factors

(Green and Solomon, 1995). 

A minority of survivors will

develop conditions that reach

diagnostic thresholds for PTSD,

depression, and anxiety.

Others will suffer significant

psychological distress over an

extended period of time with

symptom severity that falls

short of a diagnosable

disorder. 

Research on the psychological

effects following different types

of disasters is difficult to

Chapter II: Human Responses to Mass Violence and Terrorism • 17

A MINORITY OF 

SURVIVORS WILL DEVELOP 

CONDITIONS THAT REACH 

DIAGNOSTIC THRESHOLDS 

FOR PTSD, DEPRESSION, 

AND AN XI ET Y.
compare and use for predictive

purposes (Tierney, 2000). Study

measurements have been

taken at different time

intervals, after different types

of disasters, using different

instruments, and have

examined different outcomes.

In general, researchers have

found a considerable range (4

to 54 percent) in the

proportion of survivors experiencing diagnosable mental

disorders following disasters

and other traumatic events

(Green and Solomon, 1995;

American Psychiatric

Association, 1994). The

majority of studies have

examined the effects of natural

disasters, yet most experts

agree that the psychological

impact of criminal mass

victimization involving mass

casualties are at the higher

end of the range (Norris et al.,

2002; Center for Mental Health

Services, 2000b; Office for

Victims of Crime, 2000). These

findings were supported by

studies following the

Oklahoma City bombing (North

et al., 1999; Shariat et al.,

1999).

The dichotomy of “normal”

versus “abnormal” reactions

implied in the maxim “normal

reactions to an abnormal

situation” is restrictive and

carries potential stigma. While

useful in the beginning to help

survivors understand, accept,

and cope with their inevitable

and disturbing symptoms,

psychological support and

treatment for those experiencing higher levels of distress

also should be destigmatized.

Over time, the individual

survivor’s risk and resiliency

factors described earlier in the

chapter, in addition to their

level of trauma and loss

exposure, have increasing

influence over mental health

outcomes. In general,

survivors who lack effective

social supports, who lack

psychological resilience, or

who experience the chronic

life stressors associated with

lower social class and marginalization are at greater risk

(Tierney, 2000).

Traumatic Bereavement

When traumatic circumstances

surround the sudden death of

a loved one, or when the

bereaved was also involved as

a victim in the event or

witnessed the death, the

bereaved must cope with both

trauma and grief. For many

survivors and loved ones,

post-traumatic reactive

processes override mourning,

and grieving is initially blocked

(Raphael, 1997; Rando, 1993).

Instead of cherishing

reminders of the deceased, the

person may avoid them

because they conjure up

traumatic memories. During

the grieving process, the

contents of dreams typically

reflect longing for the

deceased by experiencing

them as alive and then feeling

a harsh sense of loss upon

waking and realizing that the

person is dead (Raphael and

Martinek, 1997). Trauma-based

dreams can be nightmares and

may involve re-experiencing

the trauma with intense fear

and feelings of vulnerability

upon waking.

This interplay of trauma and

grief often intensifies

symptoms common to both.

The traumatically bereaved

person can experience trauma

and grief processes simultaneously as well as in an

18 • Mental Health Response to Mass Violence and Terrorism

Screening and Assessment Checklist

✔ Trauma and loss exposure

✔ Presence of risk and resiliency factors

✔ Current psychological distress

✔ Prior coping with major stressors

✔ Availability of social support

✔ Current pressing concerns
alternating sequence—with

hallmark symptoms of each.

Assessment and intervention

must be responsive both to

distinct post-traumatic and

bereavement processes as the

person’s psychological

response moves between the

two.

When a victim’s physical

remains are not found and

identified, the bereaved family

must adapt alternative funeral

and burial rituals. Families can

be plagued with thoughts and

questions about the circumstances of death and how

much their loved one might

have suffered, without physical

evidence of how and where

the person died. These

challenges to the grieving

process are often compounded

by the lengthy process of

criminal prosecution and

sentencing.

When the traumatic death

results from a mass-casualty

incident, the individual death

may get lost in the broad

scope of the tragedy. The loved

one’s death becomes

subsumed in the larger event’s

label (e.g., “Columbine

Massacre,” “Oklahoma City

Bombing,” “September 11th,”

“9/11”). This loss of the

individuality of the death can

seem dismissive and minimize

personal losses (Spungen,

1999).

Model of Human

Responses to

Trauma and

Bereavement

Survivors and bereaved loved

ones go through a repetitive

up-and-down emotional and

physical process as they work

through extreme trauma and

unexpected bereavement. This

nonlinear process can seem

endless and relentless. Initially,

the psychological enormity of

the tragic event overwhelms

the psyche; the mind simply

cannot take it in all at once.

Self-protective mechanisms

kick in, usually unconsciously,

that allow the person to

distance temporarily from the

horror of it all. Internal

“monitors” allow the person to

take in what he or she can

manage of the harsh realities

and then to numb or partially

disconnect for respite. A

survivor or family member

may be able to deal with the

“facts” of the tragedy only by

keeping emotions about those

facts compartmentalized.

Victoria Cummock, whose

husband was killed on Pan Am

Flight 103, writes eloquently

from experience about this

process: 

Denial is an adaptive

reaction that protects

survivors of homicide from

the full force of the

tragedy. This coping

mechanism is a gradual

and graceful way to deal

with the murder of a loved

one, allowing families the

time that they need to

make the transition from

shock and denial into the

grieving process.

(Cummock, 1996)

Gradually, the facts and

realities associated with the

event become more deeply

understood. Small and large

losses become apparent. When

a person has difficulty

tolerating, regulating, or

managing the emotions and

physical sensations associated

with this unfolding, avoidance

and denial may be used

instead of other coping

strategies. Periods of feeling

“more normal” are punctuated

with trauma-based bolts of

fear and anxiety, and

upwellings of grief and

longing.

For many, this gradual

adjustment to new realities

occurs in conjunction with an

onslaught of post-traumatic

symptoms and traumatic grief

reactions. Prominent features

that may develop in the

person’s life are disturbed

sleep, intrusive upsetting

thoughts, yearning for the

event not to have happened,

jumpiness and agitation, selfdoubts, anxiety about the

future, profound sadness, and

questioning basic assumptions

about the world and humanity.

Chapter II: Human Responses to Mass Violence and Terrorism • 19
Becoming stable and getting

adequate rest is a priority

when these symptoms are

intense and constant.

Temporarily distancing from

triggers and reminders may

help survivors reduce this

reactivity and their emotional

swings.

The time required to reach the

sense of “coming to terms with

the new realities,” “reclaiming

life,” and “reconstructing one’s

life” is variable. Experiencing

extreme trauma and suffering

through homicide of a child,

spouse, or significant other

can take years to integrate into

the tapestry of one’s life in a

way that allows one to

embrace the future with hope.

Some survivors can “get stuck”

in enduring anxiety, phobic

avoidance, post-traumatic

stress syndromes, depression,

or substance abuse problems.

These reaction patterns need

to be addressed so the survivor

may resume the process of

working through the trauma

and loss and finding ways to

live with what has happened. 

Figure 2 captures elements of

this “working through”

process. It incorporates the

interweaving of trauma and

grief reactions and the roller

coaster of emotions that

survivors often describe. For

some individuals, the “event”

may not be actual exposure to

the shooting or trauma, but

enduring the threat and anticipation while being aware that

others were being killed or

injured. This normal process

moves back and forth from

periods of high to low

intensity. The high peaks and

20 • Mental Health Response to Mass Violence and Terrorism

F IGURE 2: M ODEL OF R ESPONSES TO T RAUMA AND B EREAVEMENT

(Note. Adapted from CMHS, 1994)
low valleys suggest the

intensity of these emotions

may sometimes be

overwhelming and warrant

additional medical, psychological, or spiritual support. 

The stars in Figure 2 represent

reminders and triggering

events that can activate

intensification of symptoms

and reactions, often causing

the person to question if he or

she will ever feel “normal”

again or if “backsliding” is

occurring. Potential triggers

include holidays, birthdays,

surprise encounters with

personal reminders of the

deceased or the event,

necessary official procedures,

particular media stories,

delayed receipt of belongings

or identified remains, and

anniversaries of the event.

Because these mass violent

events are also crimes, the

criminal justice system is

actively engaged. The phases

and events in the criminal

justice process often continue

over a period of years and can

be extremely distressing for

victims and loved ones.

Triggering criminal justice

procedures include the investigation, arrests, hearings,

continuances, trials, verdicts,

sentencing, and appeals. When

the alleged perpetrators have

not been arrested, the absence

of justice can contribute to

difficulties in moving toward

closure.

When considering the

challenging human process of

coming to terms with horrific

life events, key points to keep

in mind are listed below:

◆ The majority of people

will move through this

progression successfully

without mental health or

other “professional” help;

it is a normal life process.

Sometimes mental health

providers can be most

helpful by staying out of

the way of this natural

“working through,” or by

providing brief assistance

along the way and then

respectfully leaving

survivors to their

journeys;

◆ Some survivors and

bereaved loved ones may

“get stuck” in high

intensity reactions,

avoidance, or persistent

psychological problems.

Mental health

intervention addresses

these issues so that the

person returns to the

“working through”

process; and 

◆ The process moves

toward a stage that

involves “coming to

terms with realities and

losses,” “reclaiming life,”

and “reconstructing new

life.” These concepts

convey a different

meaning from the term

“recovery.” The person

will not return to the life

they knew before the

tragedy. They must

reconnect with and

reconstruct a new life

(Spungen, 1999). 

Children and

Adolescents:

Priority

Considerations

And Reactions

A child experiences disasters,

violent victimization, and

sudden death of loved ones

within the context of his or her

stage of psychological

development, life and family

situation, and critical

caretaking relationships.

Incomprehensible, terrifying

events can stimulate

overwhelming and unfamiliar

physical reactions and

emotions that can be traumatizing to children. The

boundaries between fact and

fantasy, and internal and

external experience can

become blurred. The child’s

universe can become chaotic

and filled with potential

danger.

A young child relies on the

stability and predictability of

his or her environment, and

the secure availability of

dependable caretakers. Family,

significant adults, pets,

playmates, school, and

neighborhood are important

Chapter II: Human Responses to Mass Violence and Terrorism • 21
features in a child’s world.

When a major traumatic event

occurs, much of what is

known and familiar may be

disrupted, if not destroyed.

Human-caused violence may

confound the child’s trust in

adults or in human nature. The

child may experience feelings

of homicidal rage toward the

perpetrator, which may be

disorienting and frightening.

Children commonly arrive at

erroneous conclusions,

sometimes implicating

themselves in causing or

worsening the incident, which

can result in feelings of guilt

and shame. A review of

studies on childhood traumatic

stress found that:

◆ Children experience the

full range of posttraumatic stress

reactions;

◆ The level of exposure to

the trauma is strongly

associated with the

severity and course of

post-traumatic

symptoms;

◆ Grief, post-traumatic

stress, depression, and

separation anxiety

reactions are

independent of, but

interrelated with, one

another; and 

◆ Parent and child

experience similar levels

of distress in response to

shared traumatic

experience.

(Pynoos, Steinberg, and

Goenjian, 1996; Vogel and

Vernberg, 1993).

As children move into

adolescence, they become

more concerned with peer

acceptance, appearing

competent, and achieving

independence from their

families. Underlying this

movement toward separation

is the simultaneous wish to

maintain the more dependent

role of childhood. When a

major traumatic event directly

impacts the adolescent’s

parents, caretakers, school, or

immediate community, it can

disrupt the normal developmental process. Fears,

anxieties, and vulnerabilities

associated with a younger age

may resurface. The normal

self-centeredness of

adolescence may give way to

preoccupation with death and

danger, a sense of alienation,

or feelings of guilt (Vogel and

Vernberg, 1993). In general, as

adolescents mature, they are

more likely to experience and

express the post-traumatic

symptoms associated with

adult trauma responses

(Cohen, Berliner and March,

2000).

The subjective experience of a

child or adolescent during a

traumatic event involves

“intense moment-to-moment

22 • Mental Health Response to Mass Violence and Terrorism

AS WITH ADULTS , 

THE CLOSER AND MORE 

EXPOSED CHILDREN OR 

ADOLESCENTS ARE TO 

THE TRAUMATIC EVENT, 

THE MORE AFFECTED THEY

AR E LIK ELY TO B E . 

(PYNOOS, 1996; VOGEL AND

VERNBERG, 1993)
perceptual, kinesthetic, and

somatic experiences

accompanied by appraisals of

external and internal threats”

(Pynoos, 1996). Children

process information and

experience and express

emotions in qualitatively

unique ways (Center for

Mental Health Services,

2000c). They may use selfprotective dissociation to

control their overwhelming

emotions, leaving memory

gaps or amnesia for parts or all

of the event. Anxiety-inducing

reminders may seem strange

and confusing in their effects,

causing the child to feel less

secure.

Traumatic Event and

Stressor Characteristics

As with adults, the closer and

more exposed children or

adolescents are to the

traumatic event, the more

affected they are likely to be

(Pynoos, 1996; Vogel and

Vernberg, 1993). Children’s

subjective experiences and

perceptions regarding a

traumatic event are significant

as well. For example, if the

child thought that a parent was

killed, thought the parent was

safe when there actually was

danger, or thought that he

could have prevented the

tragedy, his or her trauma

responses are likely to be

linked to these perceptions.

Dimensions of a traumatic

event and related stressors

associated with greater posttraumatic reactivity and longterm difficulties include: 

◆ Exposure to direct life

threat and physical injury;

◆ Witnessing mutilating

injuries or grotesque

injuries (especially of

family and friends);

◆ Hearing unanswered

screams for help and

cries of distress;

◆ Degree of brutality and

malevolence associated

with victimization;

◆ Extent of violent force

and use of weapons;

◆ Unexpectedness and

duration of the event; and 

◆ Separation from family

members, especially

when they are at risk.

(Pynoos, 1996; Vogel and

Vernberg, 1993).

Most child experts agree that

when faced with severe

trauma that is sufficiently

shocking and terrifying, posttraumatic reactions are

inevitable for most children

and may be expressed

immediately or become

apparent over time (Gordon

and Wraith, 1993). While

family stability and supportive

protection and communication

contribute to the child’s

resilience and aid recovery,

they do not prevent symptoms

from occurring altogether.

Post-Trauma and Grief

Reactions

Children and adolescents may

experience physical,

emotional, behavioral, and

cognitive reactions in varying

levels of intensity and

sequencing. Children may

appear to cope well, yet may

struggle with fears and selfdoubts. Some children and

adolescents will have

pervasive and intense

reactions to seemingly low

levels of exposure; others will

appear to have minimal

reactions to high degrees of

traumatic exposure. Siblings

and friends of children who

were primary victims may

have vicarious reactions, also

experiencing symptoms.

Watching disaster news

coverage and viewing

destruction, devastation, and

human carnage and suffering

can be terrifying to children.

Children who have witnessed

the disaster only through the

media also can experience

symptoms. Parents, school

administrators, teachers, and

caretakers need to work

together to protect children

from media exposure. When

children do view disaster

scenes on television,

thoughtful explanations and

emotional support are

indicated.

When the young person is

coping with both trauma and

grief reactions, responses can

Chapter II: Human Responses to Mass Violence and Terrorism • 23
be multilayered, with a

confusing mix of feelings

related to the loss of their

loved one interspersed with

post-trauma symptoms and

periods of shutting down

emotionally to avoid pain.

Efforts at relieving traumatic

anxiety often take psychological priority over mourning

(Pynoos and Nader, 1993). A

review of the reactions below

provides ample evidence of the

potential for significant

psychological and developmental disruption (Gordon and

Wraith, 1993; Pynoos and

Nader, 1993; Vogel and

Vernberg, 1993). 

Young Children (1–5 years):

■ Helplessness and passivity

■ Heightened arousal and

agitation

■ Generalized fears and

anxieties

■ Cognitive confusion

■ Inability to comprehend

and talk about event or

feelings

■ Sleep disturbances,

nightmares

■ Anxious attachment,

clinging

■ Regressive symptoms

■ Unable to understand

death as permanent

■ Grief related to

abandonment of caregiver

■ Somatic symptoms

School-Aged Children (6–11

years):

■ Responsibility and guilt

■ Repetitious traumatic play

and retelling

■ Reminders trigger

disturbing feelings

■ Sleep disturbances,

nightmares

■ Safety concerns, preoccupation with danger

■ Aggressive behavior, angry

outbursts

■ Irrational fears and

traumatic reactions

■ Close attention to parent’s

anxieties and reactions

■ Preoccupation with

“mechanisms” of death

■ Concentration and learning

problems

■ School avoidance

■ Worry and concern for

others

Pre-Adolescents and

Adolescents (12–18 years):

■ Detachment from feelings

■ Shame, guilt, humiliation

■ Self-consciousness

■ Post-traumatic acting out

■ Life-threatening

reenactment

■ Rebellion at home or

school

■ Abrupt shift in

relationships

■ Depression, social

withdrawal

■ Decline in school

performance

■ Desire for revenge

■ Radical change in attitude

■ Premature entrance into

adulthood

Older Adults:

Priority

Considerations

And Reactions

The wisdom and experience

accrued over a lifetime can

provide older people with tools

to cope with the losses,

changes, and painful emotions

associated with mass trauma

and victimization. They may

have successfully adjusted to

deaths of family members and

24 • Mental Health Response to Mass Violence and Terrorism

Screening and Assessment Checklist

✔ Trauma and loss exposure (objective and subjective)

✔ Current level of distress

✔ Social, academic, emotional, and behavioral changes

✔ Traumatic reminders at home and school

✔ Ongoing stressors at home and school

✔ Other trauma in the past year
friends, or to losses of physical

abilities, life roles, and

employment. Most have been

touched, at some point in their

lives, by the vagaries of

random, unexpected life

events as well as crime victimization. Research following

natural disasters has shown

that social support is often

mobilized when the older

person’s life or health is

threatened, but assistance is

less forthcoming when the

older person is faced with

property damage or

disruptions in daily living

(Kaniasty and Norris, 1999).

When older adults have

entered the “elderly” stage in

the aging process and have

health problems or have

become physically frail, their

experience of the tragedy often

is influenced by their physical

needs. A sudden, threatening,

traumatic event evokes fear,

helplessness, and a vulnerability in many survivors. When

an older person already feels

increasingly vulnerable due to

changes in health, mobility,

cognitive abilities, and sensory

awareness, the feelings of

powerlessness associated with

the trauma can seem

overwhelming (Young, 1998).

Sudden evacuations from

nursing homes, residential

facilities, motor home parks,

senior apartment complexes,

or moves from one facility to

another often are disorienting

and confusing. Cognitive

decline may make it more

difficult for older persons to

understand evacuation

instructions or emergency

assistance information and to

begin the process of coping

with unexpected, disruptive

changes (Massey, 1997).

Sensory impairment may

cause elderly survivors to not

respond to offers of help.

The untimely, traumatic deaths

of children or grandchildren

may be especially difficult for

older adults. An important

sense of continuity of the

Chapter II: Human Responses to Mass Violence and Terrorism • 25

Screening and Assessment Checklist

✔ Trauma and loss exposure

✔ Psychological and physical distress

✔ Medical and health conditions

✔ Sensory, cognitive, behavioral abilities and needs

✔ Prior coping with trauma and loss

✔ Current living situation

✔ Current priority concerns and needs

✔ Availability of social support

THE WISDOM AND 

EXPERIENCE ACCRUED OVER

A LIFETIME CAN PROVIDE 

OLDER PEOPLE WITH TOOLS

TO COPE WITH THE 

LOSSES, CHANGES, AND 

P AINFUL EMOTIONS 

ASSOCIATED WITH MASS 

TRAUMA AND 

VICTIMIZATION.
family, its traditions and

legacies, may be lost. Family

support and contact important

to the elder may be diminished

due to the next generation’s

preoccupation with the

aftermath of the tragedy and

their immediate losses. With

the reduced availability of

family support, the elder may

fear being moved to an

institution. This fear may cause

underreporting of concerns,

difficulties, and reactions

related to traumatization and

bereavement.

Following the traumatic death

of adult children who are also

parents, grandparents may

assume the parenting role with

their grandchildren. They are

faced simultaneously with

grieving the death of their own

child, assisting their

grandchildren to cope with the

loss of their parent(s), giving

up their lifestyle and routines,

and making numerous

adaptations and changes to

accommodate becoming a

parent again. When health and

financial issues are present for

the grandparent(s), their stress

load may seem unmanageable.

Health status, cultural

background, prior traumatization, religious affiliation,

proximity of family and other

social support, and living

situation influence the older

adults’ experience of mass

violence and terrorism. A

gradual building of trust and

rapport is necessary to

effectively assess mental

health needs (Center for

Mental Health Services,

1999b). 

Cultural and

Ethnic Groups:

Priority

Considerations

And Reactions

Acts of terrorism and mass

violence inevitably touch

people from different cultures

and diverse backgrounds.

Victims of the September 11

terrorist attacks came from

many different countries.

Some were U.S. citizens, some

had visas to work or study in

the United States, some were

illegal immigrants, and some

were visiting for other

purposes. Death, community

trauma, and violent victimization were interwoven.

Rituals surrounding death, the

appropriate handling of

physical remains, funerals,

burials, memorials, and beliefs

of an afterlife are deeply

embedded in culture and

religion. The serious injury of a

family member in the United

States brings families from

different cultures in contact

with Western medicine; the

health care delivery system is

made even more challenging

when English is not the

primary language. 

Cultural and ethnic groups

with histories of violent

oppression, terrorism, and war

in their countries of origin may

experience community

violence in the United States

through the lens of their prior

traumatization. Those who

have suffered from political

oppression and abuses of

military power in their

countries of origin can find the

high visibility of uniformed

personnel highly distressing, if

not retraumatizing. When it is

assumed that the perpetrators

of mass violence are from a

particular part of the world or

ethnic group, members of that

group living in the United

States may face threats and

harassment. For example, after

the September 11 attacks,

violence against citizens of

Middle Eastern descent and

those who had similar physical

attributes was reported

frequently. These individuals

became victims of hate-based

crimes, harassment, and

intimidation, while at the same

time coping with their own

losses and reactions to the

terrorist attacks.

Survivors from particular

groups may live in a context of

poverty, discrimination, or

marginalization as illegal

immigrants and face high rates

of violent crimes in their

neighborhoods. Exposure to

chronic community violence

influences how an individual

26 • Mental Health Response to Mass Violence and Terrorism
responds to a discrete, largerscale violent event. When

members of a group have had

prior contact with law

enforcement and have

experienced stereotyping and

prejudice, they may be

suspicious of the primary role

of law enforcement in

controlling the crime scene. 

When cultural, racial, or ethnic

groups within a community are

affected by an incident

involving mass criminal victimization, mental health

providers must consult with

community leaders, crosscultural experts, and culturally

competent mental health

practitioners to effectively

assess mental health effects

and needs. Cultural and ethnic

norms and traditions dictate

what constitutes “mental

health” and “mental illness,”

how traumatic stress and grief

are experienced and expressed,

how the mental health

responder is perceived, and

who is considered “family.”

Over-diagnosis is common

when Western mental health

professionals work with people

from different cultures

(Paniagua, 1998).

Ethnocultural studies following

natural disasters, industrial

accidents, and terrorist attacks

within the United States and

around the world have found

universal as well as culturespecific features in post-trauma

responses (deVries, 1996).

Biophysical research findings

suggest that all people

experience similar underlying

physical and biological

responses to severe trauma,

but that the psychological and

behavioral manifestations vary

across cultures (Marsella et al.,

1996). Considerable variation

exists across cultures regarding

tolerance for the expression of

strong emotions. Culture may

place differential emphasis on

particular symptoms, assign

unique attributions to the

intensity of their experience as

well as expression, and shape

the general tone of emotional

life to which a person should

aspire. The threshold at which

“normal” is demarcated from

“abnormal” may vary by

gender, ethnicity, and cultural

group (Manson, 1997).

Adding complexity, there is

variation within cultural groups

due to generational differences,

levels of acculturation,

multicultural influences, and

life situations within the United

States. Mental health

responders must be cautious

about generalizing culturespecific characteristics to every

member of that group; they

must learn to ask effective

questions and be open to

revising assumptions.

The Los Angeles civil unrest of

1992, following the acquittal of

four police officers in the

beating of Rodney King,

resulted in 52 deaths, 2,664

injuries, and more than 12,500

arrests (Center for Mental

Health Services, 2000b). This

outbreak was fueled by

underlying, unresolved issues

among racial, cultural, and

ethnic groups in the

community; high unemployment and poverty; and high

Chapter II: Human Responses to Mass Violence and Terrorism • 27

Cultural Response Checklist

✔ Meanings associated with current disaster and

emergency response

✔ Beliefs and practices regarding death, burial, mourning,

trauma, and healing

✔ Trauma and violence in country of origin and within the

United States

✔ Signs and symptoms of post-traumatic stress, grief,

depression, and anxiety

✔ Views about mental health and providers

✔ Professional courtesy (e.g., greetings, who to talk to

first, who is “family”)
levels of gang and drug

activity. Effective mental health

assessment and intervention

had to take into account the

many layers of cultural

influence and differences in

this disaster involving mass

violence. Bridging cultural

differences and language

barriers was a priority, if

mental health providers were

to access and assist affected

groups.

Recommended

Reading

Doka, K. J. (Ed.). (1996). Living

with Grief After Sudden Loss.

Bristol, PA: Taylor and Francis. 

Green, B. L. (1993). Identifying

survivors at risk: Trauma and

stressors across events. In J. P.

Wilson and Raphael, B. (Eds.),

International Handbook of

Traumatic Stress Syndromes

(pp. 135-143). New York:

Plenum. 

Green, B. L. (1996). Traumatic

stress and disaster: Mental

health effects and factors

influencing adaptation.

International Review of

Psychiatry, 2, 177-210.

Janoff-Bulman, R. (1992).

Shattered Assumptions: Towards

a New Psychology of Trauma.

New York: Free Press.

Marsella, A. J., Friedman, M. J.,

Gerrity, E. T., et al. (1996).

Ethnocultural Aspects of Posttraumatic Stress Disorder:

Issues, Research and Clinical

Application. Washington, DC:

American Psychological

Association.

Massey, B.A. (1997). Victims or

survivors? A three-part

approach to working with

older adults in disaster. Journal

of Geriatric Psychiatry, 30, 193-

202.

McIntyre, R. V. (Ed.) (1999).

The Oklahoma City bombing

and its effects [Special Issue].

Journal of the Oklahoma State

Medical Association, 92(4).

Norris, F. H., Friedman, M. J.,

Watson, P. J., et al. (2002).

60,000 disaster victims speak,

Part I: An empirical review of

the empirical literature, 1981-

2001. Psychiatry.

Paniagua, F. (1998). Assessing

and Treating Culturally Diverse

Clients. Thousand Oaks, CA:

Sage.

Pynoos, R. S. (1996). Exposure

to catastrophic violence and

disaster in childhood. In C. R.

Pfeffer (Ed.), Severe Stress and

Mental Disturbance in Children

(pp.181-208). Washington, DC:

American Psychiatric Press.

Rando, T. A. (1993). Treatment

of Complicated Mourning.

Champaign, IL: Research Press.

van der Kolk, B. A., McFarlane,

A. C., and Weisaeth, L. (Eds.).

(1996). Traumatic Stress: The

Effects of Overwhelming

Experience on Mind, Body, and

Society. New York: Guilford.

Vogel, J. M. and Vernberg, E.

M. (1993). Children’s psychological responses to disasters.

Journal of Clinical and Child

Psychology, 22, 464-484.

Wilson, J. P. and Keane, T. M.

(Eds.). (1997). Assessing

Psychological Trauma and

PTSD. New York:

Brunner/Mazel.

28 • Mental Health Response to Mass Violence and Terrorism

30 • Mental Health Response to Mass Violence and Terrorism

Mental health support,

psychological first-aid, and

crisis intervention have

become expected and valued

components of disaster

response, particularly

following mass casualty

incidents. A range of mental

health services are provided

for victims, bereaved family

members, first responders,

disaster workers, and the

community-at-large. Mental

health workers assist with

hotlines responding to queries

about missing persons, on

death notification teams, at

respite centers for rescue and

recovery workers, at the site of

the disaster to support

grieving loved ones, and as

consultants to government

officials. Mental health

services are practical,

accessible, empowering, and

compassionate.

This chapter presents the key

overarching principles for

mental health intervention

following mass violent victimization. Only credentialed

mental health professionals

should provide some of these

interventions; others are

appropriate for all human

service and crime victim

assistance workers serving

survivors. The mental health

response manager usually

determines the appropriate

scope of practice for providers

with varying backgrounds.

This chapter provides general

guidelines.

CHAPTER III

MENTAL HEALTH

INTERVENTION
Immediate and long-term

interventions with adults,

followed by similar

information related to children

and adolescents, are

presented. The “immediate”

time frame generally refers to

the first several weeks postincident; “long-term” refers to

months, sometimes years,

after the event. Since many

long-term interventions

require specialized in-service

training, this chapter provides

only an orienting overview.

Chapter VIII includes topics for

in-service training. Many of the

immediate interventions are

appropriate throughout the

recovery period, especially in

first contacts with survivors,

family members, and the

community-at-large. 

Special considerations for

mental health intervention

with older adults are included

throughout the chapter.

Developing cultural

competence and effectively

serving all groups in the

community is important.

Suggestions for cultural

sensitivity are included

throughout the chapter and

addressed in a specific section

toward the end of this chapter.

Because these tragic events

occur in a larger community

and recovery context, the next

section describes predictable

events with mental health

implications, such as death

notifications and stages in the

criminal justice process. The

mental health support role is

discussed in relation to each

event. Then, the importance of

community support through

memorials, rituals, and

maintenance of local traditions

is discussed. A practical table

providing a list of reactions to

trauma and intervention

options for different age

groups appears at the end of

the chapter.

Key Principles

For Mental

Health

Intervention

Violence, destruction, and

death that is deliberately and

malevolently caused by

another human is horrific and

tragic. Victims, responders, the

community, and sometimes

the entire country experience

the impact of mass criminal

victimization, along with

varying degrees of outrage,

sadness, and feelings of

vulnerability. The following 10

key principles guide mental

health providers, as well as

other responders and human

service workers assisting

survivors:

1. No one who witnesses the

consequences of mass

criminal violence is

unaffected by it. Many

groups may be

emotionally affected,

including emergency

responders, government

officials, media

personnel, disaster

workers, the community,

those who view extensive

media coverage, and

mental health providers.

A range of psychological

support and educational

interventions are

important components of

the overall response;

2. Mass crimes, involving

trauma and loss, affect

both the individual and

the community.

Psychological and

physical damage to

community structures

that normally provide

social support can

compound an individual

survivor’s trauma and

grief effects. This

community harm

impedes the recovery

process. Blaming and

scapegoating of particular

groups, which may occur

during the aftermath of

mass victimization, can

undermine the

community’s integrity and

its capacity to care for its

members. Intervention on

both the individual and

the community levels is

necessary;

3. Most people pull together

and function following a

mass tragedy, but their

effectiveness is diminished

Chapter III: Mental Health Intervention • 31
32 • Mental Health Response to Mass Violence and Terrorism

and they may have brief

periods of being

emotionally overwhelmed.

Because of the magnitude

and severity of psychological impacts inherent

in mass violent criminal

victimization, a wide

range of intense

emotional, physical, and

behavioral responses are

expected. However,

human resilience and

kindness predominate;

4. While most traumatic

stress and grief reactions

are normal responses to

extraordinary circumstances, a significant

minority of survivors

experience serious longterm psychological

difficulties. Survivors

personally involved in the

traumatic incident who

experienced a threat to

their lives, the death of a

child, spouse, or

significant other, are

more likely to suffer longterm mental health

consequences (North et

al., 1999). In addition,

survivors with prior

histories of traumatization, psychiatric

problems, or substance

abuse are at greater risk;

5. Mental health, crime

victim assistance, and

other human services

must be tailored to the

communities they serve.

Cultural competence is

essential. Communities

vary according to

demographic characteristics, regional

differences, religious

affiliations, and cultural,

ethnic, and racial groups

represented. Each

variable must be

considered when

developing an effective

mental health response;

6. Most survivors respond to

active, genuine interest

and concern. However,

some will reject services

of all kinds. Respectful

human kindness is the

basis for intervention.

This includes supporting

survivors’ choices to not

receive outside

assistance, and

understanding that, for

some, choices may

change over time;

7. Mental health assistance

is practical, flexible, and

empowering. It reflects

survivors’ needs to pace

their exposure to harsh

realities resulting from

the event. First and

foremost, providers must

do no harm when

intervening. Mental

health providers

sensitively must

determine each survivor’s

needs and coping style,

quickly establish rapport

and connection, and offer

support and assistance

appropriate for that

MOST SURVIVORS 

RESPOND TO ACTIVE, 

GENUINE INTEREST AND 

CONCERN. HOWEVER, 

SOME WILL REJECT 

SERVICES OF ALL 

KINDS.
individual. Some

survivors manage their

intense reactions through

protective denial and

distancing, so that they

may gradually come to

realize the magnitude of

the tragedy and their

losses;

8. Law enforcement

procedures, medical

examiner’s protocols,

disaster relief

requirements, and

criminal justice

proceedings often confuse

and distress survivors.

Mental health efforts that

include effective coordination with key response

agencies can mitigate

survivors’ frustration,

anger, and feelings of

helplessness. Providing

clear information and

support, and facilitating

access to resources can

help survivors and family

members feel more in

control and less alone;

9. Provision of mental health

services is an element of a

multidisciplinary

emergency response and

supports the efforts of the

primary responding

agencies. Law

enforcement, emergency

medical services, and

rescue and recovery

personnel have primary

responsibilities and roles.

Importantly, each contact

with a survivor has the

potential for easing the

pain of the tragedy,

whether by a mental

health worker, a crime

victim assistance

provider, an emergency

responder, or a disaster

worker; and 

10. Support from family,

friends, and the

community helps

survivors cope with the

trauma and their losses.

Social support from loved

ones and social networks

comforts survivors,

reduces their alienation

and isolation, fosters

hope, and promotes

healing. Effective

intervention involves

connecting survivors with

their primary supports

and facilitating support

systems coming together.

Mental Health Assistance

Coordination

Mental health support may be

provided by mental health

professionals, crime victim

services counselors, mental

health volunteers from the

American Red Cross and other

responding voluntary organizations, and faith-based

counselors. Effective coordination between responder

groups providing mental health

support is necessary to reduce

conflicts and potentially

intrusive duplications of effort,

and to ensure appropriate

services for survivors. Each

group has a significant role in

the overall response effort, so

teamwork and cooperation are

essential. Preplanning and

preparedness involve defining

the roles, responsibilities, and

procedures for coordination

between the various mental

health responder groups and

participating in drills before

the event occurs. 

Mental Health Service

Provider Groups

In reality, all first responders,

government officials, law

enforcement personnel, crime

victim assistance providers,

and employers, as well as

those more formally charged

with “mental health services”

have the potential to positively

affect the mental health of

survivors and family members.

While the material presented

here is oriented toward

“counseling and support

services,” all who come in

contact with survivors may

find useful suggestions. The

terms “mental health

responder,” “mental health

worker,” and “mental health

provider” are used

interchangeably to refer to

individuals whose response

efforts involve alleviating the

pain and distress of affected

groups and individuals. 

Crime victim assistance

providers assist crime victims

and family members to access

crime victim benefits and

services and to provide

Chapter III: Mental Health Intervention • 33
34 • Mental Health Response to Mass Violence and Terrorism

information regarding the

criminal justice process. They

also use many of the mental

health interventions described

in this chapter. While “crime

victim assistance providers”

are mentioned specifically

when warranted by the

context, they are intended to

be included in the various

mental health worker

designations. 

The term “mental health

professional” refers to social

workers, psychologists, psychiatrists, and other credentialed

or licensed mental health

providers. In general, psychological support, comfort, and

practical assistance may be

provided by other

appropriately trained and

supervised responders.

Assessments and interventions

with people showing higher

levels of distress or with prior

psychiatric problems, facilitation of group interventions,

and mental health consultation

with organizations and

officials should be provided by

mental health professionals.

The designation “mental health

response manager” refers to

individuals responsible for

determining needs, service

targets, the mental health

response plan, and the scope

of practice for mental health

responder groups, and for

screening, training, assigning,

and supervising mental health

responders.

Immediate

Mental Health

Intervention

Goals and Priorities

During and immediately

following a mass violent

incident, those most impacted

may experience shock,

confusion, fear, numbness,

panic, anxiety, distancing and

“shutting down.” Witnessing or

suspecting the deaths of

friends or family members can

be emotionally overwhelming.

Survivors who are not

physically injured may be

taken to separate sites to be

interviewed as witnesses and

to be connected with loved

ones. Those with injuries are

taken quickly to area hospitals.

When the perpetrators have

not been apprehended or the

event is considered to be

terrorism, all experience a

sense of continued danger and

threat. Mental health

responders have four initial,

immediate intervention goals:

(1) identify those in need of

immediate medical attention

for stress reactions; (2) provide

supportive assistance and

protection from further harm;

(3) facilitate connecting

survivors with family and

friends; and (4) provide

information about the status of

the crime scene, perpetrator(s),

and immediate law

enforcement efforts.

During this phase of the

response, emotional

stabilization is the primary

objective. Because an

overriding response of many

crime victims is to feel

vulnerable and fearful,

interventions emphasize

protection, safety, and

promotion of a sense of

security.

Acute response shock and

confusion gradually give way

to increasing awareness and

understanding of what has

occurred and the related

personal consequences. Those

most affected and their loved

ones may be in hospitals,

gathered at sites awaiting

critical information, searching

for missing loved ones, or in

their homes. If homes and

buildings were destroyed,

those displaced may be in

shelters, at alternate care

facilities, staying in hotels, or

in the homes of friends and

family. 

Mental health response

managers quickly must

determine those groups most

affected and the best ways to

reach them. Assuming that the

survivor has achieved some

degree of emotional

stabilization and has the ability

to verbalize and process

limited information,

intervention goals follow: 

◆ Alleviate distress through

supportive listening,
Chapter III: Mental Health Intervention • 35

providing comfort, and

empathy;

◆ Facilitate effective

problem-solving of

immediate concerns;

◆ Recognize and address

pre-existing psychiatric or

other health conditions in

the context of the

demands of the current

stressor; and 

◆ Provide psychoeducational information

regarding post-trauma

reactions and coping

strategies.

Immediate

Mental Health

Interventions

With Adults

The following section

describes eight interventions

commonly used during the

immediate aftermath of an

incident involving mass violent

victimization: 

1. Psychological first-aid;

2. Crisis intervention;

3. Informational briefings;

4. Crime victim assistance;

5. Community outreach;

6. Psychological debriefing;

7. Psycho-education; and 

8. Mental health consultation.

These interventions may be

used with adults, older

adolescents, and elderly

individuals with adequate

cognitive abilities. Descriptions

of the interventions include

guidance on when they are

most appropriate, who should

provide them, and how they

can be implemented most

effectively.

1. Psychological First-Aid

Rapid assessment determines

those survivors in most acute

distress and in need of medical

attention. Initial triage

decisions are based on

observable and apparent data.

Survivors experiencing obvious

physiological stress reactions

including shaking, screaming,

or complete disorientation may

need emergency medical

attention. Those survivors who

appear profoundly shut down,

numb, dissociated, and disconnected may also require

medical attention. Medical

assessment and assistance are

necessary for elderly survivors

who are vulnerable because of

health conditions and physical

or cognitive limitations. When

survivors do not speak English,

effective assessment and triage

involves ready access to

bilingual mental health

responders and interpreters.

Survivors who appear at risk

for life-endangering behavior

need to be evaluated by a

mental health or other

RAPID ASSESSMENT 

DETERMINES THOSE 

SURVIVORS IN MOST 

ACUTE DISTRESS AND 

IN NEED OF MEDICAL 

A TTENTION.
appropriate professional and

receive necessary protective

action.

Emergency intervention

involves three basic concepts:

protect, direct, and connect

(Myers and Wee, 2003).

Survivors need to be protected

from viewing traumatic

stimuli, from onlookers, and

from the media. When

disoriented or in shock,

survivors should be directed

away from the trauma scene

and danger, and toward a safe

and protected environment. A

brief human connection with

the mental health responder

can help to orient and calm

survivors. Also, responders

help survivors connect with

loved ones and needed

resources.

Psychological support

involves:

◆ Comforting the distressed

survivor;

◆ Addressing immediate

physical necessities (e.g.,

dry clothing, fluids, food,

shelter);

◆ Supporting reality-based,

practical tasks;

◆ Providing concrete

information about what

will happen next to

increase a sense of

control;

◆ Listening to and

validating feelings;

◆ Linking the survivor to

systems of support;

◆ Normalizing stress

reactions to trauma and

sudden loss; and 

◆ Reinforcing positive

coping strengths. 

(Centre for Mental Health

Services and NSW

Psychiatric Institute, 2000;

Osterman and Chemtob,

1999; Young, 1998;

Raphael et al., 1996;

Myers, Zunin and Zunin,

1990)

Mental health responders

sensitively tune in to survivors

and family members and

assess their states of mind and

capacities to address

immediate problems.

Intervening involves taking the

survivor’s lead in terms of

pacing the interaction and not

probing areas that are

obviously painful. A number of

experts have argued that when

survivors or family members

are using denial, wishful

thinking, forgetting, or

distancing to regulate their

intense reactions, immediate

interventions should not

attempt to penetrate these

coping defenses (Raphael and

Dobson, 2002; Sitterle and

Gurwitch, 1999; Lord, 1996). 

2. Crisis Intervention

The goals of crisis intervention

involve helping survivors

regain some sense of control

36 • Mental Health Response to Mass Violence and Terrorism

MENTAL HEALTH 

R E S POND ER S S EN SITI V ELY 

TUNE IN TO SURVIVORS 

AND FAMILY M EMB ER S 

AND ASSESS THEIR 

STATES OF MIND AND 

CAPACITIES TO ADDRESS 

IMMEDIATE PROBLEMS.
over their immediate situations

and re-establish rational

problem-solving abilities. Crisis

intervention typically involves

four components: (1) promote

safety and security; (2) identify

current priority needs,

problems, and possible

solutions; (3) assess

functioning and coping; and

(4) provide reassurance,

normalization, psychoeducation, and practical

assistance. 

1. Promote safety and security:

“May I get you something to

drink?”

“Are you feeling

comfortable/safe here?”

Survivors need to feel

protected from threat and

danger. When given simple

choices, many come to feel

less powerless as they exercise

some control over their

situations—which is critical for

engaging initial coping.

2. Identify current priority

needs and problems and

possible solutions:

“Describe the

problems/challenges that

you are facing right now.”

“Who might help you?”

Selecting and successfully

addressing one solvable

problem as most immediate

can help bring back a sense of

control and capability. Existing

sources of assistance among

friends, family, health care

providers, or community

resources may be helpful.

Assist with accessing

resources when necessary. 

3. Assess functioning and

coping:

“How are you doing? How

do you feel you are coping

with this?”

“How have you coped with

stressful life events in the

past?”

Through observation, asking

questions, and reviewing the

magnitude of the survivor’s

problems and losses, the

worker develops an

impression of the survivor’s

capacity to address current

challenges. Based on this

assessment, the worker may

make referrals, point out

coping strengths, and facilitate

the survivor’s engagement

with social supports. The

worker also may seek consultation from a medical or

mental health professional. 

Discussion of individual

disaster experiences must be

carefully tailored to the

person’s situation and coping

style. For example, for those

who are highly distressed,

talking in much detail about

their disaster experience and

expressing related emotions

might promote further destabilization. With these

individuals, provide

reassurance and comfort and

move on with problem-solving,

if the person is able. For other

survivors, detailed verbalization of their traumatic

experience can facilitate some

reality-based acceptance that,

in turn, can contribute to

appropriate problem-solving.

4. Provide reassurance, normalization, psycho-education,

and practical assistance:

Support, reassurance, and

acknowledgment and normalization of feelings and

reactions occur throughout the

intervention. It is important

that the survivor feel the

response provided by the

worker is both personal and

individual. Mental health

workers must pay close

attention to the individual’s

experience and style and not

offer “pat” or “canned”

responses. Psycho-education

should address the particular

reactions mentioned by the

survivor, and provide

additional information through

a brochure or individualized

information. Practical

assistance may involve helping

to arrange childcare, making a

phone call, or obtaining critical

information.

Mental health responders are

challenged to determine how

to assist each individual

survivor and not to apply the

same approaches to all. The

Chapter III: Mental Health Intervention • 37
importance of flexibility and

sensitivity is underscored as

responders intervene with

survivors from different

cultural groups. The basic

operating principle of “first, do

no harm” dictates that

responders approach each

person and family with respect

and sensitivity, and be vigilant

to cues that might suggest

their services are not wanted

or their approach needs to be

altered.

3. Informational Briefings 

In large-scale crises, rumors

and misinformation are

common. Survivors and loved

ones need accurate, reliable

information delivered often,

clearly, humanely, and in the

appropriate languages. They

seek information regarding the

location and well-being of

loved ones, progress of rescue

and recovery efforts, the

disaster’s impact and resulting

loss of life, current levels of

threat and danger, and what

might happen next. Receiving

procedural information and

updates regarding criminal

investigations and the rescue

operation can promote a sense

of control when survivors feel

powerless. Informational

briefings may be provided by a

government official, a law

enforcement representative, or

a spokesperson from a medical

examiner’s office. Official

personnel should be available

to provide current and

accurate information in

response to the questions of

loved ones and family

members (Sitterle and

Gurwitch, 1999).

Mental health responders

typically do not provide

informational briefings directly,

however, they may consult

with those responsible for

them. Mental health providers

may convey information to

officials about the value of

frequent briefings for survivors

and family members. When

cultural and ethnic groups are

affected, mental health

consultants may promote

equivalent access to

information and government

officials, and facilitate liaisons

with cultural group leaders.

Mental health professionals

also may offer suggestions

regarding appropriate wording

or terminology, the level of

detail for sensitive information,

approaches for addressing

intense emotional reactions

from survivors, and language

to convey messages of

compassion and condolence.

4. Crime Victim Assistance

Crime victim services are a

central element of effective

response. Interventions linked

to the criminal justice process

include:

◆ Protecting and advocating

for the rights of crime

victims;

◆ Providing information

about the criminal justice

process and the roles of

the various participants

in that process, provided

in the primary, spoken

languages;

◆ Facilitating access to

State crime victim and

other appropriate

compensation programs

for payment of crimerelated expenses as well

as other community

resources; and 

◆ Streamlining procedures

for accessing services

and benefits and

responding to unique

needs.

While no one can undo the

losses and trauma of the

event, sensitive and responsive

recognition of victims’ rights

and needs throughout the

criminal justice process can

mitigate some of the most

painful effects. When a large

number of survivors have a

“need to know” following a

mass criminal event, an

effective, centralized, and

accessible system of

information dissemination is

appropriate. An active,

working partnership between

mental health responders and

crime victim assistance

providers ensures that the

broad range of survivor and

family needs will be addressed.

Cross-referral, cross-training,

38 • Mental Health Response to Mass Violence and Terrorism
and cross-consultation is

recommended (Office for

Victims of Crime, 2000).

5. Community Outreach

Community outreach is an

essential component of a

comprehensive mental health

response to acts of mass

violence and terrorism. Many

survivors will not seek mental

health services actively,

especially during the first

several weeks. They often are

not aware of the crime victim

benefits available to them.

When mental health providers

sensitively initiate contact with

survivors, their access to

mental health services, crime

victim services, practical

assistance, and information

about criminal justice

proceedings can be

established. When cultural,

economic, language,

transportation, disability, or

age-related barriers exist,

outreach is a valuable tool for

reaching special populations

and at-risk survivors.

Community outreach involves:

◆ Initiating supportive and

helpful contact at sites

where survivors are

gathered;

◆ Reaching out to survivors

through the media, the

Internet, and 24-hour

telephone hotlines with

responders who speak

different languages;

◆ Participating in or

conducting meetings for

natural pre-existing

groups through religious

organizations, schools,

employers, community

centers, and other

organizations; and 

◆ Providing psychoeducational, resource,

and referral information

to health care and human

service providers, police

and fire personnel, and

other local community

workers. 

Mental health outreach

workers form alliances with

existing, trusted community

entities and leaders to gain

credibility and acceptance.

Skilled outreach workers take

the approach that they must

earn the right to serve. While

simple in concept, community

outreach requires a range of

skills. Outreach mental health

workers must be comfortable

initiating conversations with

survivors who have not

requested their services. Good

interpersonal skills and the

ability to quickly establish

rapport, trust, and credibility

are necessary. Workers must

be able to think on their feet

and be diplomatic. While it is

ideal for outreach workers to

be from the cultural and ethnic

groups they are serving, this is

not always possible, especially

in the first weeks after an

event. Workers must be

knowledgeable and respectful

of the values and practices of

the cultural groups impacted

by the event.

Chapter III: Mental Health Intervention • 39

COMMUNITY 

OUTREACH IS AN 

ESSENTIAL COMPONENT OF

A COMPREHENSIVE MENTAL 

HEALTH RESPONSE TO ACTS 

OF MASS VIOLENCE AND 

TERRORISM.
6. Psychological Debriefing

A variety of organizations

currently provide “psychological debriefing” in the

aftermath of traumatic events.

While most debriefing

approaches are generally wellreceived by participants and

perceived as helpful, it is

important for community

leaders to be well-informed

about the specific intervention

techniques being used in order

to assure that any services

provided are truly helpful and

appropriate. 

In recent years, many mental

health experts have expressed

concerns about the

indiscriminate use of the term

“debriefing” to apply to a wide

array of individual and group

approaches for various

populations. In 2001, a panel

of international experts

convened to examine early

intervention techniques stated

the following:

Use of the term “debriefing”

for a variety of mental

health interventions is

misleading. Workshop

participants recommended

that this stand-alone term

no longer be used to

describe early mental health

interventions following

mass violence and disasters.

For clarity, “debriefing”

should be used only to

describe operational

debriefing,* and should not

be used to describe psychological debriefing, Critical

Incident Stress Debriefing

(CISD), and so on.

National Institute of 

Mental Health, 2002

*Note: As used in this

context, the term

“operational debriefing”

refers to routine information

sharing without the psychological or emotional

processing components.

Behind the concerns expressed

regarding the indiscriminate

use of the term debriefing is a

concern regarding the varying

quality and appropriateness of

group interventions in the

immediate aftermath of crisis

events. While there are

different views among experts

on specific debriefing

techniques, there is growing

consensus regarding the need

for more precision in tailoring

intervention techniques for

specific populations (Watson,

2004). It is generally agreed

that there is no “one size fits

all” approach that works for all

populations and types of

disasters.

The most commonly used

debriefing technique is the

Critical Incident Stress

Debriefing (CISD) model,

which was developed

originally for emergency

responders, who are occupationally exposed to repeat

trauma and at risk for

accumulated stress effects

40 • Mental Health Response to Mass Violence and Terrorism

IN RECENT YEARS, 

MANY MENTAL HEALTH 

EXPERTS HAVE EXPRESSED 

CONCERNS ABOUT THE 

INDISCRIMINATE USE OF THE

TERM “DEBRIEFING” TO 

A P PLY TO A WID E ARRAY OF

INDIVIDUAL AND GROUP 

APPROACHES FOR VARIOUS 

POPULATIONS.
(Mitchell, 1983; Mitchell and

Everly, 1993). The CISD model,

which is intended to be

implemented as a part of a

larger Critical Incident Stress

Management (CISM) approach,

has often been modified for

particular groups with needs

different from emergency

responders. 

A variety of group and

individual psychological

debriefing approaches have

been used with a wide range

of groups including emergency

responders, employee groups,

highly exposed survivors,

community bystanders, and

groups from the larger affected

community. Some approaches

may be referred to inaccurately

as CISD, and sometimes simply

referred to as “debriefing.”

Therefore, in all situations, it is

important to carefully assess

the actual techniques being

implemented.

Careful attention must be paid

to individual exposure levels

and response to a traumatic

event when considering the

timing and goals of any group

intervention techniques. For

example, intervention

techniques that strongly

encourage “emotional

processing” in the immediate

aftermath of a trauma may not

be appropriate for many

individuals who are still in a

state of shock or agitation

(Watson, 2004). 

In addition, mental health

providers should be careful not

to “promise” more than an

intervention can actually

deliver. While group

techniques may provide an

early method of survivor

contact and may be useful for

social support, preliminary

screening and psychoeducation, there is no evidence

that existing early debriefing

techniques alone can “prevent”

later mental health needs. In

addition, many experts have

expressed concerns that

mandatory participation in

debriefings that require

emotional processing in the

immediate aftermath of a

trauma can actually increase

stress levels (Watson, 2004).

Facilitating group approaches

requires extraordinary skill and

care and should not be

performed without specific

training. Simply knowing and

following the steps of a

specified debriefing model is

not enough. A skilled group

facilitator will carefully assess

the needs of a group and will

take care to assure that

activities do not disrupt the

normal human processes of

remembering, forgetting,

meeting challenges, and

incorporating losses (Raphael

and Wilson, 2000). 

When working with disaster

victims at a time of great

vulnerability, it is important to

assure that any psychological

interventions do no harm.

When in doubt about the

appropriateness of a group

intervention technique,

community leaders may be

well advised to seek “a second

opinion.” Consultation with a

variety of experts with careful

attention to the goals, required

training, and demonstrated

evidence base for specific

populations can help assure

that early intervention sets a

foundation for emotional

recovery for all individuals

exposed to trauma. 

7. Psycho-Education 

Psycho-education is a core

component of mental health

response for survivors and

their families, health care

providers, social service

workers, and providers of

other community services.

Information is provided about

post-trauma reactions, grief

and bereavement, effective

coping strategies, and when to

seek professional consultation.

Brochures or simple handouts

that describe common

physical, emotional, cognitive,

and behavioral trauma

reactions for children and

adults are widely distributed in

appropriate languages.

Material should be oriented

specifically to the actual event

and locale and adapted to

each survivor group or

audience to ensure ageappropriate, role-specific, and

Chapter III: Mental Health Intervention • 41
culturally relevant materials.

All forms of media are used to

disseminate information, so

that the messages reach the

largest number of people. 

Validation and reassurance

through psycho-educational

information mitigate survivors’

fear that they are “going

crazy.” When survivors learn

their reactions are “normal”

and expected following similar

events, many can understand,

accept, and cope with their

reactions and situations.

However, some survivors

experience this normalization

of their pain as minimizing or

dismissive. Psycho-education

is more successful when

mental health responders

adapt their educational

comments and materials to

each survivor’s concerns and

style.

Parents and caretakers

typically ask mental health

providers questions about how

best to help children following

traumatizing mass victimization. Educational presentations for parents may be

offered through schools,

religious organizations, and

other community organizations. Psycho-education

regarding children’s needs

addresses common questions

and provides practical

guidance.

Samples of brochures and

public information materials

are readily available in print

(American Red Cross, 2001,

1997; Office for Victims of

Crime, 2001; Center for Mental

Health Services, 2000a, 1995;

American Academy of Child

and Adolescent Psychiatry,

1998; American Psychological

Association, 1996; Grollman,

1995; Lord, McNeil and Frogge,

1991) and on the Internet (see

Internet Sites at the end of this

publication).

8. Mental Health 

Consultation

Emergency services and law

enforcement administrators

make many decisions that

have mental health

implications for survivors.

Government officials also

make critical decisions,

provide information, and make

statements directly to survivors

and their families and through

the media. Mental health

professionals can be brought

into decision-making and

planning teams to advise

leaders regarding mental

health issues. Leaders may

seek mental health consultation on issues such as

optimal scheduling, mental

health support, and leave time

for rescue and recovery

workers; sensitive procedures

for obtaining personal

information and DNA samples

from families for body identification; whether children

should accompany families to

the disaster site; rituals and

memorials for honoring the

dead; integrating acknowledgment of the tragedy into

traditionally celebratory or

recreational events; and

management roles and support

as affected employees return

to work. When mental health

consultation is sought,

inadvertent retraumatization

or unnecessary stress may be

avoided (Pynoos and Nader,

1988). To function effectively

in this consulting role, mental

health professionals must be

well-versed in emergency and

criminal response protocols, as

well as experienced in

reactions to disaster, trauma,

and bereavement.

Survivors with serious psychological reactions to the

traumatic event also may be

members of religious groups,

students at local schools,

recipients of services at senior

centers, community mental

health center consumers, or

members of culturally

identified organizations.

Service providers, clergy,

principals, and teachers can be

supported and educated

through mental health consultation regarding the effects of

trauma and how best to assist

their constituents. In addition,

impacted businesses, organizations, or government offices

may seek to develop

systematic mental health

support and recovery

assistance for their employees

and managers (Young et al.,

1998).

42 • Mental Health Response to Mass Violence and Terrorism
Long-Term

Mental Health

Interventions

With Adults 

Goals and Priorities

Mental health response

managers must set realistic

goals, priorities, and

expectations for long-term

mental health services. This is

a time when need probably

will exceed available

resources. Managers must be

vigilant to prevent programs

and staff from overextending

and suffering stress overload.

The immediate interventions

of psychological first-aid and

crisis intervention may be

adapted for initial contact with

survivors seeking psychological support and mental

health services during the

recovery period. Survivors and

family members may have

delayed reactions or have

traumatic symptoms triggered

by reminders, community

events, or criminal justice

proceedings. They may need to

wait for physical injuries to

heal before seeking psychological assistance. Many seek

more intensive counseling and

psychotherapy following

immediate intervention.

Specialized services are

provided by mental health

professionals with training in

treating PTSD, depression,

anxiety, and traumatic

bereavement. 

Crime victim assistance,

community outreach, psychoeducation, and communitybuilding interventions are

ongoing. Mental health

providers should design their

intervention services to be

appropriate to the particular

group receiving those services

and relevant to their stage in

the recovery process. 

Activities for long-term mental

health intervention include:

◆ Identifying individuals

and groups in need of

mental health and crime

victim assistance

services;

◆ Using systematic

screening approaches to

prioritize the delivery of

more intensive mental

health services;

◆ Providing different levels

and types of mental

health services: outreach,

consultation, crisis

intervention, and

individual and group

counseling;

◆ Supporting the provision

of a range of crime victim

services: accessible crime

victim benefits, available

criminal justice

procedural information,

practical assistance, and

trouble-shooting;

Chapter III: Mental Health Intervention • 43

MENTAL HEALTH 

PROVIDERS SHOULD DESIGN 

THEIR INTERVENTION 

SERVICES TO BE 

APPROPRIATE TO THE 

P ARTICULAR GROUP 

RECEIVING THOSE SERVICES 

AND RELEVANT TO THEIR 

STAGE IN THE RECOVERY 

PROCESS. 
◆ Providing mental health

support and consultation

for community rituals,

memorials, and other

community events; and 

◆ Providing appropriate

psycho-educational

information to all affected

survivor and responder

groups and health care

and social service

providers in the

community.

In this section, crime victim

services, brief counseling

interventions, and support

groups are briefly discussed.

These overviews orient the

reader to possibilities and

highlight directions for further

study and training.

Recommended readings are

provided at the end of the

chapter. 

Crime Victim Services

Crime victims are eligible to

receive compensation for

certain crime-related

expenses. Eligibility and

benefits vary from State to

State. These benefits may

include payment for medical

and mental health treatment

expenses, funeral and burial

expenses, and compensation

for lost wages and loss of

support. Assistance, including

crisis intervention, emergency

transportation and shelter,

counseling and criminal justice

advocacy, also is available.

Through close coordination

and communication with crime

victim assistance providers,

mental health workers can be

informed about helpful

resources.

For many survivors and family

members, understanding and

participating in the criminal

justice process is a critical part

of coming to terms with being

traumatically victimized. Crime

victim assistance seeks to

safeguard victims’ rights by

ensuring access to information

on all criminal justice

proceedings. Survivors and

family members may observe

trial proceedings and provide

victim impact statements. They

are entitled to explanations of

the trial process, updates on

current developments, and

emotional support. Mental

health providers should be

trained specifically to provide

mental health services during

trial proceedings because they

need to be knowledgeable

about criminal justice

proceedings and their mental

health implications. 

The following descriptive

overview of criminal justice

procedures is intended as an

orientation for mental health

workers who may be

unfamiliar with the steps in the

judicial process. Following an

act of mass violence or

terrorism, when the investigation has identified suspect(s)

and sufficient evidence, the

alleged perpetrator(s) are

44 • Mental Health Response to Mass Violence and Terrorism

FOR MANY SURVIVORS 

AND FAMILY M EMB ER S , 

UNDERSTANDING AND 

P ARTICIPATING IN THE 

CRIMINAL JUSTICE 

PROCESS IS A CRITICAL 

P ART OF COMING TO 

TERMS WITH BEING 

TRAUMATICALLY 

VICTIMIZED.
arrested. If the alleged

perpetrator is charged as a

juvenile, his or her identity

may not be disclosed. Upon

completion of an initial investigation, the investigating law

enforcement agency makes

recommendations for criminal

offense charges to the

prosecutor’s office. The case is

then transferred to the

prosecutor’s office. When no

suspects are identified or no

arrests are possible, family

members’ and victims’

reactions are related to the

absence of criminal justice

proceedings and, ultimately, to

the absence of possible justice

for the wrongs they have

suffered.

Some of the evidence collected

at the crime scene will be

essential to the prosecution of

the case and will not be

released until after the trial.

Other items, not required as

evidence, such as personal

effects or clothing, may by

returned to families and loved

ones. It may be difficult for

loved ones to see the

deceased’s personal items for

the first time when they are

presented at trial. Prosecutors

and crime victim assistance

and mental health providers

often prepare family members

for seeing personal items to be

presented at trial. For example,

personal items held as

evidence following the terrorist

bombing of Pan Am Flight 103

in 1988 were returned to

families and loved ones after

the trial was concluded 13

years later. Each item was

cleaned, packaged, and

personally delivered by

detectives from Lockerbie,

Scotland.

The prosecutor may conduct a

preliminary hearing or grand

jury to determine if sufficient

evidence exists to charge an

individual with a crime. Then,

an arraignment hearing is held

and the accused is informed

formally of the charges

pending. At this point, the

accused becomes referred to

as “the defendant.” The

defendant enters a plea of

“guilty” or “not guilty.” Each of

these steps is likely to be

psychologically distressing for

survivors and loved ones.

Their sense of control is

enhanced by being informed,

anticipating events and how

they might react, and planning

for social support. 

A long delay may occur before

the case goes to trial. The case

may be postponed several

times before the trial or

sentencing is actually heard,

making it difficult for family

members to make

arrangements or take time off

from work. Delays and

postponements also can

increase victims’ fear of

testifying. If there has been

considerable publicity

surrounding the event, the

location of the trial may be

moved to another part of the

country, making it more

difficult for survivors or loved

ones to attend. They still need

accurate information and

updates regarding the

discovery process, continuances, and plea or sentencing

bargaining. The trial,

sentencing, and appeals

processes may continue for

years after the event. Some

survivors are likely to be

involved in providing victim

impact statements to the judge

and jury.

Because of the long time span

involved in these cases, mental

health and crime victim

services need to be available

over an extended period. The

“working through” and

reconstruction processes from

a traumatic loss often take

years and occur in stages over

time. Inevitably, key events in

the criminal justice process

trigger reactions and pain.

However, these expressions

may also lead to a gradual

integration and acceptance of

the tragedy.

“Responding to Terrorism

Victims: Oklahoma City and

Beyond” provides a detailed

account of crime victim

assistance services and

underscores the considerable

overlap and coordination

between mental health and

crime victim services (Office

for Victims of Crime, 2000).

Additional background

Chapter III: Mental Health Intervention • 45
information is available in the

Attorney General Guidelines

for Victim and Witness

Assistance (U.S. Department of

Justice, 1999) and through the

OVC Resource Center

(www.ncjrs.org).

Brief Counseling 

Survivors most immediately

exposed to the event, and

those who suffered the death

of loved ones or serious

injuries, may need intensive

counseling (North et al., 1999;

Green, 1993). In addition,

survivors and community

members with prior or preexisting psychiatric conditions

or substance abuse problems,

and those with histories of

prior traumatization are at

greater risk for long-term

difficulties (Halligan and

Yehuda, 2000; North et al.,

1999; Breslau et al., 1998).

Some survivors will continue

to experience high levels of

psychological distress and may

suffer disturbing and intrusive

symptoms that interfere with

their daily functioning.

Survivors who are developing

PTSD or who already have

developed PTSD remain

“stuck” on the trauma. They

constantly relive it through

their thoughts, feelings, or

actions, and begin to organize

their lives around avoiding

triggers and reminders. They

continually act out their

overgeneralized sense that the

world is unsafe (van der Kolk,

McFarlane, and van der Hart,

1996). The therapeutic goals of

long-term interventions

involve:

◆ Stabilizing emotions and

regulating distress;

◆ Confronting and working

with the realities

associated with the

event;

◆ Expressing related

emotions during and

since the event;

◆ Understanding and

managing post-trauma

symptoms and grief

reactions;

◆ Developing a sense of

meaning regarding the

trauma;

◆ Coming to accept that the

event and resulting losses

are a part of one’s life

story; and 

◆ Moving on and

reconstructing one’s life.

Most therapeutic approaches

recognize the vulnerable

survivor’s capacity to confront

painful realities and the

intense emotions that develop

gradually. The treatment

process must move at a rate

the survivor can tolerate. The

therapeutic relationship is an

essential part of this process.

The survivor progresses to

facing the trauma experience

and losses, self doubts, fears,

and pain when there is

sufficient trust that the

therapist is genuinely engaged

and can truly bear witness to

the personal significance of the

trauma. The therapist must be

able to remain solidly and

empathically engaged while

hearing of the horror, tragedy,

and intense emotions

associated with the traumatic

event (Raphael and Wilson,

1993; Herman, 1992). The

normal “working through”

process that allows

traumatized survivors and

bereaved family members to

move on and reconstruct their

lives can take years. Five years

was common for survivors of

the Oklahoma City bombing

(Office for Victims of Crime,

2000).

Counseling may use a

particular treatment approach

or incorporate a combination

of different approaches.

Treatments commonly used for

post-traumatic stress and

traumatic bereavement include

cognitive-behavioral therapy

(Ehlers and Clark, 2000; Young

et al., 1998; Foa, Rothbaum,

and Molnar, 1995); phaseoriented treatment (van der

Kolk et al., 1996; Herman,

1992); bereavement counseling

(Raphael et al., 2001; Rando,

1993; Worden, 1982); eye

movement desensitization and

reprocessing (EMDR) (Shapiro,

1995); brief dynamic therapy

(Marmar, Weiss, and Pynoos,

1995; Lindy, 1996; Horowitz,

1986); and psychopharmacology (Friedman et al., 2000;

46 • Mental Health Response to Mass Violence and Terrorism
Davidson and van der Kolk,

1996). These modalities have

varying levels of scientific

evidence supporting their

efficacy. Many practicing

mental health professionals

attempt to match the

treatment approach to the

recipient’s perception of its

acceptability and helpfulness.

The various trauma and

bereavement psychotherapy

approaches have elements in

common as well as

differences. All approaches set

stabilizing the survivor’s posttrauma reactivity as a primary

objective. Psychopharmacological treatment can help

reduce the severity of

symptoms so the survivor can

function better and engage in

psychotherapy more

effectively.

Cognitive-behavioral treatment

focuses initially on teaching

skills to manage anxiety, cope

with stressors, and challenge

irrational and maladaptive

thoughts. Dynamically oriented

approaches place greater

initial emphasis on developing

the therapeutic alliance, and

then on the symptom

reduction and relief that can

occur by telling the “trauma

story” in a safe environment.

Cognitive-behavioral

approaches incorporate

repeated exposure to details of

the trauma while actively

managing the related distress

facility. Dynamic approaches

look for links between key

aspects of the trauma, the

survivor’s vulnerabilities, prior

life experiences, and past

coping behavior. Bereavement

counseling often takes a more

developmental or stage-related

approach, viewing successful

“working through” of a

traumatic death as requiring

completion of a series of tasks.

Each approach considers the

recovery process to occur in

stages over an extended period

of time. Thus, returns to

treatment for “booster”

sessions or for additional

support and processing are

expected as survivors confront

environmental triggers and

challenges in their psychological recovery.

Mental health responders may

employ intervention strategies

used in these modalities to

assist with crisis intervention.

Having the necessary skills to

conduct meaningful

assessments and provide a

course of treatment with atrisk survivors, however,

requires specific training and

supervision, as well as a

mental health professional

license or certification,

depending on State

regulations.

Support Groups

Group treatment is especially

appropriate for survivors of

mass victimization because

groups provide social support

through validation and

normalization of thoughts,

Chapter III: Mental Health Intervention • 47

THE VARIOUS 

TRAUMA AND BEREAVEMENT 

PSYCHOTHERAPY 

APPROACHES HAVE 

ELEMENTS IN COMMON 

AS WELL AS 

DIFFERENCES.
emotions, and post-trauma

symptoms. Telling one’s

“trauma story” in the

supportive presence of others

who understand can be

powerful. In addition, group

reinforcement for stress

management and problemsolving techniques may bolster

courage and creativity.

Because some trauma

survivors feel isolated in their

struggles to cope, groups

provide much needed social

connection through support for

shared experiences. Sharing

helpful information about

service and financial resources

and other types of assistance is

another important function of

support groups.

Groups with homogenous

memberships may be offered

for parents, children, members

of a particular neighborhood or

commonly affected occupational group, and for survivors

who suffered a particular

trauma or loss (e.g., bereaved

parents, people who lost their

jobs as a result of the trauma,

grandparents who are raising

grandchildren). Group

members may be connected by

age, gender, or cultural group.

Support group sessions often

combine some structured

sharing and discussion about

trauma experiences and

recovery issues and psychoeducational presentations.

Because of the potential for

intense group dynamics and

members with complicated

trauma and grief reactions,

these groups should be

facilitated by an experienced

mental health professional,

ideally with a co-facilitator. In

most instances, groups should

be time-limited with

expectations defined at the

outset. A cohesive, effective

group often will want to

continue meeting. Mental

health response managers and

facilitators must decide if

continuing the group is the

best use of limited program

resources, given other

community needs. Group

members may elect to

transition into a more self-help

or social support model.

Facilitators may assist with this

transition, but end their formal

role with the group.

Immediate

Mental Health

Interventions for

Children and

Adolescents 

Goals and Priorities

Initial contacts with children,

adolescents, and their families

often take place at schools,

hospitals, family notification

and support sites, and shelters

providing support services.

These settings typically serve

multiple functions, so the

environment can be chaotic,

noisy, and not be suited for

48 • Mental Health Response to Mass Violence and Terrorism

CHILDREN AND 

ADOL E SC ENT S DIR ECTLY 

INVOLVED IN THE 

TRAUMATIC EVENT, OR 

WITNESSES TO IT, MAY 

NEED IMMEDIATE 

MENTAL HEALTH 

SUPPORT.
lengthy or private conversation. In the immediate

aftermath of a horrific incident

involving mass violent victimization, parents and caretakers

attempt to respond to their

children’s needs as well as

their own. They seek mental

health consultation regarding

their children’s well-being.

Parents and caretakers ask

questions about their

children’s behavior, what to

tell their children about the

specifics of the incident, how

to help them deal with a

missing or deceased parent, if

they should limit TV exposure

to traumatic scene replays, and

if their child should go to a

funeral, stay with an out-oftown relative, or see them cry.

Psycho-education for parents

and caretakers is an essential

component of early mental

health response.

Through psycho-educational

and other immediate mental

health interventions, the

mental health response assists

traumatized and bereaved

children to: 

◆ Regain a sense of safety

and security;

◆ Gain an understanding

and acceptance of the

events that have

occurred;

◆ Appropriately identify and

express reactions;

◆ Grieve and effectively

cope with traumatic

stress; and 

◆ Resume age-appropriate

roles and activities.

(Pynoos and Nader, 1993;

Vernberg and Vogel, 1993)

The last two goals are not

likely to be achieved during

the short term, yet they do

underlie mental health

intervention throughout the

recovery period. The following

section highlights several

interventions: psychological

first-aid, play areas, participation in disaster relief, and

school interventions. The table

at the end of this chapter

provides specific suggestions

for intervening with children

and adolescents.

Psychological First-Aid

Children and adolescents

directly involved in the

traumatic event, or witnesses

to it, may need immediate

mental health support. If they

appear to be disoriented, in

shock, or behaving strangely,

one-to-one support with a

protective adult and contact

with a child mental health

professional are necessary.

Immediate interventions

include physical comforting,

rest, repeated concrete

explanations of what

happened and what is going to

happen, repeated assurances

that they are safe and secure,

access to materials to draw or

play, and opportunities to

verbalize (Pynoos and Nader,

1993). In addition, traumatized

children may be calmed with

snacks for nurturance,

blankets for warmth and

nesting, familiar structured

play activities, and appropriate

limit setting (James, 1989). 

Play Areas

Play areas for children often

are set up adjacent to or within

family gathering settings.

Opportunities for quiet play,

structured activities, and more

active play can be provided for

children of different ages and

interests. Certified pet therapy

animals have been used

successfully in play areas

(American Psychological

Association Task Force, 1997).

Providing a setting and

structure for play gives

children an opportunity to

release energy and be

distracted from the trauma,

and gives parents some

respite. While play activities

should not involve “focused

therapy,” child mental health

professionals may offer

individual nondirective and

nonintrusive interventions

regarding feelings, talking

about experiences, or

correcting misconceptions

with children and their

parents.

Participation in Disaster

Relief

Some adolescents value

playing an active role in the

relief effort and helping others.

They may feel enhanced selfefficacy and greater mastery of

their situations when

Chapter III: Mental Health Intervention • 49
contributing in meaningful and

concrete ways. For example,

they may assist with food and

beverage distribution, moving

supplies, child care,

functioning as helpers at an

operations center, etc.

However, it is critically

important that they not be

asked to function in roles that

expose them to additional

trauma. Their role in assisting

others should be viewed, in

part, as a mental health

intervention and should be

monitored accordingly.

School Interventions

School is a central part of

children’s and adolescents’

lives. The school environment

provides an ideal locus for

mental health contact because

it is familiar, offers structures

conducive to re-establishing

routines and a group setting in

which sharing of experiences

and group support may occur.

Schools constitute the most

effective and efficient context

for post-trauma mental health

assistance for children and

their families (Pynoos et al.,

1998). Mental health support

must be provided to principals,

teachers, and other school

personnel. Teachers and staff

may experience their own

trauma and grief reactions, as

well as anxiety about returning

to a seemingly unsafe school

environment. They need

support to address the

incident’s impact on

themselves and their own

families. 

Multifaceted school interventions are recommended

(Flynn and Nelson, 1998).

Telephone hotlines for parents,

staff, and students that provide

up-to-date information and

mental health support may be

established. Schools often set

up walk-in clinics or drop-in

centers for students to selfrefer or for referral by teachers

or parents. Informational,

psycho-educational, and

supportive meetings may be

provided for parents and

caretakers. Special support

groups may be provided for atrisk students who were directly

exposed, whose parent was

killed, or who are having

severe reactions. Absenteeism

outreach that is nonpunitive

and responsive to students’

and parents’ concerns helps

facilitate students’ return to

school.

Classroom Interventions

Classroom interventions are

conducted as soon after the

traumatic incident as possible.

Teachers and child mental

health professionals may

cooperatively facilitate

interventions. The objectives

of these age-appropriate

classroom sessions are to: (1)

foster cognitive understanding

of the facts surrounding the

trauma and to clarify misconceptions; (2) provide an

opportunity to discuss and

express thoughts and feelings;

(3) identify at-risk students and

staff; and (4) plan for a gradual

return to normal routines

(Gillis, 1993; Klingman, 1993).

Intervention methods are

drawn from an array of options

including group discussion,

free or focused drawing,

sentence-completion, and

story-telling (Young, 1998;

Vernberg and Vogel, 1993;

Federal Emergency

Management Agency, 1991b). 

Classroom intervention

addresses the level of exposure

and trauma experienced by the

class and minimizes the

potential for restimulating

fears and anxieties. Mental

health professionals must take

care to avoid exposing

children who were not directly

involved in the trauma to

material that could become a

basis for subsequent posttraumatic stress reactions. The

overarching principle, “first, do

no harm,” again has relevance.

Long-Term

Mental Health

Interventions for

Children and

Adolescents

Goals and Priorities

Children and adolescents who

have witnessed and closely

experienced an incident

50 • Mental Health Response to Mass Violence and Terrorism
involving mass violence or

who have suffered the

traumatic death of a loved one

can face significant psychological effects and an extended

recovery. Pre-existing

adjustment or learning

difficulties often are

exacerbated. The sense of

innocence and security

associated with childhood may

be lost. The normal developmental stages associated with

growing up bring predictable

challenges, yet the traumatized

child’s ability to negotiate

these challenges is

compromised. Family, school,

and other networks in the

child’s world all have

important roles in the recovery

process. Mental health

intervention and treatment

address the following five

areas: 

1. Understanding the child’s

unique experience of the

trauma; 

2. Assisting the child in

developing strategies to

cope with traumatic

reminders; 

3. Addressing grief and the

interplay of traumatization and bereavement; 

4. Intervening with posttrauma adversities such

as a decline in school

performance; and 

5. Identifying and redressing

missed developmental

opportunities and

trauma-based selfattributions and

worldview.

(Pynoos et al., 1998)

These various areas and tasks

may be addressed in school,

group, family, and individual

interventions, and through

different therapeutic

modalities. The following

discussion explores both brief

counseling and support

groups. A multifaceted

approach includes thoughtful

construction of a “safety net”

for the child’s welfare. Both the

Recommended Readings at the

end of the chapter and the

Reference List at the end of the

manual provide additional

resources for mental health

professionals. Clearly,

specialized training is

necessary.

Brief Counseling

The safety, rapport, and trust

developed in one-to-one

counseling may be necessary

for the traumatized and/or

bereaved child or adolescent

to explore underlying fears,

fantasies, distorted

perceptions, guilt, shame, and

self-blame. Over time, the

child may approach the terror,

horror, and helplessness that

they experienced during the

event. As the child develops

the ability to identify,

understand, and manage

feelings, he or she is more able

to deal with difficult, painful

Chapter III: Mental Health Intervention • 51

THE SCHOOL 

ENVIRONMENT PROVIDES AN 

IDEAL LOCUS FOR MENTAL 

HEALTH CONTACT BECAUSE IT 

IS FAMILIAR, OFFERS 

STRUCTURES CONDUCIVE TO 

RE-ESTABLISHING ROUTINES 

AND A GROUP SETTING IN 

WHICH SHARING OF 

EXPERIENCES AND GROUP 

SUPPORT MAY OCCUR.
memories. The child therapist

uses a range of supportive,

nonthreatening approaches

including art and play therapy,

therapeutic games, and

psychodrama.

Support Groups 

Many children and adolescents

benefit from group activities

and support. School classes,

religious groups, day camps,

youth groups, day care centers,

and 4-H clubs are often

suitable for mental health

intervention. These

interventions may involve a

memorial or commemorative

activity, or education about

some related aspect of the

event, followed by a discussion

of reactions, feelings, and

coping skills. Through these

group interventions, at-risk

children may be identified and

contact may be made with

their families. In addition,

ongoing support groups may

be offered for highly exposed

and traumatized children and

adolescents. These groups for

at-risk children are more

therapeutic in nature and may

follow a structured format over

6 to 10 weeks. Groups may be

helpful, especially for

traumatized adolescents, to

allow working through disturbances in peer relationships

(Pynoos and Nader, 1993).

Considerations

For Immediate

And Long-Term

Mental Health

Intervention with

Cultural and

Ethnic Groups

The increasing population

diversity of the United States

and the constant flow of

visitors from other parts of the

world ensure that survivors of

acts of mass violence and

terrorism are likely to be

culturally, racially, and

ethnically diverse. Similarly,

survivor’s experiences are

shaped, in part, by their

cultural, ethnic, and racial

backgrounds. Different levels

of acculturation within a

cultural group may result in

younger survivors having a

more bicultural or dominant

culture perspective; older

survivors may adhere more to

the ways of their countries of

origin (Paniagua, 1998). Also,

cultural differences between

rural and urban survivors,

among the various regions of

the United States, across

differences in educational and

socioeconomic levels, among

different age groups, and

among different religious and

nonreligious groups, color how

people view the event, mental

health intervention, healing,

and recovery. Consequently,

mental health services,

criminal justice procedures,

emergency medical services,

and medical examiner’s office

protocols require culturally

sensitive explanation,

adaptation, and liaison.

Mental health responders may

conduct triage and immediate

interventions with survivors

who do not speak English,

who attribute very different

meanings and expectations to

traumatization, who express

emotions and symptoms in

culture-specific ways, and who

have divergent notions

regarding “mental health,”

“recovery,” and appropriate

psychological intervention. 

Groups with different cultural

customs define “family” in

different ways and have

different traditions and rituals

surrounding death and burial.

Mental health providers

quickly must become culturally

competent with each affected

survivor group. Cultural

experts, community leaders of

the affected cultural groups,

elders, and indigenous social

service providers can provide

valuable insights, training, and

consultation for mental health

workers. Cultural competence

is the responsibility of each

mental health responder,

program administrator,

manager, and supervisor.

Competencies include:

◆ Valuing diversity,

respecting differences,

52 • Mental Health Response to Mass Violence and Terrorism
and seeking to develop

and adapt service

delivery models to fit

cultural groups;

◆ Recognizing differences

in communication styles,

social etiquette, and

problem-solving

methods;

◆ Providing services and

information in

appropriate languages;

◆ Understanding of and

respect for different

cultural definitions of

personal well-being and

recovery from traumatic

events;

◆ Knowing which

“accepted” crisis

intervention practices fit

and which do not;

◆ Incorporating the sophisticated and varied

cultural pathways to

mental health including

healing rituals;

◆ Using strength-based and

empowerment

approaches to cultural

group survivorship and

healing; and 

◆ Providing extensive and

ongoing cultural

competence training and

supervision of mental

health responders.

(U.S. Department of Justice,

2000; Nader et al., 1999;

Hernandez and Isaacs, 1998).

The following description of

interventions used after the

1989 mass shooting of school

children and staff in Stockton,

CA, illustrates cultural

competence and a blending of

approaches:

With an awareness of

cultural beliefs and practices

including religious and

medical practices, the

school principal invited local

clergy including Cambodian

and Vietnamese Buddhist

monks, a Vietnamese

Catholic priest, and

Protestant ministers to

perform a blessing

ceremony upon the school

and school grounds. This

included the exorcism of

Chapter III: Mental Health Intervention • 53

Tips for Working with Interpreters

✔ Avoid using relatives, children, and friends as 

interpreters

✔ Use certified, qualified interpreters with mental health 

and trauma training

✔ Allow opportunity for interpreter to build rapport with 

survivor

✔ Allow at least twice as much time. Use sequential mode 

of interpretation (survivor speaks, interpreter interprets 

what has been said into English, mental health provider 

speaks, interpreter speaks again

✔ Be aware of the interpreter’s discomfort, avoidance, 

and biases

✔ Interpreters should also receive cultural competence 

training, if possible

✔ Debrief interpreter’s reactions

(Paniagua, 1998; Westermeyer, 1995)

Basic Cultural Sensitivity Checklist

✔ Convey respect, good will, nonjudgment, courtesy

✔ Ask permission to speak with the person or family

✔ Explain role of mental health worker in culturally 

relevant terms

✔ Acknowledge differences in behavior due to culture

✔ Respond to concrete needs

(Paniagua, 1998; Young, 1998)
spirits including the bad

spirit of the man who killed

the children and himself and

the spirits of dead children

who might grab other

children and take them into

the next world. Children

were given chants to use

when frightened; children

and adults were given

factual information to dispel

rumors and unfounded

fears.

(Dubrow and Nader, 1999)

Loss of hope, meaning, and

perceived control are universal

aspects of trauma. The

rebuilding of hopes,

reconstructing of meaning,

and finding a sense of

empowerment to regain

control are necessary for

recovery from trauma and loss

(Herman, 1992). Experts

propose that there are

meaning-making and selforganizing parts within

everyone that are particularly

active following catastrophic

traumatic events. These parts

can help survivors construct

meaning around horrific

events or may lead them to the

repetitive rigidity associated

with post-traumatic stress

disorder (Gusman et al., 1996). 

Community-building and

empowerment are essential for

regaining control and fostering

community survivorship. On

the individual level, human

contact, kindness, listening,

and respect can transcend

cultural differences and

provide an avenue for

survivors to be heard and

witnessed regarding their

traumatic experiences and

losses.

Key Events with

Mental Health

Implications

Survivors’ and family

members’ psychological

responses to mass criminal

victimization occur within a

context of a number of

predictable events, each with

inherent mental health

implications. These events

may be tied to relief, rescue,

and recovery efforts; criminal

justice proceedings; and

cultural and religious rituals

for honoring those who were

killed. While individuals vary in

their reactions to these events,

mental health responders can

be more effective when they

anticipate and prepare for their

potential psychological impact.

The following discussion

focuses on seven key events,

potential psychological

reactions to them, and possible

mental health interventions.

Events included in this section

are: (1) death notification; (2)

ending rescue and recovery

operations; (3) applying for

death certificates when no

identified remains have been

found; (4) events involved in

54 • Mental Health Response to Mass Violence and Terrorism

MENTAL HEALTH 

PROFESSIONALS MAY 

HAVE AN IMMEDIATE 

SUPPORT ROLE WITH 

BEREAVED FAMILIES AND 

LOVED ONES DURING 

AND AFTER FORMAL 

DEATH NOTIFICATION.
Chapter III: Mental Health Intervention • 55

criminal justice proceedings;

(5) returning to the crime

scene and disaster impacted

areas; (6) memorials and

funerals; and (7) determination

of formulas and methods for

distributing Federal, State,

employer and charity funds to

victims and families. Each

occurrence of mass violence or

terrorism has unique elements

and circumstances with

significant mental health

consequences. An important

component of the mental

health response is identifying

events with potential mental

health implications during the

aftermath, determining

potential mental health needs,

and flexibly and creatively

implementing a system for

mental health support and

intervention.

Death Notification

Mental health professionals

may have an immediate

support role with bereaved

families and loved ones during

and after formal death notification. Mental health professionals typically do not deliver

information regarding deaths,

but may participate on teams

with the person(s) responsible

for this notification. These

teams may include a representative from the medical

examiner’s office, a funeral

director, a health care professional, a chaplain, and a

mental health professional

(Jordan, 1999). Mental health

professionals provide support

to the family receiving the

news, mental health consultation, and conducting the

notifications when requested. 

Including a mental health

professional with child specialization on the notification

team is advised when families

have questions about their

children’s needs (Sitterle and

Gurwitch, 1999). Notifiers can

more sensitively provide death

notification for families from

different cultural and ethnic

backgrounds when they are

informed about the group’s

customs regarding the

expression of grief and

anguish and rituals

surrounding death and burial.

The most traumatic moment

for many people is notification

of a sudden death and can

become a focal point for later

PTSD (Young, 1998; Lord,

1996). Properly conducted, the

notification process can help

begin healing. The following

guidelines are included in the

Mothers Against Drunk Drivers

comprehensive curriculum on

death notification (Lord, 1996):

◆ Obtain critical information before notification. It

is important to be able to

provide information

about how, when, and

where the person died,

how the identification

was made, and where the

body is. If possible, learn

about the person(s) to be

notified, any medical

conditions, and who is

included in their support

system;

◆ Notify the family member

of the deceased simply,

directly, and in-person.

After the persons

responsible for notification have identified

themselves and are

seated, clarify the family

members’ relationship to

the deceased. Using the

victim’s name, state

clearly and without

euphemisms that he or

she has died. Use warmth

and compassion and say,

“I’m sorry.” Do not take

the deceased’s personal

items to the notification;

◆ Expect intense emotional

and physical reactions

(flight, fight, and freeze).

A member of the team

should have CPR training

and be able to treat

shock reactions. Respond

non-judgmentally and

supportively to all

reactions and questions.

Avoid leaving the

bereaved person alone,

but do allow privacy for

grief reactions;

◆ Provide practical

assistance. The bereaved

person may need

assistance making

arrangements to be

transported to identify or
view the body. They may

need help making phone

calls to arrange for

transportation, child care,

or to contact relatives or

their employer; and 

◆ Help the family decide

about viewing the body

or photographs. Ensure

that the bereaved person

is informed and prepared

regarding what they will

see and the condition of

the body. For many, it is

very important to see the

remains of their loved

one. A lesson learned

from the Oklahoma City

bombing is that many

families ended up

regretting not viewing

their loved one’s remains.

They had been

discouraged from doing

so because of the degree

of mutilation (Office for

Victims of Crime, 2000;

Jordan, 1999). For others,

viewing the body may be

seen as inappropriate for

cultural or religious

reasons. Family members

should be supported in

making informed choices

and encouraged to have

accompaniment and

support.

Mental health professionals

may provide training for

notifiers on how best to

support those receiving the

devastating information.

Families may prefer to have

privacy after receiving the

notification or they may desire

continued support from the

mental health professional.

The Mother’s Against Drunk

Drivers resource materials

provide additional guidance

regarding delivering sensitive

death notification (Lord, 1996).

Ending Rescue and

Recovery Operations

Waiting for official notification

that a loved one was killed

violently is excruciating.

Family members must depend

on rescue workers and

passively wait, while the site of

impact is typically secured by

local law enforcement and, in

some cases, military units.

Families hold out hope that

their loved one was spared

and many protect themselves

from the anguish associated

with the reality of their loved

one’s death through denial.

Often, it is not until the body is

recovered and official death

notification received, that the

death is accepted and grieving

may begin.

The psychological impact for

affected families is profound

and intense when a recovery

operation ends before all

bodies have been recovered.

Some feel the physical body

and person they loved is being

abandoned. They are left in a

state of limbo, unable to

accept the reality of the death

and to engage in rituals to

acknowledge the ending of

their loved one’s life. For some

cultural groups, failure to

provide a proper burial has farreaching meanings.

Officials responsible for

deciding when to end body

recovery operations may

consult with mental health

professionals regarding how to

sensitively communicate this

to families. It is critically

important that families receive

this information directly from

the proper authorities and not

through the media. Typically,

families focus on several

questions, “Is there a chance

anyone is still alive?” “What is

the condition of the bodies?”

“How much did my loved one

suffer?” and “Will all the bodies

be recovered?” Officials should

be truthful, straightforward,

and precise. They should

provide loved ones with the

facts so that they may better

understand why certain

decisions are being made

(Cummock, 1996).

Applying for Death

Certificates When No

Identified Remains Have

Been Found

An official death certificate is

required for beneficiaries to

receive life insurance benefits,

Social Security benefits,

Federal and State victims

compensation, death benefits

from State and Federal

Workers Compensation, and

death benefits from the Public

Safety Officers Benefit

Program. Three weeks after

56 • Mental Health Response to Mass Violence and Terrorism
the September 11 attacks on

the World Trade Center,

families could begin the

procedures for obtaining death

certificates at the Family

Assistance Center.

Government officials

recognized that remains, if

they were ever found, would

not be identified for months,

which could threaten many

families’ financial stability

because they would not be

able to access death benefits. 

Families with limited savings

and resources needed to

address their financial needs

quickly. Families needed to

complete legal procedures and

provide documentation to

obtain a death certificate so

that they could receive funds

and benefits payable upon

death. Some experienced this

step as abandoning hope and

betraying their commitment to

their loved one. Bereaved

family members had to act

more accepting of the death

than they truly felt.

Mental health professionals

can assist families as they

struggle with the dilemmas

posed by the decision to apply

for a death certificate. Mental

health workers can accompany

families as they meet with

attorneys, provide documentation, and complete forms.

They can offer alternative

perspectives when families

view obtaining the death

certificate as a betrayal or

acceptance of the death. In

some cases, mental health

professionals can explore

other financial options with

those who are unable to begin

the process of obtaining a

death certificate.

Events Involved in Criminal

Justice Proceedings

The psychological grieving and

recovery process is interrupted

and complicated by triggering

events throughout criminal

justice proceedings. Survivors,

loved ones, and the

community demand that

justice be served. Some sense

of resolution is often linked to

trial outcomes. However, for

many, the devastating

consequences of the evil acts

of the perpetrators are never

adequately or justly redressed

through the criminal justice

system. When the alleged

perpetrator(s) are not identified

or arrested, survivors and

victims’ families must live with

the knowledge that the

perpetrators are alive and at

large.

Survivors are thrown into an

unfamiliar and disorienting

criminal justice system.

Criminal justice procedures

may not appear to make sense

and can seem removed from

the attainment of justice.

Crime victim assistance

providers, law enforcement

personnel, prosecutors’ offices,

Chapter III: Mental Health Intervention • 57

THE PSYCHOLOGICAL 

GRIEVING AND RECOVERY 

PROCESS IS INTERRUPTED 

AND COMPLICATED BY 

TRIGGERING EVENTS 

THROUGHOUT CRIMINAL 

JUSTICE PROCEEDINGS.
and mental health providers

work together to ensure that

survivors have:

◆ Information about the

investigation, the

criminal justice system,

and upcoming

proceedings and status

updates;

◆ Psychological support

that anticipates and

responds to the impact of

key events in

proceedings; and 

◆ Opportunities to make

informed decisions

regarding participation in

the criminal justice

process.

Key events with mental health

implications during the

criminal justice process

include the investigation, lack

of arrests, prosecution, court

delays, sentencing, and

possible post-disposition

events such as an appeal,

parole hearing, escape from

prison, a request for clemency

or pardon, and an execution

(U.S. Department of Justice,

2000).

Returning to the Crime

Scene and DisasterImpacted Areas

The first time survivors return

to or view the scene of mass

violence can be extremely

upsetting, if not overwhelming.

Many view the impact zone as

sacred ground and expect the

area to be treated with respect

and reverence. Visiting the

actual location of the event

can trigger a range of intense

reactions. When property

destruction is widespread,

witnesses can view the

physical damage as visible

evidence of their personal

losses. When physical damage

has been repaired and cleaned

up quickly, those most closely

affected may find that

everything “looks the same,”

when nothing for them is the

same.

Residents returning to homes

or apartments where mass

trauma took place may have

lost their sense of home as a

safe haven. Their

neighborhood may sound and

look like a “combat zone” with

sirens, police-enforced

checkpoints, and a massive

rescue and recovery operation

underway. Views out of

windows may be permanently

altered. When buildings are

deemed to be sufficiently safe,

residents may be allowed to

return to their homes for 15 to

30 minutes to retrieve

important items and check on

pets who may have been

trapped. Law enforcement

typically controls this process

and maintains security at the

buildings. Mental health

providers may talk with

residents as they wait for

entry, providing support for

concerns about valued

58 • Mental Health Response to Mass Violence and Terrorism

TRADITIONS 

ASSOCIATED WITH 

MEMORIALS, FUNERAL 

SERVICES, AND BURIAL 

RITUALS HELP FAMILIES 

AND LOVED ONES HONOR

THEIR DEAD.
possessions and pets or

helping with housing issues.

Employees may be returning to

their place of employment or

students to a school where the

mass violence or terrorist

attack took place. Frequently,

survivors experience

previously unexpressed

traumatic reactions, such as a

profound upwelling of grief.

They may feel unsafe,

insecure, and unable to

concentrate on their duties.

Mental health professionals

may provide consultation to

employers and school administrators on re-entry activities,

mental health interventions,

and reasonable expectations of

job or school performance.

Mental health professionals

may assist those returning to

or viewing impact sites by

describing what they will see,

hear, and smell, and by

informing families and victims

about what they will be

allowed to do at the site.

Mental health professionals

may help families and victims

anticipate and prepare for their

reactions. As family members

were transported by ferry to

Ground Zero, the site of the

World Trade Center attacks,

mental health and spiritual

care providers offered gentle,

nonintrusive support. Before

boarding the ferry, a representative from the Police

Department briefed families.

Mental health workers

provided note cards and pens

for loved ones to write

messages to leave at the site.

As family members walked

from the ferry to the site,

recovery workers stopped

working, took off their hard

hats, and silently paid respect

to the grieving families. Some

family members were

overcome by their physical and

emotional reactions, and

required emergency medical

attention. Many families

requested chaplains to assist

with honoring their deceased

loved ones. Mental health

professionals solved the

immediate concerns and needs

of the families and maintained

a nonintrusive, supportive

presence.

Memorials and Funerals

A site for memorializing often

spontaneously appears within

hours of a mass tragedy.

Community members bring

flowers, photographs,

mementos, and messages. The

site, often close to the location

where the violence occurred,

becomes a place for

remembering, honoring,

grieving, and giving and

receiving support. Following

the September 11 terrorist

attacks on the Word Trade

Center, families and friends

posted photographs of missing

loved ones in the hope they

would be found alive.

Thousands of photographs of

people on vacation, with their

families, at weddings, at work,

graduating from college, or

playing sports were posted on

walls in public areas in New

York City. Gradually these

pictures, capturing so much

life and vibrancy, became a

memorial of tragic loss.

Mental health professionals

may assist government

officials or emergency

managers to consider

appropriate and protected

locations for memorials.

Logistical issues often need to

be addressed following a

large-scale, mass-casualty

tragedy. At memorial sites,

mental health professionals

may be available for support.

At the same time, mental

health professionals should

allow and support the natural

human processes that take

place and not intrude on

mourners’ private moments.

Traditions associated with

memorials, funeral services,

and burial rituals help families

and loved ones honor their

dead. When the family has not

received physical remains,

funeral directors, mental

health professionals, and faithbased counselors may assist

the family in defining

meaningful rituals and

symbolic gestures to both

acknowledge the death and

commemorate the life of the

victim. Funerals are typically

private. Mental health

providers should attend only

Chapter III: Mental Health Intervention • 59
as participants unless they

have specifically been

requested to serve a different

function.

Determination of Formulas

And Methods for

Distributing Federal, State,

Employer, and Charity

Funds to Victims and

Families

Mass violence and terrorist

attacks against U.S. citizens

can cause the desire to help

those victimized. This desire

translates into sizable

donations of money, goods,

and services that need to be

managed and appropriately

distributed. Charities,

employers, and a number of

Federal and State programs

have funds for providing

assistance and benefits to

victims and families. Congress

established the Federal Victims

Compensation Fund following

the September 11 terrorist

attacks. Victims and families of

those killed could apply for

compensation for physical

injuries, lost wages, lost future

earnings, and pain and

suffering resulting from the

attacks.

Challenging issues surrounding

eligibility criteria, definitions of

“family” and “spouse,”

citizenship status, disability

compensation, treatment of

high vs. low-income

individuals, deduction of other

Federal benefits, differential

benefits for emergency

services or military personnel,

and fairness and equity can

result in divisive conflicts

between victim groups,

government officials, elected

officials, and fund administrators. In addition, those

victimized by previous terrorist

attacks both inside and outside

of the United States may feel

that their needs were ignored

in the face of current, larger

compensation levels. Similarly,

subsequent victims may feel

that prior victims were treated

more generously.

Interventions

With the

Community

Violent acts that victimize a

group of people harm not only

individuals but also the

community. Before the tragedy,

the community may have

thought that “this sort of thing

doesn’t happen here.” The

community’s collective

assumption pertaining to

safety and the ability to protect

its citizens from criminal

attack are shattered. The

reality that any community is

vulnerable to random acts of

mass violence and terrorism

penetrates a sense of security,

the fabric of the social order.

In communities with high rates

of violent crime and prior mass

violence, the current incident

involving mass victimization

reinforces the perception that

the community’s systems for

ensuring public safety are

ineffective and, in some

instances, that the community

must be attracting violence. In

each scenario, the

community’s perceived

capacity to protect and care for

its members has been

damaged. Community-based

healing activities and rituals

may reinforce community

strengths and promote

community recovery.

Memorials, Rituals, and

Commemorations

For many survivors, bereaved

families, and affected

community members, rituals

and symbolic gestures provide

a way to acknowledge the

tragedy, experience emotions,

reaffirm life, honor “goodness”

in the community, grieve what

has been lost, communicate

messages of hope and

remembrance, and join with

others (Sitterle and Gurwitch,

1999; Flynn, 1995; Rando,

1993). Symbolic activities may

connect people with each

other and to the past and the

future, as well as to a power or

spirit beyond the human

realm. Rituals may be personal

such as privately reading a

letter to a deceased loved one

at a cemetery, or communitywide such as reading the

names of those killed while

lighting a candle for each

person or honoring victims by

installing a symbolic work of

art or planting a tree at a

public ceremony. Effective

60 • Mental Health Response to Mass Violence and Terrorism
community memorial and

commemorative events

transcend political, religious,

class, and cultural differences

and provide an opportunity for

all to come together. When

these differences have played a

role in the event’s impact or

the community’s recovery,

such as with racially motivated

or hate-based crimes,

community leaders need to

foster understanding,

tolerance, and forgiveness

across groups through public

ceremonies.

Mental health professionals

may function in a consulting

role and should not be overdirective in planning these

ceremonies. Survivor and

community ownership of an

event enhances the significance for those the event is

intended to help. Mental health

consultants may suggest

strategies to include children

or other special survivor

groups. They may alert

planners to the potential for

misunderstandings or

alienation of survivors or

groups through the use of

particular language or

symbolic activities. Mental

health professionals may

attend these community

gatherings to provide psychological support as needed and

requested.

The six-month and one-year

anniversaries of a traumatic

event trigger many reactions in

survivors. The anniversary can

be a time of remembering and

acknowledging losses and the

people who were killed along

with celebrating human

resilience, kindness, and the

courage to continue (Center

for Mental Health Services,

1994). Community and

religious leaders may provide

messages of hope, tolerance,

and healing. Commemorative

plaques, trees, art projects,

pins, or dedications may be

incorporated. Group activities

such as singing, participating

in a period of silence, or

sharing food together may

contribute to community

building.

Typically, criminal justice

proceedings have not

concluded when the one-year

anniversary occurs. When

investigations or criminal

justice proceedings are

ongoing, planners must clarify

the purposes and focus for the

one-year anniversary, as

distinct from the determination

of cause or the achieving of

justice. Consultation with and

participation of community

members and representatives

from all affected community

groups ensure that commemorative events have meaning for

all community survivors.

Usual Community

Gatherings

Most communities have an

annual schedule of events that

may include holiday commemChapter III: Mental Health Intervention • 61

SYMBOLIC ACTIVITIES 

MAY CONNECT PEOPLE WITH 

EACH OTHER AND TO THE 

P A ST AND THE FUTURE, AS 

WELL AS TO A POWER 

OR SPIRIT BEYOND THE

HUMAN REALM.
orations, fairs, parades, and

festivals. Similarly, schools

have activities throughout the

academic year such as

homecoming weekend, plays,

musical performances, and

proms. Religious groups also

mark the year with ceremonies

and symbolic rituals. Each

cultural group has gatherings

with meanings tied to central

beliefs and long-held

traditions. Communities have

found that a sense of

continuity and strength can be

provided through familiar

events, especially when they

are combined with an

appropriate acknowledgment

of the community tragedy. 

Continuing familiar gatherings

promotes hope and the sense

that the community can

overcome harm and eventually

recover. Decisions to cancel or

postpone these events must be

made carefully, as they can

provide valuable opportunities

for social support and healing. 

Mental health professionals

may assist community leaders

in deciding whether to hold a

celebratory event in the wake

of a tragedy, considering the

potential for minimizing the

enormity of people’s losses.

Mental health consultants may

suggest ways to adapt the

event so that it both honors

the losses sustained by the

community and provides a

venue for members to come

together. Community and

religious leaders often play a

significant role and may

provide comfort, inspiration,

and perspective to their

constituents in attendance.

Symbolic Gestures

Symbols and rituals can have

profound significance for

people who wish to

communicate gratitude and

good will or who are searching

to find meaning, courage, and

hope. Even simple gestures

can become powerful

conveyors of compassion and

condolence. In Oklahoma City,

following the bombing of the

Federal Building in 1995, a

brown teddy bear linked

rescue and recovery workers

inside the perimeter and the

community members standing

vigil outside the chain-link

fence surrounding the secured

bombing site. Each day, the

bear was hugged by

community members outside

and then carried inside and

hugged by workers: 

The bear became a link

between those inside who

were involved in some of

the most difficult work

imaginable and those who

stood vigil outside wanting

so much to help. It was the

bearer or their connection,

their affection, their

hope...such a simple, but

moving, way to connect

people necessarily

separated by role, steel, and

troops, yet connected by

their common hopes and

persistence. 

(Flynn, 1995)

Similarly, many families

waiting for the recovery of

their loved ones’ bodies and

formal notification of their

deaths expressed appreciation

of the recovery workers

through gifts of yellow ribbons

held by guardian angel pins:

The purpose of the ribbons

was to recognize workers’

valor and courage, to

provide guidance and

support, and to symbolize

care and concern for

workers’ safety and welfare

during the dangerous search

for bodies. The firefighters

were grateful and, in fact,

insisted on wearing the

ribbons before entering the

bombing site. 

(Sitterle and Gurwitch, 1999)

Mental health responders often

are awed by the comforting

and healing power of

symbolism and rituals.

Frequently, the best of the

human spirit is communicated

in the simplest manner. Mental

health workers may assist

affected groups in developing

rituals or provide assistance

with the logistics necessary to

carry out their ideas. The

power of the symbolic gestures

come from survivors’ hearts

and minds. Mental health

responders need to take care

62 • Mental Health Response to Mass Violence and Terrorism
Chapter III: Mental Health Intervention • 63

Behavioral Symptoms

• Clinging to parents or

familiar adults

• Helplessness and passive

behavior

• Resumption of bed

wetting or thumb sucking 

• Fears of the dark

• Avoidance of sleeping

alone 

• Increased crying

Physical Symptoms

• Loss of appetite

• Stomach aches

• Nausea

• Sleep problems,

nightmares

• Speech difficulties

• Tics

T ABLE 3: R EACTIONS TO T RAUMA AND S UGGESTIONS FOR I NTERVENTION

Ages

1-5

Continued on next page

Emotional Symptoms

• Anxiety

• Generalized fear

• Irritability

• Angry outbursts

• Sadness 

• Withdrawal

Intervention Options

• Give verbal reassurance and physical

comfort

• Clarify misconceptions repeatedly

• Provide comforting bedtime routines

• Help with labels for emotions

• Avoid unnecessary separations

• Permit child to sleep in parents’ room

temporarily

• Demystify reminders

• Encourage expression regarding

losses (deaths, pets, toys)

• Monitor media exposure

• Encourage expression through play

activities

not to interfere in this

important process.

Summary Table

Table 3 summarizes

information provided in

Chapters II and III. Trauma

reactions are divided by age

with intervention options

applicable to each age group.

These practical suggestions

are appropriate for all human

service workers, disaster relief

workers, crime victim

assistance providers, and

mental health responders. All

workers are advised to

exercise caution when

intervening in ways that might

penetrate victims’ selfprotective coping. With

immediate response

interventions, being supportive

and fostering safety and

security are priorities.
64 • Mental Health Response to Mass Violence and Terrorism

Continued from previous page

Behavioral Symptoms

• Decline in school

performance

• School avoidance

• Aggressive behavior at

home or school

• Hyperactive or silly

behavior

• Whining, clinging, acting

like a younger child

• Increased competition

with younger siblings for

parents’ attention

• Traumatic play and

reenactments

• Decline in academic

performance

• Rebellion at home or

school

• Decline in previous

responsible behavior

• Agitation or decrease in

energy level, apathy

• Delinquent behavior

• Risk-taking behavior

• Social withdrawal

• Abrupt shift in 

relationships

Physical Symptoms

• Change in appetite

• Headaches

• Stomach aches

• Sleep disturbances,

nightmares

• Somatic complaints

• Appetite changes

• Headaches

• Gastrointestinal problems

• Skin eruptions

• Complaints of vague

aches and pains

• Sleep disorders

T ABLE 3: R EACTIONS TO T RAUMA AND S UGGESTIONS FOR I NTERVENTION

Ages

6-11

12-18

Emotional Symptoms

• Fear of feelings

• Withdrawal from friends,

familiar activities

• Reminders triggering

fears

• Angry outbursts

• Preoccupation with

crime, criminals, safety,

and death

• Self blame 

• Guilt

• Loss of interest in peer

social activities, hobbies,

recreation

• Sadness or depression

• Anxiety and fearfulness

about safety

• Resistance to authority

• Feelings of inadequacy

and helplessness

• Guilt, self-blame, shame

and self-consciousness

• Desire for revenge

Intervention Options

• Give additional attention and 

consideration

• Relax expectations of performance

at home and at school temporarily

• Set gentle but firm limits for acting

out behavior

• Provide structured but undemanding

home chores and rehabilitation

activities

• Encourage verbal and play

expression of thoughts and feelings

• Listen to child’s repeated retelling of

traumatic event

• Clarify child’s distortions and 

misconceptions

• Identify and assist with reminders

• Develop school program for peer

support, expressive activities,

education on trauma and crime,

preparedness planning, identifying

at-risk children

• Give additional attention and 

consideration

• Relax expectations of performance

at home and school temporarily

• Encourage discussion of experience

of trauma with peers, significant

adults

• Avoid insistence on discussion of

feelings with parents

• Address impulse to recklessness

• Link behavior and feelings to event

• Encourage physical activities

• Encourage resumption of social

activities, athletics, clubs, etc.

• Encourage participation in

community activities and school

events

• Develop school programs for peer

support and debriefing, at-risk

student support groups, telephone

hotlines, drop-in centers, and 

identification of at-risk teens

Continued on next page
Chapter III: Mental Health Intervention • 65

Continued from previous page

Behavioral Symptoms

• Sleep problems

• Avoidance of reminders

• Excessive activity level

• Protectiveness toward

loved ones

• Crying easily

• Angry outbursts

• Increased conflicts with

family

• Hyper-vigilance

• Isolation, withdrawal,

shutting down

• Withdrawal and isolation

• Reluctance to leave home

• Mobility limitations

• Relocation adjustment

problems

Physical Symptoms

• Nausea

• Headaches

• Fatigue, exhaustion

• Gastrointestinal distress

• Appetite change

• Somatic complaints

• Worsening of chronic

conditions

• Worsening of chronic

illnesses

• Sleep disorders

• Memory problems

• Somatic symptoms

• More susceptible to hypo

and hyperthermia

• Physical and sensory

limitations (sight, hearing)

interfere with recovery

T ABLE 3: R EACTIONS TO T RAUMA AND S UGGESTIONS FOR I NTERVENTION

Ages

Adults

Older

Adults

Emotional Symptoms

• Shock, disorientation, and

numbness

• Depression, sadness

• Grief

• Irritability, anger

• Anxiety, fear

• Despair, hopelessness

• Guilt, self-doubt

• Mood swings

• Depression

• Despair about losses

• Apathy

• Confusion, disorientation

• Suspicion

• Agitation, anger

• Fears of institutionalization

• Anxiety with unfamiliar

surroundings

• Embarrassment about

receiving “hand outs”

Intervention Options

• Protect, direct, and connect

• Ensure access to emergency

medical services

• Provide supportive listening and

opportunity to talk about experience

and losses

• Provide frequent rescue and

recovery updates and resources for

questions

• Assist with prioritizing and problemsolving

• Assist family to facilitate communication and effective functioning

• Provide information on traumatic

stress and coping, children’s

reactions, and tips for families

• Provide information on criminal

justice procedures, roles of primary

responder groups

• Provide crime victim services

• Assess and refer when indicated

• Provide information on referral

resources

• Provide strong and persistent verbal

reassurance

• Provide orienting information

• Ensure physical needs are

addressed (water, food, warmth)

• Use multiple assessment methods

as problems may be underreported

• Assist with reconnecting with family

and support systems

• Assist in obtaining medical and

financial assistance

• Encourage discussion of traumatic

experience, losses, and expression

of emotions

• Provide crime victim assistance 
Recommended

Reading

Center for Mental Health

Services. (1994). Disaster

Response and Recovery: A

Handbook for Mental Health

Professionals. Rockville, MD:

Substance Abuse and Mental

Health Services

Administration, U.S.

Department of Health and

Human Services.

Center for Mental Health

Services. (1999). Psychosocial

Issues for Older Adults in

Disasters. Rockville, MD:

Substance Abuse and Mental

Health Services

Administration, U.S.

Department of Health and

Human Services.

Center for Mental Health

Services. (2000). HumanCaused Disasters:

Recommendations for the Crisis

Counseling Assistance and

Training Program. Rockville,

MD: Substance Abuse and

Mental health Services

Administration, U.S.

Department of Health and

Human Services.

Center for Mental Health

Services. (2000). Psychosocial

Issues for Children and

Adolescents in Disasters (2nd

Ed.). Rockville, MD: Substance

Abuse and Mental Health

Services Administration, U.S.

Department of Health and

Human Services.

Centre for Mental Health and

NSW Institute of Psychiatry.

(2000). Disaster Mental Health

Response Handbook. North

Sydney, New South Wales,

Australia: New South Wales

Health Department.

Herman, J. L. (1992). Trauma

and Recovery. New York: Basic

Books.

Hernandez, M. and Isaacs, M.

(1998). Promoting Cultural

Competence in Children’s

Mental Health Services.

Baltimore: Paul Brookes.

Lord, J. H. (1996). Trauma,

Death and Death Notification: A

Seminar for Professional

Counselors and Victim

Advocates. Mothers Against

Drunk Driving (MADD) and the

Office for Victims of Crime

(OVC).

Lurigio, A. J., Skogan, W. G.,

and Davis, R. C. (1990). Victims

of Crime: Problems, Policies and

Programs. Newbury Park, CA:

Sage. Office for Victims of

Crime. (2000). Responding to

Terrorism Victims: Oklahoma

City and Beyond. Washington,

DC: U.S. Department of Justice.

Paniagua, F. (1998). Assessing

and Treating Culturally Diverse

Clients. Thousand Oaks, CA:

Sage.

Pynoos, R. S., Goenjian, A. K.,

and Steinberb, A. M. (1998). A

public mental health approach

to the postdisaster treatment

of children and adolescents.

Child and Adolescent Psychiatric

Clinics of North America, 7(1)

195-210.

Pynoos, R. S. and Nader, K.

(1993). Issues in the treatment

of post-traumatic stress in

children and adolescents. In

Wilson, J. P. and Raphael, B.

(Eds). International Handbook

of Traumatic Stress Syndromes

(pp. 535-549). New York:

Plenum.

Rando, T. A. (1993). Treatment

of Complicated Mourning.

Champaign, IL: Research Press.

Raphael, B. and Wilson, J.P.

(Eds.) (2000). Psychological

Debriefing: Theory, Practice, and

Evidence. Cambridge:

University Press.

Sitterle, K. A. and Gurwitch, R.

H. (1999). The terrorist

bombing in Oklahoma City. In

Zinner E. S., and Williams M.

B. (Eds.), When a Community

Weeps: Case Studies in Group

Survivorship (pp. 161-189).

Philadelphia: Brunner/Mazel.

Stroebe, M. S., Stroebe, W.,

and Henk, S. (Eds.). (2001).

Handbook of Bereavement

Research: Consequences,

Coping, and Care. Washington,

DC: American Psychological

Association.

66 • Mental Health Response to Mass Violence and Terrorism
U. S. Department of Justice.

(1999). Attorney General

Guidelines for Victim and

Witness Assistance.

Washington, DC. 

van der Kolk, B. A., McFarlane,

A. C., and Weisaeth, L. (1996).

Traumatic Stress: The Effects of

Overwhelming Experience on

the Mind, Body, and Society.

New York: Guilford.

Vernberg, E. M. and Vogel, J.

M. (1993). Interventions with

children after disasters. Journal

of Clinical Child Psychiatry 22(4)

485-498.

Wilson, J. P. and Keane, T. M.

(Eds.) (1997). Assessing

Psychological Trauma and

PTSD. New York: Guilford.

Young, B. H., Ford, J. D., Ruzek,

et al. (1998). Disaster Mental

Health Services: A Guidebook

for Clinicians and Administrators. Menlo Park, CA:

Department of Veteran Affairs.

Chapter III: Mental Health Intervention • 67
68 • Mental Health Response to Mass Violence and Terrorism

Following a mass casualty

criminal incident, emergency

response priorities involve

saving lives, protecting the

safety of first responders,

securing the crime scene, and

initiating investigation

activities. The mental health

response must not interfere

with these priorities. Mental

health providers often are

unfamiliar with the unique

demands associated with

responding to criminal mass

victimization. 

In particular, mental health

responders must be oriented

to three critical aspects of

emergency operations: (1) the

incident command structure

and the position and function

of mental health in that

structure; (2) first responder

immediate response priorities

following a mass casualty

incident; and (3) the role and

boundaries of the mental

health response in an ongoing

criminal investigation.

Preplanning, training on

response protocols, and preestablishing relationships and

channels of communication

are essential for effective

integration of mental health

services into the overall

emergency response.

States vary in their levels of

emergency mental health

preparedness. States are

working toward clearly

defined and practiced plans

that involve coordination

between the Department of

CHAPTER IV

ORGANIZATIONAL PREPARATION

AND RESPONSE TO MASS

VIOLENCE AND TERRORISM AND

THE MENTAL HEALTH ROLE
Emergency Management

(DEM), the Department of

Mental Health (DMH), law

enforcement agencies, and the

crime victim assistance and

compensation agency at the

State level. They also are

coordinating with the

necessary county and local

mental health response plans

and cadres of trained

providers. This degree of

planning and preparedness

requires a high level of

commitment, funding, a State

mandate, and repeated

training and drills. This

process helps ensure that

appropriately trained mental

health providers are available

to respond and provide mutual

aid of mental health services

following community crises.

The community’s emergency

response must be carried out

in a protocol-driven and

efficient manner. This saves

lives. Mental health responders

must understand that they are

part of the larger organizational structure. During the

emergency response phase,

mental health workers have a

support role and operate in

settings and circumstances

controlled by other entities. 

Emergency

Operations

The scope, complexity, and

nature of an incident

determine the level of

emergency response. The local

jurisdiction responds initially,

but large-scale mass casualty

incidents often require a multicounty response, a State

response, or a Federal

response. Many communities

use the Incident Command

System (ICS) structure or a

locally determined variation to

organize and manage the

emergency response. The ICS

is a standardized approach for

commanding, controlling, and

coordinating the response to

all types and sizes of

emergency incidents. 

An effective ICS structure

includes common terminology,

integrated communication, a

top-down organizational

structure, and comprehensive

resource management. This

standardization helps expand

the incident response when

the demands of the emergency

situation exceed available

resources. Figure 3, the first

organizational chart, illustrates

the ICS. Figure 4 shows the ICS

with a Unified Command (UC)

with police, fire, and

Emergency Medical Services

(EMS) in charge. A mass

casualty incident would

necessitate this type of

structure (Federal Emergency

Management Agency, 1998).

The Incident Commander, the

first senior emergency

responder to arrive at the

scene, is responsible for

protecting life and property

and implementing the

response plan. The Incident

Commander is accountable for

both first responder and public

safety. Command can be

transferred as an incident

becomes more complex and as

the responsible agency

jurisdiction changes. Authority

may shift as the cause of the

incident becomes clearer. For

example, the local fire chief

may respond to an explosion

and be the Incident

Commander. 

At the local level, the Police

and Sheriff’s departments,

Emergency Medical Services

(EMS), Urban Search and

Rescue, the Fire Department,

the Medical Examiner’s Office,

the Department of Emergency

Management, and the

American Red Cross may have

high-profile roles (Federal

Emergency Management

Agency, 1998). If an incident is

human-caused, jurisdiction

may shift or expand to include

State law enforcement. If it is

determined to be an act of

terrorism, authority shifts to

the Federal Bureau of

Investigation (FBI) (United

States Government, 2001). The

FBI has a law enforcement

function and oversees

technical activities such as

forensics, intelligence, negotiations, and the investigation.

As shown in Figures 3 and 4,

four functional components

support incident management:

Chapter IV: Organizational Preparation and Response to Mass Violence and Terrorism • 69

And the Mental Health Role
70 • Mental Health Response to Mass Violence and Terrorism

Safety 

Officer

Planning/Intel

Section

Fire Service 

Branch

Fire

Rescue

HAZMAT

Security 

Group JTTF

NOC

TOC

Air Mission

Group

Aviation

Support 

Group

Aviation

HMRU

FBI ERT

Situations

Unit Personnel

Staging

Supply

Food

Compensation/

Claims Unit

Unified

Command

(Police, Fire, EMS, FBI)

Forward

Coordinating

Team

Liaison

Officer

Command

Post Scribe

Public 

Information

Officer

Operations

Section

Logistics

Section

Finance/Admin

Section

Law 

Enforcement

Branch

FBI Crisis

Management

Branch

Air Ops

Branch

Medical 

Services

Branch

Evacuation 

Group

Traffic 

Control 

Group

Tactical 

Group

Civil

Disorder 

Group

Medical 

Response 

Group

Crisis 

Negotiation 

Team

Technical

Specialists

Investigations

Unit

 Demobilization

Unit

Documentation

Unit

Resource

Unit

Time

Unit

Procurement

Unit

F IGURE 3: I NCIDENT C OMMAND S YSTEM (ICS) O RGANIZATIONAL C OMPONENTS

FIGURE 3: ON-SCENE COORDINATION—THE FBI, POLICE, FIRE, AND EMS

United States Government (2001), Interagency Domestic Terrorism Concept of Operations Plan

Note: Operational control of assets at

the scene is retained by the designated

officials representing the agency (local,

State, or Federal) providing the assets.

FBI Acronym Key

HMRU– Hazardous Materials Response Unit

JTTF– Joint Terrorism Task Force

FBI ERT– FBI Evidence Response Team

TOC– Tactical Operations Center

NOC– Negotiations Operations Center
planning, operations, logistics,

and finance/administration.

These components are the

foundation upon which the ICS

is built and apply to routine

emergencies as well as to

mass casualty incidents. The

ICS operates at an Incident

Command Post located near

the site of the incident. The

Operations Section Chief or

Logistics Section Chief may

request mental health services,

and chaplaincy services for

emergency responders

at the staging area, a

respite area, or as they

end shifts. Mental

health services may be

requested for families

and loved ones

gathering near the

disaster impact zone,

which is also a crime

scene. Initially, when

crisis mental health

response plans are not

in place, these services

usually are provided by

mental health professionals, or chaplains

affiliated with the local

Fire and Police

Departments. In States

prepared with an

integrated crisis mental

health plan, providers

from the local mental

health agency may

respond to the scene.

In the future, “crisis

mental health” or

“victim services” may

become a recognized

and established

component within the

Operations Section of the 

ICS for incidents involving

criminal mass victimization 

(B. Hammond, personal

communication, 7/30/01).

Crisis Mental

Health Response 

The Incident Commander is

responsible for the on-scene

response. When there are

multiple sites of impact or a

need for a more communitywide response, an Emergency

Operations Center (EOC)

typically is set up by the local

or State Department of

Emergency Management

(DEM). The EOC is where

department heads, government

officials, and volunteer

agencies gather to coordinate

the larger community

response. The Incident

Commander establishes and

maintains liaisons with

primary responding agencies

and organizations, including

the EOC. At the EOC, the

public health or human

services functions have

jurisdiction over mental health

services for the public. The

DMH may be requested to

manage the delivery of mental

health services at particular

sites. Depending on the State’s

level of preparedness, the

DMH may or may not be able

to respond to the request. 

Voluntary agencies such as the

American Red Cross (ARC) are

often represented at the EOC.

The ARC usually has responsibility for mass care, including

feeding and sheltering victims.

The ARC disaster mental

health function is activated

following mass casualty

incidents. ARC disaster mental

health services (DMHS)

personnel quickly arrive onscene to provide mental health

support for victims and family

members and to provide stress

Section

Chief

Division/Sector/

Group

Supervisor

Branch

Director

Unit/Task Force/

Strike Team

Leader

Incident

Commander

F IGURE 4: 

ICS U NIFIED C OMMAND

Chapter IV: Organizational Preparation and Response to Mass Violence and Terrorism • 71

And the Mental Health Role
72 • Mental Health Response to Mass Violence and Terrorism

management services for other

ARC staff and volunteers.

Local mental health providers

initially may volunteer through

ARC or provide services under

other auspices. Coordination

between ARC disaster mental

health services providers, the

State’s mental health workers,

and responding crime victim

assistance providers is

essential.

An excerpt from the Federal

Emergency Management

Agency (FEMA) After Action

Report from the Oklahoma City

bombing demonstrates this

collaboration and partnering:

The American Red Cross

(ARC), which is responsible

for immediate protective

measures for disaster

victims, worked in concert

with local clergy and other

support groups to establish

the Family Notification

Center, also known as the

Compassion Center. For two

weeks, 250 mental health

professionals volunteered

their expertise in support of

the shocked and griefstricken community. The

center provided victim

information, crisis

counseling, and resource

information at one location

to better assist victims’

families and friends.

(Federal Emergency

Management Agency, 1995)

Similarly, in New York City

following the September 11

terrorist attacks, the Mayor’s

Office established the Family

Assistance Center for families

of victims, survivors, and

others affected by the attacks.

Numerous Federal, State, and

city agencies; insurance

companies; legal assistance

resources; World Trade Center

companies; and voluntary

agencies were represented. 

Mental health, crime victims

services, therapeutic child

care, translation services,

spiritual care, and disaster

psychiatry services were

available. Hundreds of

providers worked under the

auspices of the State Office of

Mental Health, ARC, the State

Crime Victims Compensation

Board, local crime victim

assistance programs, and

Disaster Psychiatry Outreach.

All providers had special

identification (ID) for access to

the Family Assistance Center.

Managing the outpouring of

volunteers wanting to provide

mental health support has

become a challenge following

recent mass casualty incidents

(Center for Mental Health

Services, 2000b). When local

planning and preparatory

mental health training have

not taken place, the genuine

need for mental health

services will remain unmet 

COORDINATION 

BETWEEN ARC DISASTER 

MENTAL HEALTH SERVICES

PROVIDERS, THE STATE’S

MENTAL HEALTH 

WORKERS, AND 

RESPONDING CRIME 

VICTIM ASSISTANCE 

PROVIDERS IS 

ESSENTIAL.
Chapter IV: Organizational Preparation and Response to Mass Violence and Terrorism • 73

And the Mental Health Role

until these mental health

volunteers are screened,

oriented, and integrated into

the emergency response.

Systems must quickly be

established to: track mental

health provider contact

information, availability,

relevant professional

experience, and areas of

specialization; check

credentials; schedule; and

provide ID badges. No

individual should be allowed to

provide mental health services

without proper identification,

authorization, and orientation.

To avoid the need to develop

and implement systems under

emergency conditions,

communities are advised to

develop systems before a

disaster occurs.

In many parts of the country,

the immediate mental health

response often occurs in a

crisis-driven manner, drawing

from resources that happen to

be available or from invited

“experts” who are flown in for

several days or weeks. The

ARC may bring in hundreds of

trained disaster mental health

volunteers over a period of

weeks or months, but

eventually the local mental

health system assumes

responsibility for mental health

services. 

Key

Considerations

For Mental

Health Providers

Responding to

Criminal Mass

Violence

Mental health providers must

be knowledgeable about the

issues unique to responding to

a mass criminal event.

Emergency responders face

unfamiliar circumstances,

uncertainty about what might

happen next, and lack of

precedence on how best to

respond. Operational decisions

with far-reaching

consequences must be made

rapidly and often with partial

information. Mental health

workers need to recognize the

larger context and conscientiously follow guidelines set

forth by the mental health

response manager and the

Incident Commander. The

following parameters provide

further guidance for mental

health responders:

◆ The Incident Commander

is in charge and directs

when and where mental

health services are

provided. The mental

health response is

subordinate to the

emergency response, the

goals of law enforcement,

and the criminal investigation process. Mental

health responders provide

emotional support,

stabilization, and

assistance as directed by

the Incident Commander.

In most instances, victims

and witnesses initially are

interviewed by investigators before they can

speak with mental health

providers. Frequently,

mental health providers

are first assigned to work

with worried and frantic

loved ones at the crime

scene;

◆ Securing and protecting

the crime scene are law

enforcement priorities. The

scene of the incident

automatically becomes a

crime scene and the focus

of a criminal investigation.

Anything contained within

this “crime scene” area

may be evidence.

Evidence must not be

disturbed before it has

been documented and

collected, thus necessitating tight security and

control by law

enforcement officials (e.g.,

the FBI, National Guard,

local police officers).

Unauthorized passage

through a secured area

could jeopardize the

safety of emergency

workers and mental

health workers. 

Mental health responders

and victims’ loved ones do
not have access to the

crime scene and are

frequently directed to a

nearby site. This may

cause distress for family

members who want to

help locate and rescue

their loved ones. Mental

health responders may be

asked to help distraught

family members at a

gathering site or hospital.

Mental health workers

must remain within the

geographic boundaries of

their assignments and

have appropriate identification and legitimate

assignments for access to

protected areas;

◆ Information regarding the

status of victims is

released by designated

government officials

through sanctioned

channels. Through the

course of coordinating

with emergency

responders, law

enforcement, or the

Incident Commander,

mental health providers

may learn the status of

individual victims—

whether they were killed,

injured, or missing.

Families are desperate for

this information. However,

it is outside of the mental

health responder’s role to

deliver this information to

families, the media, or

anyone else before it has

been officially verified and

formally provided. This

can be a challenging and

stressful position for

mental health providers

(R. Benedetto, D.P.A.,

personal communication,

7/31/01). In fact, mental

health providers may

choose to avoid seeking

this information before

official family notification

or only receive it as a part

of briefing for their

immediate support role

with a particular family;

◆ Mental health providers

must work within

established protocols for

dealing with the media to

protect survivors and

families. Catastrophic

mass casualty disasters

attract considerable media

attention. Typically,

reporters seek interviews

with victims and those

most seriously affected.

They may approach

mental health providers to

gain access to victims.

Mental health responders

should not act as agents

for the media, and recruit

or coach victims. Also,

mental health providers

should avoid describing

how first responders,

victims, and family

members are reacting

when giving media

interviews, which can give

the appearance of a

violation of confidentiality

and might undermine the

credibility of mental

health efforts. The mental

health response manager

coordinates with the

Incident Commander to

clarify protocols and to

ensure that adequate

security and protection

from the media is

provided for survivors and

bereaved family members. 

In addition, the mental

health response manager

works with the ICS Public

Information Officer to

ensure appropriate mental

health information is

provided to the public.

Using the media to

disseminate helpful

mental health information

is a valuable way to reach

large numbers of people.

Under no circumstances

should mental health

responders provide

information to the media

without prior authorization sanctioned by the

agency or organization of

which they are a part; and 

◆ Conflicts may arise

between law enforcement’s

search for information

relevant to the criminal

investigation and the

prosecutorial process and

mental health’s protection

of client confidentiality.

Pre-incident planning,

coordination, communication, and cross-training

between law enforcement

and mental health

74 • Mental Health Response to Mass Violence and Terrorism
providers can alleviate turf

battles regarding roles and

boundaries (B. Hammond,

personal communication,

7/30/01). Teamwork and

cooperation are fostered

through a respectful

understanding of each

group’s responsibilities

and obligations. Mental

health providers are not

trained to be detectives or

to know what information

is relevant to the investigation process, yet they

may counsel witnesses or

suspects. They have a

legal and ethical duty to

protect the privacy of

those with whom they

speak. Mental health goals

are to stabilize survivors’

emotional reactivity and

to facilitate appropriate

coping, which also may

enable survivors and

family members to

participate more helpfully

in the investigative

process.

Mental health providers should

consult first with their clinical

supervisor or the mental

health response manager with

questions regarding whether

information gained through a

counseling contact has

relevance to the criminal

investigation (R. Benedetto,

D.P.A., personal communication, 7/31/01). A determination may be made for the

worker to maintain confidentiality and to trust that the

criminal investigative process

will uncover the information,

or the mental health response

manager may consult with the

agency’s legal counsel or the

State’s attorney. Ideally, the

mental health response

manager and the Incident

Commander have a

cooperative alliance for sorting

out these inevitable

challenging dilemmas.

Crisis Mental

Health

Response:

Future Directions

Every community should have

a Crisis Mental Health Plan as

part of its overall Emergency

Operations Plan. Local mental

health providers are pretrained

and their job descriptions

include responding to the

psychological needs of first

responders and community

members during and after

community crises. Crisis

mental health responders may

be drawn from community

mental health centers, crime

victim assistance programs,

faith-based counseling

agencies, and social service

agencies that serve special

populations. While involving

mental health professionals as

volunteer responders adds

depth to human resources, the

community’s crisis mental

health plan should not rely on

volunteers only. Management

and supervision positions, in

particular, should be filled by

Chapter IV: Organizational Preparation and Response to Mass Violence and Terrorism • 75

And the Mental Health Role

EVERY COMMUNITY 

SHOULD HAVE A CRISIS 

MENTAL HEALTH PLAN 

AS PART OF ITS OVERALL 

EMERGENCY OPERATIONS 

PLAN.
individuals whose job

descriptions include these

responsibilities. In addition,

responders should be prepared

to step into the community’s

ICS and EOC structures and

have prior relationships with

the key players.

The crisis mental health plan

fits more effectively into the

overall emergency response

when the ICS management

structure is used. An On-Site

Commander functions as the

mental health response

manager and stays at the

Incident Command Post or the

EOC, coordinates with other

responding entities, receives

information from the field, and

manages and directs the

mental health response and

resources. A Personnel

Coordinator must be activated

quickly to facilitate callout and

deployment of mental health

personnel. Depending on the

magnitude of the incident and

the degree of mental health

preparedness of the

community, the response

structure may range from

paralleling the ICS to providing

limited mental health support

at designated sites. At a

minimum, each site should

have a Coordinator, and every

five mental health responders

should have a Lead. The City

of Austin Mental Health Crisis

and Disaster Plan provides an

example of a plan that utilizes

the ICS structure and is

integrated into the local

emergency response and the

crime victim services agency

(see Recommended Reading at

end of this chapter). While

specific descriptions of

comprehensive crisis mental

health plans are beyond the

scope of this manual, the

following components

generally are addressed:

◆ Training and guidelines

for crisis mental health

interventions;

◆ Descriptions of

assignment settings and

mental health roles;

◆ Callout, deployment,

human resource

management;

◆ Certification and badging

for responders;

◆ ICS and EOC structure,

responsibilities, and the

role of mental health;

◆ Mental health response

management, supervision,

and line-staff roles and

responsibilities defined;

◆ Services to special

populations, use of

interpreters, guidelines,

and resources;

◆ Communications,

transportation, supplies,

and logistics;

◆ Public information and

dealing with the media;

◆ Mutual aid agreements;

and 

◆ Mental health staff stress

management.

Every State Mental Health

Authority (SMHA) should have

a federally funded full-time

position for disaster mental

health planning and response

and a State disaster mental

health plan (Center for Mental

Health Services, 2000b;

American Psychological

Association Task Force, 1997).

The State disaster mental

health coordinators’ responsibilities typically include: (1)

ensuring that all counties have

plans and participate in drills;

(2) providing repeat training on

disaster mental health for all

counties; (3) maintaining a

resource bank of post-disaster

psycho-educational materials;

(4) maintaining cooperative

relationships with State,

Federal, and voluntary

agencies involved in

emergency and disaster

response; and (5) helping

counties obtain Federal grants

for post-disaster mental health

services.

Long-Term

Mental Health

And Crime Victim

Assistance

Services

The Office for Victims of Crime

(OVC) has authority to provide

assistance to victims of acts of

terrorism or mass violence.

Since victims of terrorism and

mass violence experience a

76 • Mental Health Response to Mass Violence and Terrorism
range of physical, financial,

emotional, and legal needs

that may persist over an

extended period of time (Office

for Victims of Crime, 2000),

Federal funding that

supplements existing State

resources is available. OVC

assistance includes funding for

counseling, community needs

assessment, crime victim

services, and technical

assistance and training. State

crime victim compensation

programs reimburse crime

victims or their families for

out-of-pocket expenses such

as medical expenses, mental

health counseling, funeral and

burial costs, and lost wages

related to their victimization.

State and local victim service

agencies provide assistance to

victims of Federal and State

crimes such as criminal justice

advocacy, temporary shelter,

and crisis counseling (U.S.

Department of Justice, 2001).

Eligibility and benefits vary

from State to State, and may

change with the particular

terrorist or mass violence

event, so mental health

providers and others working

with victims should learn

about Federal and State

eligibility requirements. OVC

coordinates with local and

State programs to maximize

services for victims. For

information about OVC grant

programs, see the OVC

Resource Center Web site at

www.ncjrs.org or call 1-800-

851-3420.

Recommended

Reading

American Psychological

Association Task Force. (1997).

The Task Force on the Mental

Health Response to the

Oklahoma City Bombing:

Implications for Future Mass

Casualty and Terrorist Incidents.

Prepared for the American

Psychological Association.

Center for Mental Health

Services. (2000). HumanCaused Disasters:

Recommendations for the Crisis

Counseling Assistance and

Training Program. Rockville,

MD: Substance Abuse and

Mental Health Services

Administration. (Not available

to the public)

City of Austin (Texas). (2001).

Mental Health Crisis and

Disaster Plan: A Component of

Annex-O-Human Services.

Austin/Travis County

Emergency Operations Plan.

Federal Emergency

Management Agency. (1995).

Report of the FEMA EM 3115,

DR-1048 Review. Oklahoma

City, OK.

Federal Emergency

Management Agency,

Emergency Management

Institute. (1998). Basic Incident

Command System (ICS)

Independent Study. Available:

www.fema.gov.

United States Government.

(2001). Interagency Domestic

Terrorism Concept of Operations

Plan. Available:

www.fema.gov.

U.S. Department of Justice.

(1999). Attorney General

Guidelines for Victim and

Witness Assistance.

Washington, DC. 

U.S. Department of Justice,

Office for Victims of Crime.

(1999). Criminal Crisis Response

Initiative (CCRI). Available:

www.jijs.org/ccri/index.htm.

U.S. Department of Justice.

(2001). Antiterrorism and

Emergency Fund Guidelines for

Terrorism and Mass Violence

Crimes. Federal Register,

66(63), 17577-17583.

Chapter IV: Organizational Preparation and Response to Mass Violence and Terrorism • 77

And the Mental Health Role
78 • Mental Health Response to Mass Violence and Terrorism

When mental health professionals, crime victim

assistance counselors, and

other responder groups come

forward to assist survivors

following mass violence and

terrorism, they experience the

rewards associated with

meaningful service and cope

with a range of challenging

stressors. The devastating

losses, deaths and injuries,

destruction of property, and

emotional pain of survivors

and bereaved loved ones can

touch providers in powerful

and personal ways. The

emergency response working

environment can involve

physical hardship, unclear

roles and responsibilities,

limited resources, rapidly

changing priorities, intrusive

media attention, and long

work hours. When an ongoing

threat of future attacks or

potential exposure to

biohazards exist, workers

cope with risks and threats to

their own safety while helping

others.

Despite the inevitable stresses

and challenges associated

with community crisis

response, workers experience

personal gratification by using

their skills and training to

assist fellow humans in need.

Active engagement in the

disaster response and “doing”

for others can be an antidote

for feelings of vulnerability,

powerlessness, and outrage

commonly experienced by

CHAPTER V

STRESS PREVENTION,

MANAGEMENT, AND

INTERVENTION
nonimpacted community

members. Witnessing the

courage and resilience of the

human spirit and the power of

human kindness can have

profound and lasting effects.

Mental health providers may

work for several intense weeks

as part of the immediate

response and then return to

their former jobs and lives.

They may be local community

members, or from other

counties in the State providing

mutual aid, or have flown in

from other parts of the country

as volunteers or paid

consultants. Others may

continue working for several

years as mental health and

crime victim services programs

are developed, funded, and

implemented. New staff may

join the mental health

response as formal

intervention programs become

funded and operational

months after the disaster. Each

scenario presents the worker

with distinct stress-related

challenges and may expose to

the mental health response

manager potential targets for

stress management

interventions.

This chapter discusses factors

that contribute to worker

stress and provides strategies

for stress prevention and

management. In counseling

and assistance programs that

continue for months, and even

years, mental health providers

counsel survivors and family

members suffering significant

psychological difficulties

related to their trauma and

losses. Mental health response

managers must implement

systems for clinical training,

supervision, and case consultation to ensure high quality,

appropriate mental health

services and to mitigate the

inevitable stress associated

with this work. The end of the

chapter includes a list of signs

and symptoms of worker

stress.

Sources of

Stress

Mental health worker stress

results from the interaction of

three factors: (1) the amount of

exposure to trauma; (2)

environmental factors such as

working conditions and

management practices; and (3)

individual factors including the

worker’s perceptions, personal

coping and stress reduction

practices, personality, and

applicable training and

experience. 

For example, high exposure

assignments may involve

participating in death notifications, accompanying and

supporting families at

morgues, supporting families

as they provide DNA samples,

viewing physical injuries and

mutilation, counseling families

who are planning funerals with

no physical remains or formal

death notification, supporting

family members who are

waiting for rescue and

recovery information, and

ongoing bereavement

counseling following the

traumatic death of a loved one.

These assignments can be

particularly challenging when

prior professional roles have

not included similar activities. 

Inevitably, a criminal mass

casualty event is experienced

personally to some degree by

all who reside in the targeted

community. Mental health

responders, who also are

residents of the impacted

community, may have been

personally affected, may know

victims, or may be touched

through acquaintance

networks. These individuals

are at risk for stress reactions

and should be assessed,

monitored, and supported by

their immediate supervisors.

Mental health providers and

crime victim assistance

counselors often are drawn to

their professions from a desire

to help people. This altruism

and dedication to making a

positive difference in people’s

lives, while valuable qualities,

can contribute to unrealistic

expectations or frustration

with “interfering” policies.

Altruism run amok may lead to

taking on too many responsibilities, ignoring professional

boundaries, and working

beyond physical, psychological, and training limits.

Responders, especially those

Chapter V: Stress Prevention, Management, and Intervention • 79
80 • Mental Health Response to Mass Violence and Terrorism

who are inexperienced, face a

particularly high risk of

damaging over-involvement

following mass violence and

terrorism because of the

powerful feelings evoked.

The terms “compassion

fatigue” (Figley, 2001; 1995),

“vicarious traumatization”

(Pearlman and Saakvitne,

1995), and “empathic strain”

(Wilson and Lindy, 1994)

describe the gradual psychological and physical erosion

that can occur when mental

health providers become

overloaded with traumatic

material, and their usual

professional management and

personal coping strategies

begin to falter. As mental

health workers’ relationships

with survivors and bereaved

families deepen, the possibility

for over-identification and

over-involvement increases.

Over time, mental health

providers are more likely to

encounter their own

unresolved losses or traumatic

experiences which can

interfere with therapeutic

effectiveness and lead to

added stress.

Stress

Prevention,

Management,

And Intervention

Effective mental health

response managers and

supervisors are well informed

about the factors associated

with worker stress and

integrate a range of administrative controls and stress

management strategies. Under

the intense working conditions

that are inevitable following

criminal mass violence,

supervisors and managers

must assume shared responsibility for promoting a positive

and healthy work

environment, and not rely

exclusively on workers’

initiating their own self-care

practices.

A proactive stress

management plan focuses

both on the environment and

the individual. Providers feel

valued and supported when

stress prevention and

management strategies are

built into mental health

operations and the organizational culture. 

Environmental Context

A clear organizational

structure with defined roles

and responsibilities for linestaff responders, leads,

supervisors, and managers

reduces the potential for staff

stress (Quick et al., 1997).

Research with first responders

has shown that training and

preparation helps reduce onthe-job stress (Ursano, et al.,

1996). Consistent adherence to

administrative controls, such

as limiting shifts to no more

than 12 hours and rotating

between high, mid, and lowstress tasks promotes occupational health. Pre-event

training in high-stress tasks

contributes to a more prepared

mental health work force.

While guidelines may be

difficult to put in place during

the first week after a mass

casualty incident when

resources are likely to be

overwhelmed, managers

should aim for them as quickly

as possible.

Team support also is a critical

stress-reducer. The mental

health response manager and

supervisors are role models. If

they do not observe the stress

management practices that

they recommend for staff, their

efforts may lack credibility.

Managers should address the

following dimensions when

designing a mental health

response that prioritizes

environmental and organizational health:

◆ Effective management

structure and leadership;

◆ Clear purpose, goals, and

training;

◆ Functionally defined roles;

◆ Administrative controls;

◆ Team support; and 

◆ Plan for stress

management.

Table 4 provides strategies that

address these six dimensions.

Many suggestions for the

immediate response time

frame are applicable for the
E NVIRONMENTAL AND O RGANIZATIONAL A PPROACHES FOR

S TRESS P REVENTION AND M ANAGEMENT

T ABLE 4: 

Immediate Response

• Clear chain of command and reporting

relationships

• Available and accessible leaders and clinical

supervisors

• Use of managers experienced in

emergency response and community

trauma

• Clearly defined intervention goals and

strategies appropriate to different

assignment settings (e.g., crisis intervention,

psychological debriefing)

• Training and orientation provided for all MH

workers

• Staff oriented and trained with written role

descriptions for each assignment setting as

part of preparedness plan

• When setting is under the jurisdiction of

another agency (e.g., Mayor’s Office,

Medical Examiner’s Office, American Red

Cross), staff informed of MH role, contact

people, and mutual expectations

• Shifts no longer than 12 hours, with 12

hours off

• Rotation between high, mid, and low-stress

tasks

• Breaks and time away from the assignment encouraged and required when

necessary 

• Necessary supplies available (e.g., paper,

forms, pens, educational materials)

• Communication tools available (e.g., cell

phones, radios)

Long-Term Response

• Full-time disaster and crime victim

assistance-trained supervisors and

program manager with demonstrated

management and supervisory skills

• Clinical supervisors and consultants

experienced in content areas and trained in

MH response to community trauma

• Clear and functional organizational

structure

• Program direction and accomplishments

reviewed and modified as needed

• Community needs, focus, and scope of

program defined

• Periodic assessment of service targets and

strategies

• In-service training on current recovery

topics

• Staff trained and supervised to define limits,

make referrals

• Feedback provided to staff on program

accomplishments, numbers of 

contacts, etc.

• Job descriptions and expectations for all

positions

• Participating crime victim services’ and

recovery agencies’ roles defined and

working relationships with key agency

contacts maintained

• Limits on working more than 40

hours/week

• Two consecutive days off and vacation

time required

• Limits on and rotation from high-exposure

duties (e.g., groups with bereaved parents,

trauma counseling)

Continued on next page

Dimension

Effective

Management

Structure and

Leadership

Clear Purpose,

Goals, and

Training

Functionally

Defined Roles

Administrative

Controls

Chapter V: Stress Prevention, Management, and Intervention • 81
long-term response

as well. Some approaches

eliminate potential stressors,

while others minimize the

effects of unavoidable

stressors. Mental health

planners and managers must

adapt the following to their

own locale, resources, and

disaster.

Many of these principles were

applied at the Compassion

Center (the family gathering

site) in Oklahoma City

following the Alfred P. Murrah

building bombing, and at the

Family Assistance Center in

New York City following the

World Trade Center terrorist

attacks. At the Compassion

Center, a stress management

team focused exclusively on

the needs of mental health

workers and volunteers

(Sitterle and Gurwitch, 1999).

“Defusing” sessions, which

consisted of 20–25 minute,

structured conversations about

distressing aspects of the

assignment followed by

psycho-education, were

required for workers at the end

of every shift. Mental health

professionals participated in

no more than two death notifications during a shift, four

notifications in total, and

attended defusing sessions

after each notification. Stress

management information was

readily provided and available.

Mental health professionals

were available for consultation

and support on an informal,

individual basis and more

formally when needed. The

long-term response program,

Project Heartland, contracted

with an area psychologist to

82 • Mental Health Response to Mass Violence and Terrorism

E NVIRONMENTAL AND O RGANIZATIONAL A PPROACHES FOR

S TRESS P REVENTION AND M ANAGEMENT

T ABLE 4: 

Immediate Response

• Buddy system for support and monitoring

stress reactions

• Positive atmosphere of support, mutual

respect, and tolerance with “thank you” and

“good job” said often

• Attention to workers’ functioning and stress

management

• Supervisors “float through” work areas to

observe signs of stress

• Education about signs and symptoms of

worker stress and coping strategies

• Individual and group support, defusing, and

debriefing provided

• Exit plan for workers leaving the operation:

debriefing, re-entry information, opportunity

to critique, and formal recognition for

service

Long-Term Response

• Team approach that avoids a program

design with isolated workers from separate

agencies

• Informal and formal case consultation,

problem-solving, and resource sharing 

• Regular, effective meetings with productive

agendas, personal sharing, and creative

program development

• Clinical consultation and supervision

processes built on trust, safety, and respect

• Ongoing education and workshops

regarding long-term stresses of disaster

MH work and methods for self-monitoring

and intervention

• Comprehensive plan for environmental,

organizational, and individual approaches

and implementation timeline

• Plan for regular stress interventions at work

and meetings (see Table 5)

• Confidential individual counseling available

for work-related issues

• Extensive program phase-down plan:

timelines, debriefing, critique, formal

recognition, celebration, and assistance

with job searches

Dimension

Team Support

Plan for

Stress

Management

Continued from previous page
provide group debriefing and

psychological support sessions

with staff and confidential

individual counseling for selfreferring staff members.

At the Family Assistance

Center, mental health workers

were divided into teams

assigned to different areas and

functions within the center.

Another team supported

families and victims on the

buses as they were brought to

the center. Each team leader

oriented and monitored their

mental health providers,

ensured that they took breaks

and had meals, and provided

support and consultation as

providers engaged in difficult

and distressing situations. 

Participation in high-stress

assignments such as

accompanying families to

Ground Zero and intensive

contacts with distraught,

grieving families was limited,

and workers rotated into

lower-stress activities. Shifts

were limited to 10 hours;

taking a day off every seven

days was required. Mental

health professionals were

designated to address mental

health and other staff stress

issues and to provide support,

defusings, and debriefings.

Individual Context

Entering a chaotic setting and

providing mental health

services to victims and family

members immediately after a

mass violent and highly

traumatizing incident is likely

to stimulate anxiety,

adrenalized responses, and the

intense desire to be helpful.

While few would question that

psychologically healthy and

well-balanced individuals are

best equipped to implement

and maintain an effective

mental health response, it can

be challenging to function

within a balanced range,

especially during the initial

stages of response. Mental

health response planners and

managers need to build in a

range of supports and

interventions that are

appropriate to their workers’

needs and personal styles. In

addition, workers must

assume personal responsibility

for taking care of themselves,

to remain effective and not

impose burdens on others.

Asking for help and support

should be encouraged and

validated.

As the community’s mental

health needs change over time,

so, too will workers’ stress

management intervention

needs. The individual

component of a staff stress

management program should

address:

◆ Management of workload;

◆ Balanced lifestyle;

◆ Strategies for stress

reduction; and 

◆ Self awareness.

Table 5 provides practical

suggestions. Immediate

response suggestions apply to

the long-term response as

well. Involving staff in defining

program norms and

developing program-wide

stress management practices

encourages ownership and

follow-through, and builds a

basis for team support.

Compassion

Fatigue and

Secondary

Traumatization

National experts experienced

in the mental health response

to acts of mass violence and

terrorism emphasize the need

for systematic and comprehensive stress management

with mental health staff

(Center for Mental Health

Services, 2001). The stressors

associated with dealing with

mass criminal victimization

and mass casualties are

intense and long lasting. Like

other responder groups,

mental health providers risk

becoming secondary victims of

the crime and its aftermath.

Mental health response

managers must evaluate how

long mental health workers

should remain in highexposure roles and whether

certain assignments should be

time-limited.

Chapter V: Stress Prevention, Management, and Intervention • 83
84 • Mental Health Response to Mass Violence and Terrorism

I NDIVIDUAL A PPROACHES F O R S TRESS P REVENTION AND

M ANAGEMENT

Immediate Response

• Clarification with immediate on-site supervisor

regarding task priority levels and work plan

• Recognition that “not having enough to do” or

“waiting” is an expected part of crisis mental health

response

• Existing “regular” workload delegated so workers

do not attempt disaster response plus usual job

• Nutritional eating and hydration, avoidance of

excessive junk food, caffeine, alcohol, or tobacco

• Adequate sleep and rest, especially on longer

assignments

• Physical exercise and gentle muscle stretching

when possible

• Contact and connection maintained with primary

social supports

• Reducing physical tension by using familiar

personal strategies (e.g., taking deep breaths,

washing face and hands, meditation, relaxation

techniques)

• Using time off to “decompress” and “recharge

batteries” (e.g., getting a good meal, watching TV,

shooting pool, reading a novel, listening to music,

taking a bath, talking to family)

• Talking about emotions and reactions with

coworkers during appropriate times

• Early warning signs for stress reactions recognized

and heeded (see “Signs and Symptoms” section)

• Acceptance that one may not be able to selfassess problematic stress reactions

• Over-identification with or feeling overwhelmed by

victims’ and families’ grief and trauma may result in

avoiding discussing painful material

• Trauma overload and prolonged empathic

engagement may result in vicarious traumatization

or compassion fatigue (Figley, 2001, 1995;

Pearlman, 1995)

Long-Term Response

• Planning, time management, and avoidance of

work overload (e.g., “work smarter, not harder”)

• Periodic review of program goals and activities to

meet stated goals 

• Periodic review to determine feasibility of program

scope with human resources available

• Family and social connections maintained away

from program

• Exercise, recreational activities, hobbies, or spiritual

pursuits maintained (or begun)

• Healthy nutritional habits pursued

• Over-investment in work discouraged

• Cognitive strategies employed (e.g., constructive

self-talk, restructuring distortions) 

• Relaxation techniques (e.g., yoga, meditation,

guided imagery) explored

• Pacing self between low and high-stress activities,

and between providing services alone and with

support

• Talking with coworkers, friends, family, or counselor

about emotions and reactions

• Exploration of motivations for helping (e.g.,

personal gratification, feeling needed, personal

history with victimization or trauma)

• Understanding when “helping” is not being helpful

• Understanding differences between professional

helping relationships and friendships 

• Examination of personal prejudices and cultural

stereotypes 

• Recognition of discomfort with despair,

hopelessness, rage, blame, guilt, and excessive

anxiety which interferes with the capacity to “be”

with clients

• Recognition of over-identification with survivors’

frustration, anger, anguish, and hopelessness

resulting in loss of perspective and role

• Realizing when own disaster experience or

personal history interferes with effectiveness

• Involvement in opportunities for self-exploration

and addressing emotions evoked by disaster work 

Dimension

Management of

Workload

Balanced

Lifestyle

Stress

Reduction

Strategies

SelfA wareness

T ABLE 5: 
Self-awareness involves

recognizing and heeding early

warning signs of stress

reactions and understanding

one’s countertransference

reactions. Countertransference refers to the

impact that the survivor and

his or her situation has on the

mental health provider.

Depending on the provider’s

history and vulnerabilities,

countertransference reactions

might involve: survivor guilt;

helplessness at not being able

to protect child victims from

being killed; feeling heroic,

altruistic, and indispensable to

the response operation; finding

the anguish of bereaved

parents to be intolerable; or

questioning human nature,

God, or one’s basic

assumptions about the world.

These reactions may not be

fully conscious yet they can

erode the provider’s

perspective and ability to

maintain balance.

As a result of over-identification with survivors, mental

health responders may not

exercise appropriate personal

and professional boundaries in

their work. This is especially

dangerous for those who seek

to “fix” survivors’ problems or

try to right the wrongs

experienced by them. The

unfortunate reality is that

many survivor losses are

permanent and survivors will

never be as they were before

the event. These realities can

be difficult for providers to

accept, especially when their

lives and sense of self are tied

to “making” survivors feel

better. Supervisors must

recognize these

understandable tendencies and

assist workers with setting

realistic goals and

expectations.

Alternatively, mental health

providers may distance

themselves to avoid experiencing survivors’ anguish and

rage and unconsciously restrict

survivors’ emotional

expression (Wilson and Lindy,

1994). During the immediate

response, when mental health

workers are typically engaged

for a time-limited assignment,

it may be less crucial or

appropriate to explore

providers’ countertransferential reactions in depth.

However, it can be extremely

useful to identify and label

these reactions and to help the

responder put them in context.

This may occur in defusing

sessions, supervisor support

contacts, or debriefing

sessions.

Clinical supervision and case

consultation help mental

health workers identify,

understand, and address

countertransferential reactions.

When providers have a

grounding in clinical theory

and can view their work from

a theoretical perspective, they

are better able to maintain

their professional role and

“psychological space.” Group

case consultation built on solid

clinical principles, safety, and

trust can infuse necessary

social support and human

connectedness into work

teams.

Training staff to identify

vulnerabilities and measure

stress symptoms helps workers

to monitor themselves and

each other. When the psychological demands are great and

the mental health response is

prolonged, a systematic

approach involving ongoing

assessment and educational

and therapeutic interventions

with staff may be indicated.

Mental health responders must

maintain genuine empathic

engagement with survivors

and bereaved family members

and “be willing to enter their

affective space...to join and

hold them in their loss in an

effort to understand their

experience and help them

tolerate it” (Charney and

Pearlman, 1998). Figley (1995)

describes four reasons why

trauma workers are especially

vulnerable to compassion

fatigue: (1) empathy is a

necessary skill, yet it inducts

traumatic material from the

survivor to the provider; (2)

many workers have personally

experienced some type of

trauma; (3) unresolved trauma

will be activated by reports of

Chapter V: Stress Prevention, Management, and Intervention • 85
similar trauma by clients; and

(4) children’s traumatic

experiences are provocative

for caregivers. This normalization of compassion fatigue

can provide the foundation for

a proactive and responsible

approach to addressing staff

stress, in much the same way

that survivors’ responses are

addressed.

Signs and

Symptoms of

W orker Stress

Educating supervisors and staff

about signs of stress enables

them to be on the lookout and

to take appropriate steps.

When mental health response

programs emphasize stress

recognition and reduction,

norms are established that

validate early intervention

rather than reinforcing the

“worker distress is a sign of

weakness” perspective.

Mental Health Provider

Stress Reactions

Psychological and Emotional:

■ Feeling heroic,

invulnerable, euphoric

■ Denial about one’s stress

level

■ Anxiety and fear

■ Worry about safety of self

and others

■ Anger or irritability

■ Restlessness

■ Sadness, grief, depression,

moodiness

■ Distressing dreams

■ Guilt or “survivor guilt”

■ Feeling overwhelmed,

hopeless

■ Feeling isolated, lost, or

abandoned

■ Apathy

■ Identification with

survivors

■ Feeling misunderstood or

unappreciated

Cognitive:

■ Memory problems and

forgetfulness

■ Disorientation and

confusion

■ Slowness in thinking and

comprehension

■ Difficulty calculating,

setting priorities, making

decisions

■ Difficulty concentrating

■ Limited attention span

■ Loss of objectivity

■ Inability to stop thinking

about the disaster

Behavioral:

■ Change in activity level

■ Decreased efficiency and

effectiveness

■ Difficulty communicating

■ Outbursts of anger,

frequent arguments

■ Inability to rest or

“letdown”

■ Change in eating habits

■ Sleep disturbances

■ Change in patterns of

intimacy, sexuality

■ Change in job performance

■ Periods of crying

■ Increased use of alcohol,

tobacco, or drugs

■ Social withdrawal,

isolation

■ Vigilance about safety or

environment

■ Avoidance of activities or

places that trigger

memories

■ Proneness to accidents

■ Blaming and criticizing

others

Physical:

■ Increased heartbeat,

respiration

■ Increased blood pressure

■ Upset stomach, nausea,

diarrhea

■ Change in appetite, weight

loss or gain

■ Sweating or chills

■ Tremors or muscle

twitching

■ “Muffled” hearing

■ Tunnel vision

■ Feeling uncoordinated

■ Headaches

■ Soreness in muscles, back

pain

■ Feeling a “lump in the

throat”

■ Exaggerated startle

reaction

86 • Mental Health Response to Mass Violence and Terrorism
■ Fatigue that does not

improve with sleep

■ Decreased resistance to

colds, flu, or infection

■ Flare-up of allergies,

asthma, or arthritis

As with trauma survivors,

assessment hinges on the

question of “How much normal

stress reaction is too much?”

Each worker has his or her

own pattern of stress

responses. Some may respond

physically with headaches or

sleep problems; others may

have trouble thinking clearly or

may isolate themselves from

others. Mental health

responders commonly

experience many of the

reactions listed with limited

job effects. 

However, functioning is likely

to be impaired when

responders experience a

number of stress reactions

simultaneously and with

moderate intensity. When this

stress overload occurs over an

extended period of time

without adequate rest and

rejuvenation, the worker may

experience adverse health and

more pronounced psychological effects. Taking a break

from the disaster assignment

for a few hours at first, and

then longer if necessary is

often helpful. Using the stress

management strategies

described in this chapter can

help counteract stress effects.

Clinical supervisory support

benefits mental health workers

when their personal coping

strategies are wearing thin.

Over time, mental health

providers may engage in more

concrete “doing for” assistance

as an antidote to feeling

helpless to relieve the

seemingly bottomless pain of

some victims and families.

Supervisors and consultants

may intervene by exploring the

provider’s underlying feelings

and motivations, identifying

appropriate roles and

boundaries, and redefining the

goals of mental health

interventions. 

Clinical support also might

involve an exploration of

distressing aspects of

assignments and their

meanings, the worker’s prior

related experiences and

vulnerabilities, and his or her

personal coping strategies.

Supervisors can make

suggestions for stress

reduction activities. These

supportive contacts might also

include the validation and

normalization of reactions. In

most cases, stress symptoms

gradually subside when the

worker is no longer in the

emergency response

environment or has achieved a

balance of time off and

outside, nonrelated activities.

When symptom reduction does

not occur, professional mental

health assistance is indicated.

Chapter V: Stress Prevention, Management, and Intervention • 87

IN MOST CASES, 

STRESS SYMPTOMS 

GRADUALLY SUB SID E WH EN

THE WORKER IS NO 

LONGER IN THE EMERGENCY

RESPONSE ENVIRONMENT 

OR HAS ACHIEVED A 

BALANCE OF TIME OFF AND

OUTSIDE, NONRELATED 

ACTIVITIES.
Rewards 

And Joys of

Disaster Work

Most people find it enormously

rewarding to help survivors,

family members, and

communities following tragic

incidents involving mass

victimization. Responders

witness both gut-wrenching

grief and sorrow and the

power of the human spirit to

survive and carry on. Assisting

people as they struggle to put

their lives back together is

fundamentally meaningful.

Mental health workers learn

about their own strengths and

vulnerabilities. They may be

reminded of the preciousness

of human life and their

significant relationships. Many

workers have said their view

of human nature has been

changed through the

community outpouring of

kindness, generosity, and the

power of simple gestures

following a mass tragedy.

Recommended

Reading

Center for Mental Health

Services. (1994). Disaster

Response and Recovery: A

Handbook for Mental Health

Professionals. Rockville, MD:

Substance Abuse and Mental

Health Services

Administration, U.S.

Department of Health and

Human Services.

Center for Mental Health

Services. (in press). A Guide to

Managing Stress in Crisis

Response Professions. Rockville,

MD: Substance Abuse and

Mental Health Services

Administration, U.S.

Department of Health and

Human Services.

Charney, A. E. and Pearlman,

L. A. (1998). The ecstasy and

the agony: The impact of

disaster and trauma work on

the self of the clinician. In P. M.

Kleepsies et al. (Eds.),

Emergencies in Mental Health

Practice: Evaluation and

Management (pp. 418-435).

New York: Guilford.

Figley, C. R. (Ed.) (1995).

Compassion Fatigue: Coping

with Secondary Traumatic Stress

Disorder in Those that Treat the

Traumatized. New York:

Brunner/Mazel.

Figley, C. R. (Ed.) (2001).

Treating Compassion Fatigue.

Philadelphia: Brunner/Mazel.

Mitchell, J. T. and Bray, G. P.

(1990). Emergency Services

Stress: Guidelines for Preserving

the Health and Careers of

Emergency Services Personnel.

New Jersey: Prentice-Hall. 

Quick, J. C., Quick, J. D.,

Nelson, D. L., et al. (1997).

Preventive Stress Management

in Organizations. Washington,

DC: American Psychological

Association.

Stamm, B. H. (Ed.) (1995).

Secondary Traumatic Stress: Self

Care Issues for Clinicians,

Researchers, and Educators.

Maryland: Sidran.

Wilson, J. P. and Lindy, J. D.

(Eds.). (1994).

Countertransference in the

Treatment of PTSD. New York:

Guilford.

88 • Mental Health Response to Mass Violence and Terrorism

90 • Mental Health Response to Mass Violence and Terrorism

Training may be offered

soon after a mass criminal

incident to orient immediate

responders, or later as part of

mental health program

implementation of local or

State planning and

preparedness activities. The

focus, content emphasis, and

length of the training varies

according to its timing and

function. Training participants

may be mental health professionals only, a mixture of

licensed mental health professionals and paraprofessionals,

or a more diverse group that

also could include crime

victim assistance providers,

law enforcement personnel,

emergency services workers,

voluntary agency providers,

disaster relief personnel,

medical examiner’s office

staff, and volunteers from

faith-based organizations and

chaplains. To be effective,

trainers must adapt modules

to the needs of the particular

groups in attendance.

Each incident involving mass

violence is unique. The timing

and setting of its occurrence;

the assumed reasoning behind

the malevolent act; the ages

and characteristics of the

perpetrator(s), victims,

affected families, and those

killed; and the nature of the

community and its reaction all

contribute to the overall

mental health impacts.

Trainers need to recognize the

CHAPTER VI

SETTING UP 

TRAINING
Chapter VI: Setting Up Training • 91

importance of these variables

and responsibly orient

themselves to significant

dynamics pre-existing within

the community and those

recently provoked by the

tragedy.

Effective crisis mental health

responders are flexible, easily

able to establish rapport,

respectful of differences

among people, able to remain

calm in the presence of intense

emotional expression, and

tolerant of ambiguity and

confusion. Not everyone is

suited to the rigors of

responding to community

crises. Participation in

appropriate training can

prepare workers for the unique

organizational, procedural,

emotional, and environmental

aspects of mass criminal

incident response. 

While mental health providers

attending the training

undoubtedly will have relevant

skills from prior professional

activities and training, the

complex and varied demands

present most providers with

some significantly different

challenges. Prior experience

with grief and bereavement

counseling, disaster mental

health response, critical

incident stress management,

hospital-based social work,

faith-based emergency

response, crime victim

assistance and advocacy,

trauma counseling, and crisis

intervention can provide a

helpful foundation for

acquiring additional necessary

skills.

Training combines lecture

presentations, films, skills

practice, self-awareness

exploration, group discussion,

and experiential learning.

Participants are exposed to

case scenarios and videotapes

that simulate mass crisis

situations, to explore their own

reactions and achieve some

stress-inoculation before

assignment. Adult training is

most effective when participants learn by seeing, doing,

discussing, practicing, and

receiving new information

presented through multiple

methods.

The training process is not

designed to be a psychological

“debriefing” for those

personally affected by the

tragedy. When it is necessary

to involve workers who are

also survivors, they should

participate in a supportive

group session before the

training and also be

individually assessed. Staff and

program supervisors may find

that these individuals’ personal

reactions may interfere with

their functioning as mental

health responders. Survivors

who are also mental health

responders should be

cautioned about their

increased vulnerability for

adverse reactions and closely

monitored and supported by

supervisors. Trainers and

supervisors should check in

with local mental health

responders, observe stress

levels, and provide opportunities for expressing thoughts,

feelings, and reactions.

Rapid Response

Training

During the immediate

aftermath, administrators must

rapidly identify and deploy

staff. If a pretrained cadre of

mental health professionals

does not already exist, then

training becomes a priority.

Even those with prior training

and experience need to be

oriented to the current disaster

and response operation. An

initial four to eight-hour rapid

response training should be

offered quickly and repeated as

new mental health responders

enter the operation.

Chapters II, III, IV, and V

provide useful background and

content for distribution at the

training. Also, the CMHS

companion Field Manual for

Mental Health and Human

Service Workers in Major

Disasters provides a practical

overview and “how to”

information. It is a valuable

pocket guide for readyreference in the field.
92 • Mental Health Response to Mass Violence and Terrorism

Comprehensive

Training

Mental health training may

take place after the immediate

response phase for workers

providing short and long-term

mental health services. These

mental health providers may

be employed through a

Federally funded crisis

response program or may be

local mental health professionals who encounter

survivors as they carry out

their usual roles.

The comprehensive training

program described in Chapter

VII requires between 2.5 and 4

days, depending on the

emphases and amount of time

allocated to different topics

and activities. Representatives

from key agencies and

specialists with particular

survivor groups may present

portions of the training.

Comprehensive training

addresses: 

◆ Human reactions to mass

victimization and

traumatic loss; 

◆ General principles for

community trauma

response and crime

victim services;

◆ Mental health

interventions appropriate

to each survivor group;

◆ Local, State, and Federal

response to mass

community violence and

terrorism; and 

◆ Mental health staff stress

prevention, management,

and intervention.

Selection of

Qualified

Trainers

Comprehensive training must

be taught by a qualified mental

health professional or team of

trainers with collective

experience and knowledge in

disaster, trauma, crime victimization, and traumatic

bereavement. Trainers should

have formal training on these

topics. In addition, the training

team collectively needs prior

community trauma response,

crime victim assistance, and

disaster mental health

experience, particularly with

long-term recovery issues. 

Not only should the trainers

have the requisite knowledge

to present the material, but

they also should be engaging

presenters and highly skilled

with group processing of

emotions. Trainers must be

able to model skills, as well as

teach them. 

Trainers coming from outside

the geographic area will need

to become familiar with the

local community and the

specifics of the recent incident

of mass criminal victimization—its impact, population

groups affected, extent of

property damage, status of

criminal justice efforts, and

relief and recovery activities to

date. Videotapes of news

coverage, summary newspaper

articles, grant applications,

and emergency management

bulletins can be useful sources

of background information.

When training participants

include recently hired staff of a

Federally funded, post-disaster,

mental health program,

training should be consistent

with funding guidelines for

services. Trainers need to be

familiar with these guidelines

and incorporate them into

training content. For example,

if funding supports a limited

number of counseling

sessions, valuable training

time is better spent focusing

on interventions appropriate to

that time frame.

The comprehensive training

program could include

different trainers with special

expertise in certain topics,

such as traumatic

bereavement, children and

trauma, or the Federal

response. A crime victim

assistance provider might

present a session on Federal

and State crime victim rights,

services, and benefits. Topical

presenters should also be

familiar with long-term

community trauma and grief

recovery processes, so that

their presentations are
Chapter VI: Setting Up Training • 93

relevant to the needs of the

participants. When particular

cultural or ethnic groups are

affected by community victimization, representatives of

these groups may be included

in the training. These

representatives may be

community leaders, social

service agency workers, or

educators on cultural

sensitivity and competence.

Setting Up

Training

The training should be held in

a comfortable setting with

audiovisual equipment suitable

for the room and size of the

group. To avoid last minute

problems, trainers should

anticipate possible

malfunctions and plan

backups. Although fewer than

30 participants is an ideal class

size for training, logistics may

dictate that the group be

larger. Under those circumstances, having additional

small group facilitators and

trainers to review and give

feedback on role-plays

enhances the depth of the

training.

Who Should

Attend?

All service providers,

supervisors, and administrators should attend the

training. When individuals who

have not been oriented to the

material presented in this

training provide clinical

supervision or administer crisis

response programs,

unnecessary conflicts and

inconsistencies arise.

Paraprofessional counselors

need initial training in basic

counseling skills before

attending the comprehensive

training. This basic training

allows them to become

familiar with the role of

counselor and the inherent

ethical and boundary issues

involved. An overview is

provided in Chapter VIII.

Representatives from law

enforcement, emergency

services, crime victim

assistance programs, faithbased organizations, the ARC,

or Federal agencies assisting

the community may attend the

training. These individuals

bring valuable information and

perspective. Their presence

and participation convey the

importance of the multidisciplinary effort involved in

emergency response and

recovery. Program administrators need to balance the

need for a cohesive group

training with the value of

including people from key

agencies and referral sources.

When appropriate, the training

may be designed so that a

broader group is included in

the first day and only the

mental health workers in the

remaining days.

THE COMPREHENSIVE 

TRAINING PROGRAM COULD

INCLUDE DIFFERENT 

TRAINERS WITH SPECIAL 

EXPERTISE IN CERTAIN 

TOPICS, SUCH AS 

TRAUMATIC BEREAVEMENT,

CHILDREN AND TRAUMA, 

OR THE FEDERAL 

RESPONSE.
94 • Mental Health Response to Mass Violence and Terrorism

The comprehensive training

course requires 2–4 days,

depending on the depth and

scope of material presented. It

has nine major content areas,

organized into “modules,”

each requiring from 1–4 hours.

Each of the nine modules has

five components:

1. Topics Covered;

2. Objectives;

3. Time Required;

4. Materials Required; and 

5. Procedures.

Most of the modules include a

balance of lectures, overheads,

videos, and experiential

activities. Module 9, Stress

Prevention, Management, and

Intervention, includes group

and individual exercises that

can be used throughout the

training to vary the teaching

method and pace of the

training. Examples of

overheads and references for

videotapes are included at the

end of this chapter. Handouts

and lecture content may be

drawn from Chapters II–V of

this manual. Trainers are

encouraged to develop their

own disaster and crisis

response stories and case

examples to bring the training

to a more personal and

specific level.

This comprehensive training

may be held weeks or months

CHAPTER VII

COMPREHENSIVE

TRAINING COURSE

OUTLINE
Chapter VII: Comprehensive Training Course Outline • 95

after crisis impact. The specific

lecture content for each topic

will need to be adapted to the

current stage in the recovery

process, the appropriate

response activities, and current

and anticipated criminal justice

proceedings. Chapter VIII

describes training topics for

subsequent in-service training

and training modules during

the long-term response phase.

Trainers are encouraged to

become knowledgeable about

the current incident. Media

coverage, consultation with

managers of the immediate

mental health response,

emergency response reports,

and grant applications for

funding of mental health

programs can provide essential

information. Local information

can be woven into the training

and used as examples

throughout the more general

discussions of common issues.

Videos from local news

coverage or special reports are

an effective component of

training.

Content experts may conduct

portions of the training (e.g., a

child specialist, a representative from law enforcement, a

resource person from a

cultural group, a crime victim

assistance educator, and an

emergency manager).

Course 

Overview

The following overview lists

course objectives, training

content areas, and suggested

time requirements. The

training content is not further

divided into daily agendas,

because it is assumed that the

trainer’s preferences, training

class’ composition and needs,

timing of the training, and

current local issues will dictate

this level of specificity.

Course

Objectives

◆ Understand human

reactions to incidents of

mass violence and

terrorism including

incident-related risk

factors, at-risk survivor

groups, post-traumatic

stress, traumatic

bereavement, and key

events affecting the

recovery process;

◆ Identify the key concepts

and principles of mental

health intervention, the

differences between

natural and criminally,

human-caused disasters,

the interplay of the

criminal justice process

and survivors’ psychological reactions, and the

simultaneous and

interacting community

and individual impacts;

◆ Learn and convey the

organizational aspects of

the local, State, and

Federal responses to

mass violence and

terrorism including the

roles and responsibilities

of emergency services,

law enforcement, the

medical examiner’s

office, voluntary

agencies, and the

supporting role of mental

health services;

◆ Master methods for

providing appropriate

mental health assistance

to survivors and bereaved

family members in

community settings with

emphasis on psychological first-aid, crisis

intervention, crime victim

assistance, psychoeducation, community

outreach, psychological

debriefing, group

counseling, and stress

management techniques;

◆ Lay out key considerations for intervening

effectively with special

populations including

children and adolescents,

the elderly, and local

cultural and ethnic

groups and methods for

adapting mental health

services to fit particular

communities;
96 • Mental Health Response to Mass Violence and Terrorism

◆ Present methods for

providing mental health

services at the

community level

including psychoeducation through the

media and group presentations, consultation with

employers and social

service agencies, and

assistance with

community rituals and

memorials; and 

◆ Understand the dynamics

of mental health worker

stress and the strategies

for preventing, managing,

and intervening with

stress overload and

vicarious traumatization

at the personal, group,

and administrative levels.

The time and content

emphasis devoted to each

module varies according to the

audience. The time and

content emphasis devoted to

each module varies according

to the audience, the goals of

the training, the amount of

time after the incident, and the

total time allocated for the

training session. For example,

a one-day training during the

immediate response phase

might briefly include all topics

but not include group

exercises. The emphasis in

Module 5 on immediate

interventions would provide

practical guidance readily

applicable to the current

disaster response. Each

module is intended to expand

or contract, be more clinically

oriented or more appropriate

for a lay audience, and shift in

focus depending on the phase

of the recovery process.

Overview of Comprehensive

Training Course

Module 1: 

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 hour

Module 2: 

Criminal Mass Victimization . . . . . . . . . . . . . . . . .1.5 hours

Module 3: 

Adult Responses to Mass Violence and 

Terrorism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2.5 hours

Module 4: 

Organizational Response and Mental 

Health Roles . . . . . . . . . . . . . . . . . . . . . . . . . . . .1.5 hours

Module 5: 

Community Crisis Response and Mental Health 

Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 hours

Module 6: 

Children’s and Adolescents’ Reactions and

Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 hours

Module 7: 

Cultural and Ethnic Groups: Considerations and 

Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 hours

Module 8: 

Planning Workgroups . . . . . . . . . . . . . . . . . . . . . .1.5 hours

Module 9: 

Stress Prevention, Management, and 

Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 hours
Materials Required

■ Training handouts

■ Name tags

MODULE 1

Introduction

Topics Covered

■ Distribution of materials

■ Welcome and brief overview of the training

■ Introductions

■ Training objectives, agenda, and materials

Objectives

■ Introduce trainers and participants

■ Review training objectives, agenda, and values underlying

the training

■ Begin group building through participant disclosure

■ Model listening skills

Time Required

1 hour

Procedures

Distribute Materials: Distribute name tags, handout materials, 

booklets, etc.

Welcome and Brief Overview: Give a welcoming statement,

brief overview of the training day, and discuss logistics (e.g.,

breaks, lunch, phones, bathrooms, etc.). Encourage group

participation and questions.

Introductions: Trainers introduce themselves, highlighting

trauma, crisis, crime victim, disaster, and other related

experience. Participants introduce themselves giving name,

agency affiliation, current job, description of experience with

current incident and prior crises or disasters, and expectations

for the training. The trainer needs to model active listening

and may briefly bring out points relevant to training content.

Training Goals and Objectives: Review the goals and

objectives for training. Trainer addresses participants’ stated

expectations, commenting on what will and will not be

included in the training and how other training needs may be

met.

Chapter VII: Comprehensive Training Course Outline • 97
98 • Mental Health Response to Mass Violence and Terrorism

Agenda and Training Techniques: Review overall training

agenda and discuss training techniques (e.g., short lecture,

discussion, videos, small group exercises, and role-plays).

Discuss rationale and values underlying techniques (e.g.,

people learn by doing, trauma response work affects mental

health providers personally so sharing and support is

important, balance learning new content with developing new

skills).

MODULE 1:

Introduction (Continued)
Chapter VII: Comprehensive Training Course Outline • 99

MODULE 2

Criminal Mass Victimization

Topics Covered

■ Definitions of terrorism and mass violence occurring in the

United States 

■ Comparison of natural and criminally human-caused

disasters

■ Unique aspects of human reactions to mass violence and

terrorism

■ Current incident information

Objectives

■ Acquaint participants with characteristics of traumatic

exposure

■ Compare the impact of natural and criminally human-caused

disasters and related implications for mental health

intervention

■ Provide orientation to the current incident—its scope,

impact, populations affected, emergency response efforts,

and status of criminal justice activities

■ Increase understanding of unique elements of the current

incident that may contribute to mental health effects

Time Required

1.5 to 2 hours

Procedures

Definitions: Using Overheads #1 and #2, present definitions

for terrorism and mass violence. Discuss how mass violent

incidents can target a group of individuals, affect entire

communities, and strain social support systems.

Dimensions of Traumatic Exposure: Discuss these generic

dimensions (see Overhead #3) and their relationship to

increased post-traumatic stress in victims, responders, and

the community-at-large. Focus presentation on the current

incident. 

Comparison of Natural and Criminally Human-Caused

Disasters: Discuss the dimensions listed on Overhead #4. The

lecture content is provided in Chapter II and in Table 1.

Materials Required

■ Overheads #1–4

■ Video of news coverage 

of current incident and

response
100 • Mental Health Response to Mass Violence and Terrorism

Description of the Current Incident: Provide overview of

information about the current incident including nature of the

event, number of people killed and injured, scope of property

damage, populations affected, emergency response and

recovery efforts, relief efforts, and status of criminal investigation and criminal justice proceedings.

Processing Trainees’ Reactions to the Incident: Depending on

the size of the group, facilitate small or large group

discussions focusing on questions such as the following: What

did you think or feel as you watched the video? What

reactions might you expect the people who directly

experienced this incident to have? What aspects of this

incident would you expect to be related to mental health

effects? What do you think will be the difficulties/challenges

for this community during the recovery/reconstruction

process? 

This discussion is not intended to be a “debriefing” for those

who had personal exposure to the incident. The discussion

provides an opportunity for trainers and/or program managers

to continue assessing if there are participants who may be too

involved in their own reactions to assist others effectively.

Refer to Overhead #4 and review assumptions and predictions

that participants have regarding the community’s response to

each dimension. Begin fostering the “anticipate and think-onyour-feet” approach to community trauma response. This can

become an exercise in connecting theory with real world issues.

Display photographs, newspaper articles, and maps of impacted

areas. This can be a group activity, if some participants have

been involved in the mental health response immediately after

the incident. It can give them an opportunity to describe their

experiences while educating new staff.

MODULE 2:

Criminal Mass

Victimization

(Continued)
Chapter VII: Comprehensive Training Course Outline • 101

Adult Responses to Mass 

Violence and Terrorism

Topics Covered

■ Population Exposure Model

■ Survivor risk and resiliency factors

■ Model and phases of psychological response

■ Physical, behavioral, emotional, and cognitive reactions

■ Traumatic grief

Objectives

■ Acquaint participants with the community impacts of mass

victimization

■ Orient participants to survivor risk and resiliency factors that

can assist with screening and prioritization of mental health

services

■ Present a phenomenological model of coping with phases of

psychological response

■ Provide information about the normal range of reactions to

trauma and sudden bereavement including considerations

for older adults

■ Address the interplay of trauma and grief processes

■ Explore participants’ personal reactions to the video and

begin discussing countertransference and the importance of

self-awareness

Time Required

2.5 hours

Procedures

Population Exposure Model: Use Overhead #5, or 

Figure 1. Discuss collective trauma and the potential

widespread effects, emphasizing the differences between

individually experienced trauma and community trauma.

Involve participants in identifying the groups that compose

the various concentric circles and the potential nature of

impacts. Orient participants to think on the “macro”

community level.

MODULE 3

Materials Required

■ Overheads #5–13

■ Videotapes: “OVC Special

Award for Extraordinary

Response to International

Terrorism” and “Disaster

Psychology” 
102 • Mental Health Response to Mass Violence and Terrorism

Survivor Risk and Resiliency Factors: Pose the question “Why,

when faced with identical overwhelming traumatic circumstances, do people have such different reactions, particularly

over time?” Continue with the public health perspective

initiated in the section above, and discuss screening and

allocation of limited mental health services. Present material

related to survivor vulnerability and resilience. Ask the group

to brainstorm implications for outreach and service delivery.

Use Overhead #6.

Model and Phases of Psychological Responses: Using Overhead

#7 or Figure 2, discuss the phenomenological process of

coping with trauma and sudden bereavement. Encourage

participants to share what they have seen clinically and ways

that they have helped survivors “understand” and tolerate

this “working through” process. Chapter II also provides

presentation material. Discuss the process in terms of phases

as well as the influence of predictable events in the criminal

justice process. Address the importance of denial. Connect

this presentation with survivor risk and resiliency factors.

Emphasize that each survivor is unique, and that a model is a

generalization. Use Overhead #8 to address phases in the

community. These are typically used following natural

disasters. Facilitate a group discussion regarding their current

applicability.

Show Videotape: Ask the group questions about survivor

reactions in the film and where these reactions “fit” or “didn’t

fit” in the model just discussed. Begin discussing the physical,

behavioral, emotional, and cognitive symptoms of trauma and

bereavement portrayed in the video, and if they seemed to

change over time. If appropriate, ask participants to speculate

which survivors in the film would need more intensive mental

health services, and why. Provide short lectures on topics

relevant to current disaster and phase.

Participant Self-Reflection: Invite participants to explore what

touched them personally as they watched the film—which

survivors, what circumstances, and why they were impacted.

Use this discussion to model giving permission and control

(“Share what you feel comfortable talking about here.”), good

listening skills, nonjudgmental acceptance, and normalization. Continue with a lecture about countertransference in

very practical terms, and introduce the importance of selfawareness, self-care, talking with others, stress management, 

MODULE 3: Adult

Responses to Mass

Violence and

Terrorism (Continued)
Chapter VII: Comprehensive Training Course Outline • 103

and staff consultation. As a wrap-up, ask the group to

comment on techniques and approaches used by the

facilitator and their applicability to work with survivors.

Range of Adult Reactions to Trauma and Bereavement: Use

Overheads #9–12 in this section. Use case examples,

examples from the film, participant examples from the current

disaster, and their other clinical experiences to make these

lists come alive. Focus on reactions that are relevant to the

timing of the training and what participants may deal with in

their work with survivors. Emphasize that for the majority of

survivors, these reactions are normal and will subside over

time—with episodic resurgences triggered by events in

criminal justice proceedings, media coverage, anniversaries,

holidays, and other traumatic reminders.

Considerations with Older Adults: Using Overhead #13, discuss

the challenges faced by older adults, particularly the elderly.

Discuss this population in relation to issues and needs

expressed in the current disaster. Review the section in

Chapter II and Table 3. Expand section if this is a highly

impacted group.

Interplay of Trauma and Grief: Review this section in Chapter

II. Survivors who suffered serious and disabling physical

injuries, those who had a loved one killed in the incident, and

those who were both involved and suffered the death of a

family member or close friend experience an intensification of

both trauma and grief responses. Often, post-trauma

reactions take precedence and must be dealt with before

grieving can take place. The process of “working through” is

more arduous and often takes longer, because of the overlay

of psychological processes. If traumatic grief is prevalent in

the current disaster, focused, in-service training, clinical

supervision, and consultation on this topic are strongly

encouraged.

MODULE 3: Adult

Responses to Mass

Violence and

Terrorism (Continued)
MODULE 4

Organizational Response 

And Mental Health Roles

Topics Covered

■ Federal, State, local, and volunteer agencies involved in

crisis response 

■ Incident Command System (ICS) and Unified Command (UC)

■ Local crisis response and key area resources

■ Glossary of acronyms

Objectives

■ Acquaint participants with representatives from primary

responding agencies (e.g., emergency management, law

enforcement, crime victim assistance-witness program, State

crime victims compensation program, ARC, OVC, CMHS,

FEMA)

■ Orient participants to the organizational context of

community crisis response and the role of mental health 

■ Provide an overview of Federal programs that supplement

State resources for mental health and crime victim services

■ Inform participants of the chronology of emergency response

and criminal justice events involved in the current incident

■ Increase knowledge of local resources, contacts, and how to

access them

Time Required

1.5 hours

Procedures

Organizational Aspects of Crisis Response: Local, State, or

Federal representatives may conduct much of this section.

Participants benefit from having names and faces to attach to

unfamiliar agencies. Review the background information and

figures provided in Chapter IV. Include key topics: the ICS, UC,

emergency response procedures, coordination between law

enforcement and mental health, the EOC, lead agencies, and

participating agencies. Use Overhead #14 and organizational

charts in the figures. Mental health responders need to 

Materials Required

■ Overheads #14 and #15

■ Figure 4

■ Handouts from agencies

represented

■ Contact information for

local resources

■ Videotape: “Surviving the

Secondary Device”

104 • Mental Health Response to Mass Violence and Terrorism
Chapter VII: Comprehensive Training Course Outline • 105

understand the big picture of emergency operations, the

organizational players, and their roles. Show the video to

graphically portray a bombing incident crime scene and some

of the issues and challenges associated with emergency

response. Ask participants to discuss the potential mental

health impacts of procedures described in the film.

Local, State, and Federal Response and Recovery Activities:

Present a chronology of emergency response and law

enforcement activities, highlighting aspects that might have

mental health implications. Plan the presentation according to

the current phase in the response so that participants become

informed about the history, as well as who the current key

players are, and current phase-related recovery issues and

activities. Representatives from Federal agencies that have

funds available for mental health and crime victim services

may provide information relevant to the incident, the phase,

timing, and the participants. If the ARC has been active

providing disaster mental health services (DMHS), a DMHS

volunteer or staff person could present information about

community reactions and needs.

Mental Health Roles in Crisis Response: Using Overhead #14,

briefly describe the various mental health roles as they relate

to this discussion of the larger organizational context during

the early response phase.

Emergency Response Lingo and Defining Acronyms: Distribute

the glossary of acronyms, or develop a similar list for the

current local, State, and Federal agencies.

MODULE 4:

Organizational

Response and Mental

Health Roles

(Continued)
106 • Mental Health Response to Mass Violence and Terrorism

MODULE 5

Community Crisis Response and

Mental Health Interventions

Topics Covered

■ Key concepts of community crisis response

■ Mental health interventions

■ Key events with mental health implications

■ Community interventions

■ Limits and boundaries of mental health intervention

Objectives

■ Orient participants to normal stress reactions to mass

violence and sudden bereavement

■ Acquaint participants with mental health interventions used

following community disasters as distinct from traditional

office-based clinical practice

■ Increase understanding of the importance of community

rituals and interventions and the mental health role

■ Describe key events in emergency response and recovery

and the criminal justice process that have mental health

implications

■ Provide guidance regarding professional and ethical limits

and boundaries

Time Required

Up to 4 hours

Procedures

Key Concepts of Community Crisis Response: Using Overheads

#16 and #17 and material in Chapter III, review basic orienting

principles for community response. Emphasize flexibility,

empowerment, respect for differences, and practicality.

Community Crisis Response vs. Traditional Office-Based

Practice: Discuss how community crisis response differs from

traditional therapy. Emphasize aspects such as the service

provider goes to the client, rather than the client coming to

the office (especially initially); early intervention focuses on 

Materials Required

■ Overheads #16–29

■ Sample public information brochures and

materials

■ Case scenarios

■ Videotapes: “Hope and

Remembrance,” “Death

Notification,” and “The

News Media’s Coverage 

of Crime and Victimization”
Chapter VII: Comprehensive Training Course Outline • 107

problem-solving rather than achieving insight; and terms like

“mental health” and “counseling” are de-emphasized and

terms like “assistance with problem-solving” and “providing

support and an ‘ear’” are emphasized.

Immediate Mental Health Interventions: Adapt this section to

the current phase of response, training participants in

attendance, survivor populations affected, and the needs of

the group. Overheads #18–27 provide information about a

range of interventions. Use concrete examples of appropriate

interventions, selecting from the material in the overheads.

Clearly describe each intervention and give examples of when

it is used. Demonstrate the intervention and then have the

group practice through role-plays. Including all of these steps

will enhance learning through hearing, seeing, and then

doing.

Role-Play Exercises: Facilitate brief role-play exercises

throughout this section. Develop case scenarios that

exemplify relevant situations and the approaches being

taught. The focus might be psychological first-aid, a

supportive conversation about a survivor’s trauma experience,

or providing psycho-educational information through

reviewing a brochure and discussing coping strategies.

Participants need to have their performance anxieties relieved

while receiving feedback to enhance their learning.

Assessment and Referral: Provide program guidelines for

assessment and referral. Define when mental health providers

should consider the level of distress and symptoms to be such

that a referral, more formal assessment, and more “advanced”

intervention are indicated. Participants will need a program

procedure for case consultation and referral.

Long-Term Mental Health Interventions: The facilitator must

determine which interventions are most relevant. Community

outreach is often an important element of service delivery. A

section on strategies and skills for effective outreach may

assist with this less formal style of service delivery.

Crime Victim Assistance: Mental health workers must be

familiar with the criminal justice process and crime victim

rights and issues, as well as the role of crime victim

advocates. A specialist in this area may present this

information, as it relates specifically to the current criminal

justice response, if this is not in the trainer’s background.

MODULE 5:

Community Crisis

Response and Mental

Health Interventions

(Continued)
108 • Mental Health Response to Mass Violence and Terrorism

Limits and Boundaries of Mental Health Intervention: When

the incident has particularly tragic and heart-wrenching

consequences, mental health responders are often challenged

to maintain appropriate professional and ethical boundaries.

The common risks and pitfalls listed on Overhead #28 provide

a basis for lecture, discussion, and establishing clear service

or program guidelines. Using examples for each pitfall will

help participants apply them to their own practices.

Key Events with Mental Health Implications: The facilitator and

group may identify anticipated key events (see Overhead #29)

and discuss anticipated mental health needs. If specific skillbuilding is called for, then focus section in that direction (e.g.,

for participation on death notification teams, for assisting

survivors with return to work anxieties). This could include

large group brainstorming of service delivery ideas. A small

group exercise could assign a key event to each small group,

and request that each group brainstorm creative mental

health service and outreach suggestions. The section

emphasizes thinking on the “macro” community level and

anticipating events that will send ripples of mental health

effects through the community, as well as at the “micro” level

of the specifics of what an intervention would look like.

Community Intervention: Provide a brief lecture on the

importance of disseminating information on trauma, stress,

and coping. Community education is essential. Show samples

of educational efforts (e.g., brochures, public information

media spots, Internet sites, newspaper articles, etc.). Mental

health providers may help plan community events or be

present as a support (Overhead #30). Again, fit this discussion

to real events and needs occurring in the community.

Often, mental health providers are asked to give presentations

to different audiences including survivor groups defined by

age, culture, needs, employment, or affiliation with an organization. Other audiences might be service provider groups

such as primary care providers, health care professionals,

disaster workers, faith-based counselors, or school teachers.

Specific training modules need to be developed to address

these particular needs and groups. The facilitator should

address these topics in a way that fits the needs of the group.

However, additional in-service training is also recommended.

MODULE 5:

Community Crisis

Response and Mental

Health Interventions

(Continued)
Chapter VII: Comprehensive Training Course Outline • 109

Show Videotape: The videotape “Hope and Remembrance”

deals with the importance of community ritual and

memorials. The video is moving and is likely to elicit reactions

and emotions. It can provide an opportunity for self-reflection,

facilitator modeling of good listening and “counseling” skills,

and discussion of countertransference vulnerabilities.

MODULE 5:

Community Crisis

Response and Mental

Health Interventions

(Continued)
110 • Mental Health Response to Mass Violence and Terrorism

Children’s and Adolescents’

Reactions and Interventions

Topics Covered

■ Age-related reactions and concerns

■ Age-appropriate interventions

■ Coordination with the schools

■ Special projects

Objectives

■ Provide information about children’s normal and problematic

responses to trauma, loss, and family stress

■ Assist participants in understanding developmental

influences so they can design appropriate interventions

■ Identify strategies for working with the local schools and

children’s organizations

■ Provide examples of creative projects and partnerships 

■ Brainstorm

Time Required

Up to 3 hours

Procedures

Children’s Reactions to Crisis and Trauma: Review background

material in Chapters II and III, and Recommended Reading.

Present a lecture on children’s reactions emphasizing

developmental stages and the significant role of the family.

Identify features of the current event that have salience for

children (e.g., witnessing frightening events in person or on

the television, separation from family members, traumatic

reminders at school). Use Overheads #31–33 as a starting

point. Discuss observed expressions of distress and trauma in

children following the recent disaster and interventions with

children to date.

Risk Factors: Review Overhead #34. Discuss at-risk groups of

children in the community. Using the concentric circle model

(Overhead #5), identify groups of children and adolescents

with different levels of exposure.

MODULE 6

Materials Required

■ Overheads #5 and #31–36

■ Handout: “Age Specific

Interventions for Children

and Adolescents”

■ Videotape: “Children and

Trauma: The School’s

Response”

■ Examples of coloring

books, expressive and

commemorative school

projects (photos, journals,

posters, drawings, and

documentaries)
Chapter VII: Comprehensive Training Course Outline • 111

Interventions: Present a lecture on appropriate interventions

with children for different phases. Emphasize the importance

of parent education, support and consultation. The handout

can provide a structure for this lecture. Encourage participants

to assess the child or group before initiating expressive or

reenactment activities and to use them only when confident

that they will not be retraumatizing. With highly exposed

children, many of these interventions are most appropriate in

the context of a therapy relationship. The lecture on

intervention options may be broken up by group discussion,

showing examples, role-plays, and demonstrations of

techniques. This presentation should fit the roles of the participants.

Show Videotape: “Children and Trauma” captures many of the

points discussed, demonstrates techniques, and emphasizes

the importance of school involvement in interventions.

Discuss relevant aspects of the film and participant reactions.

Systematic Strategy for Assessing the Needs of Children: If a

high rate of more serious trauma and grief reactions are

anticipated because of the presence of risk factors and the

dynamics of the incident and recovery efforts, a systematic

system for screening children is advised. Multiple strategies

including gathering assessment information from parents and

teachers and directly from children and adolescents should be

used. Overhead #35 provides guidance for topics to include in

an assessment. Checklists have been developed for this

purpose. The program must define procedures and protocols

for systematic screening. The participants may practice brief

screening interviews with parents, children, or teachers—

depending on the program’s plan and their roles.

Psychological Tasks: Using Overhead #36, discuss the psychological tasks that a child must accomplish to integrate the

traumatic experience and move on. Discuss how age and

developmental stage affect the child’s capacity to accomplish

these tasks and how these affect intervention strategies.

Emphasize that children may harbor a distorted

understanding of the event, what caused it, or their role in it.

These idiosyncratic distortions must be uncovered and

corrected for the child to work through their experiences. 

When children have been highly impacted, child specialists

may conduct specific in-service training for mental health 

MODULE 6:

Children’s and

Adolescents’

Reactions and

Interventions (Continued)
112 • Mental Health Response to Mass Violence and Terrorism

professionals on providing counseling for traumatized and

bereaved children and their families.

School Systems: Schools are a critical point of contact to reach

children, parents, caretakers, and school personnel who have

regular contact with children. However, gaining access to

schools can be challenging. Access may be facilitated through

coordination with the U. S. Department of Education, which

has a crisis intervention program, the State Department of

Education, or more local official entities that have vested

interests in children’s welfare. Other, less official channels

include working with the school nurse or counseling staff,

presenting educational sessions at PTA meetings, and

conducting in-service training for teachers. Hiring former

school personnel as program staff can be helpful for gaining

credibility and acceptance.

Determine what angles would help to promote collaboration

and a working relationship. These might be referrals for atrisk children and families (due to the disaster), consultation

and training with school counselors and nurses, or parent

presentations. The interventions listed in the handout may be

used for training teachers and mental health professionals for

classroom sessions.

Other organizations serving children may be more accessible

and welcoming of outside assistance. Possibilities include day

care centers, YMCA/YWCA youth programs, scout programs,

religious youth groups, summer camps, or community

centers.

School and Community Projects: The videotapes shown have

demonstrated numerous ways that children can participate in

community commemoration. Display samples of children’s

projects. Expressive activities provide a vehicle for expression,

validation and normalization, gaining social support, and

“working through” reactions. Engage participants to

brainstorm innovative projects for the current crisis to foster

community healing and survivorship.

MODULE 6:

Children’s and

Adolescents’

Reactions and

Interventions (Continued)
Chapter VII: Comprehensive Training Course Outline • 113

MODULE 7

Cultural and Ethnic Groups:

Considerations and Interventions

Topics Covered

■ Cultural competency

■ Cultural information about affected groups

Objectives

■ Identify special populations including cultural, ethnic, racial,

immigrant, and refugee groups affected by the disaster

■ Review unique issues associated with each group and

special considerations for intervention

■ Understand how traumatic stress, grief, healing, and

recovery may be experienced and expressed by each group

Time Required

2 hours

Procedures

Cultural, Ethnic, Racial, Immigrant, and Refugee Groups: Staff

must acquire cultural competency with and earn the

acceptance of affected groups in the community. Chapters II

and III highlight important topics. Overhead #37 presents

components of cultural competence. Program managers

should strongly state the program’s position regarding valuing

diversity and respecting differences, and that everyone in the

community should have access to high quality, appropriate

services. Managers may present steps that the mental health

program is taking to promote cultural awareness and

sensitivity and to ensure cultural competence. 

Information about Local Affected Groups: Representatives

from local ethnic, cultural and racial groups may present

portions of this section. Overhead #38 may provide guidance

regarding topics to address in these presentations. They may

share information about their groups’ experience with the

disaster and the crisis response. Ideally, a specialist in the

group’s cultural experience can provide insights on how to

work most effectively with the group and avenues for credible 

Materials Required

■ Overheads #37–39

■ Handouts and resource

materials on specific

groups in community

■ Videotapes about working

with particular groups in

the community
114 • Mental Health Response to Mass Violence and Terrorism

liaison and helpful collaboration. Additional training on

cultural issues and awareness may be provided as in-service

training.

Basic Cultural Sensitivity: The tips listed on Overhead #39 are

the basics of respectful engagement with all people, yet must

be especially emphasized when trying to bridge cultural

differences. If interpreters are being used, suggestions are

included in Chapter III.

MODULE 7: Cultural

And Ethnic Groups:

Considerations and

Interventions (Continued)
Chapter VII: Comprehensive Training Course Outline • 115

Planning Workgroups

Topic Covered

■ Program planning for special population groups

Objectives

■ Develop specific program strategy plans for addressing the

mental health needs of each affected special population

group in the community

■ Encourage a team approach to program planning

■ Identify expertise and interests of mental health staff

relevant to special groups

■ Identify strategies for outreach, relationship-building with

community leaders and agency resources, and culturally

sensitive interventions

Time Required

1.5 hours

Procedures

Identifying Special Populations: Identify groups requiring

special program focus. Examples are children; older adults;

traumatically bereaved family members; people who lost their

jobs as a result of the disaster; people with disabling injuries

resulting from the incident; people in institutions, people with

pre-existing disabilities; cultural, ethnic, and racial groups;

and people with serious and persistent mental illness. Human

service workers in the community might receive a different

set of interventions, as a target group for networking,

outreach and educational presentations.

Special Population Workgroups: Establish workgroups of

participants for each identified population group. Assign tasks

to the workgroups. Group tasks could include: (1) identifying

points of contact to reach the group; (2) identifying group

leaders, key people, and gatekeepers; (3) identifying future

significant events with mental health implications; (4)

reviewing effective program or outreach strategies to date;

and (5) brainstorming program ideas, intervention, or

outreach strategies for the future. Groups may take 45 

MODULE 8

Materials Required 

(For each workgroup)

■ Flip chart

■ Pens

■ Questions
116 • Mental Health Response to Mass Violence and Terrorism

minutes to discuss and generate ideas and then transcribe

them to the flip chart. Then each group may present their

ideas to the larger group for input and discussion.

The trainer further comments on groups or issues raised,

summarizes common themes and challenges, and recognizes

the work of each group. This exercise provides a welcome

opportunity to encourage teamwork and demonstrate the

benefits of a collective process.

The program manager may discuss how the workgroup ideas

will be addressed and incorporated into the program plan.

MODULE 8:

Planning Workgroups

(Continued)
Chapter VII: Comprehensive Training Course Outline • 117

MODULE 9

Stress Prevention, Management,

And Intervention

Topics Covered

■ Sources and nature of worker stress

■ Organizational and individual approaches

■ Self-awareness

■ Stress reduction strategies

Objectives

■ Provide information regarding sources and symptoms of

worker stress and compassion fatigue

■ Introduce and discuss specific organizational and individual

approaches to prevent and manage work-related stress

■ Enhance team support and group cohesiveness

■ Identify individual vulnerabilities to stress and personal

prevention and management strategies

Time Required

2 hours (Exercises can be interspersed throughout the training

course.)

Procedures

Sources of Stress: Using Overhead #40, discuss potential

sources of work-related stress. Use examples relevant to the

timing of the training. Engage participants to identify

examples in each category. This exercise could be made more

personal by asking participants to identify their top three

stressors. These work-related stressors could be compiled,

voted on, and tallied—arriving at the top 10 stressors

identified by the entire group. These results could be the basis

for subsequent problem-solving exercises addressing these

top stressors.

The trainer may lecture on sources of stress for workers,

adding to the material generated by the group. The lecture

might include topics such as participants’ motivations for

helping and how these might also generate stress; discomfort

being with someone who is angry, tearful, grief stricken, 

Materials Required

■ Overheads #40–44

■ Flip chart

■ Pens
118 • Mental Health Response to Mass Violence and Terrorism

hopeless, depressed, emotionally shut down, etc.; identifying

images or events that are traumatic; and difficulties managing

the boundaries of the “helper-helpee” relationship—especially

under such tragic life circumstances.

Concept of Stress: Overhead #41 provides important

perspectives on stress—that it is both good and bad and, most

importantly, identifiable and manageable. In moderation,

stress can enhance performance and mental acuity. Too much

stress continuing over a period of time can erode well-being,

coping, and eventually health. The program managers,

supervisors, and individual staff members each have responsibility to prevent and manage stress. Review Chapter V.

Symptoms of Worker Stress: Review list of worker stress

symptoms in Chapter V. Invite participants to identify

symptoms that they have experienced during the current crisis

response. Participants may complete an assessment checklist

to determine how they are doing and their personal areas of

vulnerability. Figley (2001) provides resources for assessment.

Coping Strategies: Invite participants to list coping strategies

that they use to reduce stress. Next, ask participants to

identify three strategies that they think they should use to

reduce stress. Divide the group into groups of three or four

and ask them to share what they have identified. Also, remind

the group that this can be another opportunity to practice

listening skills. Then, ask the groups to consider how

coworkers and the program as a whole might support their

staff’s continuing efforts to do what is helpful to them and to

begin doing activities on their “should” lists.

Ask each group to summarize and report ideas, and write on

a flip chart. The flip chart list will contain some ideas for

assisting staff with follow through on stress management.

Model giving positive and encouraging feedback. Make the

point that giving positive feedback and saying “thank you”

often can be a powerful stress intervention.

This exercise can specify methods of team support for stress

management (e.g., group walks at lunch, reduced group rates

at a nearby gym, on-site yoga classes at lunch, a positive

incentive system for stress-reducing activities with “rewards,”

buddy support, and accountability system).

MODULE 9: 

Stress Prevention,

Management, and

Intervention (Continued)
Chapter VII: Comprehensive Training Course Outline • 119

Organizational and Individual Approaches to Preventing and

Managing Stress: Using Overheads #42 and #43, present

information contained in Tables 4 and 5. Program managers

may discuss how organizational recommendations are

addressed and the plan for future stress management. They

may make a strong statement about the program’s

commitment to supporting workers and promoting stress

management. Stress reduction strategies generated in the

previous exercise may also provide examples.

Team Building Exercise: Ask participants to jot down their best

team experiences (sports, clubs, jobs, etc.). Then, invite them

to silently reflect on the characteristics of those teams and the

roles they had. List these characteristics on a flip chart and

lecture on what contributes to effective work teams.

Next, ask participants to consider how they want to work

together and what norms or principles they would like to see

the group adopt. Examples might include “We will encourage,

initiate, and participate in direct communication;” “We will

discuss work issues with an involved third person as they

occur;” “We will responsibly manage our time and workload;”

or “We will treat each other with respect.” Combine

individual lists to generate a list that reflects all of the input.

After reviewing the combined list, each participant votes on

his or her top three. Narrow the list down to five to seven

briefly stated items and ask, “Is there anything on this list with

which anyone cannot live?” The agreed upon list can be

written up and posted at program offices. At staff meetings,

groups can check back to determine how they are abiding by

the principles. A more formal evaluation can provide the basis

for future team-building interventions. This process may be

started at the comprehensive training and then continued at

in-service training sessions.

Self-Awareness Exercises: Self-awareness is an essential

ingredient in understanding and managing stress and

addressing compassion fatigue. In this initial training, it is

important that participants do not feel pushed to disclose

personal information that they do not want to share. Over

time, it will be important for staff to understand and deal with

their personal reactions, countertransference, their own

experiences of trauma and loss, and their motivations for and

vulnerabilities to helping survivors. This process may occur 

MODULE 9: 

Stress Prevention,

Management, and

Intervention (Continued)
120 • Mental Health Response to Mass Violence and Terrorism

through in-service workshops, group consultation, group

debriefing sessions, clinical supervision, or confidential

individual counseling support.

Stress Reduction Exercises: These exercises can be

incorporated at different points during the training. Later, they

can be used to start or end staff meetings, group consultation

sessions, or as scheduled activities:

1. Invite the group to stand and stretch, reaching hands

toward the ceiling and breathing deeply with each stretch;

2. Facilitate a guided imagery process. Ask participants to

close their eyes and sit comfortably. Dim the lights and

encourage deep breathing, physical relaxation, and visualization of a personal and peaceful place;

3. Encourage participants to take a quiet 15-minute break by

themselves. They might walk outside, noticing vegetation,

smells, etc., or sit and read or write, or close their eyes and

meditate. Suggest that the group maintain silence during

the break as an experiment; and

4. As a homework exercise, encourage participants to do one

self-care activity. This could be exercising, reading a book,

spending time with a friend or family member, doing a

crossword puzzle, working in the yard, taking a bath, etc.

The next morning in class, invite participants to share what

they did. Again, respond positively to participants’ efforts.

These activities and the group encouragement help foster a

workplace culture that supports stress management.

MODULE 9: 

Stress Prevention,

Management, and

Intervention (Continued)
Chapter VII: Comprehensive Training Course Outline • 121

TRAINING OVERHEADS
Terrorism within the 

United States

“An activity that involves a violent

act or an act of dangerousness to

human life that is in violation of

the criminal laws of the United

States, or of any State...and that

appears to be intended to

intimidate or coerce a civilian

population...or to influence the

policy of government by assassination or kidnapping.” 

[18 U.S.C. 3077]

O VERHEAD 1
Mass Violence within the 

United States

“An intentional violent criminal

act, for which a formal investigation has been opened by the FBI

or other law enforcement agency,

that results in physical, emotional,

or psychological injury to a

sufficiently large number of people

as to significantly increase the

burden of victim assistance for the

responding jurisdiction.”

O VERHEAD 2
Dimensions of Traumatic

Exposure

■ Threat to life and limb

■ Severe physical harm or injury

■ Receipt of intentional harm or

injury

■ Exposure to the grotesque

■ Violent/sudden loss of a loved

one

■ Witnessing or learning of

violence to a loved one

(Green, 1993)

O VERHEAD 3
Comparing Criminally HumanCaused and Natural Disasters

■ Causation

■ Appraisal of Event

■ Psychological Impact

■ Subjective Experience

■ Worldview/Basic Assumptions

■ Stigmatization of Victims

■ Phases of Recovery

■ Media

■ Secondary Injury

O VERHEAD 4
Population Exposure Model

O VERHEAD 5

A

E

D

C

B

A: Community victims killed and seriously injured

Bereaved family members, loved ones, close friends

B: Community victims exposed to the incident and disaster scene, but

not injured

C: Bereaved extended family members and friends

Residents in disaster zone whose homes were destroyed

First responders, rescue and recovery workers

Medical examiner’s office staff

Service providers immediately involved with bereaved families, 

obtaining information for body identification and death notification 

D: Mental health and crime victim assistance providers

Clergy, chaplains

Emergency health care providers

Government officials

Members of the media

E: Groups that identify with the target-victim group

Businesses with financial impacts

Community-at-large

F IGURE 1: P OPULATION E XPOSURE M ODEL
Survivor Risk and Resiliency

Factors

■ Psychological

■ Capacity to tolerate stress

■ Prior trauma history

■ Socioeconomic and educational

level

■ Family stability

■ Social support

■ Female gender

O VERHEAD 6
Model of Psychological

Responses to Trauma and

Traumatic Bereavement

O VERHEAD 7

F IGURE 2: M ODEL OF R ESPONSES TO T RAUMA AND B EREAVEMENT

(Note. Adapted from CMHS, 1994)
Community Response Phases

■ Impact

■ Heroic

■ Honeymoon

■ Disillusionment

■ Reconstruction

O VERHEAD 8
Physical Reactions

■ Agitation, hyper-arousal

■ Fatigue, exhaustion

■ Hot or cold sensations

■ Gastrointestinal distress

■ Tightness in throat, chest

■ Appetite change

■ Worsening of health conditions

O VERHEAD 9
Behavioral Reactions

■ Sleep problems, nightmares

■ Jumpiness, easily startled

■ Hyper-vigilance 

■ Crying and tearfulness

■ Avoidance of reminders

■ Increased family conflicts

■ Isolation, social withdrawal

O VERHEAD 1 0
Emotional Reactions

■ Shock, disbelief

■ Anxiety, fear about safety

■ Irritability, anger, rage

■ Sadness, grief, depression

■ Numbness, disconnection

■ Hopelessness and despair

■ Survivor guilt, self-doubt

O VERHEAD 1 1
Cognitive Reactions

■ Confusion, disorientation

■ Intrusive thoughts, images

■ Recurring dreams, nightmares

■ Memory and concentration

difficulties

■ Difficulty making decisions

■ Focus on protecting loved ones

■ Questioning spiritual beliefs

O VERHEAD 1 2
Considerations with 

Older Adults

■ Physical vulnerability

■ Chronic health conditions

■ Medication needs

■ Auditory, visual, mobility, or

cognitive impairment

■ Increased anxiety, confusion

■ Loss of home health support

O VERHEAD 1 3
Incident Command System (ICS)

Organizational Components

O VERHEAD 1 4

Safety 

Officer

Planning/Intel

Section

Fire Service 

Branch

Fire

Rescue

HAZMAT

Security 

Group JTTF

NOC

TOC

Air Mission

Group

Aviation

Support 

Group

Aviation

HMRU

FBI ERT

Situations

Unit Personnel

Staging

Supply

Food

Compensation/

Claims Unit

Unified

Command

(Police, Fire, EMS, FBI)

Forward

Coordinating

Team

Liaison

Officer

Command

Post Scribe

Public 

Information

Officer

Operations

Section

Logistics

Section

Finance/Admin

Section

Law 

Enforcement

Branch

FBI Crisis

Management

Branch

Air Ops

Branch

Medical 

Services

Branch

Evacuation 

Group

Traffic 

Control 

Group

Tactical 

Group

Civil

Disorder 

Group

Medical 

Response 

Group

Crisis 

Negotiation 

Team

Technical

Specialists

Investigations

Unit

 Demobilization

Unit

Documentation

Unit

Resource

Unit

Time

Unit

Procurement

Unit

FIGURE 3: ON-SCENE COORDINATION—THE FBI, POLICE, FIRE, AND EMS

United States Government (2001), Interagency Domestic Terrorism Concept of Operations Plan

Note: Operational control of assets at

the scene is retained by the designated

officials representing the agency (local,

State, or Federal) providing the assets.

FBI Acronym Key

HMRU– Hazardous Materials Response Unit

JTTF– Joint Terrorism Task Force

FBI ERT– FBI Evidence Response Team

TOC– Tactical Operations Center

NOC– Negotiations Operations Center
Mental Health Roles in Crisis

Response

■ Mental health consultation

■ Liaison with key agencies

■ Psycho-education through media

■ Mental health services with

survivors, families

■ Mental health services with

responders

■ Stress management support

O VERHEAD 1 5
Key Concepts

■ Normal reactions to an abnormal

situation

■ Avoid “mental health” terms and

labels

■ Assume competence and

capability

■ All who witness are affected

■ Respect differences in coping

O VERHEAD 1 6
Key Concepts (continued)

■ First, do no harm

■ Assistance is practical and

flexible

■ Focus on strengths and potential

■ Encourage use of support

network

■ Tailor for active, community fit

■ Be innovative in helping

O VERHEAD 1 7
On-Scene Interventions

■ Direct to medical care, safety,

shelter

■ Protect from trauma, media,

onlookers

■ Connect to family, information,

comfort 

(Myers and Wee, 2003)

O VERHEAD 1 8
Immediate Interventions

■ Rapid assessment and triage

■ Psychological first-aid

■ Crisis intervention

■ Crime victim assistance

■ Psycho-education

O VERHEAD 1 9
Immediate Interventions 

(continued)

■ Informational briefings

■ Community outreach

■ Participation in death 

notifications

■ Mental health consultation

■ Debriefing and community

meetings

■ Information and referral

O VERHEAD 2 0
Psychological First-Aid

■ Provide comfort, empathy, an

“ear”

■ Address physical needs

■ Provide concrete information

about what will happen next

■ Link to support systems

■ Reinforce coping strengths

O VERHEAD 2 1
Crisis Intervention

■ Promote safety and security

■ Gently explore trauma

experience

■ Identify priority needs and

solutions

■ Assess functioning and coping

■ Provide: Reassurance

Psycho-education

Practical assistance

O VERHEAD 2 2
Crime Victim Assistance

■ Protect victims’ rights

■ Ensure control over media

contacts

■ Provide criminal justice

information

■ Facilitate access to 

compensation

■ Streamline bureaucratic

procedures

O VERHEAD 2 3
Community Outreach

■ Initiate contact at gathering sites

■ Set up 24-hour telephone

hotlines

■ Outreach to survivors through

media, Internet

■ Educate service providers

■ Use bilingual and bicultural

workers

O VERHEAD 2 4
Participation in Death

Notification

Responsible notifier:

■ Obtains critical information 

■ Notifies next-of-kin directly,

simply, in person

■ Expects intense reactions

■ Provides practical assistance

■ Mental health participates on

team, provides support and

information

O VERHEAD 2 5
Brief Trauma Intervention

■ Factual information

■ Thoughts during event

■ Reactions and feelings

■ Psycho-education

■ Problem-solving and action

O VERHEAD 2 6
Long-Term Interventions

■ Community outreach

■ Brief counseling

■ Support and therapy groups

■ Crime victim assistance

■ Psycho-education

O VERHEAD 2 7
Beware! Common Pitfalls 

And Risks

■ Over-involvement, doing too

much

■ Confusing friend and counselor

roles

■ Becoming lax about 

confidentiality

■ Providing services beyond

competency

■ “I’m the only one who can...”

syndrome

■ Disengaging from family and

own life

O VERHEAD 2 8
Key Events with Mental Health

Implications

■ Death notification

■ Ending rescue and recovery

■ Applying for death certificates

■ Criminal justice proceedings

■ Returning to impacted areas

■ Funerals and memorials

O VERHEAD 2 9
Community Interventions

■ Memorials and rituals

■ Usual community gatherings

■ Anniversary commemorations

■ Symbolic gestures

O VERHEAD 3 0
Preschool-Age Children’s

Reactions

■ Sleep problems, nightmares

■ Clinging, separation anxiety

■ Helplessness, passivity

■ Death not permanent

■ Fearfulness

■ Regression

■ Repetitive play 

O VERHEAD 3 1
School-Age Children’s

Reactions

■ Sleep problems, nightmares

■ Preoccupation with disaster,

death

■ Fears about safety

■ Self blame, guilt, responsibility

■ Angry outbursts

■ Retelling and repetitious play

■ Social withdrawal

■ Somatic complaints

■ School performance problems

O VERHEAD 3 2
Pre-Adolescents and

Adolescents

■ Sleep problems and nightmares

■ Self blame, guilt, shame

■ Self-consciousness

■ Depression, social withdrawal

■ Desire for revenge

■ Somatic complaints

■ Aggressive and risk-taking

behavior

■ School performance problems

O VERHEAD 3 3
Risk Factors for Children

■ Exposure to direct life threat and

injury

■ Witnessing mutilating injuries

■ Hearing unanswered cries for

help

■ Degree of brutality and violence

■ Unexpectedness and duration

■ Separation from family

(Pynoos, 1996; 

Vogel and Vernberg, 1993)

O VERHEAD 3 4
Screening Checklist

■ Trauma and loss exposure

■ Current level of distress

■ Social, academic, emotional, and

behavioral changes

■ Traumatic reminders at home

and school

■ Ongoing stressors at home and

school

■ Other trauma in the past year 

O VERHEAD 3 5
Tasks for Psychological

Recovery

■ Regain a sense of safety and

security

■ Gain understanding of child’s

unique experience of the trauma

■ Gain understanding of actual

events that have occurred

■ Identify and express reactions

and emotions

■ Grieve and cope with traumatic

stress

■ Resume age-appropriate roles

and activities

(Pynoos and Nader, 1993; 

Vernberg and Vogel, 1993)

O VERHEAD 3 6
Cultural Competence

■ Recognize the importance of culture and respect

diversity

■ Maintain a current profile of the cultural composition of

the community

■ Recruit disaster workers who are representative of the

community or service area

■ Provide ongoing cultural competence training to disaster

mental health staff

■ Ensure that services are accessible, appropriate, and

equitable

■ Recognize the role of help-seeking behaviors, customs

and traditions, and natural support networks

■ Involve as “cultural brokers” community leaders and

organizations representing diverse cultural groups

■ Ensure that services and information are culturally and

linguistically competent

■ Assess and evaluate the program’s level of cultural

competence

(CMHS, 2003)

O VERHEAD 3 7
Cultural Group Information

■ Meanings associated with the

event 

■ Experience with emergency

response

■ Trauma and violence in country

of origin

■ Signs and symptoms of trauma,

grief

■ View about mental health,

providers

■ Tips for professional courtesy

O VERHEAD 3 8
Basic Cultural Sensitivity

■ Convey respect, good will,

courtesy

■ Ask permission to speak with

people

■ Explain role of mental health

worker

■ Acknowledge differences in

behavior due to culture

■ Respond to concrete needs

(Paniagua, 1998; Young, 1998)

O VERHEAD 3 9
Sources of Stress

■ Exposure to trauma

■ High-intensity assignments

■ Environmental factors

■ Organizational factors

■ Individual factors

O VERHEAD 4 0
Stress Is:

■ Normal

■ Necessary

■ Productive and destructive

■ Acute and delayed

■ Cumulative

■ Identifiable

■ Preventable and manageable

O VERHEAD 4 1
Organizational Approaches

■ Effective management structure

■ Effective managers and

supervisors

■ Clear purpose and goals

■ Functionally defined roles

■ Team support

■ Plan for stress management

O VERHEAD 4 2
Individual Approaches

■ Management of workload

■ Balanced lifestyle

■ Stress reduction strategies

■ Self-awareness

O VERHEAD 4 3
Compassion Fatigue

“The natural consequent

behaviors and emotions resulting

from knowing about a traumatic

event experienced by a significant

other—the stress resulting from

helping or wanting to help a

traumatized or suffering person.”

(Figley, 1995)

O VERHEAD 4 4
HANDOUTS

166 • Mental Health Response to Mass Violence and Terrorism
A G E - S PECIFIC I NTERVENTIONS FOR C HILDREN

AND A DOLESCENTS

At Home

• Maintain family routines

• Give extra physical comfort and

reassurance

• Avoid unnecessary separations

• Permit child to sleep in parents’ room

temporarily

• Encourage expression of feelings through

play

• Monitor media exposure to disaster trauma

• Develop disaster safety plan

• Give additional attention and consideration

• Set gentle but firm limits for acting-out

behavior

• Listen to child’s repeated telling of disaster

experience

• Encourage verbal and play expression of

thoughts and feelings

• Provide structured but undemanding home

chores and rehabilitation activities

• Rehearse safety measures for future

disasters

At School or Other Organizations

For Children 

• Draw expressive pictures

• Tell stories of disaster and recovery

• Use coloring books on disaster, loss,

coping with feelings

• Read books on related themes

• Use dolls, puppets, toys, blocks for reenactment play

• Facilitate group activities that foster

empowerment and understanding

• Talk about safety and self protection

• Provide parent education and support

meetings

• Provide absenteeism outreach to families

and children*

• Identify stressed children for assessment

and referral*

• Provide in-service training on children and

disaster, trauma, and grief*

• Provide school-based crisis hotline*

• Provide educational brochure for parents*

• Encourage students to resume normal

roles and routine activities*

• Encourage free drawing after discussion of

disaster

• Encourage free writing after discussion of

disaster, complete-a-sentence exercise

• Tell stories of disaster, loss, and recovery

• Read books on related themes that may

generate discussion or healing

• Create a play about related themes and

survivorship

• Facilitate school study or projects to

increase understanding, promote

discussion

• Talk about safety, family protection, school

and family preparedness*

• Teach calming techniques (deep breathing,

visualization)*

• Conduct small group or individual

interventions for at-risk children*

• Conduct group “debriefing” discussion to

express and normalize reactions, correct

misinformation, and enhance coping and

peer support*

Continued on next page

Age Group

Pre-Schoolers

Elementary-Age

Children

Chapter VII: Comprehensive Training Course Outline • 167
A G E - S PECIFIC I NTERVENTIONS FOR C HILDREN

AND A DOLESCENTS

At Home

• Give additional attention and consideration

• Encourage discussion of disaster

experiences with peers, significant adults

• Avoid insistence on discussion of feelings

with parents

• Encourage physical activities

• Encourage resumption of regular social and

recreational activities

At School or Other Organizations

For Children 

• *All interventions starred above apply

• Conduct school programs for assisting

community with recovery, helping others

• Conduct projects for commemoration and

memorialization

• Encourage discussion of losses and

feelings with peers and adults

• Address rebellious, risk-taking, aggressive,

or isolating behaviors

• Resume sports, club, and social activities

when appropriate

Age Group

Pre-Adolescents

And Adolescents

Continued from previous page

168 • Mental Health Response to Mass Violence and Terrorism
VIDEOTAPES

Death Notification. Mother’s

Against Drunk Drivers

(MADD), 1996. Available:

www.madd.org

Disaster Psychology: Victim

Response. Catonsville, MD:

Instructional Media Resources,

University of Maryland,

Baltimore County, 1985.

The Federal Emergency

Management Agency (FEMA)

funded the two videotape

projects listed below through

the Crisis Counseling Program.

Copies are available at no

charge from the Center for

Mental Health Services,

National Mental Health

Services Knowledge Exchange

Network, P.O. Box 42490,

Washington, DC 20015 or by

contacting www.mentalhealth.org or calling 1-800-

789-2647.

Children and Trauma: The

School’s Response. Alameda

County Department of

VIDEOTAPES

Mental Health, Santa Cruz

County Department of

Mental Health, and

California Department of

Mental Health, 1991.

Hope and Remembrance.

Texas Department of

Mental Health, 1997.

The Office for Victims of

Crime (OVC), U.S. Department

of Justice, funded the two

videotape projects listed

below. Copies are available at

no charge through the OVC

Resource Center at

www.ncjrs.org or by calling 

1-800-851-3420.

Special Award for

Extraordinary Response to

International Terrorism.

Office for Victims of Crime,

2001.

The News Media’s Coverage

of Crime and Victimization.

National Victim Assistance

Academy, 2000.

The Bureau of Justice

Assistance, U.S. Department

of Justice, funded the

videotape project listed below.

Copies are available at no

charge through the OVC

Resource Center at

www.ncjrs.org or by calling 

1-800-851-3420.

Surviving the Secondary

Device: The Rules Have

Changed. Georgia

Emergency Management

Agency, 1997.

VII: Comprehensive Training Course Outline • 169
170 • Mental Health Response to Mass Violence and Terrorism

In the immediate phase of

crisis response, training

quickly provides necessary

logistical and intervention

information. The training is

action-oriented, brief, and

repeated as new mental health

staff join the operation.

Several months after the

disaster, program managers

assemble a group of more

permanent workers. When the

mental health response

program’s organizational

structure and procedures have

become further defined, they

resemble an established

program, as opposed to a

rapid-response mobilization. 

The comprehensive disaster

mental health training

presented in Chapter VII may

be conducted at this point in

the implementation process,

or may have been offered

earlier. This comprehensive

training provides extensive

disaster mental health and

crime victim background and

intervention information, and

also addresses team

development and worker

stress management. Over the

duration of the mental health

program, in-service continuing

education is essential, as new

training needs are identified

and phase-related issues

emerge.

Paraprofessional peer

counselors can be valuable

members of disaster mental

health recovery programs.

CHAPTER VIII

ADDITIONAL 

TRAINING NEEDS 

AND OPTIONS
While bringing varied and

salient life experiences to their

disaster work, paraprofessionals need additional

training on counseling skills,

mental health assessment and

referral, and ethical issues. 

This section addresses training

needs beyond the comprehensive training outlined in

Chapter VII. Training options

included in this chapter are:

◆ Training for paraprofessional staff;

◆ Training for human

service workers; and

◆ Topics and considerations

for in-service training.

Training for

Paraprofessional

Staff

Paraprofessional counseling

staff may be recruited from

existing community programs

such as crime victim advocacy

and service programs, senior

outreach services, faith-based

programs, cultural grouporiented service programs, or

disaster response volunteer

organizations. These workers

often reflect the demographic

characteristics and ethnic and

cultural groups present in the

disaster-affected community.

Solid interpersonal communication skills, the ability to work

cooperatively with others, the

psychological capacity to help

others without judgment, and

the ability to maintain

confidentiality are desired

qualities for paraprofessional

counselors.

When paraprofessional staff

have participated in a training

session on counseling skills

before the program’s comprehensive disaster mental health

training, they are able to

engage with the material from

a broader context and

foundation. An initial two or

three-day training course with

regular weekly or biweekly

continuing education and

supervision sessions is

suggested.

Newly trained paraprofessional

counselors should initially

work in teams with mental

health professionals. It is

critically important that roles

and limits are clearly defined

for paraprofessional

counselors and that they have

ready access to clinical

supervisors.

The following topics are

recommended for inclusion in

training for paraprofessional

staff:

Counseling Skill

Development

Active listening: Using

nonverbal cues, giving

minimal encouragement (nods

and “uh-huhs”), conveying

empathy, paraphrasing,

reflecting feelings,

summarizing, differentiating

content and feelings.

Asking questions: Interviewing

techniques, asking open and

closed questions, focusing with

questions, avoiding using

questions to give advice or

make judgments.

Providing support and encouragement: Establishing rapport,

empowering the survivor,

giving positive feedback about

coping strengths, offering

suggestions, avoiding

communication blocks and

unhelpful phrases.

Counseling Interventions

Crisis intervention: Assessing

capacity to live independently,

evaluating suicide and dangerousness risk, giving

reassurance, building hope,

protocols for immediate

response, procedures for

consultation, referral and

follow-up.

Listening to disaster

experiences: Active listening to

the telling (and retelling) of

traumatic and loss

experiences, exploring feelings

and reactions, educating about

traumatic stress and healthful

coping strategies.

Problem-solving: Identifying

and defining the problem,

exploring feelings,

brainstorming solutions and

resources, setting realistic

Chapter VIII: Additional Training Needs and Options • 171
172 • Mental Health Response to Mass Violence and Terrorism

goals, taking action, evaluating

results.

Self-Awareness

Motivations for helping:

Exploring personal

experiences, understanding

helping relationships versus

friendships, over-identifying

with survivors.

Awareness of feelings:

Identifying and articulating

feelings, becoming familiar

with range of “feeling words,”

tolerating expressions of

intense emotions that may be

uncomfortable.

Stereotypes and values:

Exploring personal biases and

prejudices, avoiding

judgmental attitudes,

promoting respect for

differences.

Assessment of Mental

Health and Other Problems

◆ Basic overview of 

post-traumatic stress,

grief and loss,

depression, anxiety,

alcohol and drug abuse,

child and elder abuse,

mental illness, cognitive

impairment/dementia–

symptom recognition,

initial assessment

strategies, procedures for

consultation, referral and

follow-up. 

Legal, Ethical, and Program

Considerations

◆ Confidentiality, State law,

and reporting

requirements and

procedures;

◆ Record keeping, program

reporting and monitoring;

◆ Boundaries of

relationship with clients;

◆ Stress prevention and

management (Chapter V);

and

◆ Consultation, supervision,

and continuing

education.

Paraprofessional staff training

emphasizes that the helping

person is in a privileged

position. Helping someone in

need implies a sharing of

problems, concerns, and

anxieties—sometimes with

very personal details. This

sharing cannot be done

without a trust built upon

mutual respect and the explicit

understanding that all

discussions are confidential

and private. This mutual

respect also involves

acceptance of the survivor’s

experience, thoughts, and

feelings. Judging, moralizing,

or telling survivors how to feel

only alienates and undermines

the helping relationship.

Counseling skill-building

through role-playing,

observing role models,

discussing case examples, and

giving and receiving feedback

helps paraprofessional staff

gain competency. Having clear

guidelines for assessment and

referral helps counselors

function within the boundaries

of their training. Training facilitators must be adept at

identifying and processing

feelings, evaluating and

promoting counseling skill

development, and providing

clear and concise procedures

for handling challenging

situations. Training for

paraprofessional counselors

should be ongoing and

integrated with case consultation and practicing

counseling skills.

Training for

Human Service

W orkers

Human service workers may

be directly involved in the

disaster relief effort through

Federal, State or local

agencies, emergency services,

law enforcement, crime victim

services agencies, the

American Red Cross, the

Salvation Army, or local

religious organizations. Most

will benefit from focused

training on disaster mental

health issues geared to their

respective roles. Developing a

good working relationship with

these entities for mutual

referrals is a valuable byproduct of such training. The

companion Field Manual is a

helpful resource as an adjunct

to training.
This training can be

accomplished in several ways.

Representatives from the

various agencies and organizations may attend the

comprehensive mental health

course described in Chapter

VII. When this occurs, the

trainer should rearrange the

training schedule so that

representatives from outside

agencies attend for the first

day, or mornings. The training

agenda should efficiently

address these representatives’

needs, while meeting the

diverse training needs of the

mental health program staff.

Another alternative is

providing on-site disaster

mental health training with

each group. The training then

can specifically address each

group’s needs. Activities,

overheads, videos, and

handouts can be used from the

comprehensive training as

needed. However, losing

exposure to the entire mental

health program staff is a 

trade-off.

Disaster relief and recovery

workers compose one type of

human service worker

involved with survivors. Other

human service workers

encounter survivors in the

course of conducting business

or providing services.

Examples are home health

nurses, public assistance

workers, school personnel,

building permit inspectors,

faith-based staff, or primary

health care providers. Disaster

mental health training and

educational materials can

assist these individuals in

better serving survivors and to

refer those in need for mental

health services. Also, these

individuals can distribute

disaster stress and coping

brochures to survivors.

The program may establish a

task group to design outreach

strategies, training presentations, and educational

materials for these collateral

providers and human service

workers in the community.

Since experience has shown

that many survivors are more

likely to talk with their

physician, faith-based

counselor, or someone already

known to them before talking

with a professional, outreach

and education with these

groups is extremely important.

T opics and

Considerations

For In-Service

Training 

The comprehensive training

course provides staff with an

overview of mental health

interventions following

incidents involving mass

violence and terrorism.

Because of the significant

psychological and physical

impact of these events,

SINCE EXPERIENCE 

HAS SHOWN THAT MANY 

SURVIVORS ARE MORE 

LIK ELY TO TALK WITH 

THEIR PHYSICIAN, FAITHBASED COUNSELOR, OR 

SOMEONE ALREADY KNOWN 

TO THEM BEFORE TALKING

WITH A PROFESSIONAL, 

OUTREACH AND EDUCATION

WITH THESE GROUPS IS 

E XTR EM ELY IM PORTANT.

Chapter VIII: Additional Training Needs and Options • 173
additional training and clinical

supervision on group and

individual counseling

interventions with survivors

and family members is

necessary. As staff engage

with the various disasteraffected communities over

time, additional phase-related

training needs become

apparent. These identified

training needs may involve

particular population groups,

specific community issues, or

needed modifications of

intervention strategies. Timing

or phase-related topics, such

as the one-year anniversary of

the disaster, may become

relevant.

In-service training also brings

the staff together to strengthen

group cohesion, social support,

morale, and creativity. The

focus of the session may be

tending to the emotional

challenges of disaster work

through personal sharing and

problem-solving new

solutions. Some of the

suggestions and exercise ideas

in Chapter V, “Stress

Prevention, Management and

Intervention,” can be included

in the training. A skilled

facilitator may identify organizational issues or procedures

that may interfere with staff

well-being or program

effectiveness that can be

addressed through teambuilding interventions.

The following are examples of

in-service training topics:

◆ Media policies, relations,

and dissemination of

public information;

◆ Public speaking skills for

disaster mental health

presentations;

◆ Stress management

interventions for

survivors, disaster

workers, and program

staff;

◆ Addressing compassion

fatigue and secondary

traumatization;

◆ Outreach, support, and

interventions with

emergency responders

and other high-exposure

occupational groups and

their families;

◆ More extensive training

on serving children, elder

adults, or ethnic/cultural

groups in the community;

◆ Long-term family stress

issues, family counseling,

and intervention;

◆ Criminal justice process

and impact on survivors

and families;

◆ Mental health program

role and interventions

with post-traumatic

stress disorder, traumatic

bereavement, anxiety

disorders, depression,

adjustment to disabling

injuries, and alcohol and

drug abuse problems;

◆ Expressive intervention

approaches (art, music,

drama, writing,

community projects) with

adults and children;

◆ Individual and group

trauma and grief

counseling with at-risk

children;

◆ Models for therapy and

support groups;

◆ Community organizing to

address unmet disasterrelated needs;

◆ Anniversary reactions

and commemorative

events;

◆ Steps for program phasedown and termination of

program and services;

and

◆ Final celebration of

program success and

lessons learned.

174 • Mental Health Response to Mass Violence and Terrorism
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