∙

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center 

the Dialogue

2016 | VOLUME 12 | ISSUE 3

Stress Management and Self-Care
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TABLE OF CONTENTS

1 In This Issue

2 Data Snapshot

3 Contributors

4 The Dialogue Reader Responses

5 Recent Technical Assistance Requests

6 Texas Flooding: A Team Bands Together

10 Promoting On-the-Job Stress Management Among Disaster Behavioral Health 

Coordinators and Responders

13 Stress Management When Implementing a CCP Grant: A Carolinian Perspective

15 Recommended Resources

The Dialogue is a quarterly technical assistance journal on disaster behavioral health which 

is produced by the Substance Abuse and Mental Health Services Administration (SAMHSA)

Disaster Technical Assistance Center (DTAC). Through the pages of The Dialogue, disaster 

behavioral health professionals share information and resources while examining the 

disaster behavioral health preparedness and response issues that are important to the field. 

The Dialogue also provides a comprehensive look at the disaster training and technical 

assistance services SAMHSA DTAC provides to prepare states, territories, tribes, and local 

entities so they can deliver an effective behavioral health (mental health and substance 

misuse) response to disasters. To receive The Dialogue, please go to SAMHSA’s home 

page (http://www.samhsa.gov), click the “Sign Up for SAMHSA Email Updates” button, enter 

your email address, and mark the checkbox for “SAMHSA’s Disaster Technical Assistance 

newsletter, The Dialogue,” which is listed in the Newsletters section.

SAMHSA DTAC provides disaster technical assistance, training, consultation, resources, 

information exchange, and knowledge brokering to help disaster behavioral health 

professionals plan for and respond effectively to mental health and substance misuse needs 

following a disaster.

To learn more, please call 1-800-308-3515, email DTAC@samhsa.hhs.gov, or visit the 

SAMHSA DTAC website at http://www.samhsa.gov/dtac.

The Dialogue is not responsible for the information provided by any web pages, materials, or organizations referenced in this publication. Although 

The Dialogue includes valuable articles and collections of information, SAMHSA does not necessarily endorse any specific products or services 

provided by public or private organizations unless expressly stated. In addition, SAMHSA does not necessarily endorse the views expressed by such 

sites or organizations, nor does SAMHSA warrant the validity of any information or its fitness for any particular purpose.
2016 | VOLUME 12 | ISSUE 3 | PAGE 1

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

In This Issue

Stress management and self-care are topics that many of 

us in the disaster response and recovery field struggle to 

pay more than lip service to. We preach it and teach it, 

but it can be difficult to model it. After all, some stress 

is good—it keeps us alert and focused. But, our bodies 

cannot stay in a constant state of alertness for too long 

without experiencing negative health effects. It can be 

hard to see this right after a disaster or crisis because 

there is just too much to do, and not enough people to do 

it all, and someone needs something from us right now, 

and, and, and...

It’s easy to justify why we just keep working. We 

care very much about the disaster survivors and our 

colleagues. We do not want to let them down or burden 

them with work by taking a break. The reality is that 

working longer hours has been shown to make us less 

productive, not more so. Pushing through when we 

are exhausted or sick or burnt out has short-term and 

long-term health effects, such as poor concentration, 

reduced memory, restlessness, irritability, headaches, 

stomachaches, and more.

When we talk about stress management and selfcare in disaster behavioral health, we need to model 

it. Modeling it ensures that we are practicing what 

we teach and providing a consistent message to our 

coworkers and staff. While stress tolerance is different 

for everyone, modeling stress management creates an 

environment that allows people to acknowledge their 

differences and engage in self-care.

The authors in this edition know firsthand the challenges 

of managing the desire to help with the need for rest. We 

hope their ideas and experiences help you in setting the 

example for self-care. We owe it to ourselves and those 

we serve to be our best selves. So, go get some rest, 

see a friend, or do whatever you like to do, and come 

back tomorrow better than today and ready to serve. As 

always, we welcome your suggestions and comments on 

integrating stress management and self-care into disaster 

behavioral health practice.

CAPT Erik Hierholzer, B.S.N.

Program Management Officer, Emergency Mental

Health and Traumatic Stress Services Branch

Erik.hierholzer@samhsa.hhs.gov

Brenda Mannix

SAMHSA DTAC Project Director

DTAC@samhsa.hhs.gov
2016 | VOLUME 12 | ISSUE 3 | PAGE 2

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

DATA SNAPSHOT

Crisis Counselor Stress Reactions

The data below come from surveys of crisis counselors working for the Crisis Counseling Assistance and 

Training Program (CCP). Under CCP grants, crisis counselors provide services and support in communities 

affected by disasters.

CCP crisis counselors are asked to complete surveys about their work within the program. The surveys cover 

several aspects of program experience, including stress reactions. The data shown here come from 446 

surveys of crisis counselors working for CCP grants in Colorado, Texas, New Jersey, New York, Washington, 

Louisiana, and Oklahoma.

The providers were asked to share their reactions (feelings, emotions, and thoughts) to their work using a scale 

of 1 to 5, where 1 is not at all, 2 is a little bit, 3 is somewhat, 4 is a quite a bit, and 5 is very much. The numbers 

shown are the averages of all responses.

Have you had difficulty handling other stressful events or situations due to your crisis counseling work or your 

reactions to it?

1 2 3 4 5

1.5

Has the crisis counseling work or your reaction to it interfered with how well you take care of your physical health?

1 2 3 4 5

1.6

Has the crisis counseling work or your reaction to it interfered with your ability to work or carry out your other 

daily activities, such as housework or schoolwork?

1 2 3 4 5

1.5

Has your crisis counseling work or your reaction to it affected your relationships with your family or friends or 

interfered with your social, recreational, or community activities?

1 2 3 4 5

1.5

Have you been distressed or bothered about your reactions?

1 2 3 4 5

1.4

These numbers suggest that crisis counselors in these programs generally experienced very low levels of stress, 

if any, related to their jobs. The articles in this issue by CCP providers talk about stress management training 

and other activities in which their teams participate. Team activities to keep stress at bay may be part of why 

crisis counselors in the programs surveyed indicated low levels of stress.
2016 | VOLUME 12 | ISSUE 3 | PAGE 3

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

Contributors

Nancy R. Divis, LCSW, Crisis 

Counselor, Texans Recovering 

Together

Teresa R. Gonzales, Team 

Lead Crisis Counselor, Texans 

Recovering Together

Charlie Cook is the Executive 

Director of Hearth Connection, 

a nonprofit agency providing 

permanent supportive housing 

for people who are homeless. 

He previously served as the 

Chief Administrative Officer of Chemical and Mental 

Health at the Minnesota Department of Human 

Services, and worked as the Executive Director of the 

Louisiana Spirit Hurricane Recovery with the Louisiana 

Department of Health and Hospitals to provide crisis 

counseling to many victims of Hurricanes Katrina and 

Rita.

Jay Little, M.S., has been in 

the management and (lay) 

counseling fields for 15 years. 

He is obtaining his M.S. 

in clinical counseling from 

Lenoir-Rhyne University, while 

working for the Carolina United Program. He is married, 

and he and wife are expecting their first child this year.

William Wells, M.S.W., has been 

in the human services fields 

for over 40 years, the last 10 

of which involved emergency 

preparedness and response. He 

obtained his M.S.W. from the 

University of South Carolina and is the proud father of 

a lovely 35-year-old daughter and an energetic 13-yearold son.
2016 | VOLUME 12 | ISSUE 3 | PAGE 4

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

The Dialogue Reader Responses

In this section, read selected responses from readers about their thoughts on previous issues of The Dialogue. Find 

past issues at http://www.samhsa.gov/dtac/resources/dialogue. If you have a comment about an article, send it to 

DTAC@samhsa.hhs.gov.

Klaryce from New Castle, 

Pennsylvania, writes:

Back in 2005, I had the opportunity 

to visit the museum for the 

Oklahoma City bombing, and the 

memories of that visit are still so 

vivid even now. 

I am not from Oklahoma and have 

never lived there. I did not know 

anyone who was directly affected by 

the bombing. I was just visiting and 

happened to end up at the memorial 

museum. Seeing the pictures of the 

destruction and all of the exhibits 

was such a sad experience. I 

remember seriously crying while 

walking through the museum. It 

was heartbreaking. Even as I write 

this message and think back on the 

experience, my eyes are welling up 

with tears.

I also remember thinking that it 

was really impressive—the effort 

and thought that must have gone 

into designing the museum and the 

order of the exhibits. It was very 

structured as I felt like I was walking 

through April 19, 1995. It was clear 

that the organizers of the museum 

had a message they were telling with 

the whole design.

It was such a somber experience. I 

haven’t been back to that museum 

since, and I’m not sure that I’d want 

to revisit it, but I’m really glad 

that I had the chance to at least 

visit there once. It gave me a real 

appreciation of what the folks in 

Oklahoma City went through with 

that event.

Read more about the Oklahoma 

City National Memorial and 

Museum at http://www.samhsa.

gov/sites/default/files/dtac/

dialogue-vol-12-issue-2.pdf

Kelli from Frankfort, 

Kentucky, writes:

I was finally able to get around 

to reading the Dialogue 2016,

Volume 12, Issue # 2. On Page 6 

under “Recent Technical Assistance 

Requests,” I was reading the 

request “A Community Prevention 

Professional contacted SAMHSA 

DTAC about resources for 

addressing the mental health needs 

of first responders and guidance on 

establishing peer support groups.” 

I wanted to remind some and let 

new folks know that this is what 

we the Kentucky Community 

Crisis Response Board does on a 

daily basis. We have been doing 

this for 19 years though we were 

established in Statute 20 years ago. 

We train a lot of first responders and 

others in Critical Incident Stress 

Management and have a team of 167 

first responders, behavioral health, 

military, coroners, nurses, teachers, 

faith based, hospital chaplains, 

fire, and law chaplains. We also 

have a Kentucky Law Enforcement 

Assistance Program strike team 

that provides Critical Incident 

Stress Management to other law 

enforcement. We are a peer-driven 

team. ■
2016 | VOLUME 12 | ISSUE 3 | PAGE 5

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

Recent Technical Assistance Requests

In this section, read about recent questions SAMHSA DTAC staff have answered, technical assistance (TA) requests 

received, and responses to past articles in The Dialogue. Send your questions and comments to DTAC@samhsa.hhs.gov.

Request: SAMHSA DTAC received a request for 

assistance from a person looking for training to become 

a crisis counselor for purposes of career enhancement.

Response: SAMHSA DTAC sent the following 

resources to this individual.

• Centers for Disease Control and Prevention (CDC)

Preparedness and Emergency Response Learning

Centers (PERLC)

CDC funds 14 centers across the United States. The

PERLC in several states offer disaster response-related

courses online free of charge.

http://www.cdc.gov/phpr/perlc.htm

• Federal Emergency Management Agency (FEMA)

Citizen Corps

The mission of Citizen Corps is to “harness the power

of every individual through education, training, and

volunteer service to make communities safer, stronger,

and better prepared to respond to the threats of

terrorism, crime, public health issues, and disasters of

all kinds.”

http://www.ready.gov/citizen-corps

• FEMA Community Emergency Response Team

(CERT) Program

This program educates people about disaster

preparedness for hazards that may affect their area

and provides training in basic skills in emergency

response.

https://www.fema.gov/community-emergencyresponse-teams

• American Red Cross: Disaster Mental Health

Worker

Red Cross disaster mental health volunteers are

licensed psychiatrists, psychologists, psychiatric

nurses, social workers, school counselors, and

marriage and family therapists. They volunteer to

be trained in specialized disaster counseling skills

and then travel to disasters to help victims and relief 

workers deal with the trauma and stresses of disaster.

http://www.redcross.org/take-a-class/disastertraining

Request: SAMHSA DTAC received an email from 

a state disaster behavioral health coordinator (SDBHC) 

who had a “white powder incident” in a hospital in her 

state and was interested in guidance on how hospitals 

can handle the behavioral health aftermath of false 

alarms during a critical incident event. 

Response: In response to this request, SAMHSA 

DTAC sent the SDBHC the names of two SDBHCs who 

have experience in the area of critical incident response, 

as well as the following resources:

• SAMHSA DTAC Supplemental Research Bulletin:

Disaster Behavioral Health Interventions Inventory:

http://www.samhsa.gov/sites/default/files/dtac/

supplemental-research-bulletin-may-2015-disasterbehavioral-health-interventions.pdf

• An article titled “Emotional and Behavioral

Consequences of Bioterrorism: Planning a Public

Health Response”: http://www.ncbi.nlm.nih.gov/

pmc/articles/PMC2690224

• Risk Communication Toolkit for Local Health

Agencies—New Jersey Department of Health: http://

www.state.nj.us/health/er/documents/lha_risk_

comm_toolkit.pdf ■
2016 | VOLUME 12 | ISSUE 3 | PAGE 6

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

Texas Flooding: A Team Bands Together

By Nancy R. Divis, LCSW, Crisis Counselor, Texans Recovering Together; and Teresa R. Gonzales, Team Lead 

Crisis Counselor, Texans Recovering Together

On May 24, 2015, severe weather 

erupted across Texas, leaving 24 

people dead and hundreds injured. 

Fifteen hundred homes sustained 

major damage or were destroyed, 

leaving hundreds of people to seek 

shelter. Texas experienced 

tornadoes, severe thunderstorms, 

damaging winds, large destructive 

hail, and record-breaking rainfall, 

which produced widespread flash 

flooding. The National Weather 

Service reported that the total 

amount of rain received in May 

exceeded 37 trillion gallons, enough 

to cover the entire state of Texas 

with 8 inches of water.

The severe weather across Texas 

resulted in Governor Abbott issuing 

a state disaster declaration for 94 of 

the 254 counties in Texas. Of the 94 

declared counties, 23 counties were 

submitted to President Obama for 

consideration of a federal 

disaster declaration, and 

all were approved. The price 

of living in the Hill Country 

along the Blanco River was 

unprecedented.

Hill Country Mental Health 

and Developmental Disabilities 

recruited a team of six mental 

health professionals to embark on 

the mission to provide emotional 

support and resources to survivors.

Stress is caused by 

being “here” but 

wanting to be “there.” 

—Eckhart Tolle

We all had many years of experience 

providing intervention services.

We felt confident in our abilities 

to provide quality service to the

survivors. The early days were 

long and demanding as we problem 

solved, linked survivors to services, 

and, most importantly, listened to the 

stories survivors needed to tell. We 

heard the stories of loss, of homes 

and neighborhoods destroyed, deaths 

of beloved pets, of neighbors, and 

family members. Some perished 

immediately in the floodwaters 

or they died later, the result of 

flood-related health conditions. We 

strived to educate ourselves about 

community resources; application 

processes and deadlines; and 

donation center locations.

COUNTY HIT BY 4 DISASTERS

COUNTY HIT BY 3 DISASTERS

COUNTY HIT BY 2 DISASTERS

COUNTY HIT BY 1 DISASTERS
2016 | VOLUME 12 | ISSUE 3 | PAGE 7

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

From Bad to Worse

For Central Texans, the recovery 

became much more complicated, 

when less than 6 months after the 

Memorial Day floods, torrential rain 

again fell over the area. Another 

national disaster was declared 

covering an even larger geographic 

area. This second flood contributed 

to a general feeling of vulnerability 

in the communities. We could 

no longer rationalize the recordbreaking May flood as an extremely 

rare event. The idea of a 100- or 

500-year event became a sick joke. 

Not only could it happen again, it 

did. In the city of San Marcos, the 

October 2015 floods hit the very 

same neighborhoods affected by the 

Memorial Day floods. Some folks 

had only been back in their homes a 

few weeks. Many were still working 

on repairs.

This second event created a second 

task force of crisis counselors. 

Coordinating our work became 

more challenging since the two 

task forces needed to operate 

separately, although we often served 

people affected by both floods. 

Bureaucratic snarls became more 

frequent as federal, state, county, 

and local agencies staked out their 

territory, and we were often in the 

middle of political battles we didn’t 

understand.

Left: Cocktail ring found on riverbank during 

riparian tree and vegetation planting along the 

Blanco River in Wimberley. Photo by Teresa R. 

Gonzales. Below: Devastated home near the 

Fisher Store Bridge in Wimberley. Photo by Teresa 

R. Gonzales.

Be kind. Everyone you 

meet is fighting a hard 

battle.

—Philo of Alexandria

We saw community resources dry 

up. Volunteer groups were drawn 

to other disaster areas in Texas and 

around the country. Fundraising 

efforts stalled. People were tapped 

out. We frequently heard from those 

unaffected by the disaster that this 

should be over by now; folks should 

be moving on. They often expressed 

surprise that a significant part of 

the population was still struggling 

to recover. As of June 2016, more 

than 600 people were still awaiting 

case management services; a large 

portion of the survivors had yet to 

return to their homes. Many had 

simply decided that after multiple 

floods it was time to head for higher 

ground elsewhere.

Debris still litters riverbanks and 

private property. Rebuilding has 

slowed with many waiting to see 

what flood diversion programs will 

be put in place so that future rain 

events can be mitigated. Many of the 

flood survivors, frustrated by delays, 

direct these frustrations and anger 

toward whoever is present for the 

fallout, even toward those trying to 

help. At times we have been targeted 

with that emotional angst.

Self-Care While Caring 

for Others

Texans Recovering Together 

continues to operate on the ground, 

in homes and at community events, 

offering linkage to resources, 
2016 | VOLUME 12 | ISSUE 3 | PAGE 8

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

community education, and 

crisis counseling. But from the 

beginning of our work a year ago, 

we have been instructed, cajoled, 

and encouraged to take care of 

ourselves so that we could do the 

job; individually and as a team we 

had to learn to be resilient as well as 

resourceful. Just as we ask of those 

we serve, we must commit to selfcare and stress management. Our 

leadership asked us to see self-care 

as an ethical requirement. After all, 

how could we do the best job if we 

were sick, tired, burned out?

Fortunately, our leadership made 

self-care part of our mission and 

our training. From our team leads, 

we were constantly reminded and 

encouraged to work within 40-hour 

work weeks, to take time for lunches 

together, to staff difficult cases with 

our colleagues, and to share tips on 

successful strategies for self-care. 

We learned to acknowledge and 

celebrate our successes, however 

small they might be.

The training we have received 

through the state, the Federal 

Emergency Management Agency 

and SAMHSA, and national 

religious organizations emphasized 

the need for self-care and selfmonitoring. One of the most helpful 

aspects of this training dealt with 

compassion fatigue.

Compassion fatigue results from 

a combination of the secondary 

experience of trauma as we 

Top: San Marcos home in Blanco Gardens 

neighborhood nearly 1 year from the Memorial 

Day flood and 6 months since the All Saints’ Day 

flood. Photo by: Teresa R. Gonzales. Above:

Debris found in river from All Saints’ flood. Photo 

by: Teresa R. Gonzales
2016 | VOLUME 12 | ISSUE 3 | PAGE 9

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

hear these accounts from the 

survivors, and burnout, which 

tends to be caused by organizational 

frustrations. As crisis counselors, we 

tend to be empathetic and want to 

be helpful. However, this puts us at 

greater risk for compassion fatigue. 

What program trainers remind us 

is that in this work, we are not in 

control of our outcomes. Whatever 

satisfaction we get from our work 

won’t necessarily come from how 

things turn out but from whether 

we did the best we knew how to do 

and that we worked according to 

our values and our mission. Shifting 

focus from outcome to “job well 

done” is challenging. It usually 

requires courageous conversations 

with ourselves and with our 

colleagues whenever we lose focus. 

Frustration is the wake-up call that 

our focus is badly aimed.

It always seems 

impossible until it’s done.

—Nelson Mandela

These courageous conversations 

should also include concerns about 

physical and emotional health. As

a team, we experienced more than 

our normal health issues, whether 

from unhealthy habits or because 

of the contaminated environments 

in which we often worked. Our 

coping choices were not always 

the textbook version we promoted 

for others and at times included an 

unhealthy diet, poor sleep habits, 

and excessive drinking.

Fortunately, we share a sense of 

humor. We laugh whether we’re 

at lunch together, on the road to a 

community event or a training, or 

engaged in a team-building exercise 

involving bandanas, two boards, 

and cement blocks to cross a “toxic 

river.” Trust me, this latter exercise 

could be the subject of a whole new 

article.

It’s been quite a ride. ■

Left: Blindfolded team members during “toxic river” 

team-building exercise. Photo by: Nancy R. Divis.

Below: Team-building by performing acts of 

service to help meet needs of survivors brought 

joy to the team and helped them manage stress. 

Photo by: Teresa R. Gonzales.
2016 | VOLUME 12 | ISSUE 3 | PAGE 10

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

Promoting On-the-Job Stress Management 

Among Disaster Behavioral Health 

Coordinators and Responders

By Charlie Cook, Executive Director of Hearth Connection, and Former Executive Director of the Louisiana Spirit 

Hurricane Recovery Program

I don’t need no stinkin’ stress 

management: We’ve all taken the 

training on stress management: 

eat right, get plenty of sleep, get 

some exercise, drink a lot (water of 

course), use breathing techniques 

and meditation maybe; so that’s 

not what this article is about. All 

of that is good, and we need to 

pay attention. But then there is the 

reality of responding to disasters. 

There are a few given stressors in 

doing the work of behavioral health 

after a disaster—vicarious trauma, 

heavy workloads, and my favorite, 

administration. The following 

discusses some of the other causes 

of stress and some practical ways of 

mitigating the effects.

Nightmares: We will often turn to 

“war stories” in casual conversations 

among a group of experienced 

disaster behavioral health workers. 

Things seen or experienced, 

exposure that remains etched in our 

brains and evokes strong emotions 

weeks, months, or years later. I 

can describe in detail a number of 

circumstances that touched me, 

angered me, scared me, hurt me. 

When they occur is somewhat 

random, and not always when you 

might expect. For me, exposures 

while working a small tornado in 

Georgia and localized flooding in 

Kentucky hold as much power as 

some in the Oklahoma City bombing 

or Hurricane Katrina. If you are 

doing disaster behavioral health 

work, you will be affected. You will 

get hurt. Talking it through with 

others helps make sense of your 

reactions. We all have nightmares.

I forgot to eat: Twelve-hour days 

seem fairly normal in this work, 

writing a grant, report, or plan seems 

to last forever, and it’s really never 

good enough or quite complete. 

There are more calls to make, emails 

to respond to, and reports to read. We 

better get the latest documentation, 

and why does every agency have 

a different damage report? Why 

does it take so long to hire—what’s 

the holdup? Who is organizing the 

training? FEMA wants counselors 

at all eight of the Disaster Recovery 

Centers. Everything is Priority #1. 

“At 7:00 that evening I realized I had 

not eaten all day, got a bucket of fried 

chicken and a half gallon of 

chocolate milk. Not such a good idea.”

Managing Stress: A Few Ideas

1. Know your limits. You are human 

and flawed. Avoid unnecessary 

exposure.

a. Share your experiences with 

someone you trust—it’s what you 

would tell others to do.

b. Make it okay for you and your 

team to talk about exposure and 

vulnerability.

c. Make sure you and everyone 

working the disaster has access to 

counseling.

d. Have a cup of coffee with a friend 

who is not involved with disaster 

response, preferably someone who 

wants to discuss clothes, sports, or 

NASCAR.

e. Know and understand your own 

resilience and what contributes to 

your own ego strength, and rely on 

that.
2016 | VOLUME 12 | ISSUE 3 | PAGE 11

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

2. Keep life predictable. Create

a schedule that allows for routine

interaction with loved ones, friends,

and your pet.

a. Get up at the same time and go to

bed at the same time.

b. Eat at the same times every day.

c. Listen to some music you love that

always makes you feel good.

d. Exercise every day, whatever you

can do, even for 5 minutes.

e. Mow the lawn, iron your clothes,

or do some other mindless but

productive activity at least once a 

week.

f. Do not make major life changes or

decisions in the midst of a disaster.

3. Know the response plan.

a. Update contact information

constantly.

b. Create an information flow chart,

from whom, to whom, and the

sequence; work backward from

deadlines.

c. Inform others relentlessly; you

never want to hear “I didn’t

know...”

d. Checklists (yes, plural) are your

friends.

e. Make time for your training.

f. Make a to-do list of things you’ve

already done and then check them

off. It just feels good and you’ll

have something you can report to

your boss.

By following these steps, you 

won’t be able to eliminate stress 

completely—after all, it is a disaster—

but you should be able to get through 

it healthier and better prepared for the 

next one. ■

Role ambiguity Lack of clarity 

of tasking

Mismatching 

skills with tasks

Lack of team 

cohesion

Discomfort 

with hazardous 

exposure

Lack of or too 

much autonomy

Laboratory 

specimen 

tracking, 

reporting

Resources/

equipment 

shortages

Command 

and control 

ambiguities

Reintegration 

barriers

Domestic/family 

conflict

Ineffective communication 

within team, with non-team 

members, with headquarters

Intense local needs for information 

(media/health officials) that cannot 

await clearance delay

Coworkers had to pick up 

your work...or no one did, and 

it is overwhelming

Lack of understanding of 

or appreciation for what you have 

been through

Database issues, linkage between 

epidemiology, laboratory, 

and environmental sampling

Source: Centers for Disease Control and Prevention: Disaster Mental Health for Responders: Key Principles, Issues and Questions

Sources of Stress 

for Responders
2016 | VOLUME 12 | ISSUE 3 | PAGE 12

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

An increase or 

decrease in your energy 

and activity levels

An increase in your 

alcohol, tobacco use, or 

use of illegal drugs

An increase in irritability, 

with outbursts of anger 

and frequent arguing

Having trouble relaxing 

or sleeping

Crying frequently

Worrying excessively

Wanting to be alone 

most of the time

Blaming other people 

for everything

Having difficulty 

communicating 

or listening

Having difficulty giving 

or accepting help 

Inability to feel 

pleasure or have fun

SIGNS OF

STRESS

Immune system. Constant stress can make

you more likely to get sick more often. And if you 

have a chronic illness such as AIDS, stress can 

make your symptoms worse.

Heart. Stress is linked to high blood pressure,

abnormal heartbeat (arrhythmia), blood clots, and 

hardening of the arteries (atherosclerosis). It’s also 

linked to coronary artery disease, heart attack, and 

heart failure.

Muscles. Constant tension from stress can lead

to neck, shoulder, and lower back pain. Stress may 

make rheumatoid arthritis worse.

Stomach. If you have stomach problems, such

as gastroesophageal reflux disease (GERD), 

peptic ulcer disease, or irritable bowel syndrome, 

stress can make your symptoms worse.

Reproductive organs. Stress is linked to low

fertility, erection problems, problems during 

pregnancy, and painful menstrual periods.

Lungs. Stress can make symptoms of asthma

and chronic obstructive pulmonary disease 

(COPD) worse. 

Skin. Skin problems such as acne and psoriasis

are made worse by stress.

Source: WebMD Medical Reference from Healthwise

LONG-TERM EFFECTS OF STRESS
2016 | VOLUME 12 | ISSUE 3 | PAGE 13

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

Stress Management When Implementing a 

CCP Grant: A Carolinian Perspective

Contributed by Jay Little, M.S., Program Director of Carolina United; and William Wells, M.S.W., Program 

Manager, Emergency Preparedness and Response

During the floods of October 2015, 

the Carolinas were pummeled by 11 

trillion gallons of water in roughly 

1 week, an amount of precipitation 

that would have been enough to end 

California’s drought. On October 

5, 2015, a Presidential disaster 

declaration (SC-4241) was issued 

for eight counties in South Carolina. 

On October 19, the South Carolina 

Emergency Management Division 

(SCEMD) applied for a Crisis 

Counseling Assistance and Training 

Program (CCP) Immediate Services 

Program grant to cover the first 

eight and, later, another 12 counties 

identified as affected by the disaster. 

SCEMD partnered with the South 

Carolina Department of Mental 

Health (SCDMH), the state mental 

health authority, to implement 

Carolina United. To date, this 

SCDMH program has reached more 

than 100,000 South Carolinians in 

20 counties, and has succeeded in 

helping provide referrals and other 

services with fewer than 30 staffers. 

Dealing With Nuts and Bolts

Because SCDMH is a state agency,

and therefore subject to laws and 

regulations affecting government 

entities, the establishment of 

positions, ordering of supplies, 

and hiring of staff was expedited 

whenever possible. Because no 

activity involving the program’s 

budget could be performed until 

the award letter was in hand, basic 

supplies, such as cell phones and 

laptops, were not available until the 

end of the third week of operation. 

Carolina United staff were able to 

train its initial four teams beginning 

November 9, less than 1 month 

Effects of Stress on

YOUR BODY

 ̈ Having stomachaches 

or diarrhea

 ̈ Having headaches and 

other pains

 ̈ Losing your appetite 

or eating too much

 ̈ Sweating or having chills

 ̈ Getting tremors or 

muscle twitches

 ̈ Being easily startled

Effects of Stress on

YOUR EMOTIONS

 ̈ Being anxious or fearful

 ̈ Feeling depressed

 ̈ Feeling guilty

 ̈ Feeling angry

 ̈ Feeling heroic, euphoric, 

or invulnerable

 ̈ Not caring about anything

 ̈ Feeling overwhelmed 

by sadness
2016 | VOLUME 12 | ISSUE 3 | PAGE 14

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

Stress Reduction Techniques:

1

Tai Chi or Yoga

2

Exercise

3

Meditation

4

Deep Breathing

5

Write About 

What You Are 

Thankful For

6

Take a Nap

7

Play With a Pet

8

Aromatheraphy

9

Listen to Music

10

Take a Walk

after receiving the funding award. 

The program is off to an ambitious 

start because of the diligent work of 

SCDMH administration and service 

personnel. 

Carolina United team members 

work out of SCDMH community 

mental health centers to provide 

services in local communities. Some 

program crisis counselors found 

it overwhelming to see and hear 

the people who were financially, 

physically, or mentally distressed, 

but ashamed or afraid to be referred 

for assistance. The counselors have 

also expressed frustration both with 

trying to locate resources and a lack 

of available resources. 

Effects of Stress on

YOUR THINKING

 ̈ Having trouble

remembering things

 ̈ Feeling confused

 ̈ Having trouble thinking

clearly

Source: SAMHSA’s Coping With Stress 

during an Infectious Disease Outbreak

The Importance of Self-Care

Both the Program Director and 

community mental health clinical 

staff monitor and assess team 

members’ mental and emotional 

health status, to ensure they 

are coping with the stressors of 

their roles. The stress that crisis 

counselors report arises mainly from 

the frustration of learning internal 

state processes, correctly completing

travel sheets, entering attendance 

into the agency computer system, 

and experiencing processing delays 

on equipment and informational 

needs. 

The program team members have 

had to learn how to care for their 

community as well as themselves,

and quickly. As such, they adopted 

an early, simple strategy of selfcare. The Program Director reminds 

team leads about the importance of 

self-care and these techniques during 

weekly conference calls, onsite visits 

to teams, and via text and email. 

Communal meals, attention to diet, 

good mental health, and leisure/rest 

are integral to ensuring that team 

members care for themselves as well 

as those they seek to help. ■
2016 | VOLUME 12 | ISSUE 3 | PAGE 15

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

RECOMMENDED RESOURCES

Understanding Compassion Fatigue 

and Compassion Satisfaction: Tips 

for Disaster Responders

Presented by an expert who developed a tool to measure 

compassion satisfaction (CS) and compassion fatigue 

(CF), this presentation defines CS and CF, provides 

details of the ProQOL (Professional Quality of Life 

Scale) by which they can be measured, and offers 

strategies for responders to help increase their CS and 

avoid the likelihood of CF during and after their work.

View the webcast at http://bit.ly/1U9GUBd

Check out companion tip sheets in 

English at http://1.usa.gov/1K2erMy and 

Spanish at http://1.usa.gov/1Q4UWHI

Tip Sheets About Stress 

Management for Responders

These SAMHSA DTAC tip sheets provide information 

and suggestions for preparing for deployment, stress 

prevention and management during disaster response, 

and coping with issues for responders that may arise as 

they return to work.

Download Tips for Disaster Responders: 

Preventing and Managing Stress in 

English at http://1.usa.gov/21mEROo and 

Spanish at http://1.usa.gov/1sGwsKD

Download Tips for Disaster Responders: Returning 

to Work in English at http://1.usa.gov/23aoxle and 

Spanish at http://1.usa.gov/1XXhQnx

Self-Care for Disaster Behavioral 

Health Responders

This webcast identifies aspects of disaster response that 

may cause stress for responders, presents best practices 

in responder self-care, and explains how managers and 

organizations can support responders in maintaining 

good behavioral health throughout their response work.

View the webcast at http://bit.ly/1rq69a8

Access the presentation at http://1.usa.gov/1XpBtDG

Disaster Responders DBHIS 

Installment

Part of SAMHSA’s Disaster Behavioral Health 

Information Series (DBHIS), this collection of resources 

covers self-care and stress management for disaster 

responders, as well as other topics relevant to disaster 

response, such as post-disaster behavioral health 

interventions and sources of additional support for 

responders.

View the installment at http://1.usa.gov/1S5AIb7 ■
∙

Behavioral Health is Essential To Health

Prevention Works • Treatment is Effective • People Recover

SUBSCRIBE

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The SAMHSA Disaster Behavioral Health Information Series contains resource 

collections and toolkits pertinent to disaster behavioral health. Installments focus on 

specific populations, specific types of disasters, and other topics related to all-hazards 

disaster behavioral health preparedness and response. Visit the SAMHSA DTAC 

website at http://www.samhsa.gov/dtac/dbhis-collections to access these materials.

CONTACT US

SAMHSA Disaster Technical 

Assistance Center

Toll-Free: 1-800-308-3515 

DTAC@samhsa.hhs.gov

http://www.samhsa.gov/dtac