A F i e l d

G u i d e • c1

A FIELD GUIDE

MENTAL HEALTH RESPONSE TO 

MASS VIOLENCE AND TERRORISM

MENTAL HEALTH RESPONSE TO 

MASS VIOLENCE AND TERRORISM

Disaster

Response

Disaster

Planning

U.S. DEPARTMENT OF JUSTICE

Office of Justice Programs

Office for Victims of Crime

www.ojp.usdoj.gov/ovc

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A FIELD GUIDE

U.S. Department of Health and Human Services

Substance Abuse and Mental Health Services Administration

Center for Mental Health Services

2005

MENTAL HEALTH RESPONSE TO 

MASS VIOLENCE AND TERRORISM

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This publication was produced under Interagency Agreement

#RA00C5400A between the U.S. Department of Justice (DOJ),

Office for Victims of Crime (OVC), and the Center for 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, and layout of the publication; and the Federal

Emergency Management Agency (FEMA) provided the funds for

printing. 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. This publication is a companion piece for Mental Health Response to Mass Violence and

Terrorism: A Training Manual (SAMHSA Publication No. SMA

3959), and all material referenced in the Field Guide is cited in the

Training Manual, References and Additional Reading section.

Public Domain Notice

All material appearing in this publication 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).

ACKNOWLEDGMENTS

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A F i e l d G u i d e • iii

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 4025, at 

1-800-789-2647, 1-866-889-2647 (TDD); or contact the OVC

Resource Center, and ask for Publication No. NCJ 205452, 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 Field Guide. DHHS Pub.

No. SMA 4025. Rockville, MD: Center for Mental Health Services,

Substance Abuse and Mental Health Services Administration,

2005.

Originating Office

Substance Abuse and Mental Health Services Administration

1 Choke Cherry Road, Rockville, Maryland 20857

DHHS Publication No. SMA 4025

Printed 2005

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

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

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

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

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

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

Some Possible Do’s and Definite Don’ts . . . . . . . . . . . . . . . . . . . .9

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

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

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

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

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

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

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

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

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

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

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

Human Service, Criminal Justice, and Emergency 

Response Workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

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

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

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

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

A F i e l d G u i d e • v

TABLE OF CONTENTS

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This Field Guide is intended for mental health and disaster

workers; first responders; government agency employees; and

crime victim assistance, faith-based, healthcare, and other service

providers who assist survivors and families during the aftermath

of mass violence and terrorism. All who come in contact with

victims and families can contribute to restoring their dignity and

sense of control by interacting with sensitivity, kindness, and

respect. This Field Guide provides the basics of responding to

those in crisis. 

Human-caused events such as mass shootings, bombings, riots,

exposure to biohazards, and acts of terrorism are deliberately

planned and perpetrated for political, sociocultural, revengemotivated, or hate-based reasons. Acts of mass violence and

terrorism target a building, neighborhood, particular site, or event.

Those confronted with life threat, mass casualties, overwhelming

terror, and human suffering may experience severe psychological

stress and trauma. Survivors, families, and the affected communities cope not only with the resulting deaths, injuries, and

destruction but also with the horrific knowledge that their losses

were caused by intentional human malevolence. When rescue

and recovery efforts extend over weeks and months, family

members endure prolonged uncertainty and an ongoing threat of

possible future attacks, which contribute to heightened anxiety

and a sense of vulnerability. These traumatic realities also impact

first responders, media personnel, government officials, and

others whose job-related responsibilities bring them in contact

with the disaster’s tragic impact.

Because disasters caused by mass violence and acts of terrorism

are also crimes, law enforcement and the criminal justice system

fill primary roles. When the underlying motivation is terrorism,

Federal criminal justice agencies are responsible for the investigation and prosecution. The disaster’s impact zone becomes a

A F i e l d G u i d e • vii

INTRODUCTION

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secured crime scene. Crime victims and their families have the

legal right to receive information about criminal justice activities,

participate in the criminal justice process, and receive protection

from intimidation and harassment. They may apply for benefits

and compensation for crime-related expenses. This interplay of

emergency response, criminal justice, and disaster relief and

recovery systems is a defining feature of the response to mass

violence and terrorism.

This Field Guide includes essential information about survivors’

and family members’ reactions and needs, with specific suggestions for assisting children, adolescents, adults, and older adults.

It describes basic “helping” skills with indicators for when to refer

someone to a licensed mental health professional. The last

section presents strategies for worker* stress prevention and

management.

This Field Guide draws from material contained in Mental Health

Response to Mass Violence and Terrorism: A Training Manual and

highlights practical approaches. The Training Manual provides

indepth and comprehensive information, and references for

additional reading.

*In this Field Guide, the term “worker” refers to service providers and

others who assist survivors and families.

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Workers assisting survivors

and family members may

find the following key

principles helpful, as they

frequently are used by

seasoned crime victim

assistance and disaster

mental health professionals:

◆ No one who witnesses

the consequences of

mass criminal violence is

unaffected by it.

◆ Mass violence and

terrorism result in two

types of human impact—

individual and

community.

◆ Mental health, crime victim assistance and other

human services must be

uniquely and individually

tailored to the communities they serve. Cultural

competence is essential.

◆ While most traumatic

stress and grief reactions

are normal responses to

extraordinary circumstances, a significant

minority of survivors

experience serious, longterm psychological

difficulties.

A F i e l d G u i d e • 1

KEY PRINCIPLES

FOR MENTAL HEALTH

INTERVENTION

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◆ Most survivors and families respond to active, genuine interest

and concern. However, some will reject services of all kinds.

◆ Mental health assistance is practical, flexible, empowering, and

respectful of survivors’ needs to pace their exposure to harsh

realities resulting from the event. First and foremost, providers

must do no harm when intervening.

◆ Procedures and protocols used by emergency services, law

enforcement, medical examiners’ offices, and the criminal

justice system can confuse and distress survivors. Clear,

sensitive explanations are helpful.

◆ Support from family, friends, and the community helps

survivors and families cope with trauma and loss.

When mass violence occurs, innocent and unsuspecting people

are caught by surprise in the course of their daily routines. These

people usually are well-functioning and resilient. They have the

capacity to cope with the profound psychological demands and

losses they experience. Communities, families, and social support

systems pull together to comfort and support those most

impacted.

Workers providing emotional support take a practical, down-toearth approach. They reach out to survivors and respectfully offer

reassurance, a listening ear, a warm beverage, concrete information about what will happen next, and practical assistance with

immediate tasks. Survivors and families may gather at designated

sites such as community centers, schools, employment settings,

local places of worship, and disaster relief centers. They may not

think they need ”psychological counseling” or “mental health

services” but may welcome genuine concern and help to cope

with the stress. “Mental health support” can even take place over

a cup of coffee.

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

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the primary languages spoken, and demographic and socioeconomic characteristics. A particular group may have been 

the target of violence due to prejudice or hate. If the alleged

perpetrators are from a particular country or group, U.S. citizens

and residents with similar physical characteristics or origins may

be at risk for harassment and retaliatory violence. Crisis mental

health support must help each affected group in the community.

A F i e l d G u i d e • 3

Tailor Support to Community Needs

✔ Be culturally sensitive.

✔ Provide information and services in the

appropriate language.

✔ Understand the disaster’s specific impact on

affected cultural groups.

✔ Collaborate and consult with trusted organizations

and community leaders to serve all members of

the community.

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SURVIVORS’

AND FAMILIES’

IMMEDIATE NEEDS

Experiencing an act of

terrorism or mass violence

involving exposure to mass

casualties, extreme trauma,

and threats causes predictable human reactions.

Most survivors and families

have the same initial

concerns and needs. 

They accept relief efforts

more readily when first

responders, emergency

managers, law enforcement

personnel, human services

workers, and government

officials consider the

following:

◆ Physical need for

warmth, safety, rest,

fluids, and food.

◆ Emotional need for

protection, comfort,

control, reassurance, and

a “listening ear.”

◆ Fear and anxiety about

the safety and well-being

of loved ones, friends,

and coworkers.

◆ Need for connection with

loved ones and support

systems.

A F i e l d G u i d e • 5

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◆ Desire for frequent updates regarding the status of rescue and

recovery efforts, criminal investigations, potential threats, and

what is going to happen next.

◆ Need for clear, sensitive explanations of: emergency medical

procedures; medical examiner’s office procedures and

protocols; the criminal justice process; the rationale for highimpact operational decisions; and immediately available

services, benefits, grants, and assistance.

◆ Need for death notification conducted in a straightforward,

clear, and compassionate manner.

◆ Normal trauma reactions such as fearfulness, numbness,

jumpiness, sleep and concentration problems, and replaying

traumatic images and sounds.

In the days and weeks following mass violent victimization, initial

shock gives way to the realization of personal losses. The lifechanging implications of death, the destruction of home and

community, serious injuries, and the loss of a sense of safety and

security in the world become increasingly apparent. Other consequences such as loss of employment, and relocation of home,

school, or place of worship exacerbate disruption and grieving.

Survivors and families psychologically pace themselves according

to individual timeframes and personal coping styles. 

Survivors and families often face numerous logistical and

practical issues that can seem overwhelming. Workers may

facilitate assistance with transportation, child care, locating a

missing loved one or pet, funeral arrangements, finding

temporary housing, filling prescriptions, replacing eyeglasses, 

and providing healthy foods and beverages. They also may help

facilitate filling out the necessary paperwork for obtaining crime

victim compensation and benefits, a death certificate, disasterrelated unemployment, insurance benefits, and financial

assistance. Through helping with practical tasks, workers often

earn survivors’ trust and the privilege to support them when they

express their pain, fear, sorrow, and anger.

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A F i e l d G u i d e • 7

PSYCHOLOGICAL

FIRST AID AND

COUNSELING SKILLS

Workers should approach

survivors and family

members with compassion and regard for their

humanity and dignity.

This includes honoring

families’ and survivors’

wishes to be left alone 

or deal privately with 

their suffering. Workers

enhance survivors’ 

sense of control over their

situation through recognizing and reinforcing

their coping strengths,

providing clear information, and offering choices

when appropriate. When

survivors feel more secure

and in control, they can

better address immediate

challenges. Crisis support

involves guiding, listening,

reassuring, and providing

practical assistance. The

following section provides

“nuts-and-bolts”

suggestions.

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Establishing Rapport 

When making initial contact, workers should introduce themselves and briefly explain their roles. They may ask permission to

sit down, since standing over people when they are seated may

seem intimidating. Workers convey genuine interest and concern

through eye contact, the assurance of safety, offering a warm

beverage, and a calm presence. They provide comfort, support,

and nonjudgmental response to expressed immediate needs.

Trust and safety are enhanced when workers listen to what

distressed survivors and family members choose to discuss and

avoid asking intrusive questions.

Active Listening

Workers listen most effectively when they absorb information

through their ears, eyes, and hearts. Some tips for effective

listening are:

◆ Support personal “pacing”—Many survivors and family

members want to talk about their traumatic experiences.

Putting terrifying and tragic experiences into words and having

them heard while receiving emotional support can contribute

to the healing process. Others may choose to focus on concrete

tasks or seemingly inconsequential matters, temporarily

avoiding direct discussion of their trauma and loss. Workers

should look for cues regarding comfort levels, coping style, and

appropriate pacing, and allow survivors and family members to

take the lead with personal sharing.

◆ Allow silence—Silence can give a person time to reflect and

become aware of feelings. Silence may help survivors identify

what is most important to them at the moment, or be a prompt

for elaboration on thoughts and reactions. Simply “being with”

the survivor or family member can be supportive.

◆ Attend nonverbally—Eye contact, head nodding, caring facial

expressions, and being at the same physical level (e.g., sitting,

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A F i e l d G u i d e • 9

standing) let the person know that the worker is listening.

Observing and heeding cultural differences with regard to nonverbal communication conveys cultural sensitivity and can

enhance acceptance of help.

◆ Paraphrase—The worker conveys understanding, interest, and

empathy by repeating portions of what the person has said.

Paraphrasing also checks for accuracy, clarifies misunderstandings, and lets the person know that he or she is being heard.

Good lead-ins are: “So you are saying that...,” “It sounds like

you...,” or “I have heard you say that....” Paraphrasing may seem

awkward at first, but is an effective tool for building trust.

◆ Reflect feelings—The worker may notice that the person’s

tone of voice or nonverbal gestures suggest emotions such as

anger, sadness, or fear. Possible responses are, “You seem

afraid of spending the night at home alone. Is that true?” This

helps the person to identify and articulate emotions and needs.

◆ Allow expression of emotions—Communicating intense

emotions through tears or venting is an important part of healing. It often helps the survivor or family member work through

feelings so that he/she can better address the immediate tasks

at hand. Workers should stay relaxed and let the person know

that it is okay to feel and express emotions. [Suggestions in the

“Stress Prevention, Management, and Intervention” section

may be helpful.]

Some Possible Do’s and Definite Don’ts

Do say:

✔ You have temporarily lost your sense of safety and security.

You will feel better over time.

✔ It is understandable that you feel this way.

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✔ This is your body’s and mind’s way of dealing with what has

happened to you. Your reactions are normal.

✔ Feeling intense emotions and having thoughts that you have

never had before is normal. You are not going crazy.

✔ You didn’t do anything wrong. It wasn’t your fault. You did the

best you could.

✔ Things will never be the same as they were, but you will

gradually feel better.

Don’t say: 

✔ It could have been worse. You’re lucky that....

✔ It’s best if you just stay busy.

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

✔ I know just how you feel.

✔ He/she is in a better place now.

✔ You need to get on with your life.

While the human desire is to try to “fix” the survivor’s or family

member’s painful situation or to make them feel better, hearing

comments in the preceding “Don’t Say,” however, can make a

person feel discounted, judged, misunderstood, or more alone.

Workers may find it difficult not to overidentify with survivors and

families. They should allow survivors and families the space for

their own experiences, feelings, and perspectives—whatever they

are. Simply listening with respect, concern, and calmness can

comfort them.

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A F i e l d G u i d e • 11

Psychological First Aid

During and immediately after an act of mass violence or terrorism, those most affected may experience shock, confusion, fear,

numbness, panic, and anxiety. They may “shut down.” 

Witnessing or suspecting the death of loved ones or friends can

be emotionally overwhelming. Some people may be locked in disbelief. When the perpetrators have not been apprehended or the

event is considered terrorism, all may experience a sense of continued threat and danger. Workers have seven immediate tasks

and purposes:

1. Identify those in need of medical attention for intense

stress reactions.

2. Provide protection from further harm, and assistance to a

safe environment.

3. Ensure that survivors are warm/cool enough and are being

given fluids and food.

4. Promote a sense of security through orienting and

reassurance.

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

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

7. Connect survivors and family members with resources for

immediate help (e.g., voluntary agencies, crime victim

assistance, systems for locating missing persons,

emergency shelter and food, faith-based resources, and

disaster mental health and psychiatry).

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Problem Solving

Stress resulting from trauma, crime victimization, and sudden

bereavement often causes disorganized thinking, concentration

problems, and difficulty planning and making decisions. Some

people react by feeling overwhelmed and may become either

immobilized or unproductively overactive. Workers can

encourage survivors and family members to participate in simple

concrete tasks to help them focus and assume a more active role

in coping. Also, workers can guide individuals through the

following problem-solving steps to help prioritize and address

immediate issues.

◆ Identify current priority needs and problems and

possible solutions

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

Selecting one solvable problem and then successfully

addressing it can help restore a sense of control and capability.

Avoid picking a complex problem first. Support the person in

identifying a task that is easily completed. 

◆ Assess functioning and coping

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

coping?”

“How have you handled stressful life events in the past?”

Through observation, gently asking questions, and reviewing

the magnitude of the person’s problems and loss, the worker

develops an impression of the person’s capacity to address

current challenges. Based on this assessment, the worker may

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A F i e l d G u i d e • 13

point out coping strengths, facilitate the person’s engagement

with social supports, or make referrals. The worker may also

seek consultation from a medical or mental health

professional.

◆ Evaluate available resources

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

“What resources and options might be helpful?”

Explore existing sources of assistance and support such as

immediate and extended family, loved ones, friends, neighbors,

coworkers, religious leaders, and healthcare providers. Connect

the survivor or family member with the appropriate community, crime victim assistance, and disaster relief resources and

assess if he/she is able to make the calls and complete the

required paperwork. Assist with accessing resources when

necessary.

◆ Develop and implement a plan

“What steps will you take to address this problem?”

Encourage the survivor or family member to say out loud what

they plan to do and how. Offer to check in for support and to

see how he/she is doing. If the worker has agreed to perform a

task or get information, it is very important to follow through. A

plan may focus on a very short timeframe or limited actions.

For example, a plan could be to make two phone calls. Being

reliable and following up, even when there is no new information, helps survivors gain control. Workers should promise only

what they can do, not what they would like to do.

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A Word of Caution

When confronted with a survivor’s or family member’s seemingly

overwhelming and heart-wrenching needs, workers can feel the

understandable impulse to help in every way possible. Workers

may become over-involved and do too much for the survivor or

grieving family, which is usually not in the survivor’s or family’s

best interest. While being helpful and available, workers should

also convey their confidence in the individual’s coping abilities

and resilience. When survivors and families are empowered to

address their own problems, they feel more capable to tackle the

next challenge. 

Confidentiality

The privilege of helping others carries ethical responsibilities.

Helping people in need involves learning their problems,

concerns, fears, and anxieties—sometimes with very personal

details. This sharing must be done with a sense of trust, built

upon mutual respect, and the understanding that all discussions

are confidential. No person’s situation or “case” should be

discussed elsewhere without the consent of the person being

helped, except in extreme situations when the worker believes the

person might harm him/herself or others. Under those circumstances, workers should report concerns to their supervisors so

that the appropriate authorities may be contacted.

Workers should avoid discussing information in public places,

such as restaurants, that might give the impression that privacy is

not being protected. Only by maintaining the trust and respect of

the survivor or family member can the privilege of helping

continue.

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A F i e l d G u i d e • 15

WHEN TO REFER

FOR MENTAL

HEALTH SERVICES

Workers should make

referrals to mental health

and other healthcare professionals when they

encounter survivors and

family members with

severe physical or emotional reactions. Some

may have preexisting

physical or psychiatric

conditions that have worsened because of traumatic

stress. The following reactions, behaviors, and

symptoms signal a need

for the worker to consult

with his or her supervisor

and, in most cases, refer

the person for assessment

and more specialized

assistance. In all instances,

when in doubt, consult.

◆ Disorientation: The

person is dazed and

unable to give date or

time, location, and

events of the past 24

hours, or understand

what is happening.

◆ Anxiety and

Hyperarousal: The person is highly agitated,

restless, jumpy, and on

edge; is unable to sleep;

has frequent disturbing

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nightmares, flashbacks, and intrusive thoughts; or broods over

circumstances surrounding the event.

◆ Dissociation: The person exhibits pronounced emotional

disconnection, an incomplete awareness of the traumatic

experience, a sense of seeing him/herself from another

perspective, a perception that the environment is unreal or that

time is distorted.

◆ Depression: The person exhibits pervasive feelings of

hopelessness and despair; unshakeable feelings of worthlessness, guilt, or self-blame; frequent crying for no apparent

reason; withdrawal from others; or inability to engage in

productive activity.

◆ Mental Illness: Symptoms include hearing voices, seeing

things or people that are not there, delusional thinking,

appearing out of touch with reality, and excessive preoccupation with an idea or thought.

◆ Inability to Care for Self: The person does not eat, bathe, or

change clothes; is apathetic, isolated from others, and unable

to manage activities of daily living.

◆ Suicidal or Homicidal Thoughts or Plans: The person

makes statements like “I can’t go on,” “I just want to end this

terrible pain I’m feeling,” “I wish that I had died,” “I want to join

my husband in heaven,” or “I’m going to get even.” The person

feels pervasive self-blame or sense of responsibility for another

person’s death.

◆ Problematic Use of Alcohol or Drugs: The person makes

references to getting drunk, getting high, or not being able to

stop drinking; blocks out pain with mood-altering substances;

relapses from previous abstinence; misses work or other

obligations due to alcohol or drug use; or expresses concern

about a family member’s substance use.

◆ Domestic Violence, Child Abuse, or Elder Abuse: The

person mentions instances of inappropriate anger or violence

toward family members.

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A F i e l d G u i d e • 17

POPULATIONS WITH

SPECIAL NEEDS

Terrorism and mass

violence inevitably touch

all who are in their zone of

impact. This zone may

include people of different

ages and economic means;

people of various cultural,

racial, and ethnic backgrounds; people with different sexual orientations

and family configurations;

people who speak foreign

languages; people from

many occupational groups;

and people who have roles

in emergency response

and recovery efforts. 

The basic human need for

survival, safety, protection,

connection with loved

ones, and accurate information are shared, while

additional needs may be

more specific to a particular group. Workers are

most effective when they

are informed about,

respectful of, and responsive to the various groups

in the affected community.

Special consideration

should be given to the following groups as well as

others with special needs:

OVC Field Guide.qxd 9/16/2005 1:07 PM Page 17
◆ Age groups (e.g., children, teenagers, older adults);

◆ Highly impacted survivors and families;

◆ Cultural, ethnic, and racial groups;

◆ People with serious and persistent mental illness;

◆ Human service, criminal justice, and emergency response

workers.

Age Groups

Each age group is vulnerable in unique ways to the stress of

trauma, victimization, and sudden bereavement. Some of the

reactions listed in Table 1 may be immediate, while others may

appear months later. Table 1 describes possible behavioral,

physical, and emotional reactions of different age groups and

options for helpful intervention.

18 • M e n t a l H e a l t h R e s p o n s e t o M a s s V i o l e n c e a n d T e r r o r i s m

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A F i e l d G u i d e • 19

• Clinging to

parents or

familiar adults

• Helplessness

and passive

behavior

• Resumption of

bed wetting or

thumb sucking 

• Fear of the dark

• Avoidance of

sleeping alone 

• Increased crying

REACTIONS TO TRAUMA AND

SUGGESTIONS FOR INTERVENTION TABLE 1: 

Continued on next page

1-5 • Loss of appetite

• Stomach aches

• Nausea

• Sleep

problems,

nightmares

• Speech

difficulties

• Tics

• Anxiety

• Generalized

fear

• Irritability

• Angry outbursts

• Sadness 

• Withdrawal

• 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

Ages Behavioral Physical Emotional Intervention Options

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20 • M e n t a l H e a l t h R e s p o n s e t o M a s s V i o l e n c e a n d T e r r o r i s m

• 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

6-11 • Change in

appetite

• Headaches

• Stomach aches

• Sleep

disturbances,

nightmares

• Somatic

complaints

• 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

REACTIONS TO TRAUMA AND

SUGGESTIONS FOR INTERVENTION

Ages Behavioral Physical Emotional Intervention Options

• Fear of feelings

• Withdrawal from

friends, familiar

activities

• Reminders

triggering fears

• Angry outbursts

• Preoccupation

with crime,

criminals,

safety, and

death

• Self-blame 

• Guilt

Continued from previous page

TABLE 1: 

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A F i e l d G u i d e • 21

• 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

• Use of alcohol or

illegal drugs

12-18 • Appetite

changes

• Headaches

• Gastrointestinal

problems

• Skin eruptions

• Complaints of

vague aches

and pains

• Sleep disorders

• 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

REACTIONS TO TRAUMA AND

SUGGESTIONS FOR INTERVENTION

Ages Behavioral Physical Emotional Intervention Options

• 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, selfblame, shame

and selfconsciousness

• Desire for

revenge

TABLE 1: 

Continued on next page

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22 • M e n t a l H e a l t h R e s p o n s e t o M a s s V i o l e n c e a n d T e r r o r i s m

• Sleep problems

• Avoidance of

reminders

• Excessive

activity level

• Protectiveness

toward loved

ones

• Crying easily

• Angry outbursts

• Increased

conflicts with

family

• Hypervigilance

• Isolation,

withdrawal,

shutting down

• Increased use of

alcohol or illegal

drugs

Adults • Nausea

• Headaches

• Fatigue,

exhaustion

• Gastrointestinal

distress

• Appetite

change

• Somatic

complaints

• Worsening of

chronic

conditions

• 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 problem solving

• 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

REACTIONS TO TRAUMA AND

SUGGESTIONS FOR INTERVENTION

Ages Behavioral Physical Emotional Intervention Options

• Shock, disorientation, and

numbness

• Depression,

sadness

• Grief

• Irritability, anger

• Anxiety, fear

• Despair,

hopelessness

• Guilt, self-doubt

• Mood swings

TABLE 1: 

Continued from previous page

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A F i e l d G u i d e • 23

• Withdrawal and

isolation

• Reluctance to

leave home

• Mobility

limitations

• Relocation

adjustment

problems

Older

Adults

• Worsening of

chronic

illnesses

• Sleep disorders

• Memory

problems

• Somatic

symptoms

• Increased

susceptibility 

to hypo and

hyperthermia

• Physical and

sensory

limitations

(sight, hearing)

interfere with

recovery

• 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 

REACTIONS TO TRAUMA AND

SUGGESTIONS FOR INTERVENTION

Ages Behavioral Physical Emotional Intervention Options

• Depression

• Despair about

losses

• Apathy

• Confusion,

disorientation

• Suspicion

• Agitation, anger

• Fears of

institutionalization

• Anxiety with

unfamiliar

surroundings

• Embarrassment

about receiving

“handouts”

TABLE 1: 

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Highly Impacted Survivors and Families

Research has shown that those who directly experience violent

victimization and mass traumatization, witness the serious injury

and physical mutilation of others, or suffer the murder of a loved

one have a likelihood of intense and prolonged emotional, behavioral, and physical reactions. They are likely to suffer high levels of

distress during the immediate response phase and may have periods of difficulty for years to come. Critical events that occur

throughout the criminal justice process, such as trials, sentencing

hearings, and appeals, are especially significant to this group and

are often linked to restimulation of psychological wounds.

Workers support these survivors and family members by providing respectful and practical assistance, making needed information reliably available, and supporting the multiple pathways for

coming to terms with overwhelming trauma and loss. Religious

and cultural traditions; spiritual practices; community, family, and

personal rituals; and symbolic gestures can soothe survivors’

anguish and assist them with finding meaning and the courage to

continue living. At different points during the process of coming

to terms with loss and trauma, activities and interventions such

as counseling, support groups, medication, spiritual guidance,

social activism, helping others, artistic expression, and symbolic

healing rituals may be helpful.

Cultural, Ethnic, and Racial Groups

Workers must respond sensitively and specifically to the various

cultural groups affected by mass violence. The death of a loved

one, community trauma, and mass victimization are interwoven

with cultural overlays. Rituals surrounding death, the appropriate

handling of physical remains, funerals, burials, memorials, and

belief in an afterlife are all deeply embedded in culture and religion. The serious injury of a family member brings families from

different cultures into contact with Western medicine and the

24 • M e n t a l H e a l t h R e s p o n s e t o M a s s V i o l e n c e a n d T e r r o r i s m

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A F i e l d G u i d e • 25

healthcare delivery system. The situation may be even more challenging when English is not the family’s primary language.

Cultural and ethnic groups with histories of violent oppression,

terrorism, or war in their countries of origin may interpret community violence in the United States through their experiences of

prior traumatization. Those who have suffered from political

oppression and abuses of military power may find the prominent

visibility of uniformed personnel highly distressing or even traumatizing. Some survivor groups may live in a context of poverty,

discrimination, or marginalization and face high rates of violent

crime in their neighborhoods, potentially making them more vulnerable to disaster impact. 

Workers convey cultural sensitivity when they provide informational briefings, notifications, and applications for services and

benefits in primary spoken languages. Workers must learn about

each affected group’s cultural norms, practices, and traditions;

views regarding mental health, trauma, and grieving; and the

group’s local history and community politics. Establishing working relationships with trusted organizations, service providers,

and community leaders often facilitates increased acceptance. 

Workers communicate cultural sensitivity when they:

✔ Use culturally accepted courteous behavior (e.g., greetings,

physical space, know who is considered “family”);

✔ Describe their role in culturally relevant terms;

✔ Take time to establish rapport;

✔ Provide information and services in appropriate languages;

✔ Ask about cultural practices when they are unsure;

✔ Value diversity and respect differences;

✔ Develop and adapt approaches and services to fit special

group needs.

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26 • M e n t a l H e a l t h R e s p o n s e t o M a s s V i o l e n c e a n d T e r r o r i s m

People with Serious and Persistent Mental Illness

Many survivors with mental illness function fairly well following a

community disaster, especially if essential services and support

networks have not been interrupted. Most have the same capacity

as the general population to “rise to the occasion” and perform

heroically during the immediate response period. However, those

who are directly involved and traumatized by the event may need

additional mental health support services, medications, or hospitalization to regain stability. For survivors previously diagnosed

with posttraumatic stress disorder (PTSD), emergency response

stimuli (e.g., sirens, helicopters, mass casualties) may trigger an

exacerbation due to associations with prior traumatic events.

The range of support services designed for the general population

is equally beneficial for survivors and family members with

mental illness. As with all special population groups, workers

need to be aware of how people with mental illness perceive disaster assistance and services, and build bridges that facilitate

access.

Human Service, Criminal Justice, and

Emergency Response Workers

Workers in all aspects of emergency response and disaster relief

experience considerable demands to meet the needs of survivors,

families, and the community. Depending on their role, workers

may be exposed to human suffering, fatalities, people with serious

physical injuries, family demands and anguish, community anger,

and other difficulties. They may experience physical stress

symptoms or show signs of stress overload. Indicators include

irritability, over-involvement with and inability to leave the

operation, difficulty focusing, being unproductive, feeling

depressed, or feeling emotionally overwhelmed. Workers may

intervene by suggesting or using the strategies described in the

next section.

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A F i e l d G u i d e • 27

STRESS

PREVENTION,

MANAGEMENT, AND

INTERVENTION

Workers must cope with a

range of challenging

stressors. The devastating

losses, casualties, destruction of property, and emotional pain of survivors and

bereaved loved ones touch

providers in powerful and

personal ways. The emergency response working

environment often involves

physical hardship, unclear

roles and responsibilities,

limited resources, rapidly

changing priorities,

intrusive media attention,

and long work hours. 

Despite the inevitable

stress associated with

community crisis response,

workers experience

personal gratification

using their skills to assist

fellow humans in need.

Active engagement in the

disaster response can be

an antidote to feelings of

vulnerability, powerlessness, and outrage commonly experienced by the

community.

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28 • M e n t a l H e a l t h R e s p o n s e t o M a s s V i o l e n c e a n d T e r r o r i s m

A proactive stress management plan focuses on two critical

contexts: the organizational and the individual. Adopting a

preventive approach allows managers and workers to anticipate

stressors and manage potential crises rather than simply reacting

to them after they occur. 

When stress prevention and management strategies are built into

operations and the organizational culture, providers feel valued

and supported as they engage in this emotionally demanding

work. Suggestions for organizational stress prevention, management, and intervention are presented in Table 2, and suggestions

for individual stress prevention, management, and intervention

are presented in Table 3.

28 • M e n t a l H e a l t h R e s p o n s e t o M a s s V i o l e n c e a n d T e r r o r i s m

OVC Field Guide.qxd 9/16/2005 1:08 PM Page 28
Effective

Management

Structure and

Leadership

• Clear chain of command and reporting relationships

• Available and accessible leads and clinical supervisors

• Use of managers experienced in emergency response and community 

trauma

ORGANIZATIONAL APPROACHES FOR STRESS

PREVENTION, MANAGEMENT, AND INTERVENTION TABLE 2: 

Clear Purpose,

Goals, and

Training

• Clearly defined intervention goals and strategies appropriate to different

assignment settings (e.g., crisis intervention, community memorial)

• Training and orientation for all workers

Functionally

Defined Roles

• Staff who are oriented and trained according to written role descriptions for

each assignment setting

• When setting is under jurisdiction of another agency (e.g., Mayor’s Office,

Medical Examiner’s Office, American Red Cross), staff are informed of mental

health provider’s role, contact people, and mutual expectations

Administrative

Controls

• Shifts no longer than 12 hours with 12 hours off

• Rotation between high, mid, and low-stress tasks

• Breaks and time away from the assignment

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

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

• Delegating “regular” workload so workers do not attempt disaster response 

and usual job

Team Support • Buddy system for support and monitoring stress reactions

• Positive atmosphere of support, mutual respect, and tolerance

• Clinical support, consultation, and supervision processes built on trust, safety

and respect

• Attention to workers’ functioning and stress management

• “Floating through” work areas to observe signs of stress

• Education about signs and symptoms of worker stress and coping strategies

• Intervention plan incorporating elements from Table 3

• Exit plan for workers leaving the operation 

Plan for Stress

Management

Dimension Intervention

A F i e l d G u i d e • 29

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30 • M e n t a l H e a l t h R e s p o n s e t o M a s s V i o l e n c e a n d T e r r o r i s m

Management 

of Workload

• Setting task priority levels with realistic work plans

• Recognizing that “not having enough to do” or “waiting” is an expected part of

disaster mental health response

INDIVIDUAL APPROACHES FOR STRESS

PREVENTION, MANAGEMENT, AND INTERVENTION

Dimension Intervention

TABLE 3: 

Balanced

Lifestyle

• Eating nutritious food and staying hydrated, avoiding excessive caffeine,

alcohol, and tobacco

• Getting adequate sleep and rest, especially on longer assignments

• Getting physical exercise when possible

• Maintaining contact and connection with primary social supports

Stress

Reduction

Strategies

• Reducing physical tension by using familiar personal strategies (e.g., taking

deep breaths, gentle stretching, meditation, washing face and hands,

progressive relaxation)

• Pacing self between low and high-stress activities

• Using time off to “decompress” and “recharge batteries” (e.g., getting a good

meal, watching TV, exercising, reading a novel, listening to music, taking a

bath, talking to family)

• Talking about emotions and reactions with coworkers during appropriate times

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

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

reactions

• Recognizing that over-identification with or feeling overwhelmed by victims’

and families’ grief and trauma may signal a need for support and consultation

• Understanding the differences between professional helping relationships and

friendships to help maintain appropriate roles and boundaries

• Examining personal prejudices and cultural stereotypes

• Recognizing when one’s own experience with trauma or one’s personal history

interfere with effectiveness

• Being aware of personal vulnerabilities and emotional reactions and the

importance of team and supervisor support

OVC Field Guide.qxd 9/16/2005 1:08 PM Page 30
American Academy of Child and Adolescent Psychiatry

http://www.aacap.org

American Psychiatric Association

http://www.psych.org

American Psychological Association

http://www.apa.org

American Red Cross

http://www.redcross.org

Federal Emergency Management Agency

http://www.fema.gov

International Society for Traumatic Stress Studies

http://www.istss.org

Mothers Against Drunk Drivers (MADD)

http://www.madd.org

National Center for Post-Traumatic Stress Disorder/

U.S. Department of Veteran Affairs

http://www.ncptsd.org

National Child Traumatic Stress Network

http://www.nctsnet.org

Office for Victims of Crime/U.S. Department of Justice

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

Office for Victims of Crime Resource Center

http://www.ncjrs.org

Substance Abuse and Mental Health Services 

Administration

http://www.samhsa.gov

A F i e l d G u i d e • 31

INTERNET SITES

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c4 • M e n t a l H e a l t h R e s p o n s e t o M a s s V i o l e n c e a n d T e r r o r i s m

U.S. Department of Health and Human Services

Substance Abuse and Mental Health Services

Administration

Center for Mental Health Services

1 Choke Cherry Road

Rockville, MD 20857

DHHS Publication No. SMA 4025

Printed 2005

U.S. Department of Justice

Office of Justice Programs

Office for Victims of Crime

810 Seventh St., NW

Washington, DC 20531

DOJ Publication No. NCJ 205452

OVC Field Guide.qxd 9/16/2005 1:08 PM Page c4