Field Manual for Mental Health and Human

Service Workers in Major Disasters

Publisher: SAMHSA

Publication date: January 2000

Publication ID: ADM90-0537

Substance Abuse & Mental Health Services Administration

1 Choke Cherry Road • Rockville, MD 20857 • 1-877-SAMHSA-7

 U.S. Department of Health and Human Services
Field Manual for Mental Health and Human Service Workers

in Major Disasters

INTRODUCTION

This Field Manual is intended for mental health workers and other human service providers who assist survivors

following a disaster. This pocket reference provides the basics of disaster mental health, with numerous specific

and practical suggestions for workers.

Essential information about disaster survivors’ reactions and needs is included. “Helping” skills are described

with guidance for when to refer for professional assistance. Strategies for worker stress prevention and

management are presented in the last section.

The Field Manual condenses and focuses material contained in the Training Manual for Mental Health and

Human Service Workers in Major Disasters, second edition (Publication No. ADM 90-538). Separate

publications on children, older adults, people with serious and persistent mental illness, rural communities

following disasters, and disaster mental health services are available through the Substance Abuse and Mental

Health Services Administration’s National Mental Health Information Center.

KEY CONCEPTS OF DISASTER MENTAL HEALTH

The following principles guide the provision of mental health assistance following disasters. The truth and

wisdom reflected in these principles have been shown over and over again, from disaster to disaster.

Key Concepts

• No one who sees a disaster is untouched by it.

• There are two types of disaster trauma—individual and community.

• Most people pull together and function during and after a disaster, but their effectiveness is diminished.

• Disaster stress and grief reactions are normal responses to an abnormal situation.

• Many emotional reactions of disaster survivors stem from problems of living brought about by the disaster.

• Most people do not see themselves as needing mental health services following disaster and will not seek

such services.

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• Survivors may reject disaster assistance of all types.

• Disaster mental health assistance is often more practical than psychological in nature.

• Disaster mental health services must be uniquely tailored to the communities they serve.

• Mental health workers need to set aside traditional methods, avoid the use of mental health labels, and use an

active outreach approach to intervene successfully in disaster.

• Survivors respond to active, genuine interest, and concern.

•Interventions must be appropriate to the phase of the disaster.

• Social support systems are crucial to recovery.

Most people who are coping with the aftermath of a disaster are normal, well-functioning people who are

struggling with the disruption and loss caused by the disaster. They do not see themselves as needing mental

health services and are unlikely to request them. This is why disaster mental health workers must go to the

survivors and not wait and expect that survivors will come to them. Survivors often find terms like “assistance

with resources” and “talking about disaster stress” to be acceptable, and services described as “psychological

counseling” and “mental health services” to be for someone else.

Going to survivors means using community outreach strategies. Soon after the disaster, survivors gather in

shelters, at mass feeding sites, at disaster recovery centers, at disaster information meetings, and in their

neighborhoods to clean up and repair their homes. Churches, senior centers, local cafes, schools, and

community centers are also likely locations where survivors congregate. A considerable amount of

psychological support can occur informally over a cup of coffee.

Most importantly, survivors respond to genuine concern, a listening ear, and help with immediate problemsolving. Survivors find brochures and information about “normal reactions to disaster stress” and “how to cope”

to be extremely helpful. Disaster mental health services must actively fit the disaster-affected community. This

means workers are culturally sensitive, provide information in the languages spoken, and work with local,

trusted organizations and community leaders to better understand survivors’ needs.

SURVIVORS’ NEEDS AND REACTIONS

Floods, tornadoes, hurricanes, earthquakes, hazardous materials accidents, terrorist acts, and transportation

accidents cause many similar and predictable reactions. While there may be specific disaster-related stressors,

underlying concerns and needs are consistent. These are:

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• A concern for basic survival

• Grief over loss of loved ones and loss of valued and meaningful possessions

• Fear and anxiety about personal safety and the physical safety of loved ones

• Sleep disturbances, often including nightmares and imagery from the disaster

• Concerns about relocation and the related isolation or crowded living conditions

• A need to talk about events and feelings associated with the disaster, often repeatedly

• A need to feel one is a part of the community and its recovery efforts

In the days and weeks after a disaster, the most common types of problems encountered are problems in living.

These might include transportation problems, unemployment, loss of child care, inadequate temporary

accommodations, inability to locate a missing loved one, filling prescriptions, lost eyeglasses, difficulty

applying for disaster relief loans, or public health concerns. Disaster workers often find that as they assist a

survivor with the immediate problems at hand, they earn the survivor’s trust and are told about his or her unique

struggles and emotions.

DISASTER COUNSELING SKILLS

Disaster counseling involves both listening and guiding. Survivors typically benefit from both talking about

their disaster experiences and being assisted with problem-solving and referral to resources. The following

section provides “nuts-and-bolts” suggestions for workers.

Establishing Rapport

Survivors respond when workers offer caring eye contact, a calm presence, and are able to listen with their

hearts. Rapport refers to the feelings of interest and understanding that develop when genuine concern is shown.

Conveying respect and being nonjudgmental are necessary ingredients for building rapport.

Active Listening

Workers listen most effectively when they take in information through their ears, eyes, and “extrasensory radar”

to better understand the survivor’s situation and needs. Some tips for listening are:

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• Allow silence — Silence gives the survivor time to reflect and become aware of feelings. Silence can prompt

the survivor to elaborate. Simply “being with” the survivor and their experience is supportive.

• Attend nonverbally — Eye contact, head nodding, caring facial expressions, and occasional “uh-huhs” let the

survivor know that the worker is in tune with them.

• Paraphrase — When the worker repeats portions of what the survivor has said, understanding, interest, and

empathy are conveyed. Paraphrasing also checks for accuracy, clarifies misunderstandings, and lets the

survivor know that he or she is being heard. Good leadins are: “So you are saying that ...” or “I have heard

you say that ...”

• Reflect feelings — The worker may notice that the survivor’s tone of voice or nonverbal gestures suggests

anger, sadness, or fear. Possible responses are, “You sound angry, scared, etc., does that fit for you?” This

helps the survivor identify and articulate his or her emotions.

• Allow expression of emotions — Expressing intense emotions through tears or angry venting is an important

part of healing; it often helps the survivor work through feelings so that he or she can better engage in

constructive problem-solving. Workers should stay relaxed, breathe, and let the survivor know that it is OK to

feel.

Some Do’s and Don’ts

Do say:

• These are normal reactions to a disaster.

•It is understandable that you feel this way.

• You are not going crazy.

•It wasn’t your fault, you did the best you could.

• Things may never be the same, but they will get better, and you will feel better.

Don’t say:

•It could have been worse.

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• You can always get another pet/car/house.

•It’s best if you just stay busy.

•I know just how you feel.

• You need to get on with your life.

The human desire to try to fix the survivor’s painful situation or make the survivor feel better often underlies

the preceding “Don’t say” list. However, as a result of receiving comments such as these, the survivor may feel

discounted, not understood, or more alone. It is best when workers allow survivors their own experiences,

feelings, and perspectives.

Problem-Solving

Disaster stress often causes disorganized thinking and difficulty with planning. Some survivors react by feeling

overwhelmed and become either immobilized or unproductively overactive. Workers can guide survivors

through the following problem-solving steps to assist with prioritizing and focusing action.

• Identify and define the problem

Describe the problems/challenges you are facing right now.

Selecting one problem is helpful, identify it as the most immediate, and focus on it first. The problem should

be relatively solvable, as an immediate success is important in bringing back a sense of control and

confidence.

• Assess the survivor’s functioning and coping

How have you coped with stressful life events in the past?

How are you doing now?

Through observation, asking questions, and reviewing the magnitude of the survivor’s problems and losses,

the worker develops an impression of the survivor’s capacity to address current challenges. Based on this

assessment—the worker may make referrals, point out coping strengths, and facilitate the survivor’s

engagement with social supports. The worker may also seek consultation from medical, psychological,

psychiatric, or disaster relief resources.

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• Evaluate available resources

Who might be able to help you with this problem?

What resources/options might help?

Explore existing sources of assistance and support such as immediate and extended family, friends, church

community, health care providers, etc. and how the survivor might obtain their help. Refer the survivor to the

appropriate relief agencies and assess if the survivor is able to make the calls and complete the required

applications. Assist with accessing resources when necessary.

• Develop and implement a plan

What steps will you take to address this problem?

Encourage the survivor to say aloud what he or she plans to do and how. Offer to check in with the survivor

in a few days to see how it is going. If the worker has agreed to perform a task for the survivor, it is very

important to follow through. Workers should promise only what they can do, not what they would like to do.

A Word of Caution

When confronted with a disaster survivor’s seemingly overwhelming needs, workers can feel the

understandable impulse to help in every way possible. Workers may become overinvolved and do too much for

the survivor. This is usually not in the best interest of the survivor. When survivors are empowered to solve

their own problems, they feel more capable, competent, and able to tackle the next challenge. Workers should

clearly understand the scope of their role in the disaster relief effort and recognize that empowering survivors is

different from doing for them.

Confidentiality

A helping person is in a privileged position. Helping a survivor in need infers a sharing of problems, concerns,

and anxieties—sometimes with intimate details. This special sharing cannot be done without a sense of trust,

built upon mutual respect, and the explicit understanding that all discussions are confidential and private. No

case should be discussed elsewhere without the consent of the person being helped (except in an extreme

emergency when it is judged that the person will harm himself or others). It is only by maintaining the trust and

respect of the survivor that the privilege of helping can continue to be exercised.

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WHEN TO REFER FOR MENTAL HEALTH SERVICES

Referrals to mental health and other health care professionals are made as workers encounter survivors with

severe disaster reactions or complicating conditions. The following reactions, behaviors, and symptoms signal a

need for the worker to consult with the appropriate professional and, in most cases, to sensitively refer the

survivor for further assistance.

• Disorientation — dazed, memory loss, inability to give date or time, state where he or she is, recall events of

the past 24 hours, or understand what is happening

• Depression — pervasive feelings of hopelessness and despair, unshakable feelings of worthlessness and

inadequacy, withdrawal from others, inability to engage in productive activity

• Anxiety — constantly on edge, restless, agitated, inability to sleep, frequent frightening nightmares,

flashbacks and intrusive thoughts, obsessive fears of another disaster, excessive ruminations about the disaster

• Mental illness — hearing voices, seeing visions, delusional thinking, excessive preoccupation with an idea or

thought, pronounced pressure of speech (e.g., talking rapidly with limited content continuity)

• Inability to care for self — not eating, bathing, or changing clothes, inability to manage activities of daily

living

• Suicidal or homicidal thoughts or plans

• Problematic use of alcohol or drugs

• Domestic violence, child abuse, or elder abuse

POTENTIAL RISK GROUPS

Each disaster-affected community has its own demographic composition, prior experience with disasters or

other traumatic events, rural or urban setting, and cultural representation. Consideration should be given to the

following groups, as well as additional groups with particular needs residing in the disaster-affected area:

• Age Groups

• Cultural and Ethnic Groups

• People With Serious and Persistent Mental Illness

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• People in Group Facilities

• Human Service and Disaster Relief Workers

Age Groups

Each age group is vulnerable in unique ways to the stresses of disaster. Different issues and concerns become

relevant during the progression of phases in the post-disaster period. Some disaster stress reactions listed below

may be experienced immediately, while others may appear months later. The following table describes possible

disaster reactions of the different age groups and helpful responses to them.

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Disaster Reactions and Intervention Suggestions

Ages Behavioral Symptoms Physical Symptoms Emotional Symptoms Intervention Options

1-5

• Resumption of bedwetting, thumb

sucking, clinging to

parents

• Fears of the dark

• Avoidance of

sleeping alone

•Increased crying

• Loss of appetite

• Stomachaches

• Nausea

• Sleep problems,

nightmares

• Speech difficulties

• Tics

• Anxiety

• Fear

•Irritability

• Angry outbursts

• Sadness

• Withdrawal

• Give verbal assurance and

physical comfort

• Provide comforting bedtime

routines

• Avoid unnecessary

separations

• Permit the child to sleep in

parents’ room temporarily

• Encourage expression

regarding losses (i.e., deaths,

pets, toys)

• Monitor media exposure to

disaster trauma

• Encourage expression through

play activities

6-11

• Decline in school

performance

• Aggressive behavior

at home or school

• Change in appetite

• Headaches

• Stomachaches

• School avoidance

• Withdrawal from

friends, familiar

activities

• Give additional attention and

consideration

• Relax expectations of

performance at home and at

school temporarily

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Ages Behavioral Symptoms Physical Symptoms Emotional Symptoms Intervention Options

• Hyperactive or silly

behavior

• Whining, clinging,

acting like a

younger child

•Increased

competition with

younger siblings for

parents’ attention

• Sleep disturbances,

nightmares

• Angry outbursts

• Obsessive

preoccupation with

disaster, safety

• Set gentle but firm limits for

acting out behavior

• Provide structured but

undemanding home chores

and rehabilitation activities

• Encourage verbal and play

expression of thoughts and

feelings

• Listen to the child’s repeated

retelling of a disaster event

•Involve the child in

preparation of family

emergency kit, home drills

• Rehearse safety measures for

future disasters

• Coordinate school disaster

program for peer support,

expressive activities,

education on disasters,

preparedness planning,

identifying at-risk children

12-18

• Decline in academic

performance

• Rebellion at home

or school

• Appetite changes

• Headaches

• Loss of interest in peer

social activities,

hobbies, recreation

• Sadness or depression

• Give additional attention and

consideration

• Relax expectations of

performance at home and

school temporarily

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Ages Behavioral Symptoms Physical Symptoms Emotional Symptoms Intervention Options

• Decline in previous

responsible behavior

• Agitation or

decrease in energy

level, apathy

• Delinquent behavior

• Social withdrawal

• Gastrointestinal

problems

• Skin eruptions

• Complaints of

vague aches and

pains

• Sleep disorders

• Resistance to authority

• Feelings of inadequacy

and helplessness

• Encourage discussion of

disaster experiences with

peers, significant adults

• Avoid insistence on

discussion of feelings with

parents

• Encourage physical activities

• Rehearse family safety

measures for future disasters

• Encourage resumption of

social activities, athletics,

clubs, etc.

• Encourage participation in

community rehabilitation and

reclamation work

• Coordinate school programs

for peer support and

debriefing, preparedness

planning, volunteer

community recovery,

identifying at-risk teens

ADULTS

• Sleep problems

• Avoidance of

reminders

• Fatigue, exhaustion

• Gastrointestinal

distress

• Depression, sadness

•Irritability, anger

• Anxiety, fear

• Provide supportive listening

and opportunity to talk in

detail about disaster

experiences

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Ages Behavioral Symptoms Physical Symptoms Emotional Symptoms Intervention Options

• Excessive activity

level

• Crying easily

•Increased conflicts

with family

• Hypervigilance

•Isolation,

withdrawal

• Appetite change

• Somatic complaints

• Worsening of

chronic conditions

• Despair, hopelessness

• Guilt, self doubt

• Mood swings

• Assist with prioritizing and

problem-solving

• Offer assistance for family

members to facilitate

communication and effective

functioning

• Assess and refer when

indicated

• Provide information on

disaster stress and coping,

children’s reactions and

families

• Provide information on

referral resources

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 susceptible to

hypo- and

hyperthermia

• Depression

• Despair about losses

• Apathy

• Confusion,

disorientation

• Suspicion

• Agitation, anger

• Provide strong and persistent

verbal reassurance

• Provide orienting information

• Use multiple assessment

methods as problems may be

under reported

• Provide assistance with

recovery of possessions

• Assist in obtaining medical

and financial assistance

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Ages Behavioral Symptoms Physical Symptoms Emotional Symptoms Intervention Options

• Physical and

sensory limitations

(sight, hearing)

interfere with

recovery

• Fears of

institutionalization

• Anxiety with

unfamiliar

surroundings

• Embarrassment about

receiving “handouts”

• Assist in reestablishing

familial and social contacts

• Give special attention to

suitable residential relocation

• Encourage discussion of

disaster losses and expression

of emotions

• Provide and facilitate referrals

for disaster assistance

• Engage providers of

transportation, chore services,

meal programs, home health,

and home visits as needed.

Cultural and Ethnic Groups

Workers must respond specifically and sensitively to the various cultural groups affected by a disaster. Ethnic

and racial minority groups may be especially hard hit, because of socioeconomic conditions that force the

community to live in housing that is particularly vulnerable. Language barriers, suspicion of governmental

programs due to prior experiences, rejection of outside interference or assistance, and differing cultural values

can present challenges for workers in gaining access and acceptance.

Cultural sensitivity is conveyed when disaster information and application procedures are translated into

primary spoken languages and available in non-written forms. Cultural groups have considerable variation

regarding views of loss, death, home, the family, spiritual practices, grieving, celebrating, mental health, and

helping. It is essential that workers learn about the cultural norms, traditions, local history, and community

politics from leaders and social service workers indigenous to the groups they are serving. Establishing working

relationships with trusted organizations, service providers, and community leaders often facilitates increased

acceptance. It is especially important for workers to be respectful, well-informed, and to dependably follow

through on stated plans.

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People With Serious and Persistent Mental Illness

Many disaster survivors with mental illness function fairly well following a disaster, if most essential services

have not been interrupted. They have the same capacity to “rise to the occasion” and perform as heroically as

the general population during the immediate aftermath of the disaster. However, for others who may have

achieved only a tenuous balance before the disaster, additional mental health support services, medications, or

hospitalization may be necessary to regain stability. For survivors diagnosed with Posttraumatic Stress Disorder

(PTSD), disaster stimuli (e.g., helicopters, sirens) may trigger an exacerbation due to associations with prior

traumatic events.

The range of disaster mental health services designed for the general population is equally beneficial for

survivors with mental illness; disaster stress affects all groups. Workers need to be aware of how people with

mental illness are perceiving disaster assistance and services and build bridges that facilitate access where

necessary.

People in Group Facilities

People who are in group facilities or nursing homes during a disaster are susceptible to anxiety, panic, and

frustration as a consequence of their limited mobility and dependence on caretakers. The impact of evacuation

and relocation on those with health or functional impairments can be tremendous. Dependence on others for

care or on medical resources for survival contributes to heightened fear and anxiety. Change in physical

surroundings, caregiving personnel, and routines can be extremely difficult.

Both the staff and patients/residents of evacuated or disaster-impacted group facilities are in need of support

services. Interventions for these groups include reestablishing familiar routines, including residents in recovery

and housekeeping activities when appropriate, providing supportive opportunities to talk about disaster

experiences, assisting with making contact with loved ones, and providing information on reactions to disaster

and coping.

Human Service and Disaster Relief Workers

Workers in all phases of disaster relief, whether law enforcement, local government, emergency response, or

survivor support, experience considerable demands to meet the needs of the survivors and the community.

Depending on the nature of the disaster and their role, relief workers may witness human tragedy, fatalities, and

serious physical injuries. Over time, workers may show the physical and psychological effects of work overload

and exposure to human suffering. They may experience physical stress symptoms or become increasingly

irritable, depressed, overinvolved or unproductive, and/or show cognitive effects like difficulty concentrating or

making decisions. Mental health workers may intervene by suggesting or using some of the strategies described

in the next section.

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STRESS PREVENTION AND MANAGEMENT

Working with disaster survivors is inevitably stressful at times. The long hours, breadth of survivors’ needs and

demands, ambiguous roles, and exposure to human suffering can affect even the most experienced professional.

While the work is personally rewarding and challenging, it also has the potential for affecting workers in

adverse ways. Too often, staff stress is addressed as an afterthought.

Preventive stress management focuses on two critical contexts: the organizational and the individual. Adopting

a preventive perspective allows both workers and programs to anticipate stressors and shape crises rather than

simply react to them after they occur. Suggestions for organizational and individual stress prevention and

management are presented in the next four pages.

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Organizational Approaches for Stress Prevention and Management

Dimension Response

EFFECTIVE

MANAGEMENT

STRUCTURE &

LEADERSHIP

• Clear chain of command and reporting relationships

• Available and accessible clinical supervisor

• Disaster orientation provided for all workers

• Shifts no longer than 12 hours with 12 hours off

• Briefings provided at beginning of shifts as workers exit and enter the operation

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

• Communication tools available (e.g., cell phones, radios)

CLEAR PURPOSE &

GOALS

• Clearly defined intervention goals and strategies appropriate to assignment setting (e.g.,

crisis intervention, debriefing)

FUNCTIONALLY

DEFINED ROLES

• Staff oriented and trained with written role descriptions for each assignment setting

• When setting is under the jurisdiction of another agency (e.g., Red Cross, FEMA), staff

informed of mental health’s role, contact people, and expectations

TEAM SUPPORT

• Buddy system for support and monitoring stress reactions

• Positive atmosphere of support and tolerance with “good job” said often

PLAN FOR STRESS

MANAGEMENT

• Workers’ functioning assessed regularly

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Dimension Response

• Workers rotated between low-, mid-, and high-stress tasks

• Breaks and time away from assignment encouraged

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

•Individual and group defusing and debriefing provided

• Exit plan for workers leaving the operation: debriefing, reentry information, opportunity to

critique, and formal recognition for service

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Individual Approaches for Stress Prevention and Management

Dimension Response

MANAGEMENT OF

WORKLOAD

• Task priority levels set with a realistic work plan

• Existing workload delegated so workers not attempting disaster response and usual job

BALANCED

LIFESTYLE

• Physical exercise and muscle stretching when possible

• Nutritional eating, avoiding excessive junk food, caffeine, alcohol, or tobacco

• Adequate sleep and rest, especially on longer assignments

• Contact and connection maintained with primary social supports

STRESS

REDUCTION

STRATEGIES

• Reducing physical tension by taking deep breaths, calming self through meditation, walking

mindfully

• Using time off for exercise, reading, listening to music, taking a bath, talking to family,

getting a special meal—to recharge batteries

• Talking about emotions and reactions with coworkers during appropriate times

SELF-AWARENESS

• Early warning signs for stress reactions recognized and heeded

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

• Overidentification with survivors’/victims’ grief and trauma may result in avoiding

discussing painful material

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Dimension Response

• Understanding differences between professional helping relationships and friendships

• Examination of personal prejudices and cultural stereotypes

• Vicarious traumatization or compassion fatigue may develop

• Recognition of when own disaster experience or losses interfere with effectiveness

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