1 

Crisis Counseling Assistance and Training Program (CCP)

Participant Workbook 

Virtual Core Content Training

Table of Contents

Table of Contents............................................................................................... 1

SECTION 1: Disaster Response Overview...................................................... 4

SECTION 2: Crisis Counseling Program and Services.................................. 12

SECTION 3: Survivor Reactions .................................................................... 27

SECTION 4: Special Populations................................................................... 34

SECTION 5: Interventions and Skills ............................................................. 45

SECTION 6: Data Collection and Program Evaluation .................................. 64

SECTION 7: Stress Management.................................................................. 71

Applying Your Learning.................................................................................. 77

Additional Resources ..................................................................................... 78

Disaster Behavioral Health Acronyms............................................................ 78

Disaster Reactions and Interventions ............................................................ 83

Recognizing Severe Reactions to Disaster and Common Psychiatric Disorders

....................................................................................................................... 88

The Road to Resilience................................................................................ 101
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Recommended 8-Hour Agenda 

Core Content Training (Virtual Edition)

A.M. (or Day 1) Schedule

8:00 a.m. Start

Welcome and Introductions

Disaster Response Overview

CCP and Services

9:45 a.m. Break

10:00 a.m.

CCP and Services (cont.)

Survivor Reactions

P.M. (or Day 2) Schedule

12:00 p.m. Lunch

1:00 p.m. 

Special Populations

Interventions and Skills

2:00 p.m. Break

2:15 p.m.

Interventions and Skills (cont.)

3:15 p.m. Break

3:30 p.m.

Data Collection and Program Evaluation

Stress Management

Q&A, Applying Your Learning, Course Evaluation

5:00 p.m. Adjourn 
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After training, participants will be able to do the following: 

• Describe the range of crisis counseling services.

• Identify typical disaster reactions.

• Demonstrate basic crisis counseling skills.

• Explain the importance of data collection and how to use it. 

• Apply techniques for managing stress.

Guidelines for Working Together

• Keep time (start on time; return from breaks on time; end on time).

• Switch mobile phones off or to “vibrate.”

• Turn off computer notifications

• Mute yourself when you are not speaking so others can be heard clearly.

• Participate fully.

• Ask or submit questions freely.

• Balance talking and listening.

• Respect each other’s point of view.
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SECTION 1: Disaster Response Overview

Definitions of Disaster 

A disaster is a natural or human-caused occurrence (e.g., hurricane, tornado, flood, 

tsunami, earthquake, explosion, hazardous materials accident, mass criminal 

victimization incident, war, transportation accident, fire, terrorist attack, famine, 

epidemic) that causes human suffering. A disaster creates a collective need that 

overwhelms local resources and requires additional assistance.

Adapted from the Center for Mental Health Services (CMHS), 2000.

A disaster is any natural catastrophe (e.g., tornado, hurricane, storm, high water, winddriven water, tidal wave, tsunami, earthquake, volcanic eruption, landslide, mudslide, 

snowstorm, drought) or, regardless of cause, any fire, flood, or explosion in any part of 

the United States that, in the determination of the President, causes sufficient severity 

and magnitude to warrant major disaster assistance under the Robert T. Stafford 

Disaster Relief and Emergency Assistance Act of 1974 (Stafford Act). 

Robert T. Stafford Disaster Relief and Emergency Assistance Act, 1974.

Notes:
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Characteristics of This Disaster Worksheet 

Cause:

Size:

Scope:

Natural or Human-caused Disaster: 

Impact on survivors:
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Natural v. Human-Caused Disasters

Natural Human-Caused

Earthquakes, fires, floods, tornadoes Airplane crashes, chemical leaks, mass 

violence, terrorism 

No one to blame People, governments, or businesses to 

blame 

Beyond human control Seen as preventable and a betrayal by 

fellow humans 

Advance warning is possible No advance warning

Post-disaster distress is high and felt 

mainly by survivors 

Post-disaster distress is often more 

intense than the distress experienced by 

people after natural disasters, and it is felt 

by more people not directly affected by the 

disaster 
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Federal Emergency Management Agency (FEMA) Disaster Assistance 

FEMA Disaster Operations Structure

This chart reflects a typical disaster response structure in the immediate aftermath of 

large, usually natural, disasters.

In a typical disaster, it is the responsibility of the FEMA region where the disaster 

occurred to carry out the initial response, do damage assessments, set up a joint field 

office, and deploy staff.

Immediately after the declaration, FEMA disaster workers arrive and set up a central 

field office to coordinate the recovery effort. A toll-free telephone number is available for 

use by affected residents and business owners in registering for assistance (1-800-621-

FEMA [3362] or TTY 1-800-462-7585 for people with speech or hearing needs). 

Disaster recovery centers are open for disaster survivors to meet with program 

representatives and obtain information about available aid and the recovery process.
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Types of Assistance Available From FEMA 

The Presidential disaster declaration will specify the types of assistance for which a state

is eligible.

Hazard Mitigation—Disaster survivors and public entities are encouraged to avoid 

the life and property risks of future disasters. Examples include the elevation or 

relocation of chronically flood-damaged homes away from flood hazard areas, 

retrofitting buildings to make them resistant to earthquakes or strong winds, and 

adoption and enforcement of adequate codes and standards by local, state, and 

federal governments.

Public Assistance—Aid to state or local governments to pay part of the costs of 

rebuilding a community's damaged infrastructure. Generally, public assistance 

programs pay for 75 percent of the approved project costs. Public assistance may 

include debris removal, emergency protective measures and public services, repair 

of damaged public property, loans needed by communities for essential government 

functions, and grants for public schools.

Individual Assistance—Includes FEMA CCPs and is covered in detail in this 

section.

Notes:
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Overview of CCP 

Entities eligible to apply for and receive CCP funding:

• States

• U.S. territories

• Federally recognized tribes and tribal organizations

The CCP consists of two grant types:

• Immediate Services Program (ISP): 60 days

• Regular Services Program (RSP): up to 9 months

CCP Typical Timeline 
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ISP Organizational Roles and Responsibilities 

The FEMA JFO Program Specialist

• Works with the SAMHSA Project Officer, the state, and the CCP to ensure

the quality, consistency, and fiscal management of the program.

• Provides information to the state about FEMA requirements and regulations

related to the CCP.

The SAMHSA Project Officer

• Works with the state and the CCP staff to ensure that the program runs

consistently and efficiently.

• Provides ongoing technical assistance (TA) to the state and FEMA on

programmatic, behavioral health, and budgetary issues.

• Works with the CCP leadership to ensure ongoing services are relevant and

fiscally consistent.

FEMA Headquarters

• Works with the SAMHSA Project Officer, the state, and the CCP to ensure

the quality, consistency, and fiscal management of the program.

• Confers with the FEMA JFO Program Specialist and the SAMHSA Project

Officer as needed.

State Disaster Behavioral Health Coordinator

• Works with the SAMHSA Project Officer, FEMA, and the CCP to ensure the

quality, consistency, and fiscal management of the program.

• Is responsible for CCP reporting.

• Manages the CCP including oversight in hiring and training of CCP staff.
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The Substance Abuse and Mental Health Services Administration (SAMHSA) 

Disaster Technical Assistance Center (DTAC) 

• Provides TA to the SAMHSA Project Officer, FEMA, and the CCP.

• Is a resource for materials and trainings.

Notes:
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SECTION 2: Crisis Counseling Program and Services

The CCP model is . . . 

Strengths based—While CCP workers may assess significant adverse reactions and 

refer people accordingly, program services assume natural resilience in individuals and 

communities.

Anonymous—People should not be classified, labeled, or diagnosed. Each person 

should be seen as unique in his or her needs and recovery. Therefore, there are no 

case files, records, or diagnoses for users of CCP services.

Outreach oriented—Crisis counselors take services into the community rather than 

waiting for survivors to seek services.

Culturally aware—Throughout the project, staff should strive to understand and respect 

the community and the cultures within the community.

Conducted in nontraditional settings—Crisis counseling is community based and 

occurs primarily in homes, community centers, disaster shelters, and settings other than 

traditional mental health clinics or hospitals.

Designed to strengthen existing community support systems—The CCP supports 

but does not supplant natural community support systems. Likewise, the crisis 

counselor supports community recovery activities but does not organize or manage 

them.

Based on an assumption of natural resilience and competence—Most people will 

recover and move on with their lives after a disaster, even without assistance. Promote 

independence rather than dependence on the CCP, other people, or other organizations 

and assume competence in recovery. A key step in recovery is regaining a sense of 

mastery and control.
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Traditional Treatment v. Crisis Counseling 

Notes:

Traditional Treatment 

• Is office-based 

• May involve diagnosis and 

treatment of mental illness, as well 

as identification of strengths and 

coping skills 

• May focus on longer-term issues 

• Validates experiences associated 

with distress that has brought the 

person to treatment 

• Keeps records, charts, case files, 

etc. 

Crisis Counseling 

• Is home- and community-based 

• Involves identification of strengths 

and coping skills 

• Counsels on disaster-related 

issues 

• Validates common disaster 

reactions and experiences 

• Does not collect identifying 

information 
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Reach of Services 
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Overview of CCP Services

Individual crisis counseling—Assists disaster survivors in understanding their current 

situations and reactions, reviewing their options, and linking them with other individuals 

and agencies that may assist them. During individual services, crisis counseling staff 

are active listeners who provide emotional support. Individual crisis counseling also 

includes working with the family as a unit. This service is more than 15 minutes in 

duration.

Brief educational or supportive contact—The number of brief contacts with 

individuals, or groups of individuals, that did not result in indepth discussion or 

interaction of an educational or crisis counseling nature. This service is 15 minutes or 

less in duration.

Group crisis counseling—Involves providing and facilitating support or education to a 

group to help members cope with their situations and reactions.

Public education—Involves the distribution of educational information on CCP or crisis 

counseling-related topics. Educational information may be provided via public 

presentations, brochures, flyers, mailings, and training to human services personnel. 

The media are often partners in providing information through public service 

announcements, newspaper articles, and advertisements.

Assessment, referral, and resource linkage—Assessment determines the need for 

referral. Referrals can link survivors experiencing severe reactions with formal mental 

health and substance abuse treatment. Referrals also can direct survivors to other 

disaster relief resources in their community to meet physical, structural, or economic 

needs.

Community support and networking—Supports every other service delivered by the 

CCP. CCP staff participate in, but do not initiate or lead, community support activities 

(e.g., being present at remembrance events). Crisis counselors can provide a 

“compassionate presence” and be available to provide crisis counseling services, should 

the need arise.
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Needs Assessment Worksheet 

Identify the geographic areas affected in the disaster.

Who are the special population groups?

What are the priority needs in the affected communities (e.g., rebuilding/repairing 

homes, employment, treatment)?
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Resource Identification Worksheet 

For several of the priority needs selected, identify the community resources that would 

be needed to meet those needs (e.g., community organizations such as faith-based 

organizations, disaster assistance organizations, schools).
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Outreach Strategy Worksheet

What are the key actions this program should take to conduct successful outreach to 

survivors?

What key actions can you take to conduct outreach to organizations that have resources 

available for survivors?
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Individual/ Family Crisis Counseling 

Encounter Characteristics

• This service consists of encounters or visits with adults and children.

• It can last 15 minutes or longer.

• It typically ranges from one to five visits.

• The number of visits provided should be determined through discussions with

supervisors and teams.

• Multiple visits may indicate a need for referral to longer-term services and

should be discussed with supervisors.

• Each visit should stand alone. Crisis counselors should reinforce prior

successful coping skills in addition to helping survivors develop new ones.

Goals and Objectives

• Engage—Through outreach, make contact with affected individuals to

provide crisis counseling services.

• Identify immediate needs—Assist survivors in assessing their current

needs.

• Gather information—Use reframing, reflecting, paraphrasing, and opening

skills to gather information to assess the survivor’s needs.

• Prioritize needs—Disaster survivors often have safety and physical needs

that need to be met first.

• Provide practical assistance—Provide referrals and linkage to additional

services including disaster assistance, clothing, food, and shelter.

• Provide education—Teach survivors about common reactions, stress

management techniques, and coping skills.

• Provide emotional support—Normalize the survivor’s reactions, and

provide reassurance.

• Determine next steps and follow up—Assist the survivor in developing a

plan and creating action steps.

Brief Educational or Supportive Contact 

• This service is less than 15 minutes long.

• It provides reassurance, other support, and information.

• Activities, such as brief interactions, telephone calls, and handing out

brochures, are examples of brief educational or supportive contact.
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Group Crisis Counseling 

 Encounter Characteristics

• Group crisis counseling refers to services that help group members

understand their current situations and reactions to the disaster, help them

review or discuss their options, provide emotional support or referral services,

and provide skills to cope with their current situations and reactions. In group

counseling, participants do most of the talking.

• Group counseling encounters last 15 minutes or longer.

• The CCP focuses on two types of groups: support and education groups, and

self-help groups.

• Group counseling may vary from less structured, purely educational groups to

more structured support groups. All groups are likely to share some

elements of support and education.

• Groups can be led by a licensed mental health professional, co-facilitated

with a mental health professional and a paraprofessional, or led by survivors

themselves.

• When members of social support networks are struggling with the disaster’s

aftermath, counseling groups may augment overloaded support systems.

• It is important to ensure that group members have had similar levels of

exposure to the disaster event. People with low exposure should not be

exposed to the stories of those whose exposure was significantly higher.

 Support and Educational Groups

• Increase the social support network.

• Facilitate exchange of information on life situations.

• Help develop new ways of adapting and coping.

• Provide tools to obtain and process new information.

• Provide practical and concrete assistance.

• Use handouts and factual information relevant to the group’s discussion.

• Use speakers relevant to content area and group members’ needs.

 Tips for Starting and Facilitating Support and Educational Groups

• In a support group, it is acceptable to allow members to begin the dialogue.

Keep track of time, and facilitate discussion.

• It may be helpful to have homogeneous membership (e.g., bereaved parents,

neighbors, occupational groups, women, children).

• The format and content of the group and educational materials presented

should be tailored to meet the developmental and cultural needs of group

members. Consider accessing written resources in various languages and
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materials geared toward people with disabilities and targeted toward 

children’s developmental stages.

• Speakers may include mental health and substance abuse professionals,

public health workers, faith-based leaders, community leaders, and disaster

survivors.

• People need to be emotionally ready to participate in group crisis counseling.

Bringing people together too early can be detrimental. Use caution in

deciding when to begin group crisis counseling.

 Self-Help Groups

• Are initially facilitated by a crisis counselor.

• Can be co-facilitated by a group member to encourage transition to a

member-facilitated process.

• Are no longer a CCP service once the group has transitioned to a memberfacilitated process.

 Practical Concerns in Group Crisis Counseling

• Counselors should assess their own skills and knowledge about the group’s

content to set clear boundaries on how to approach the group process.

Group members may inquire about symptoms on which counselors are not

authorized to give advice. Counselors can, however, provide concrete

information and make appropriate referrals to mental health professionals.

• Be aware of personal biases related to religion, spirituality, culture, ethnicity,

and gender. It is common and healthy to recognize these qualities for

personal reflection, but it is detrimental if these qualities disrupt the group

process.

• Respect and maintain confidentiality. A group should be in a safe place in

which people, families, and communities can freely share their feelings

without worrying about other people knowing their personal business.

• Facilitate the group by making sure that each member has a chance to talk

and that no one person is dominating the conversation. Ask a member who

has not spoken if he or she would like to talk; however, respect his or her

right to just sit back and listen.

• Ask for feedback. Some groups may warrant more structure than others will;

however, it can be empowering for group members to become actively

engaged in the process of deciding what they would like to achieve in group

sessions.

Public Education

• Includes distribution of information and educational materials

• Is likely to increase during the course of the CCP

• Is designed to do the following:
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– Build resilience

– Promote constructive coping skills

– Educate about disaster reactions

– Help people access support and services

– Leave a legacy of knowledge, skills, and community resources

Distribution of educational materials:

• This includes flyers, brochures, tip sheets, guidance, and website content.

• It covers the following topics:

– Basic disaster information

– Key concepts of disaster behavioral health

– Disaster reactions

– Coping skills

– Individual and community resilience

• Contact SAMHSA DTAC for help in accessing educational materials.

• Culturally appropriate materials address special populations, are available in

multiple languages, and consider varying educational levels of survivors.

• Distribution of educational materials is captured on the Weekly Tally Sheet.
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Assessment and Referral 

• Assessment is the process of reviewing, identifying, and evaluating survivors’

needs.

• The CCP screens for the following:

– Practical or tangible needs of survivors

– Substance abuse and mental health needs

• Crisis counselors also identify resources in the community that match the

needs of survivors.

• The CCP Adult Assessment and Referral Tool may be used to assist crisis

counselors in making decisions regarding the need for referral.

• Crisis counselors provide information on available resources to meet tangible

needs.

– Crisis counselors help survivors meet unmet needs through resource

linkage.

– Services are provided regardless of level of functioning.

– Resource linkage empowers survivors to advocate for themselves.

– Crisis counselors assist survivors in prioritizing and accessing services.

– Relationships with survivors are short term.

 Assessment and Referral Considerations

• Amount of time since the event—Some reactions are very common in the

first few weeks and, by themselves, do not necessitate referral. Poor

functioning, avoidance of situations, and sleeping problems are common at

first.

• Degree to which the symptoms are interfering with daily life

functioning—This includes how well the individual is managing his or her

symptoms, and how strong his or her support systems are.

 Emergency Treatment Referral

• Alert the team leader if you notice any of the following:

– There is intent or means to harm self or others.

– A person exhibits severe paranoia, delusions, or hallucinations.

– Functioning is so poor that a person’s (or dependent’s) safety is in

danger.

– Excessive substance use is placing a person or others at risk.

– A child’s safety or health is at risk.

• When in doubt, call 911, or refer for immediate psychiatric or medical

intervention.
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 Nonemergency Treatment Referral

• Reduce perceived stigma:

– Demystify mental health or substance abuse treatment by letting people

know that counseling and treatment are methods of support,

information, education, problem solving, and coping.

– Explore referral options, and give choices.

• Increase compliance:

– Explore obstacles to accepting services.

– Encourage the person to call for the appointment while the counselor is

there.

– Accompany the person to the first appointment, if necessary and

appropriate.

• Sometimes it is acceptable to guide survivors through the referral process.

Some strategies include the following:

– Provide referral options.

– Assist them in making appointments.

– Remind them to attend appointments.

– Follow up to see if they attended.

• Facilitating the survivor’s connection with the external provider can increase

future follow-through with treatment.
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Community Support and Networking

Through community support and networking, the CCP engages in the following activities: 

• Partners with community support systems

• Participates in community gatherings and rituals

• Reaches out to community groups and leaders

• Maintains a compassionate presence

• Bolsters, but does not replace, systems in place

The CCP has the following goals for its community support and networking work: 

• Foster community resilience through improved connectivity.

• Promote familiarity with disaster relief resources.

• Create a seamless system for referral.

• Create opportunities for shared resources and training.

• Make referrals to organizations and agencies, and do not limit referrals to

those for mental health and substance abuse treatment. Referrals can be

made for other disaster relief services as well.

• Share training resources, as appropriate, with other disaster relief

organizations.

• Use networking to help identify needs, referral sources, and sources of inkind donations.

Community support and networking activities are captured on the Weekly Tally Sheet.
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Typical Community Partners 

Other potential partners:

• Emergency management

• Law enforcement

• Substance abuse prevention community

• Office for Victims of Crime

• Community-based cultural organizations

• American Indian and Alaska Native tribal community leaders

• Refugee organizations

• Suicide prevention organizations

• Mental health and substance abuse consumer groups
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Media Messaging and Risk Communication 

• Media messaging and risk communication are important parts of a

comprehensive disaster behavioral health plan and any CCP. An effective

plan for engaging the media will get the word out about CCP resources and

the message of resilience.

• The CCP reaches large numbers of disaster survivors through media

campaigns.

• Media messaging accomplishes the following:

– Increases education and awareness for survivors

– Promotes a shared understanding of the CCP message

– Delivers a clear message regarding the CCP

– Promotes the services of the CCP, such as the helpline, ongoing crisis

counseling, and referral

– Shares information on common reactions and important talking points

• The SAMHSA publication Communicating in a Crisis: Risk Communication

Guidelines for Public Officials is a good resource for planning communication

and dealing with the media. It is available online at

https://store.samhsa.gov/product/communicating-crisis-risk-communicationguidelines-public-officials/pep19-01-01-005.

Developing a CCP media plan helps to do the following things: 

• Identify spokespeople with expertise in the field of disaster behavioral health

and experience in dealing with the media.

• Develop simple talking points that reflect the goals and services of the CCP.

• Develop a press kit with information on the CCP and its services.

There are several important points to consider when developing talking points:

• The CCP emphasizes resilience and hope.

• Help is available through a variety of services provided by the CCP.

• The CCP provides education on common reactions and teaches effective

coping skills.

• Cultural diversity is respected in providing assistance.

• People often find stories of people like them interesting and compelling. If

appropriate, and while maintaining confidentiality, highlight stories of people

who have been helped by the CCP.

SECTION 3: Survivor Reactions

Key Concepts

• Everyone who experiences a disaster is affected by it in some way.
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• People pull together during and after a disaster.

• Stress and grief are common reactions to uncommon situations.

• People’s natural resilience will support individual and collective recovery.

Vulnerability Factors 

• Poverty

• Race

• Age

• Ethnicity

• Unemployment

• Gender

Risk Factors Model 

The risk factors model helps identify potential populations who are most at risk for 

adverse reactions and potentially in need of crisis counseling services.

A. Injured survivors, bereaved family members

B. Survivors with high exposure to disaster trauma, or

evacuated from disaster zones

C. Bereaved extended family and friends, first responders

D. People who lost homes, jobs, and possessions; people with

preexisting trauma and dysfunction; special groups; other

disaster responders

E. Affected people from the larger community
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Survivor Reactions Worksheet 

For the type of reaction assigned to your group, discuss the following: 

What specific reactions have you seen in this category—either in response to this 

disaster, or in previous experiences?

What differences in reactions have you seen—or could you imagine—across age 

groups?
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Summary of Survivor Reactions

Physical Reactions

• Gastrointestinal problems

• Headaches, aches, and

pains

• Weight change

• Sweating or chills

• Tremors or muscle twitching

• Clumsiness, increased

accidents

• Increased reactivity to

stimuli such as sound and

light (being easily startled)

• Chronic fatigue or sleep

disturbances

• Immune system disorders

• Sexual dysfunction

Positive responses can include 

alertness.

Emotional Reactions

• Feelings of heroism,

euphoria, or invulnerability

• Denial

• Anxiety or fear

• Depression

• Guilt

• Apathy

• Grief

Positive responses can include 

feeling challenged, involved, and 

pressured to act.

Cognitive Reactions

• Disorientation and confusion

• Poor concentration

• Difficulty setting priorities or

making decisions

• Loss of objectivity

• Recurring dreams,

nightmares, or flashbacks

• Preoccupation with disaster

Positive responses can include 

group identification and sharpened

perception.

Behavioral Reactions

• Change in activity level

• Alcohol and drug use or

abuse

• Increased use of over-thecounter medications

• Difficulty communicating or

listening

• Irritability, anger, or frequent

arguments

• Declining job performance

• Frequent crying

• Difficulty sleeping

• Avoidance of triggering

places or activities

Positive responses can include 

unselfish and helping behavior.
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Phases of Disaster

Source: Zunin/Meyers, as cited in U.S. Department of Health and Human Services. (2000). Training manual for mental health and human service workers in major disasters (DHHS Publication 90–538). Washington, DC: Substance Abuse and Mental Health Services Administration Center for Mental Health Services. 
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Pre-Disaster Phase

• Disasters with no warning can cause feelings of vulnerability and lack of security;

fears of the future and of unpredicted tragedies; a sense of loss of control; and the

sense of being unable to protect oneself and one’s family.

• Disasters with warning can cause guilt or self-blame for failure to heed warnings.

Impact Phase

• Reactions can range from shock to overt panic.

• Initial confusion and disbelief are followed by focus on self-preservation and family

protection.

• Slow, low-threat disasters and rapid, dangerous disasters have different

psychological effects.

• Great destruction and loss lead to great psychosocial effects.

• Family separation during impact causes considerable anxiety.

Heroic Phase

• Many exhibit adrenaline-induced rescue behavior and have high activity with low

productivity.

• Risk assessment may be impaired.

• There is a sense of altruism.

• Evacuation and relocation have psychological significance—effect of physical

hazards and repercussions of family separation.

Honeymoon Phase

• Disaster assistance is readily available.

• Community bonding occurs.

• Optimism exists that everything quickly will return to normal.

• CCP staff can establish program identity, gain entrée to affected people, and build

relationships with stakeholders.

Disillusionment Phase

• Stress and fatigue take a toll.

• Optimism turns into discouragement.

• There may be an increased need for substance abuse services.

• The larger community returns to business as usual.

• The CCP may have an increased demand for services, as individuals and

communities become ready to accept support.

• Reality of losses sets in.

• Diminishing assistance leads to feelings of abandonment.

Reconstruction Phase

• Individuals and communities begin to assume responsibility for rebuilding their lives.

• People begin to adjust to new circumstances.

• There is recognition of growth and opportunity.

• The reconstruction process may continue for years.

• People adjust to a new “normal,” while continuing to grieve losses.
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Resilience Worksheet 

How do you define resilience?

What helps foster the resilience of individuals? 

What helps foster the resilience of communities?

What factors decrease resilience?
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SECTION 4: Special Populations

Special Populations Worksheet 

Which populations are most affected by this disaster?

How well served are they? 

How have the services they rely on been affected? 

Prioritize the populations according to how much they have been affected. 
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Children and Youth 

For children and youth, their age and development determine their capacity to understand what 

is occurring around them and to regulate their emotional reactions.

Children are considered at risk for psychological problems following a disaster for a number of 

reasons:

• Less developed cognitive skills may limit the ways children understand and process

events.

• Limited experience coping with adversity may result in a lack of coping skills for

managing stress.

• Limited verbal skills may impede the processing of events and expressions of

reactions.

• Dependence on adults for resources and psychological support may result in limited

independence and self-reliance.

• Most importantly, children’s development is at risk if they are unable to proceed with

the normal activities and developmental tasks of childhood.

 Risk Factors

• Risk factors for children and youth include these:

– Separation from family

– Evacuation and relocation

– Loss of a family member or a close friend

– High levels of parental distress

– Family members at risk (such as first responders)

• Children’s reactions depend on how much destruction they have experienced. The

death of family or close friends is most traumatic for children; followed by loss of

home, school, or pets; and extensive damage to the community.

• Reactions also are influenced by the destruction children experience secondhand

through television and other media.

• The strongest predictor of children’s distress is parental distress.

• The caregiver is the role model for children, in terms of disaster reactions, coping,

and recovery.

• Family support and stability are positively correlated with children’s well-being.

• Preexisting adjustment or learning difficulties may be exacerbated.

• Most children will recover without professional intervention. Most simply need time

to experience their world as a secure place again and their parents as nurturing

caregivers who are again in charge.

• Each element of a child’s world—family, school, friends, pets, and social clubs—are

important in the recovery process.
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• Children are more vulnerable to difficulty when they have experienced other life

stressors in the past year (e.g., divorce, moving, death of a loved one).

• Children who have secure relationships with nurturing caregivers are the most

resilient in reconciling the disruption and recovering from traumatic events.

• Stability and security of home life affect how a child reacts to trauma.

 Special Considerations

• Parents or caregivers often deny help for themselves but accept it for their children.

• Parents or caregivers often see disaster stress in their children before seeing it in

themselves.

• Parents or caregivers sometimes overlook the disaster stress in their children.

• Parents are sometimes unaware of how their own stress affects their children.

• It is mandatory to involve parents and caregivers when working with children.

• Consideration should be given to the needs of single parents or caregivers,

especially single women.

• Sometimes the simple presence of a crisis counselor in discussion is enough to

facilitate communication within the family.

• Often parents and caregivers will deny the need for disaster mental health

information for themselves but will gladly participate in programs or gatherings in

which this type of information is provided as support for their children.

• Parents and caregivers often will recognize stress reactions in their children before

they recognize them in themselves. The crisis counselor helps all members of the

family unit by sensitizing parents to the signs of stress in their children and

suggesting strategies for helping their children.

• The caregiver is the child’s role model, in terms of disaster reactions, coping, and

recovery.

• Single parents or caregivers may be under added stress and may need specialized

referral.

 How Adults Can Support Children

• Model calm behaviors—Be a role model. Children will take cues of how to handle

situations from their parents. Modeling calm behaviors will be important during

chaotic times.

• Maintain routines—Even in the midst of chaos and change, children feel safer and

more secure with structure and routine (e.g., mealtimes, bedtime).

• Engage in fun activities—Should be age appropriate. This can include coloring,

board games, and other family activities.
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• Limit media exposure—It is important for parents to protect their children from

overexposure to sights and images of the event, including those in newspapers, on

the Internet, or on television.

• Repeat instructions often—Be patient. Children may need added reminders or

extra help with chores or homework once school is in session, as they may be more

distracted.

• Provide support at bedtime—Children may become anxious when they separate

from their parents, particularly at bedtime. Try to spend more time with the child at

bedtime with activities such as reading a book. It is okay to make temporary

arrangements for young children to sleep in bed with their parents, with the

understanding that they will go back to normal sleeping arrangements at a set future

date.

Notes:
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Older Adults 

 Risk Factors

• Physical limitations—In older adults these limitations include sensory deficits, 

limited mobility, decreased cognitive ability, or chronic illness. Older adults’ 

experience of the disaster is often influenced by their physical needs.

• Previous losses—Recent losses and cumulative unresolved trauma leave older 

adults at risk for difficulty in coping with disaster aftermath. However, successful 

coping in the past may create a reservoir of skills that increase resilience and the 

ability to adapt to disaster aftermath.

• Relocation trauma—Relocation from nursing homes and other residential facilities 

can cause distress and disorientation. Sudden evacuations sometimes precipitate a 

decline in health and functioning.

• Dependence on medications—A disaster may cause interruption of prescribed 

medications that are difficult to replace quickly after the effects of the disaster. 

Improper use of multiple medications (both prescribed and over-the-counter

medications) can pose a risk for abuse or severe side effects.

• Disaster-related health risks—Older adults are at risk for hyperthermia or 

hypothermia in disasters in which heating or air conditioning is interrupted.

• Lack of social supports—Many may not have family or close friends.

People with Prior Trauma History

• Prior trauma history includes physical, sexual, or emotional abuse, as well as combat 

veteran status or survival from prior disasters.

• In some cases, individuals may have flashbacks or other dissociative experiences. 

Disaster events may trigger preexisting posttraumatic stress disorder (PTSD) or 

place individuals with prior trauma at increased risk for developing PTSD.

• However, people with prior trauma history often have more resilience, experience, 

skills, and knowledge about how to cope with trauma. They can help others by 

sharing their coping skills and techniques.

 Risk Factors

• Feelings of increased vulnerability and decreased trust

• Increased likelihood of experiencing a trauma similar to the original one

• Increased risk for developing PTSD

• Increased risk of clinical depression or anxiety
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People with Serious Mental Illnesses 

• The needs of most survivors with serious mental illnesses will be the same as the 

needs of the larger community—physical, cognitive, behavioral, and emotional. 

Some may rise to the occasion in the immediate aftermath of disaster and function at 

a higher level than they usually do. For others, disaster stress can disrupt their 

tenuous balance and worsen their condition.

• The mere presence of serious mental illnesses does not necessarily indicate higher 

risk for disaster-related severe reactions. The type of mental illness, trauma history, 

and the level of stability before the disaster must be taken into consideration.

• When people with serious mental illnesses are able to maintain their regular mental 

health services or medications, many can cope with the additional stress presented 

by the disaster.

• If not stable prior to the disaster, they may require additional support, medication 

adjustment, or brief hospitalization.

• For those who had previously been diagnosed with PTSD, the disaster stimuli can 

trigger memories, can cause them to re-experience the trauma, or can worsen their

symptoms.

• People with serious mental illnesses may have used social support systems in the 

past and, therefore, may be more open to receiving services.

 Risk Factors

• Inability to maintain medication regimens and other essential services

• Tenuous stability prior to disaster

• Vulnerability to sudden changes in environment and routines

• Trauma or other symptoms that may be triggered or worsened by disaster stimuli
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People with a History of Substance Abuse

• Substance use increases after a disaster due to new use, increased use, or relapse.

• Increased substance use may create additional demands on treatment systems.

• Risk factors for substance abuse: 

o Current users are at greatest risk for increased use and abuse.

o Stress and PTSD are known risk factors for substance abuse.

o Alcohol and drug users may experience an increase in use. Some may cross 

the line into addiction. 

o People with current addictions may worsen; those in recovery (even for a 

long time) may relapse.

• The CCP does not fund substance abuse treatment, but staff should be prepared 

within the program in the following ways to work with people with substance use and 

abuse issues:

– Be trained to screen for substance abuse issues and make referrals

– Be educated about the effect of substance abuse on individuals, families, and 

communities

– Develop partnerships with treatment providers and the prevention community 

• Substance abuse prevention strategies can play an important role in strengthening 

individual and community resilience. Public education and outreach to people 

affected by a disaster can include general prevention information, in addition to links 

to emergency substance abuse services and resources. Such public education can 

begin immediately and continue well into the recovery process.

• Methadone patients—If a methadone clinic is closed due to a disaster, patients will 

need referrals to other methadone clinics for “guest dosing.”
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People with Disabilities 

• The disability community is not a homogeneous group. Therefore, people’s risk 

factors vary.

• Partnerships with state and local disability organizations are essential in providing 

thoughtful and appropriate services for people with disabilities.

• The state emergency management agency (SEMA) often maintains a list of 

individuals with disabilities and their locations within the community.

 Risk Factors

• Evacuation can be more difficult.

• Service animals need to be considered.

• Shelters may not be wheelchair accessible.

• Access to medication or therapy may be disrupted.

• Educational materials may not be available in accessible formats.

Low-Income Groups 

• Stress that disaster risks are not limited to people in lower socioeconomic groups.

• Low-income groups often lack material support from family and friends and have no 

insurance or savings. This makes recovery longer, harder, and sometimes 

impossible. They lose a larger part of their material assets and suffer more lasting 

negative effects. 

• Low-income housing often is more vulnerable to damage.

• There often are negative perceptions from experiences that occurred prior to the 

disaster, a lack of familiarity with sources of community support, a lack of 

transportation to obtain services, and an unwillingness to disclose immigration 

status. 

• Many must relocate due to unaffordable rent increases after repairs, often moving 

several times to undesirable housing in locations far from social support and jobs. 

These people usually stay in mass-care shelters the longest. 

 Risk Factors

• Have fewer resources

• Have greater preexisting vulnerability

• May have weaker support systems

• May be unable to relocate

• May have to spend more time in shelters
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Public Safety Workers (PSWs)

• The CCP needs to understand the distinction between traditional PSWs (e.g., police, 

firefighters, emergency medical technicians) and nontraditional PSWs (e.g., 

construction staff, electricians, sewer or gas workers). 

• The term “first responder” may carry emotional weight (e.g., people may disagree 

about who “deserves” the title). The CCP attempts to avoid this issue by taking a 

very broad definition of a PSW.

• Many traditional first responder organizations have excellent support systems 

already in place. Assess needs so that the CCP does not duplicate services.

• Risk factors include these: 

– Exposure to the disaster event

– Threat of injury or harm

– Separation from family

– View of oneself as a helper, not as a person who needs help

– Demanding work schedule
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Additional Special Populations 

• Recent immigrants

• Refugees

• Undocumented workers

• Non-English speakers

• People with preexisting medical conditions

Notes:
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Intervention Strategies for Special Adults 

• Be aware of unique needs. 

• Canvass communities to locate isolated survivors.

• Educate community providers who work with special populations on disaster 

reactions.

• Collaborate with community leaders and cultural brokers. 

• Partner with organizations that serve special populations.

• Consider cultural factors.

• Reconnect individuals to prior treatment services (i.e., substance abuse, mental 

health, medical).

• Ensure that services and materials are appropriate and accessible.

Notes:
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SECTION 5: Interventions and Skills

Engagement 

• Engagement is a means of reaching affected individuals to provide crisis counseling 

services. 

• It is also a method of creating a safe and comfortable environment. 

• Engagement is done in partnership with other organizations to plan and execute 

events. 

• Examples of engagement strategies include these: 

– Creative arts

– Social networking opportunities

– Community information fairs

– Anniversary events

• When developing engagement approaches, the primary focus always should be on 

crisis counseling services.

• Teenagers are especially vulnerable. Using writing projects, such as journal writing, 

can be a helpful way to engage this population and identify their needs and coping 

skills.

Crisis Counseling Skills

• Establishing rapport

• Calming

• Screening/assessment

• Empathy

• Reflecting feelings

• Validating feelings

• Paraphrasing

• Normalizing

• Active listening (nonverbal attending) 

• Closing
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Establishing Rapport

• Introduce yourself—Identify who you are; give your name and the name of the 

CCP. 

• Use door openers—A door opener is generally a positive, nonjudgmental response 

made during the initial phase of contact. Examples include “You seem sad; do you 

want to talk about it?” “What’s on your mind?” “Can you say more about that?” 

“What would you like to talk about today?”

• Use minimal encouragers—These interactions are brief, supportive statements that 

convey attention and understanding. Such phrases reinforce talking on the part of 

the person and are often accompanied by an approving nod of the head. Examples 

include “I see,” “Yes,” “Right,” “Okay,” “I hear you.”

• Listen—Pay close attention to what the survivor is saying. Listen with 

understanding and empathy. Do not interrupt or talk over the person.

Notes:
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Calming Skills

These are measures that may be taken if the individual is too upset, agitated, or disoriented to 

talk, or is showing extreme fear or panic. 

• Address the primary concern—Rather than encouraging the person to calm down 

or feel safe, attempt to help the person focus.

• Provide a supportive presence—Remain nearby, showing that you are available, if 

needed. Offer something tangible such as a blanket or drink.

• Enlist support—If family or friends are nearby, engage their help in providing 

emotional support. If a child or adolescent is with parents, see how the adults are 

coping, and work to empower the adults rather than undermine their role.

• Help provide focus—Offer support that helps the person focus on specific 

manageable feelings, thoughts, or goals.

Notes:
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Active Listening (Nonverbal Attending Skills)

Crisis counselors use specific nonverbal behaviors to communicate listening, attention, 

openness, and safety:

• Eye contact—Use a moderate amount of eye contact to communicate attention. A 

fixed stare can be disconcerting and should be broken intermittently if the person 

becomes uncomfortable. It may be best to try to mirror the survivor’s use of eye 

contact.

• Body position—A relaxed yet attentive posture puts a person at ease. 

• Attentive silence—Brief periods of silence give the survivor moments for reflection 

and may prompt the survivor to open up more and fill the gap in the conversation.

• Facial expressions and gestures—Try to be moderately reactive to the person’s 

words and feelings with your gestures. Occasional head nodding for 

encouragement, a facial expression that indicates concern and interest, and 

encouraging movements of the hands that are not distracting can be helpful.

• Physical distance—Personal space varies from culture to culture and from person 

to person. For most Americans, about 3 feet is a comfortable distance for personal 

interaction. Avoid physical barriers, such as desks, because they increase distance 

and add a feeling of formality.

Note: Nonverbal cues will vary depending on cultural expectations and situational factors.

Normalizing

• Educate the survivor about disaster reactions. 

• Reassure the survivor that his or her reactions are common. 

Notes:
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Empathy 

• Is an awareness of and sensitivity to the survivor’s experience

• Demonstrates that you are trying to understand how the survivor is experiencing the 

disaster

Reflecting Feelings

• Lets the survivor know you are aware of how he or she is feeling

• Can encourage emotional expression

• Should include only what you hear clearly stated

• Does not include probing, interpreting, or speculating

Paraphrasing

• Involves rephrasing or rewording what the survivor says 

• Does not change, modify, or add to the message

• Demonstrates that you have accurately heard what has been said

• Allows the survivor to either confirm that you are correct or provide additional 

clarification

Validating Feelings

• Reassures survivors that their reactions are typical

• Lets survivors know that others have felt the way they feel

Notes:
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Some Do’s and Don’ts for Empathy and Paraphrasing:

Do: 

• Find an uninterrupted time and place to talk. 

• Show interest, attention, and care. 

• Show respect for individuals’ reactions and ways of coping. 

• Talk about reactions to disasters that are to be expected and about healthy coping. 

• Be free of expectations or judgments. 

• Acknowledge that this type of stress can take time to resolve. 

• Help brainstorm positive ways to deal with their reactions. 

• Believe that they are capable of recovery. 

• Offer to talk or spend time together as many times as is needed. 

Don’t: 

• Rush to tell them they will be okay or they should just “get over it.” 

• Daydream about or discuss your own personal experiences instead of listening to 

them. 

• Avoid talking about what is bothering them because you don’t know how to handle it. 

• Judge them to be weak or exaggerating because they aren’t coping as well as you or

others are. 

• Give advice instead of asking them what works for them. 

• Refrain from asking for help from a professional if you feel you can’t help them 

enough. 

• Probe for details or insist that others must talk. 

Source: National Child Traumatic Stress Network (NCTSN), & National Center for 

Posttraumatic Stress Disorder (NCPTSD). (2006, July). Psychological First Aid: Field 

operations guide, second edition. Retrieved from http://www.nctsn.org
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Screening

• Listen and observe for cues of functioning.

• Recognize when to consult a supervisor.

• Identify and prioritize issues with the survivor.

• Check in with the survivor to clarify what you’re hearing and observing.

• Use the assessment and referral tools.

• Ask questions: 

o Closed questions—These questions ask for specific information and usually 

require a short, factual response. Closed questions are necessary when it is 

important to get the facts straight or to clear up confusion in your understanding 

of the story. 

o Open questions—These questions allow for more freedom of expression. 

They open general topics, rather than requesting specific information. 

Examples include “Can you tell me what’s been happening at school?” and 

“You say you’re experiencing [x]; what do you mean by that?”

Notes:
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Psychological First Aid 

What Is Psychological First Aid (PFA)? 

• PFA is an approach to help survivors in the immediate aftermath of disaster and 

terrorism. 

• It is designed to reduce the distress caused by traumatic events and to foster coping.

• It is consistent with the CCP model.

• It is an evidence-informed approach.

Where Does PFA Fit? 

After a disaster occurs, PFA fits into several parts of the response: 

• Immediate aftermath—State- or provider-trained staff respond to evacuation sites 

or shelters and provide PFA.

• If no Presidential disaster declaration—State or provider staff continue to provide 

PFA. 

• If there is a Presidential disaster declaration—The state applies for and delivers 

CCP services, which include PFA core actions.

PFA Core Actions

• Contact and engagement—To respond to contacts initiated by survivors, or to 

initiate contacts in a non-intrusive, compassionate, and helpful manner

• Safety and comfort—To enhance immediate and ongoing safety, and provide 

physical and emotional comfort

• Stabilization—To calm and orient emotionally overwhelmed or disoriented survivors

• Information gathering (current needs and concerns)—To identify immediate needs 

and concerns, gather additional information, and tailor PFA interventions

• Practical assistance—To offer practical help to survivors in addressing immediate 

needs and concerns

• Connection with social supports—To help establish brief or ongoing contacts with 

primary support persons and other sources of support, including family members, 

friends, and community helping resources

• Information on coping—To provide information about stress reactions and coping 

to reduce distress and promote adaptive functioning

• Linkage with collaborative services—To link survivors with available services 

needed at the time or in the future
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Simulation Exercise Case 1—Craig 

You are meeting with Craig, one of the evacuees who suffered significant damage to his house 

and minimal damage to the convenience store he owns. During your meeting, Craig conveys 

sadness about the loss of his property, as well as anxiety about when he will be able to return 

home, but he expresses relief that neither he nor his family members were hurt. He tells you 

that he’s not sure how to access financial help and requests your assistance in linking him to the 

appropriate resources.

Preparation Worksheet

As you prepare for your encounter with Craig, answer the following questions:

How will you start the conversation with Craig? What are some specific questions you want to 

ask him?

What skills do you want to be sure to use during the encounter? How will you use them? 

How will you provide information, education, and reassurance during the encounter?
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Simulation Exercise Case 2—James 

James, a 43-year-old man in recovery for 10 years from cocaine addiction, suffered injuries as 

he and his family took shelter from the disaster that devastated their home and community. 

Three months later, he is unemployed and stressed, but still a proud man as he tries to care for 

his family. You and your teammate have visited with James at his home once before.. He tells 

you he is proud of his time in recovery, yet jokes that he’s not doing too badly because of the 

“pain pills” a doctor prescribed him for his injuries. You notice that he is more withdrawn this 

visit, that during the last time you met with him. In your last meeting with him, he disclosed that 

he had a few drinks, but that it is not a big deal because he has “never had a problem with 

alcohol before.”

Preparation Worksheet

As you prepare for your encounter with James, answer the following questions:

How will you start the conversation with James? What are some specific questions you want to 

ask him?

What skills do you want to be sure to use during the encounter? How will you use them?

How will you provide information, education, and reassurance during the encounter?
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Simulation Exercise Case 3—Rachel 

Rachel, a local business owner, lost her home in the disaster. Her mother, who lived with her, 

died in the disaster. Your first encounter with Rachel is to discuss arrangements for shelter and 

financial assistance; however, during your conversation, Rachel begins to cry and confides that 

she has not been sleeping or eating much, and she can’t stop thinking about her mother dying. 

She does not feel that she will ever be able to move on.

Preparation Worksheet

As you prepare for your encounter with Rachel, answer the following questions:

How will you start the conversation with Rachel? What are some specific questions you want to 

ask her? 

What skills do you want to be sure to use during the encounter? How will you use them?

How will you provide information, education, and reassurance during the encounter?
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Simulation Exercise Observer Worksheet 

What skills did you see the crisis counselor use?

What did he or she do well?

What suggestions do you have for improvement?
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Survivor Tools 

Adapted from NCTSN, & NCPTSD. (2006, July). Psychological First Aid: Field operations guide, 

second edition. Retrieved from http://www.nctsn.org

Goal-Setting Tools

Crisis counselors assist individuals in doing the following to set goals: 

• Identifying their needs

• Prioritizing their needs and identifying the most pressing ones

• Developing a plan of action to address the needs

• Following through with the plan

• Remaining solution focused

Social Support Tools

Crisis counselors assist individuals in doing the following to access social support: 

• Identifying primary or familial supports

• Identifying which of these supports is/are readily available

• Reaching out to use immediately available supports

• Identifying options to use when support is not working

Supports vary by the individual and might include family, friends, significant others, religious

groups, support groups, or mental health or substance abuse services providers. In addition to 

identifying supports, discussing support-seeking and giving strategies also may prove helpful.

Coping Tools

To teach better coping, crisis counselors assist individuals in doing the following: 

• Identifying and addressing their primary concerns

• Seeing the crisis counselor as a supportive presence

• Allowing family or friends to provide support

• Focusing on manageable feelings, thoughts, or goals

• Exploring the options for spiritual support

• Practicing grounding exercises such as deep breathing

• Understanding common stress reactions

Suggested coping actions: 

• Talking to another person for support

• Getting needed information

• Getting adequate rest, nutrition, exercise

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

• Trying to maintain a normal schedule to the extent possible

• Telling yourself that it is natural to be upset for some period of time 

• Scheduling pleasant activities

• Eating healthful meals
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• Taking breaks

• Spending time with others

• Participating in a support group

• Using relaxation methods

• Using calming self-talk

• Exercising in moderation

• Seeking counseling

• Keeping a journal

• Focusing on something practical you can do right now to manage the situation better

• Using coping methods that have been successful for you in the past

Other coping tools:

• Positive activity scheduling—One explanation for feeling sad or being withdrawn is 

that it results from, and is maintained by, having more negative experiences than 

positive ones. In order to improve your mood, you need to increase positive 

experiences and decrease negative ones. One way of achieving this is for the 

survivor to identify some enjoyable or pleasurable activities he or she could do in the 

following week.

• Relaxation techniques and self-calming—People who have been exposed to 

extreme stress and fear as a result of disaster have bodies that are often on alert, 

ready for danger. In the absence of real danger, this anxiety is unnecessary and 

may have bad effects on one’s health. Relaxation and self-calming can include 

breathing and muscle relaxation techniques. 

• Stress management—For more information on stress management, refer to Section 

8 of Core Content Training.

Helping survivors improve or learn coping skills is a way of fostering resilience.

Notes:
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Typical Visits or Encounters 

Phase of Visit Intervention/Skills Tools for Survivors

Opening Establishing rapport

Calming

Screening/assessment

Information gathering

Self-calming

Middle Information and education

Active listening

Normalizing reactions

Empathy

Reflecting feelings

Paraphrasing

Screening/assessment

Practical assistance

Linking to resources

Validating feelings

Prioritizing needs

Goal setting

Social support

Coping skills

Relaxation techniques

Stress management

Positive activity scheduling

Problem solving

Closing Screening/assessment

Referral, if needed

Followup, if needed

Next steps

Each visit should be a standalone encounter in the event that the person is 

unavailable or not interested in additional encounters. 

Crisis counselors should remain solution focused, provide reassurance, and instill hope.

Opening 

• Opening skills

– Ask about disaster damage—“Can you tell me what happened?” “Did your 

home sustain any damage?” “Did you have to evacuate?” “Did you have any 

warning?” “When did you return home?” 

– Ask about the person—“What was it like for you?” “Where were you?” “How 

did you react?” “How are you doing now?” 

• Calming (if needed)

– “We notice you are very upset, having to catch your breath, having trouble 

sitting still, etc.; I can do a quick and easy exercise with you to help you feel 

calmer. You can even use this technique on your own.” 

– Teach calming techniques. 
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• Screening— 

– Observe behavior, emotional state, ability to think clearly; ask questions about 

daily functioning, maintenance of daily routines, eating, sleeping, working, 

caring for children, household activities, etc.

• Gathering information— 

– Ask survivors to tell you about their most pressing concerns; safety issues; 

access to food, clothing, water; issues surrounding children and substance use 

or abuse.

Middle

• Prioritizing needs—Ask survivors to tell you what they need right now. 

• Goal setting—Assist the survivor in setting attainable goals; use the intervention 

skills to teach the survivors the tools they need to promote their own recovery. 

Closing

Encourage the survivor to use the tools he or she learned during the encounter. This ensures 

that the survivor leaves the encounter with a set of next steps he or she can carry out to achieve 

the goals identified in the middle of the encounter.

Notes:
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Survivor Tools Practice Scenario 

Paula is a retired 64-year-old African-American woman who was born and raised in a place 

where she continued to live until it was affected by a disaster. She lived alone in the house 

where she grew up until she was forced to evacuate during the disaster. Paula’s house 

sustained extensive damage, and she has decided to sell the house rather than repair it. 

You first met Paula just after the disaster. She told you how upsetting it was to leave her 

childhood home and how she can’t understand why God would put her through this trial. On her 

second visit to the crisis center, Paula talked about how lonely she feels now that she lives in a 

neighboring town, and she said that the people in her apartment building are not friendly. On 

her third visit to the center, she continued to talk about her loneliness but commented that she 

thinks the disaster may have been God’s way of telling her she is getting too old to handle the 

upkeep of a house alone. She also admitted that she is beginning to like her apartment. 

How will you apply your assigned tool during your next encounter with Paula?
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Description of Ethical Considerations 

Maintain Confidentiality

Crisis counseling services provided through the CCP are anonymous and confidential. 

Crisis counselors should not share individual or group encounter experiences with anyone 

outside of the contact or group, with the exception of the following people:

• Their supervisor, for supervision purposes

• Other crisis counselors with a legitimate need to know the information to provide 

services

• Public safety personnel, if the individual or another human being is in imminent risk 

or danger

Crisis counselors should not keep formal records; there is not clinical charting in the CCP. 

However, it is appropriate to maintain basic contact information for the purpose of following up 

with individuals. 

Be sure to get permission for release of information from individuals before sharing any 

personal information for referrals or any other reason.

Follow the state and local regulations on mandatory reporting for child or elder 

abuse and neglect. 

Immediately discuss any allegations or cases of suspected child abuse with your supervisor. 

Follow state and local reporting regulations in cases of suicidal or homicidal intent.

Safeguard the interests and rights of individuals who lack decision making abilities—e.g., 

children, people with developmental disabilities, people with severe mental illness, or people 

with cognitive impairments. 

Additional Ethical Guidelines

• Do no harm.

• Participation is voluntary.

• Consider reactions in relation to the disaster phase and context.

• Individual coping styles should be respected.

• Immediate interventions are supportive.

• Talking with a person in crisis does not always mean talking about the crisis.

• Be aware of the situational and cultural contexts of the survivor and the intervention 

itself.
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Journal Reflection—Sections 3 through 5 

What were your key lessons learned from the practice sessions on using crisis counseling skills and 

survivor tools effectively?

What did you learn today about the range of individual and collective reactions to disaster that will 

be helpful to you as a crisis counselor?

What do you want to remember about the unique needs of and intervention strategies for special

populations?

How well are your training needs and expectations being met so far in this course? What 

suggestions do you have of topics or issues to focus on during tomorrow’s sessions?
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SECTION 6: Data Collection and Program Evaluation

• Data collection is a process of tracking the services provided, including these 

details of the services:

o How many 

o What kind

o To whom

o Where provided

• Program evaluation is a systematic effort to collect, analyze, and interpret 

data/information. 

• We collect data and evaluate programs to understand and improve services 

based on observable and verifiable data.
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In most cases, a separate training session will be offered to learn details 

of CCP data collection: 

• How the information is gathered

• How the encounter and contacts should be documented

• How the data are entered (for data entry staff)

• How the data are analyzed (for program staff)

Brief Overview of the Data Collection Forms

• The CCP data collection forms are cleared by the federal Office of Management 

and Budget (OMB) and have an official OMB number. They may not be altered.

• Included with each form is a page of detailed instructions for your reference.

• Every CCP is required to utilize and complete the following forms, as appropriate:

o Individual/Family Crisis Counseling Services Encounter Log 

o Group Encounter Log

o Weekly Tally Sheet

o Adult Assessment and Referral Tool

o Child/Youth Assessment and Referral Tool

o Provider Feedback Forms and Participant Feedback Surveys are also required at 

6 and 12 months after the disaster. 

Encounter Logs and Weekly Tally Sheets 

• Are used to document all services delivered

• Ensure that services are counted in a standardized way in all areas

• Should always be completed by the crisis counselor in a timely manner, so that 

information is not lost. 
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Individual/Family Crisis Counseling Services Encounter Logs

• Document interactions of 15 minutes or longer with individuals or families

• Involve participant disclosure

• Capture information gathered by a team of crisis counselors on one form, rather than 

two separate forms

– Parts of the form:

• First page captures visit type, demographic information, number of people in the 

encounter, and location of service. 

• Second page (back of form) captures risk categories, event reactions, focus of 

encounter, materials, and referrals. 

o Event reactions—Behavioral, emotional, physical, or cognitive reactions that 

are being experienced at the time of the service encounter 

o Focus of encounter—Information, skills, coping tips, or support provided to 

the individual(s) participating in the encounter

o Materials—Printed educational materials made available and left with the 

survivor(s), so in most cases, this should be “yes”

o Referrals—List of names and contact information for commonly used 

resources and referrals provided when necessary 

A copy of this form can be found at https://www.samhsa.gov/dtac/ccp-toolkit/ccp-data-formstrainings.
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Group Encounter Logs

• Document group crisis counseling (in which participants do most of the talking) and 

public education (in which the counselor does most of the talking)

• Measure encounter characteristics, group identities, and focus

• Capture information gathered by a team of crisis counselors on one form, rather than 

two separate forms

– Parts of the form:

• First page captures type of service, characteristics of encounter, and group 

identities. 

• Second page (back of form) captures demographics, focus of group session, and 

materials provided.

o Focus of encounter—This includes the information, skills, coping tips, or 

support that is provided to the individual(s) participating in the encounter. 

o Materials—Printed educational materials should be made available and left 

with the survivor(s), so in most cases, this should be “yes.” 

o Referrals—List of names and contact information for commonly used 

resources and referrals should also be provided, when necessary. 

A copy of this form can be found at https://www.samhsa.gov/dtac/ccp-toolkit/ccp-dataforms-trainings.
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Weekly Tally Sheets

• Document brief educational and supportive contacts (less than 15 minutes), 

telephone calls, e-mails, and material distribution

• Include information for 1 week (beginning Sunday)

• Tally services at the county level, using three-digit county codes

• Should be completed by crisis counselors for each county in which they work 

(one tally per crisis counselor for each county) 

• May be partly completed (the social networking and mass media sections) by 

administrative staff

– Parts of the form: 

• Captures number of contacts made through brief in-person contacts, telephone 

contacts by crisis counselors, hotline/helpline/lifeline contacts, e-mails, and 

community networking

• Captures materials distributed that are not otherwise captured on the

Individual/Family Crisis Counseling Services Encounter Log or Group Encounter 

Log

o When packets of materials are handed to people, mailed, or left at 

someone’s house, the number of packets is counted (not individual pieces 

within the packet). 

o When mass media messages and social networking announcements are 

posted, count the number of messages you post (not the number of 

viewers/listeners, and not the number that “like,” “re-tweet,” or share your 

message). 

A copy of this form can be found at https://www.samhsa.gov/dtac/ccp-toolkit/ccp-dataforms-trainings. 
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Assessment and Referral Tools

• Your employer should have protocols or procedures in place for how to respond if 

serious reactions are indicated and should provide training on how to use these tools 

and when to make a referral for more intensive services. 

• All of the following are true of the Child/Youth Assessment and Referral Tool and the 

Adult Assessment and Referral Tool: 

• They are used to facilitate referrals to more intensive behavioral health 

services. 

• They can be used at any time if you suspect the individual may be 

experiencing serious reactions. 

• They should always be used at the third individual/family crisis counseling 

encounter. 

• They measure risk categories and event reactions using a structured 

interview approach. 

• Assessment and referral tools are used in ISP and RSP, as needed. 

• At the end of the form, you should review the responses that are indicated with a 

“4” or “5,” and be prepared to offer the respondent a referral for more intensive 

services. 

• You should also have a plan in place (that adheres to your employer’s protocol) 

for what to do if the individual says “yes” to the question “Is there any possibility 

that you might hurt or kill yourself?”

Quality Assurance and Management

• Each form has a reviewer signature area at the bottom.

• A supervisor (team leader) in the field should approve and sign the form before 

sending it to data entry staff.

• Any recurring errors in completed forms should prompt followup training for crisis 

counselors. 

• Data entry staff should review forms at the time of data entry.

• Data entered by one staff member should be checked by another to increase 

accuracy and minimize errors.
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• Data and evaluation staff should be providing regular reports of the data (at least 

every 2 weeks) and working with program staff to determine the impact of the 

analysis.
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SECTION 7: Stress Management

Definition of Stress 

• Stress is a response to a challenge or a threat.

• Stress is tension, strain, or pressure that requires people to use, adapt, or develop new 

coping skills.

• Stress can be positive or negative.

• Perception plays a key role in interpreting stressful situations.

• An optimum level can act as a motivational force.

The Stress Cycle

Notes:
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Typical Stressors for Crisis Counselors 

• At the core of a CCP are its staff—the program’s success is directly dependent on staff’s 

ability to regulate their own stress.

• Particular care needs to be taken to address and process the effects this exposure can 

have on the crisis counselor. Individual supervision and process sessions following 

deployment shifts are two main venues for this type of support.

My Top Three Stressors

1.

2.

3.
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Warning Signs of Excessive Stress 

• You cannot shake distressing images from your mind.

• Work consumes you at the expense of family and friends.

• You experience increased substance use or abuse.

• You are excessively irritable and impatient.

• You exhibit other serious or severe reactions.

What To Do 

Disaster workers commonly experience many reactions that have limited impact on performance. 

However, when a number of reactions are experienced simultaneously and intensely, functioning is 

likely to be impaired. Under these circumstances, the worker should take a break from the disaster 

assignment for a few hours at first, and then, longer, if necessary. If normal functioning does not 

return, the person needs to discontinue the assignment.

Notes:
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Individual Approaches to Stress Management 

• Self-awareness

• Management of workload

• Balanced lifestyle

• Stress-reduction techniques

• Effective supervision and training

Inventory of Stress Management Techniques

This list of ways to manage stress can be used by crisis counselors themselves and recommended 

to individuals seeking crisis counseling services.

• Acupuncture—Insertion of needles at certain spots under the skin for the purpose of 

attaining a balance of the body’s energy

• Aromatherapy—Therapy through the sense of smell, using essential oils, claimed to 

produce a sense of well-being

• Asking for help and advice from family and friends

• Art therapy—Creating something, which allows free expression and results in feelings of 

achievement and mood change

• Behavioral therapy—A variety of psychotherapies based on changing ourselves by 

retraining

• Biofeedback—Monitoring rates of body functions and using results to increase relaxation

• Breathing for relaxation—Stylized breathing techniques to control blood pressure and 

stress levels

• Dance movement therapy—Freedom of expression through movement

• Eating a balanced diet

• Exercising at least three times a week

• Hobbies—Doing something just for the fun of it

• Getting enough sleep

• Going for a walk

• Guided imagery—Creating a mental picture of what is desired (creative imagery, 

visualization)

• Homeopathy—Small doses of plant, animal, or mineral substances to stimulate the 

body’s natural healing

• Learning to say no—Not taking on more than you can reasonably do

• Laughter—Not taking yourself too seriously

• Listening to your favorite music

• Massage—Use of touch or deep tissue manipulation to soothe

• Meditation—Deep, relaxed, focused concentration on a single word, object, or sound

• Psychotherapy—Talk-based therapy with a mental health professional to get to the root 

of a conflict and modify behavior and disruptive negative thought patterns
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• Reducing caffeine intake

• Quitting smoking

• T’ai chi ch'uan—System of slow, continuous exercises based on rhythm and equilibrium

• Taking a break

• Yoga—A system of exercises combining certain positions with deep breathing and 

meditation
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Individual Stress Management Plan Worksheet 

1. What do you value most about doing disaster mental health work?

2. What are—or do you expect to be—the most stressful and most rewarding aspects of disaster 

work?

Stressful

Rewarding

3. How do you know when you are stressed?

4. What can others do for you when you are stressed? 

5. How can you let them know that?

6. What can you do for yourself in each of the following areas:

Management of workload

Balanced lifestyle

Stress-reduction techniques
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Applying Your Learning

Review your journal reflections for Sections 1–5, and reflect on your lessons learned from Sections 

6 and 7—Data Collection and Stress Management.

Summarize what you have learned and what you plan to do back at work by answering the 

following questions. 

What are the most important things you have learned as a result of this course?

What are three things you plan to do in the next 2 weeks to apply in your work setting what you 

have learned here? 

What are the skills you feel will continue to be the most difficult for you, and what can you do to 

overcome those difficulties? 

How can you continue to get feedback on your crisis counseling skills? Who can help you, and how 

will you approach these people? 
CCP Participant Workbook: Core Content Training

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Additional Resources

Disaster Behavioral Health Acronyms

A 

ACF Administration for Children and Families

ADA Americans with Disabilities Act of 1990

ADP Automated Data Processing

ANH Average Number of People per Household

APA American Psychological Association

APHA American Public Health Association

APHIS Animal and Plant Health Inspection Service

ARC American Red Cross

ASL American Sign Language

ASPR Office of the Assistant Secretary for Preparedness and Response

ASTHO Association of State and Territorial Health Officials 

ATF Bureau of Alcohol, Tobacco, Firearms, and Explosives (also BATF)

B 

BH Behavioral Health

BIA Bureau of Indian Affairs

BNICE Biological, Nuclear, Incendiary, or Explosive

C 

CARD Center for Asbestos-Related Disease (Libby, MT)

CARD Collaborating Agencies Responding to Disasters

CBRN Chemical, Biological, Radiological, or Nuclear

CCP Crisis Counseling Assistance and Training Program (grant program)

CDC Centers for Disease Control and Prevention

CERT Community Emergency Response Team

CFR Code of Federal Regulations

CIO Chief Information Officer

CISD Critical Incident Stress Debriefing

CISM Critical Incident Stress Management

CMHC Community Mental Health Center

CMHS Center for Mental Health Services

COOP Continuity of Operations

CSAP Center for Substance Abuse Prevention

CSAT Center for Substance Abuse Treatment
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D 

DFO Disaster Field Office (FEMA)

DHS Department of Homeland Security

DIRM Division of Information Resource Management

DMAT Disaster Medical Assistance Team

DMH Disaster Mental Health

DMHC Disaster Mental Health Coordinator

DMORT Disaster Mortuary Operational Response Team

DOD Department of Defense

DOJ Department of Justice

DPO Disaster Psychiatry Outreach

DRC Disaster Recovery Center (FEMA)

DTAC Disaster Technical Assistance Center

DUNS Data Universal Numbering System

E 

EAP Employee Assistance Program

EAS Emergency Alert System (formerly Emergency Broadcast System)

ED Department of Education

EMA Emergency Management Agency (local)

EMAC Emergency Management Assistance Compact

EMHTSSB Emergency Mental Health and Traumatic Stress Services Branch (formerly ESDRB)

EMS Emergency Medical Services

EOC Emergency Operations Center

ESAR–VHP Emergency System for Advance Registration of Volunteer Health Professionals

ESF Emergency Support Function

F 

FAD Foreign Animal Disease

FAQ Frequently Asked Questions

FDA Food and Drug Administration

FEMA Federal Emergency Management Agency

FMD Foot and Mouth Disease

FTE Full-Time Equivalent

G 

GAR Governor's Authorized Representative

GPO Government Printing Office

GPRA Government Performance and Results Act

GPS Global Positioning System
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H 

HAZMAT Hazardous Materials

HHS Department of Health and Human Services 

HRSA Health Resources and Services Administration

HUD Department of Housing and Urban Development

I 

ICISF International Critical Incident Stress Foundation

ICS Incident Command System

ICU Incident Crisis Unit

IHS Indian Health Service

ISP Immediate Services Program (CCP)

IT Information Technology

J 

JCAHO Joint Commission on Accreditation of Healthcare Organizations

JFO Joint Field Office (FEMA)

M 

MH Mental Health

MHT Mental Health Team

MIS Management of Information Systems

MOU Memorandum of Understanding

MRC Medical Reserve Corps

MRDD Mental Retardation and Developmental Disabilities

N 

NACCHO National Association of County and City Health Officials 

NAMI National Alliance for the Mentally Ill

NASADAD National Association of State Alcohol and Drug Abuse Directors

NASMHPD National Association of State Mental Health Program Directors

NBC Nuclear, Biological, and Chemical

NCADI National Clearinghouse for Alcohol and Drug Information

NCID National Center for Infectious Diseases

NCPTSD National Center for Posttraumatic Stress Disorder

NCTSS National Center for Child Traumatic Stress

NCTSI National Child Traumatic Stress Initiative

NCTSN National Child Traumatic Stress Network

NCVC National Center for Victims of Crime

NDMS National Disaster Medical System

NGA National Governor's Association

NGO Nongovernmental Organization

NIAAA National Institute of Alcoholism and Alcohol Abuse
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NIDA National Institute on Drug Abuse

NIH National Institutes of Health

NIIMS National Interagency Incident Management System

NIMH National Institute of Mental Health

NIMS National Incident Management System

NMHA National Mental Health Association

NMHIC National Mental Health Information Center

NOVA National Organization for Victim Assistance

NVOAD National Voluntary Organizations Active in Disaster

O 

OC Office of Communications

OMB Office of Management and Budget

OVC Office for Victims of Crime

P 

PH Public Health

PIO Public Information Officer

PO Project Officer

PSA Public Service Announcement

PSW Public Safety Worker 

PTSD Posttraumatic Stress Disorder

R 

RSP Regular Services Program (CCP)

S 

SA Substance Abuse

SAMHSA Substance Abuse and Mental Health Services Administration

SCE State Capacity Expansion 

SEMA State Emergency Management Agency

SERG SAMHSA Emergency Response Grant (grant program)

SERT State Emergency Response Team

SF Standard Form

SHIN SAMHSA Health Information Network

SMHA State Mental Health Authority

SMHC State Mental Health Commissioner

SMTD Slow Motion Technological Disaster

SOP Standard Operating Procedure

SSA Single State Authority
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T 

TA Technical Assistance

TDD Telecommunications Device for the Deaf

TOT Training of Trainers

TTX Tabletop Exercise

U 

USAMRIID U.S. Army Medical Research Institute of Infectious Diseases

USPHS U.S. Public Health Service

USUHS Uniformed Services University of the Health Sciences

V 

VA Veteran's Administration

VOAD Voluntary Organizations Active in Disaster

VOLAG Voluntary Agency

W 

WHO World Health Organization

WMD Weapons of Mass Destruction
CCP Participant Workbook: Core Content Training

83

Disaster Reactions and Interventions

Age Group Behavioral 

Reactions Physical Reactions Emotional Reactions Cognitive Reactions Intervention Options

Preschool 

(1–5)

- 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

- Loss of appetite

- Stomachaches

- Nausea

- Sleep problems or 

nightmares

- Speech difficulties

- Tics

- Anxiety

- Generalized fear

- Irritability

- Angry outbursts

- Sadness

- Withdrawal

- Preoccupation with 

disaster

- Poor concentration

- Recurring dreams or 

nightmares

- 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
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84

Disaster Reactions and Interventions

Age Group Behavioral 

Reactions Physical Reactions Emotional Reactions Cognitive Reactions Intervention Options

Childhood 

(6–11)

- Decline in school

performance

- School avoidance

- Aggressive

behavior at home

or school

- Hyperactive or

silly behavior

- Whining, clinging,

or acting like a

younger child

- Increased

competition with

younger siblings

for parents’

attention

- Traumatic play

and reenactments

- Change in appetite

- Headaches

- Stomachaches

- Sleep disturbances

or nightmares

- Somatic

complaints

- Fear of feelings

- Withdrawal from

friends or familiar

activities

- Reminders

triggering fears

- Angry outbursts

- Preoccupation

with crime,

criminals, safety,

and death

- Self-blame

- Guilt

- Preoccupation with

disaster

- Poor concentration

- Recurring dreams or

nightmares

- Disorientation or

confusion

- Flashbacks

- Questioning of

spiritual beliefs

- Give additional attention and

consideration

- Relax expectations of performance

at home and at school temporarily

- Set gentle but firm limits for acting

out

- 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, and

identifying special children
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85

Disaster Reactions and Interventions

Age Group Behavioral 

Reactions Physical Reactions Emotional Reactions Cognitive Reactions Intervention Options

PreAdolescence 

and 

Adolescence 

(12–18)

- Decline in 

academic 

performance

- Rebellion at 

home or school

- Decline in 

responsible

behavior

- Agitation or 

decrease in 

energy level, or 

apathy

- Delinquent 

behavior

- Risk-taking 

behavior

- Social withdrawal

- Abrupt shift in 

relationships

- Appetite changes

- Headaches

- Gastrointestinal 

problems

- Skin eruptions

- Complaints of 

vague aches and 

pains

- Sleep disorders

- Loss of interest 

in peer social 

activities, 

hobbies, or 

recreation

- Sadness or 

depression

- Anxiety and 

fearfulness about 

safety

- Resistance to 

authority

- Feelings of 

inadequacy and 

helplessness

- Guilt, self-blame, 

shame, and selfconsciousness

- Desire for 

revenge

- Preoccupation with 

disaster

- Poor concentration

- Recurring dreams, 

nightmares, or 

flashbacks

- Disorientation or 

confusion

- Questioning of 

spiritual beliefs

- Difficulty setting 

priorities

- Difficulty making 

decisions

- Loss of objectivity

- Give additional attention and 

consideration

- Relax expectations of performance 

at home and school temporarily

- Encourage discussion of 

experience of trauma with peers 

and 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, special

student support groups, telephone 

hotlines, drop-in centers, and 

identification of special teens
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86

Disaster Reactions and Interventions

Age Group Behavioral 

Reactions Physical Reactions Emotional Reactions Cognitive Reactions Intervention Options

Adults - Sleep problems

- Avoidance of

reminders

- Excessive activity

level

- Protectiveness

toward loved

ones

- Crying easily

- Angry outbursts

- Increased

conflicts with

family

- Hypervigilance

- Isolation,

withdrawal, or

shutting down

- Nausea

- Headaches

- Fatigue or

exhaustion

- Gastrointestinal

distress

- Appetite change

- Somatic

complaints

- Worsening of

chronic conditions

- Shock,

disorientation,

and numbness

- Depression or

sadness

- Grief

- Irritability or

anger

- Anxiety or fear

- Despair or

hopelessness

- Guilt or selfdoubt

- Mood swings

- Preoccupation with

disaster

- Poor concentration

- Recurring dreams,

nightmares, or

flashbacks

- Disorientation or

confusion

- Questioning of

spiritual beliefs

- Difficulty setting

priorities

- Difficulty making

decisions

- Loss of objectivity

- 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

- Help 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 and roles of

primary responder groups

- Provide crime victim services

- Assess and refer, when indicated

- Provide information on referral

resources

- Provide information on substance

abuse self-help (for self, family,

friends)
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87

Disaster Reactions and Interventions

Age Group Behavioral 

Reactions Physical Reactions Emotional Reactions Cognitive Reactions Intervention Options

Older

Adults 

- Withdrawal and 

isolation

- Reluctance to 

leave home

- Mobility 

limitations

- Relocation 

adjustment 

problems

- Worsening of 

chronic illnesses

- Sleep disorders

- Memory problems

- Somatic symptoms

- More susceptibility

to hypothermia and 

hyperthermia

- Physical and 

sensory limitations 

(sight, hearing)

that interfere with 

recovery

- Depression

- Despair about 

losses

- Apathy

- Suspicion

- Agitation or 

anger

- Fears of 

institutionalization

- Anxiety about

unfamiliar 

surroundings

- Embarrassment 

about receiving 

“handouts”

- Preoccupation with 

disaster

- Poor concentration

- Recurring dreams, 

nightmares, or 

flashbacks

- Disorientation or 

confusion

- Questioning of 

spiritual beliefs

- Difficulty setting 

priorities

- Difficulty making 

decisions

- Loss of objectivity

- 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 and losses, and 

expression of emotions

- Provide crime victim assistance 

- Same as adults for substance 

abuse services 

Adapted from U.S. Department of Health and Human Services. (2000). Training manual for mental health and human service workers in 

major disasters (DHHS Publication 90–538). Washington, DC: Substance Abuse and Mental Health Services Administration Center for 

Mental Health Services. 
CCP Participant Workbook: Core Content Training

88

Recognizing Severe Reactions to Disaster and Common 

Psychiatric Disorders

Introduction 

When meeting with disaster survivors, crisis counselors may come into contact with people 

experiencing severe reactions to the disaster. Because treatment is not part of the Crisis 

Counseling Assistance and Training Program (CCP), the goal of crisis counseling is to 

recognize these reactions and know when to alert a team leader or program manager to any 

concerns. If unresolved, severe reactions, such as social isolation, paranoia, and suicidal 

behavior, may begin to interfere with daily functioning and develop into psychiatric disorders.

The psychiatric disorders most often associated with a traumatic event include depressive 

disorders, substance abuse, acute stress disorder, anxiety disorders, posttraumatic stress 

disorder (PTSD), and dissociative disorders. 

Crisis counselors may also encounter survivors who have preexisting psychiatric disorders 

and have become disconnected from treatment, or who may be experiencing an aggravation 

of their symptoms. These disorders include those described above, as well as bipolar 

disorder, borderline personality disorder, eating disorders, obsessive-compulsive disorder 

(OCD), panic disorder, schizoaffective disorder, schizophrenia, and co-occurring mental 

illness and substance abuse. Crisis counselors need to be able to recognize the possible 

symptoms of common psychiatric disorders so they know when to request assistance from 

their team leaders or other professionals in the program. 

Since the CCP is not a treatment program, the role of team leaders or other mental health 

professionals is to recognize and refer those in need of treatment services to local 

behavioral health services and not to provide treatment themselves. Whenever possible, 

crisis counselors, in consultation with their team leaders, may follow up with survivors to 

ensure they have connected with the needed resources. 

Please note that only a trained mental health professional can diagnose mental illness and 

provide psychotherapy, and a psychiatrist or medical doctor typically prescribes medication. 

Crisis counselors may encounter developmental disabilities, cognitive impairments, 

dementia, traumatic brain injury, traumatic or complicated grief, and attention deficit 

hyperactivity disorder in some survivors.

The contents of this handout are not exhaustive. Crisis counselors should always seek the 

assistance of supervisors and clinical personnel in any situation where there is a question 

about a person’s level of distress.
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Severe Reactions to a Traumatic Event 

The following severe reactions may result from an increase in the level of stress brought on 

by the traumatic event:

Social Isolation

• Social isolation is a feeling of loneliness experienced by the patient as a 

threatening state imposed by others; a sense of loneliness caused by the 

absence of family and friends; or the absence of a supportive or significant 

personal relationship caused by the patient's unacceptable social behavior or 

social values, inability to engage in social situations, immature interests, 

inappropriate attitudes for his or her developmental age, alterations in physical 

appearance, or mental status or illness. It is important to be aware of the 

possibility of social isolation when counseling people who are known to have 

developmental disabilities, cognitive impairments, dementia, and traumatic brain 

injury. 

• Symptoms:

– Feelings of loneliness imposed by others

– Feelings of rejection

– Feelings of difference from others

– Insecurity in public

– Sad, dull affect

– Uncommunicative and withdrawn behavior and lack of eye contact

– Preoccupation with own thoughts or repetitive, meaningless actions

– Hostility in voice and behavior

Paranoia

• Paranoia is an unfounded or exaggerated distrust of others, sometimes reaching 

delusional proportions. Paranoid individuals constantly suspect the motives of 

those around them, and believe that certain individuals, or people in general, are 

"out to get them." Acute, or short-term, paranoia may occur in some individuals 

overwhelmed by stress.

• Symptoms:

– Belief that others are plotting against him or her

– Preoccupation with unsupported doubts about friends or associates

– Reluctance to confide in others due to a fear that information may be used 

against him or her

– Reading negative meanings into innocuous remarks

– Bearing grudges

– Perceiving attacks on his or her reputation that are not clear to others and 

being quick to counterattack

– Maintaining unfounded suspicions regarding the fidelity of a spouse or 

significant other

Suicidal Behavior

• Suicidal behavior is a severe reaction that may result from several psychiatric 

disorders. Most people who kill themselves have a diagnosable and treatable 

psychiatric illness.
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• Symptoms:

– History of attempted suicide (Those who have made serious suicide 

attempts are at a much higher risk for actually taking their lives.)

– Family history of suicide, suicide attempts, depression, or other psychiatric 

illness

– Depression with an unrelenting low mood, pessimism, hopelessness, 

desperation, anxiety, psychic pain, and inner tension

– Sleep problems

– Increased alcohol or drug use

– Engagement in recent impulsive or unnecessarily risky behavior

– Making threats of suicide or expressing a strong wish to die

– Plans of self-harm or suicide

– Allocation of prized possessions

– Sudden or impulsive purchase of a firearm

– Acquiring other means of killing oneself such as poisons or medications

– Unexpected rage or anger

Psychiatric Disorders Most Often Associated with a Traumatic Event 

If left untreated or if unresponsive to crisis counseling interventions, severe reactions may 

lead to a psychiatric disorder. These disorders may be preexisting or may result from an 

increase in the level of stress brought on by the traumatic event and include the following:

Depressive Disorders

• Depressive disorders are illnesses that involve the body, mood, and thoughts. 

They affect the way a person eats and sleeps, the way one feels about oneself, 

and the way one thinks about things. A depressive disorder is not the same as a 

passing blue mood. It is not a sign of personal weakness or a condition that can 

be willed or wished away. Without treatment, symptoms can last for weeks, 

months, or years.

• Symptoms:

– Persistently sad or irritable mood

– Pronounced changes in sleep, appetite, and energy

– Difficulty thinking, concentrating, and remembering

– Physical slowing or agitation

– Lack of interest in or pleasure from activities once enjoyed

– Feelings of guilt, worthlessness, hopelessness, and emptiness

– Recurrent thoughts of death or suicide

– Persistent physical symptoms that do not respond to treatment, such as 

headaches, digestive disorders, and chronic pain
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Substance Abuse

• Substance abuse is a pattern of substance use resulting in consequences in 

major life areas. Substance misuse is the use of a substance in ways or for 

reasons other than intended for that substance. 

• Symptoms:

– Recurrent substance use resulting in a failure to fulfill major role obligations 

at work, school, or home (e.g., repeated absences or poor work 

performance related to substance use; substance-related absences, 

suspensions, or expulsions from school; neglect of children or household)

– Recurrent substance use in situations in which it is physically hazardous 

(e.g., driving an automobile or operating a machine when impaired by 

substance use)

– Recurrent substance-related legal problems (e.g., arrests for substancerelated disorderly conduct)

– Continued substance use despite having persistent or recurrent social or 

interpersonal problems caused or exacerbated by the effects of the 

substance (e.g., arguments with spouse about consequences of 

intoxication, physical fights)

Acute Stress Disorder

• Acute stress disorder is an anxiety disorder characterized by a cluster of 

dissociative and anxiety symptoms that occur within a month of a traumatic 

stressor. The immediate cause of acute stress disorder is exposure to trauma—

an extreme stressor involving a threat to life or the prospect of serious injury; 

witnessing an event that involves the death or serious injury of another person; or 

learning of the violent death or serious injury of a family member or close friend.

• Symptoms:

– Being dazed or less aware of surroundings

– Depersonalization

– Dissociative amnesia

– Reexperiencing the trauma in dreams, images, thoughts, illusions, or 

flashbacks; or intense distress when exposed to reminders of the trauma

– Tendency to avoid people, places, objects, conversations, and other stimuli 

reminiscent of the trauma

– Hyperarousal or anxiety, including sleep problems, irritability, inability to 

concentrate, an unusually intense startle response, hypervigilance, and 

physical restlessness

– Significantly impaired social functions or the inability to do necessary tasks, 

including seeking help

Anxiety Disorders

• Anxiety disorders, unlike the relatively mild, brief anxiety caused by a stressful 

event, last at least 6 months and can worsen if not treated. Anxiety disorders 

commonly occur along with other mental or physical illnesses, including alcohol 
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or substance abuse, which may mask anxiety symptoms or make them worse. In 

some cases, these other illnesses need to be treated before a person will 

respond to treatment for the anxiety disorder. Specific anxiety disorders include 

panic disorder, OCD, PTSD, social phobia (or social anxiety disorder), specific 

phobias, and generalized anxiety disorder. 

• Symptoms:

– Each anxiety disorder has different symptoms, but all the symptoms cluster 

around excessive, irrational fear and dread.

– Sometimes alcoholism, depression, or other coexisting conditions have 

such a strong effect on the individual that treating the anxiety disorder must 

wait until the coexisting conditions are brought under control.

PTSD

• PTSD is an anxiety disorder that can develop after exposure to a terrifying event 

or ordeal in which grave physical harm occurred or was threatened. Traumatic 

events that may trigger PTSD include violent personal assaults, natural or 

human-caused disasters, accidents, or military combat. Not every traumatized 

person develops full-blown or even minor PTSD. Symptoms usually begin within 

3 months of the incident but occasionally emerge years afterward. They must 

last more than a month to be considered PTSD. The course of the illness varies. 

Some people recover within 6 months; others have symptoms that last much 

longer. In some people, the condition becomes chronic.

• Symptoms:

– Persistent frightening thoughts and memories of the ordeal

– Emotional numbness, especially toward people with which the individual 

was once close

– Sleep problems

– Feelings of detachment

– Being easily startled

Dissociative Disorders

• Dissociative disorders are characterized by a dissociation from or interruption of 

a person's fundamental aspects of waking consciousness (such as one's 

personal identity or history). All of the dissociative disorders are thought to stem 

from trauma experienced by the individual with this disorder. Dissociative 

disorders include dissociative amnesia, dissociative fugue, dissociative identity 

disorder, and depersonalization disorder.

• Symptoms:

– The person literally dissociates himself or herself from a situation or 

experience too traumatic to integrate with his or her conscious self.

– Symptoms of one or more of the disorders are also seen in a number of 

other mental illnesses, including PTSD, panic disorder, and OCD.
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Preexisting Psychiatric Disorders 

In addition to the disorders described above, the following conditions may also have existed 

prior to the disaster.

Bipolar Disorder

• Bipolar disorder, or manic depression, causes extreme shifts in mood, energy, 

and functioning. These changes may be subtle or dramatic, typically varying 

greatly during a person’s life as well as among individuals. Bipolar disorder is a 

chronic, generally lifelong condition with recurring episodes of mania and 

depression lasting from days to months; episodes often begin in adolescence or 

early adulthood, and occasionally in children.

• Symptoms of mania:

– An elated, happy mood or an irritable, angry, unpleasant mood 

– Increased physical and mental activity and energy

– Racing thoughts and flight of ideas

– Increased talking, more rapid speech than normal

– Ambitious, often grandiose plans

– Risk taking

– Impulsive activity (e.g., spending sprees, sexual indiscretion, alcohol 

abuse)

– Decreased sleep without experiencing fatigue 

• Symptoms of depression:

– Loss of energy

– Prolonged sadness

– Decreased activity and energy

– Restlessness and irritability

– Inability to concentrate or make decisions

– Increased feelings of worry and anxiety

– Less interest or participation in and less enjoyment of activities normally 

enjoyed

– Feelings of guilt and hopelessness

– Thoughts of suicide

– Change in appetite

– Change in sleep patterns

Borderline Personality Disorder

• Borderline personality disorder is characterized by instability in moods, 

interpersonal relationships, self-image, and behavior. This instability often 

disrupts family and work, long-term planning, and the individual’s sense of selfidentity.

• Symptoms—A pattern of instability of interpersonal relationships, self-image, and 

affects, and marked impulsivity beginning by early adulthood and present in a 

variety of contexts, as indicated by five or more of the following:

– Frantic efforts to avoid real or imagined abandonment

– A pattern of unstable and intense interpersonal relationships characterized 

by alternating between extremes of idealization and devaluation
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– Identity disturbance—markedly and persistently unstable self-image or

sense of self

– Impulsivity in at least two areas that are potentially self-damaging (e.g.,

spending, sex, substance abuse, reckless driving, binge eating)

– Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior

– Affective instability due to a marked reactivity of mood (e.g., intense

episodic irritability, or anxiety usually lasting a few hours and only rarely

more than a few days)

– Chronic feelings of emptiness

– Inappropriate, intense anger or difficulty controlling anger (e.g., frequent

displays of temper, constant anger, recurrent physical fights)

– Transient, stress-related paranoid ideation or severe dissociative symptoms

Eating disorders 

• Anorexia nervosa is a serious, often chronic, and life-threatening eating

disorder defined by a refusal to maintain minimal body weight within 15 percent

of an individual's normal weight. Other essential features of this disorder include

an intense fear of gaining weight and a distorted body image. Symptoms include

the following:

– Preoccupation with food

– Refusal to maintain minimally normal body weight

– Continuing to think of oneself as fat even when he or she is bone-thin

– Brittle hair and nails

– Dry and yellow skin

– Depression

– Complaining of hypothermia

– Fine, downy hair growth on the body

– Strange eating habits such as cutting food into tiny pieces or refusing to eat

in front of others

• Bulimia nervosa is marked by a destructive pattern of binge eating and

recurrent inappropriate behavior to control one's weight. It can occur together

with other psychiatric disorders such as depression, OCD, substance

dependence, or self-injurious behavior. Binge eating is defined as the

consumption of excessively large amounts of food within a short period of time.

Symptoms include the following:

– Constant concern about food and weight

– Self-induced vomiting

– Erosion of dental enamel

– Scarring on the backs of the hands (due to repeatedly pushing fingers down

the throat to induce vomiting)

– Swelling of the glands near the cheeks (a small percentage of people show

this symptom)

– Irregular menstrual periods and a decrease in sexual interest

– Depression

– Sore throats and abdominal pain

OCD

• OCD is a psychiatric disorder characterized by obsessive thoughts or compulsive

behaviors. While most people at one time or another experience such thoughts
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or behaviors, an individual with OCD experiences obsessions and compulsions 

for more than an hour each day, in a way that interferes with his or her life. 

• Obsessions are intrusive, irrational thoughts or unwanted ideas or impulses that

repeatedly well up in a person's mind. Again and again, the person experiences

disturbing thoughts, such as "My hands must be contaminated; I must wash

them"; "I may have left the gas stove on"; "I am going to injure my child." On one

level, the sufferer knows these obsessive thoughts are irrational. But on another

level, he or she fears these thoughts might be true. Trying to avoid such

thoughts creates great anxiety.

• Compulsions are repetitive rituals such as hand washing, counting, checking,

hoarding, or arranging. Individuals repeat these actions, perhaps feeling

momentary relief, but without feeling satisfaction or a sense of completion.

People with OCD feel they must perform these compulsive rituals or something

bad will happen.

• Symptoms:

– Repeatedly checking things, perhaps dozens of times, before feeling

secure

– Fear of harming others

– Feeling dirty and contaminated

– Constantly arranging and ordering things

– Excessive concern with body imperfections

– Being ruled by numbers—believing that certain numbers represent good,

and others represent evil

– Excessive concern with sin or blasphemy

Panic Disorder

• Panic disorder is characterized by recurrent panic attacks, at least one of which

leads to a month of increased anxiety or avoidant behavior. Panic disorder may

also be indicated if a person experiences fewer than four panic episodes but has

recurrent or constant fears of having another panic attack.

• Symptoms:

– Sweating

– Hot or cold flashes

– Choking or smothering sensations

– Racing heart

– Labored breathing

– Trembling

– Chest pains

– Faintness

– Numbness

– Nausea

– Disorientation

– Feelings of dying, losing control, or losing one's mind

• Panic attacks typically last about 10 minutes, but may be a few minutes shorter

or longer. During the attack, the physical and emotional symptoms increase

quickly and then subside. A person may feel anxious and jittery for many hours

after experiencing a panic attack.
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Schizophrenia

• Schizophrenia often interferes with a person's ability to think clearly, distinguish 

reality from fantasy, manage emotions, make decisions, and relate to others. A 

person with schizophrenia does not have a "split personality," and almost all 

people with schizophrenia are not dangerous or violent toward others while they 

are receiving treatment. 

• Symptoms of schizophrenia are generally divided into three categories (positive, 

negative, and cognitive):

– Positive symptoms, or "psychotic" symptoms, include delusions and 

hallucinations because the patient has lost touch with reality in certain 

important ways. "Positive" refers to having overt symptoms that should not 

be there. Delusions cause individuals to believe that people are reading 

their thoughts or plotting against them, that others are secretly monitoring 

and threatening them, or that they can control other people's minds. 

Hallucinations cause people to hear or see things that are not present. 

– Negative symptoms include emotional flatness or lack of expression, an 

inability to start and follow through with activities, speech that is brief and 

devoid of content, and a lack of pleasure or interest in life. "Negative" does 

not refer to a person's attitude, but rather to a lack of certain characteristics 

that should be there. 

– Cognitive symptoms pertain to thinking processes. For example, people 

may have difficulty with prioritizing tasks, certain kinds of memory functions, 

and organizing their thoughts. A common problem associated with 

schizophrenia is the lack of insight into the condition itself. This is not a 

willful denial, but rather a part of the mental illness itself. 

Schizoaffective Disorder

• Schizoaffective disorder is one of the more common, chronic, and disabling 

mental illnesses. It is characterized by a combination of symptoms of 

schizophrenia and an affective (mood) disorder. 

• Symptoms:

– A person needs to have primary symptoms of schizophrenia (such as 

delusions, hallucinations, disorganized speech, and disorganized behavior), 

along with a period of time when he or she also has symptoms of major 

depression or a manic episode. Accordingly, schizoaffective disorder may 

have two subtypes: (1) depressive subtype, characterized by major 

depressive episodes only, and (2) bipolar subtype, characterized by manic 

episodes with or without depressive symptoms or depressive episodes.

– The mood symptoms in schizoaffective disorder are more prominent and 

last for a substantially longer time than those in schizophrenia.

– Schizoaffective disorder may be distinguished from a mood disorder by the 

fact that delusions or hallucinations must be present in people with 

schizoaffective disorder for at least 2 weeks in the absence of prominent 

mood symptoms.

– The diagnosis of a person with schizophrenia or mood disorder may 

change later to that of schizoaffective disorder, or vice versa. 
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Co-occurring Mental Illness and Substance Abuse

• Co-occurring mental illness and substance abuse are often referred to as cooccurring disorders. To recover fully, a consumer with co-occurring disorders 

needs treatment for both problems—focusing on one does not ensure the other 

will go away. Dual-diagnosis services integrate assistance for each condition, 

helping people recover from both in one setting, at the same time.

• What follows are some statistics, provided by the National Alliance on Mental 

Illness, on the prevalence of co-occurring disorders:

– Roughly 50 percent of individuals with severe mental disorders are affected 

by substance abuse.

– Thirty-seven percent of alcohol abusers and 53 percent of drug abusers 

also have at least one serious mental illness. 

– Of all people diagnosed as mentally ill, 29 percent abuse either alcohol or 

drugs.

– Of people with a 12-month addictive disorder, 42.7 percent had at least one 

12-month mental disorder.

– Of individuals with a 12-month mental disorder, 14.7 percent had at least 

one 12-month addictive disorder. 

– Forty-seven percent of individuals with schizophrenia also had a substance 

abuse disorder (more than four times as likely as the general population).

– Sixty-one percent of individuals with bipolar disorder also had a substance 

abuse disorder (more than five times as likely as the general population). 

• Often, people can suffer from more than one psychiatric disorder at a time. In 

addition, people can suffer from psychiatric and medical disorders simultaneously 

and may need treatment referrals for both.
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Treatment Approaches 

This section identifies general treatment approaches for a variety of psychiatric disorders. 

The following interventions are used either alone or in combination, depending on the 

treatment approach chosen by the survivor in consultation with his or her mental health 

treatment professional.

• A comprehensive approach to treatment would include a combination of

interventions, such as the following:

– Connecting the person with a peer counselor

– Referring the person to a support group

– Supporting family communication

– Enhancing spirituality

– Establishing a personal connection with a health care provider

– Assisting the person with the use of Internet-based supports

• It is important to note several additional points:

– Medication is most effective when it is used as part of an overall treatment

plan that includes supportive therapy.

– Medication-assisted treatment is the use of medications, in combination

with counseling and behavioral therapies, to provide a whole-patient

approach to the treatment of substance-use disorders. Research shows

that when treating substance-use disorders, a combination of medication

and behavioral therapies is most successful.

– Support groups and community-based programs, as well as 12-step

recovery programs, provide peer support to people suffering from

substance abuse.

– Cognitive therapy is used to help people think and behave appropriately.

People learn to make the feared object or situation less threatening as they

are exposed to, and slowly get used to, whatever is so frightening to them.

– Healthy living habits may also help. Exercise, a proper and balanced diet,

moderate use of caffeine and alcohol, and learning how to reduce stress

are all important.

Ten Fundamental Components of Mental Health Recovery 

Mental health recovery is a journey of healing and transformation enabling a person with a 

mental health problem to live a meaningful life in a community of his or her choice while 

striving to achieve his or her full potential.

• Self-direction—Consumers lead, control, exercise choice over, and determine

their own path of recovery by optimizing autonomy, independence, and control of

resources to achieve a self-determined life. By definition, the recovery process

must be self-directed by the individual, who defines his or her own life goals and

designs a unique path towards those goals.

• Individualized and person-centered—There are multiple pathways to recovery

based on an individual’s unique strengths and resiliencies as well as his or her

needs, preferences, experiences (including past trauma), and cultural

background in all of its diverse representations. Individuals also identify recovery

as being an ongoing journey and an end result, as well as an overall paradigm

for achieving wellness and optimal mental health.

• Empowerment—Consumers have the authority to choose from a range of

options and to participate in all decisions—including the allocation of resources—
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that will affect their lives, and are educated and supported in so doing. They 

have the ability to join with other consumers to collectively and effectively speak 

for themselves about their needs, wants, desires, and aspirations. Through 

empowerment, an individual gains control of his or her own destiny and 

influences the organizational and societal structures in his or her life.

• Holistic—Recovery encompasses an individual’s whole life, including mind, 

body, spirit, and community. Recovery embraces all aspects of life, including 

housing, employment, education, mental health and health care treatment and 

services, complementary and naturalistic services, addictions treatment, 

spirituality, creativity, social networks, community participation, and family 

supports as determined by the person. Families, providers, organizations, 

systems, communities, and society play crucial roles in creating and maintaining 

meaningful opportunities for consumer access to these supports.

• Nonlinear—Recovery is not a step-by-step process but one based on continual 

growth, occasional setbacks, and learning from experience. Recovery begins 

with an initial stage of awareness in which a person recognizes that positive 

change is possible. This awareness enables the consumer to move on to fully 

engage in the work of recovery.

• Strengths based—Recovery focuses on valuing and building on the multiple 

capacities, resiliencies, talents, coping abilities, and inherent worth of individuals. 

By building on these strengths, consumers leave stymied life roles behind and 

engage in new life roles (e.g., partner, caregiver, friend, student, employee). The 

process of recovery moves forward through interaction with others in supportive, 

trust-based relationships.

• Peer support—Mutual support—including the sharing of experiential knowledge 

and skills and social learning—plays an invaluable role in recovery. Consumers 

encourage and engage other consumers in recovery and provide each other with 

a sense of belonging, supportive relationships, valued roles, and community.

• Respect—Community, systems, and societal acceptance and appreciation of 

consumers—including protecting their rights and eliminating discrimination and 

stigma—are crucial in achieving recovery. Self-acceptance and regaining belief 

in oneself are particularly vital. Respect ensures the inclusion and full 

participation of consumers in all aspects of their lives.

• Responsibility—Consumers have a personal responsibility for their own selfcare and journeys of recovery. Taking steps toward their goals may require great 

courage. Consumers must strive to understand and give meaning to their 

experiences and identify coping strategies and healing processes to promote 

their own wellness.

• Hope—Recovery provides the essential and motivating message of a better 

future—that people can and do overcome the barriers and obstacles that 

confront them. Hope is internalized; but can be fostered by peers, families, 

friends, providers, and others. Hope is the catalyst of the recovery process.

Conclusion 

This handout was designed to give crisis counselors more information about severe 

reactions to trauma and psychiatric disorders that they may encounter in a small number of 

disaster survivors. When a severe reaction or psychiatric disorder is suspected, the crisis 

counselor needs to alert the CCP team leader and clinical personnel. The crisis counselor 
CCP Participant Workbook: Core Content Training

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should work should work with the survivor to determine if referral is needed, and then, the 

crisis counselor should make use of the resource linkage to refer the survivor to the 

appropriate resource. If possible, crisis counselors can follow up with survivors to see if they 

have made use of the referred services. Use of the Adult Assessment and Referral Tool is a 

way to keep track of survivors who may be suffering from severe reactions to disaster. As 

with all issues related to severe reactions and psychiatric disorders, use of the tool for this 

purpose should be done in consultation with CCP team leaders and clinical personnel.

Sources

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, 

fourth edition. Washington, DC. 

Gale, T. (2007–2012). Encyclopedia of Mental Disorder. Acute stress disorder. Retrieved from 

http://www.minddisorders.com/A-Br/Acute-stress-disorder.html

U.S. Department of Health and Human Services (HHS), National Alliance on Mental Illness (NAMI). 

(2007). NAMI: National Alliance on Mental Illness: Mental health support, education and advocacy 

[Website]. http://www.nami.org

HHS, National Institute on Drug Abuse. (2007). National Institute on Drug Abuse [Website]. 

http://www.nida.nih.gov

HHS, National Institute of Mental Health (NIMH). (2007). NIMH [Website]. http://www.nimh.nih.gov

HHS, Substance Abuse and Mental Health Services Administration. (2007). The Substance Abuse 

and Mental Health Services Administration [Website]. http://www.samhsa.gov
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The Road to Resilience

The Road to Realllence 

AMERICAN 

PSYCHOLOGICAL 

ASSOCIATION 
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INTRODUCTION 

How do people deal with difficult events that change 

their lives? The death of a loved one, loss of a job, serious illness, terrorist attacks, and other traumatic 

events: these are all examples of very challenging 

lite experiences. Many people react to such circumstances with a flood of strong emotions 

and a sense of uncertainty. 

Yet people generally adapt well over time to 

lite-changing situations and stressful conditions. 

What enables them to do so? It involves resilience, 

an ongoing process that requires time and effort 

and engages people in taking a number of steps. 

This brochure is intended to help readers with 

taking their own road to resilience. The information 

within describes resilience and some factors that 

affect how people deal with hardship. Much of 

the brochure focuses on developing and using 

a personal strategy tor enhancing resilience. 

WHAT IS RE ILIENCE? 

Resilience is the process of adapting well in the 

face of adversity, trauma, tragedy, threats, or even significant sources of stress - such as family and relationship problems, serious health problems, 

or workplace and financial stressors. It means 

"bouncing back" from difficult experiences. 

Research has shown that resilience is ordinary, 

not extraordinary. People commonly demonstrate 

resilience. One example is the response of many 

Americans to the September 11, 2001 terrorist 

attacks and individuals' efforts to rebuild their lives. 

Being resilient does not mean that a person doesn 't 

experience difficulty or distress. Emotional pain and 

sadness are common in people who have suffered 

major adversity or trauma in their lives. In tact, the 

road to resilience is likely to involve considerable 

emotional distress. 

Resilience is not a trait that people either have 

or do not have. It involves behaviors, thoughts, 

and actions that can be learned and developed 

in anyone. 
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SOME FACTORS IN RESILIENCE 

A combination of factors contributes to resilience. 

Many studies show that the primary factor in 

resilience is having caring and supportive relationships within and outside the family. Relationships 

that create love and trust, provide 

role models, and offer encouragement and reassurance help bolster a person's resilience. 

Several additional factors are associated with 

resilience, including: 

The capacity to make realistic plans and take 

steps to carry them out 

A positive view of yourself and confidence in 

your strengths and abilities 

Skills in communication and problem solving 

The capacity to manage strong feelings 

and impulses 

All of these are factors that people can develop 

in themselves. 

STRATEGIES FOR 

BUILDING RESILIENCE 

Developing resi lience is a personal journey. 

People do not all react the same way to traumatic 

and stressful life events. An approach to building 

resi lience that works for one person might not 

work for another. People use varying strategies. 

Some variation may reflect cultural differences. 

A person's culture might have an impact on 

how he or she communicates feelings and deals 

with adversity - for example, whether and how a 

person connects with significant others, including 

extended family members and community 

resources. With growing cultural diversity, the 

public has greater access to a number of 

different approaches to building resilience. 

Some or many of the ways to build resi lience 

in the following pages may be appropriate to consider in developing your personal strategy. 
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10 WAYS TO BUILD RESILIE CE 

Make connections. Good relationships with close 

family members, friends, or others are important. 

Accepting help and support from those who care 

about you and will listen to you strengthens 

resilience. Some people find that being active in 

civic groups, faith-based organizations, or other 

local groups provides social support and can help 

with reclaiming hope. Assisting others in their 

time of need also can benefit the helper. 

Avoid seeing crises as insurmountable problems. 

You can't change the fact that highly stressful 

events happen, but you can change how you interpret and respond to these events. Try looking 

beyond the present to how future circumstances 

may be a little better. Note any subtle ways in 

which you might already feel somewhat better as 

you deal with difficult situations. 

Accept that change is a part of living. Certain 

goals may no longer be attainable as a result of 

adverse situations. Accepting circumstances that 

cannot be changed can help you focus on circumstances that you can alter. 

Move toward your goals. Develop some realistic 

goals. Do something regularly - even if it seems 

like a small accomplishment - that enables you to 

move toward your goals. Instead of focusing 

on tasks that seem unachievable, ask yourself, 

'What's one thing I know I can accomplish today 

that helps me move in the direction I want to go?" 

Take decisive actions. Act on adverse situations 

as much as you can. Take decisive actions, rather 

than detaching completely from problems and 

stresses and wishing they would just go away. 

I·--------------------------,.._ 

Look for opportunities for self-discovery. People 

often learn something about themselves and may 

find that they have grown in some respect as a 

result of their struggle with loss. Many people who 

have experienced tragedies and hardship have 

reported better relationships, greater sense of 

personal strength even while feeling vulnerable, 

increased sense of self-worth, a more developed spirituality, and heightened appreciation for life. 

Nurture a positive view of yourself. Developing confidence in your ability to solve problems and 

trusting your instincts helps build resilience. 

Keep things in perspective. Even when facing very 

painful events, try to consider the stressful situation in 

a broader context and keep a long-term perspective. 

Avoid blowing the event out of proportion. 

Maintain a hopeful outlook. An optimistic outlook 

enables you to expect that good things will happen in 

your life. Try visualizing what you want, rather than worrying about what you fear. 

Take care of yourself. Pay attention to your own 

needs and feelings. Engage in activities that you 

enjoy and find relaxing. Exercise regularly. Taking 

care of yourself helps to keep your mind and body 

primed to deal with situations that require resilience. 

Additional ways of strengthening resilience may be 

helpful. For example, some people write about their 

deepest thoughts and feelings related to trauma or 

other stressful events in their life. Meditation and spiritual practices help some people build 

connections and restore hope. The key is to identify 

ways that are likely to work well for you as part of 

your own personal strategy for fostering resilience. 
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LEARNING FROM YOUR PAST 

SOME QUESTIONS TO ASK YOURSB.F 

Focusing on past experiences and sources of personal strength can help you learn about what 

strategies for building resilience might work for 

you. By exploring answers to the following questions about yourself and your reactions to challenging life events, you may discover how 

you can respond effectively to difficult situations 

in your life. 

Consider the following: 

What kinds of events have been most stressful 

for me? 

How have those events typically affected me? 

Have I found it helpful to think of important 

people in my life when I am distressed? 

To whom have I reached out for support in 

working through a traumatic or stressful 

experience? 

What have I learned about myself and my 

interactions with others during difficult times? 

Has it been helpful for me to assist someone 

else going through a similar experience? 

Have I been able to overcome obstacles, and if 

so, how? 

What has helped make me feel more hopeful 

about the future? 

t YI G FL BLE 

Resilience involves maintaining flexibility and 

balance in your life as you deal with stressful 

circumstances and traumatic events. This 

happens in several ways, including: 

Letting yourself experience strong emotions, 

and also realizing when you may need to 

avoid experiencing them at times in order 

to continue functioning 

Stepping forward and taking action to deal with 

your problems and meet the demands of daily 

living, and also stepping back to rest and 

reenergize yourself 

Spending time with loved ones to gain support 

and encouragement, and also nurturing yourself 

Relying on others, and also relying on yourself 
CCP Participant Workbook: Core Content Training

106

PLACES TO LOOK FOR HELP 

Getting help when you need it is crucial in building 

your resilience. Beyond caring family members and 

friends, people often find it helpful to turn to: 

Self-help and support groups. Such community 

groups can aid people struggling with hardships 

such as the death of a loved one. By sharing 

information, ideas, and emotions, group participants 

can assist one another and find comfort in knowing 

that they are not alone in experiencing difficulty. 

Books and other publications by people who have 

successfully managed adverse situations such as surviving cancer. These stories can motivate 

readers to find a strategy that might work for 

them personally. 

Online resources. Information on the web can 

be a helpful source of ideas, though the quality 

of information varies among sources. 

The APA Help Center, online at 

wwi. 11 J I r.rg is a good 

site to check. 

For many people, using their own 

resources and the kinds of help listed 

above may be sufficient for building resilience. 

At times, however, an individual might get 

stuck or have difficulty making progress 

on the road to resilience. 

A licensed mental health professional such as a 

psychologist can assist people in developing 

an appropriate strategy for moving forward. It is 

important to get professional help if you feel like 

you are unable to function or perform basic 

activities of daily living as a result of a traumatic 

or other stressful life experience. 

Different people tend to be comfortable with somewhat different styles of interaction. A person should 

feel at ease and have good rapport in 

working with a mental health professional or participating in a support group. 

u u 

To help summarize several of the main points in 

this brochure, think of resilience as similar to 

taking a raft trip down a river. 

On a river, you may encounter rapids, turns, slow 

water, and shallows. As in life, the changes you 

experience affect you differently along the way. 

In traveling the river, it helps to have knowledge 

about it and past experience in dealing with it. 

Your journey should be guided by a plan, a 

strategy that you consider likely to work well 

for you. 

Perseverance and trust in your ability to work 

your way around boulders and other obstacles 

are important. You can gain courage and insight 

by successfully navigating your way through 

white water. Trusted companions who accompany 

you on the journey can be especially helpful for 

dealing with rapids, upstream currents, and other 

difficult stretches of the river. 

You can climb out to rest alongside the river. But 

to get to the end of your journey, you need to get 

back in the raft and continue. 

EV 
CCP Participant Workbook: Core Content Training

107

For additional copies of The Road to Resilience brochure 

call 1-800-964-2000 or go to helping.apa.org