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Training Manual
for Mental Health and Human Service Workers
in Major Disasters

SECTION 6

Comprehensive Training Course Outline

A comprehensive training course for disaster mental health recovery program staff, both mental health professionals and paraprofessionals, is described in this section. The session may require 2.5 - 4 days, depending on the depth and scope of the material presented. It is assumed that the trainer has prior disaster mental health experience, particularly with a long-term recovery program, has participated in a formal disaster mental health training session, and has independently studied disaster mental health readings and research. Also, the trainer needs to be adept at group processing of emotions and to be able to model excellent listening and empathic skills.

This program design has eleven major content areas, organized into "Activities" each requiring from thirty minutes to 2.5 hours. Each of the eleven Activity descriptions has five sections:

1. Topics Covered
2. Objectives
3. Time Required
4. Materials Required
5. Procedures

Most of the Activity descriptions include a balance of lectures, overheads, films, and experiential exercises. Activity 10: Stress Prevention and Management Section includes a number of group exercises that can be used when the trainer wants to vary the pace of the training. Examples of overheads, some handouts, and references for the films are included at the end of this section. Content for the lectures is either briefly included under "Procedures" or the trainer is directed to other sections in this manual, NIMH and CMHS publications, or other resources. While these documents provide "the basics," the trainer is encouraged to develop his or her own disaster stories and case examples to bring the training to a more personal and specific level.

Since this comprehensive training may be held anytime between three to four months after the disaster, the lecture content for each topic needs to be adapted to the phase of the disaster response and tailored to the current and anticipated needs of the program staff. Alternate suggestions for later training sessions are included in the "Procedures" descriptions. In addition, the material should be presented in a way that is most suitable for the participants. For some groups, including more findings from psychosocial research is appropriate, whereas, for others focusing on nuts-and-bolts skill building is indicated.

The trainer is also encouraged to become knowledgeable about the current disaster. Reading the State's crisis counseling grant application can be useful for this purpose. Local information can be woven into the training and used as examples throughout the more general discussions of disaster issues. Although this training is divided into eleven discrete Activity areas, an effective trainer remains flexible and seizes "teaching moments" as they emerge from the group discussion.

This training plan is intended as primarily suggestive, providing the trainer with a format and some ideas that have worked successfully with other groups. Experienced trainers will have developed their own approaches to many of the topics. The content areas presented in this plan need to be covered in a comprehensive training course. For some groups and trainers, it may make sense to change the order of Activity areas or to break out portions of the Activity suggestions and then to return to the rest at a later point in the training. Content experts may conduct portions of the training (e.g., a representative from FEMA, a resource person from an ethnic group).

Course Overview

The following overview lists course objectives, training content areas, and suggested time requirements. The training content is not further divided into daily agendas, because it is assumed that the trainer's preferences, the group's composition and needs, and the local disaster dynamics will dictate this level of specificity.

Course Objectives

Understand human behavior in disaster, including factors affecting individual responses to disaster, phases of disaster, "at risk" groups, concepts of loss and grief, postdisaster stress, and the disaster recovery process.

Understand the organizational aspects of disaster response and recovery, including key roles, responsibilities, and resources; local, State, Federal, and voluntary agency programs; and how to link disaster survivors with appropriate resources and services.

Understand the key concepts and principles of disaster mental health, including how disaster mental health services differ from traditional psychotherapy; the spectrum and design of mental health programs needed in disaster; and appropriate sites for delivery of mental health services.

Understand how to intervene effectively with special populations in disaster, including children, older adults, people with disabilities, ethnic, and cultural groups indigenous to the area, and the disenfranchised or people living in poverty with few resources.

Provide appropriate mental health assistance to survivors and workers in community settings, with emphasis on crisis intervention, brief treatment, post-traumatic stress strategies, age-appropriate child interventions, debriefing, group counseling, support groups, and stress management techniques.

Provide mental health services at the community level, with emphasis on casefinding, outreach, mental health education, public education, consultation, community organization, and use of the media.

Understand the stress inherent in disaster work and recognize and manage that stress for themselves and with other workers (CMHS, 1994).

Overview of Comprehensive Training Course

	Content Area	Suggested Time Required
Activity 1: Activity 2: Activity 3: Activity 4: Activity 5: Activity 6: Activity 7: Activity 8: Activity 9: Activity 10: Activity 11:	INTRODUCTION DISASTER INFORMATION ORGANIZATIONAL DISASTER RESPONSE NETWORK PHASES OF REACTIONS TO DISASTER ADULT REACTIONS TO DISASTER DISASTER MENTAL HEALTH INTERVENTIONS CHILDREN IN DISASTER SPECIAL POPULATIONS IN DISASTER PLANNING WORKGROUPS STRESS PREVENTION AND MANAGEMENT PROGRAM IMPLEMENTATION	1 hour 1.5 hours 1.5 hours .5 hour 2 hours 4 hours 2.5 hours 2 hours 1.5 hours 2 hours 1.5 hours

INTRODUCTION

Topics Covered

• Distribution of materials
• Welcome and brief overview of training
• Introductions
• Training objectives, agenda, materials

Objectives

1. To introduce trainers and participants
2. To review training objectives, agenda, and values underlying training
3. To begin group building through participant disclosure
4. To model listening skills

Time Required

1 hour

Materials Required

• Training handout
• Name tags

Procedure

1. Distribute Materials: Distribute name tags, handout materials, booklets, etc.
2. Welcome and Brief Overview: Give a welcoming statement, brief overview of the training day, and discuss logistics (e.g., breaks, lunch, phones, bathrooms, etc.). State that group participation is encouraged and that any and all questions are welcome.
3. Introductions: Trainer introduces self, highlighting disaster and other related experience. Participants introduce themselves giving name, agency affiliation, current job, location in the disaster program, description of experience with current disaster and/or prior disasters, and expectations/desires for the training. Trainer models active listening, may briefly bring out points relevant to disaster mental health.
4. Training Goals and Objectives: Review the goals and objectives for training (see Handout #1). Trainer addresses participants' stated expectations, commenting on what will and will not be included in the training and how other training needs may be met.
5. Agenda and Training Techniques: Review overall training agenda and discuss training techniques (e.g., short lecture, discussion, films, small group exercises, and role-plays). Discuss rationale and values underlying techniques (e.g., people learn by doing, disaster work affects providers personally so sharing and support is important, balance learning new content with developing new skills).

ACTIVITY 2

DISASTER INFORMATION

Topics Covered

• Definition of disaster
• Classification of disasters
• Types of disasters
• Current disaster data

Objectives

1. To acquaint participants with characteristics of disasters and their implications for mental health effects
2. To increase understanding of factors in the current disaster that may contribute to disaster stress in local population groups
3. To provide orientation to current disaster-its scope, nature of impact, damage assessment data, populations affected, and disaster response efforts

Time Required

1.5 hours

Materials Required

• Training handouts
• Overheads
• Video of news coverage of current disaster (if one is not available, then video involving similar type of disaster), maps showing disaster-affected areas

Procedure

1. Definition of a Disaster: Present a definition of disaster (see Overhead #1). Discuss how disasters are different from individual traumas because they involve entire communities and frequently also strain social support systems.
   
   
2. Characteristics of Disasters: Using Overhead #2, describe characteristics of disasters and their potential for psychological and community effects. Focus presentation on characteristics of the current disaster. Section 2 of this manual provides information.
   
   
3. Types of Disasters: Discuss types of disasters with reference to current disaster (see Overhead #3).
   
   
4. Description of the Current Disaster: Provide overview of information about current disaster including census information and populations affected, geographic areas affected, damage assessment data, and overview of disaster's impact and early relief efforts.
   
   Show video of news coverage of current disaster. These are usually available from local TV stations and are extremely useful for both eliciting participants' own disaster experiences and orienting participants to the events that have occurred.
5. Processing Trainees' Reactions to the Disaster: Depending on the size of the group, facilitate a small or large group discussion focusing on questions like: What came up for you as you watched this film? What reactions might you expect the people who experienced this disaster to have? What particular aspects of this disaster would you expect to be related to psychological effects? What do you anticipate will be the difficulties/challenges for this community in recovery? For those of you who directly experienced this disaster, what was it like to see this film?

If there is a subgroup of participants that personally experienced the disaster, try using a "fishbowl" technique. The "personally experienced" group forms an inner circle and discusses their experiences with the trainer while the rest of the participants form an outer circle and listen. This is not intended to be a "debriefing," but is more for informational purposes. This also provides an opportunity for the trainer and/or program supervisors to continue assessing if there are staff members who may be too involved in their own recovery process to be able to assist others effectively.

Display disaster photographs, newspaper articles, and maps. This can be a group activity if some staff have been involved from the beginning. It can also give them an opportunity to describe their experiences while educating new staff.

ACTIVITY 3

ORGANIZATIONAL DISASTER RESPONSE NETWORK

Topics Covered

• Federal, State, local, and volunteer agencies involved in disaster response
• Disaster declaration process
• Glossary of abbreviations
• Local response and key resources

Objectives

1. To acquaint participants with local FEMA, State department of emergency management, and CMHS representatives who, if available, can present much of this section
2. To orient participants to the organizational context of disaster work and the role of the Crisis Counseling Program and disaster mental health workers in that context
3. To inform participants of the chronology of events involved in the disaster declaration process
4. To increase knowledge of local resources, contacts and how to access them

Time Required

1.5 hours

Materials Required

• Training handouts
• Handouts from FEMA or State department of emergency management on local resources, phone numbers, and addresses Procedure

1. Organizational Aspects of the Disaster: When FEMA and State department of emergency management representatives are available, they can usually conduct much of this section. It is also beneficial for participants to become acquainted with them and have faces and names to associate with some of the new and unfamiliar agencies. Briefly review the information and charts in Chapter 3, "Organizational Aspects of Disaster," in Disaster Response and Recovery: A Handbook for Mental Health Professionals (CMHS, 1994). Disaster mental health workers need to understand the "big" picture of the organizational players and can use Chapter 3 as a resource for specifics.
2. Federal, State, and Local Disaster Response and Recovery Activities: Present a chronology of disaster response and recovery activities including aspects like evacuations, shelters, road or bridge closures, and the local disaster declaration process and responsible agencies. Tailor the presentation to the current phase in the disaster response so that participants are acquainted with the history, as well as who the current key players are and what the current phase-related recovery activities are. If it is early in the disaster response and the American Red Cross is active, a presentation by a Disaster Mental Health or a Family Services volunteer can be informative about current community reactions and needs.
3. Speaking the Disaster Lingo/Defining Acronyms: A glossary of acronyms can be found at the end of Chapter 3 (CMHS, 1994). A similar list can be developed for the local disaster with the involved local, State, and Federal agencies.

ACTIVITY 4

PHASES OF REACTIONS TO DISASTER

Topics Covered

• Community reactions to disaster over time
• Phase-related psychological reactions

Objectives

1. To acquaint participants with the developmental sequence of community and individual responses
2. To introduce the concept that mental health interventions need to be relevant to the phase of community and individual response

Time Required

30 minutes

Materials Required

• Training handouts
• Overheads

Procedure

1. Phases of Community Reactions to a Disaster: Describe each of the six phases of community reactions to disaster. See discussion in Section 2 of this manual. Use Overhead #4.
   
   
2. Phases of Psychological Reactions to a Disaster: Using Overhead #5, discuss psychological reactions as they relate to each phase. Use case examples to provide depth and enhance learning. While discussing the graph, also emphasize that survivors are individual and unique in their reactions and some may not experience much emotion or have delayed reactions, while others may be overwhelmed by one emotion (e.g. self doubt, fear). People typically move forward and backward through the "graph;" the healing process is not a uniform progression through stages. Participants typically value the simplicity of the graph, but also need to be cautioned that it is only generally descriptive.

ACTIVITY 5

ADULT REACTIONS TO DISASTER

Topics Covered

• Film depicting adult reactions
• Participant self-reflection
• Physical, emotional, cognitive, behavioral reactions
• Trauma and grief processes

Time Required

2 hours

Materials Required

• Training handouts
• Overheads
• Film ("Faces in the Fire," "Beyond the Ashes," or "Disaster Psychology")

Procedure

1. Phase-Related Adult Reactions to Disaster: Show film as a follow-up to prior presentation on phase-related psychological reactions. Invite participants to note the reactions that they see survivors having in the film as well as their own feelings that may be touched by the film.
   
   Depending on the size of the group, discuss the film with the large group or break into smaller groups. First, facilitate discussion of the reactions that participants saw in the film and note how survivors' reactions may have changed with the passage of time. Discuss the interaction of disaster -dynamics with survivors' reactions (e.g., length of warning, visual imagery, smells and sounds, threat to life). Invite participants to comment on these areas and then provide short lectures on salient aspects.
2. Participant Self-Reflection: Invite participants to explore what touched them personally as they watched the film-which survivors, what situations, and why they impacted them. Use this discussion to model acceptance and good listening skills, and to normalize that everyone is touched personally at times when doing disaster work. Continue with a lecture about the dynamics of countertransference (in very practical terms) and introduce the importance of self-care, stress management, staff consultation, and debriefing.
   
   
3. Types of Adult Reactions: Present physical, emotional, cognitive, and behavioral reactions to disaster using Overheads #6, 7, 8, and 9. Use case examples, examples from the film, examples from the current disaster, examples from the participants' experiences, and research findings to bring these lists "alive." Review Section 3 of this manual. Depending on the timing of the training, focus more on reactions that are most relevant to current phase. Emphasize that reactions are "normal" responses for the majority of survivors and will resolve with time, support, information, and physical recovery. Activity 6 will address when reactions require additional professional attention. If the training is several months after the disaster, focusing on long-term recovery issues is appropriate (see Overheads #10 and 11).
   
   
4. Trauma and Grief Reactions: Discuss the overlay of trauma and grief reactions and processes for people who suffered both significant losses and the suddenness and fear associated with traumatic events. Recovery takes longer as these survivors must first move through their acute trauma reactions before working through the longer process of grieving losses (see Section 2). Because of the overlay of processes, the impact can be more psychologically devastating and the healing process more complex and difficult. If these issues are especially relevant for the current disaster, a focused in-service training at a later date would be indicated.

ACTIVITY 6

DISASTER MENTAL HEALTH INTERVENTIONS

Topics Covered

• Key concepts of disaster mental health
• Mental health interventions
• Assessment and referral
• Public education
• Group debriefing

Objectives

1. To orient participants to the "normalcy" of survivor populations and the "normalcy" of disaster stress reactions and when referrals are required
2. To assist mental health professionals to recognize the differences between disaster mental health work and more traditional office pathology-based psychotherapy
3. To describe specific intervention approaches with opportunities for role-play practice and observation

Time Required

4 hours

Materials Required

• Handouts
• Overheads
• Sample public information brochures and materials
• Case scenarios
• Film

Procedures

1. Key Concepts of Disaster Mental Health Service Delivery: Present "Key Concepts of Disaster Mental Health." Overhead #12 lists those that pertain specifically to service delivery. Section 1 in this manual and Chapter 1 in Disaster Response and Recovery: A Handbook for Mental Health Professionals (CMHS, 1994) provide more information and material for handouts.
   
   
2. Disaster Mental Health Versus Traditional Mental Health: Discuss how disaster mental health is different from traditional therapy. Emphasize aspects such as: service provider goes to the client rather than the client coming to the office, intervention is focused on problem-solving not achieving insight, and that terms like "mental health" or "counseling" are de-emphasized and terms like "assistance with solving problems" and "talking about disaster stress" are emphasized.
   
   
3. Disaster Mental Health Interventions and Post-Disaster Mental Health Interventions: Present Overheads #13 and #14. Chapters 6, 7, and 8 in Disaster Response and Recovery: A Handbook for Mental Health Professionals (CMHS, 1994) provide detailed information about assignment settings and specific approaches appropriate to each. Tailor the presentation to current disaster recovery settings, populations, and timing of interventions. Use concrete examples of appropriate interventions, such as, rapid assessment and triage, crisis intervention, group debriefing and town meetings, education on disaster stress and coping, information and referral, casefinding, community outreach, brief individual and group counseling, case management, and disaster preparedness.
   
   
4. Role-Play Exercise: Facilitate role-play practice exercise. Develop case scenarios that exemplify relevant situations and the approaches being taught. Trainer may set up a scenario and model the approach first and then divide participants into pairs or trios for role-play practice. Focus might be crisis intervention, structured supportive conversation about disaster experiences, or education about disaster stress and coping. Participants need to have their performance anxieties relieved while receiving feedback to enhance their learning. When presenting several types of interventions, go back and forth between describing and practicing.
   
   
5. Assessment and Referral: Provide clear guidelines for assessment and referral. While the listings of physical, emotional, cognitive, and behavioral reactions are considered "normal," in the extreme they are problematic and require further professional attention. Discuss manifestations of impairment and methods for intervention and referral. Participants will need a program procedure for case consultation and referral.
   
   
6. Community Education: Provide lecture on the significance of disseminating information on disaster stress reactions and suggestions for coping. Community education is an essential element of recovery programs. Show samples of brochures, posters, and articles from other programs. Demonstrate how to access examples via the Internet. Discuss how the program will develop and distribute materials if this hasn't been done already. If time allows, discussion could include accessing radio and television spots and coverage in local newspapers. This could also be an in-service training topic for later, or the focus of a task group.
   
   
7. Approach for Group Debriefing: Provide training on group debriefing approach and adaptations for community meetings or disaster workers. Use Overhead #15 to discuss components of a brief group intervention and how emphasis on the various components will change depending on the group, context, and purpose. Mental health professionals should be designated to conduct group sessions, as they require more experience and training. This could be a break out session in which mental health professionals focus on building group debriefing skills and paraprofessionals focus on basic counseling and listening skills.
   
   
8. Role-Play a Group Debriefing Intervention: Use a film clip of a case scenario to provide opportunity to further demonstrate and practice a group debriefing intervention. The trainer may enlist some participants to assume roles of community members following a disaster and then demonstrate the components of the intervention. As an alternative, a scenario from the film previously shown or a clip from the current disaster could be used. The trainer could also establish a "tag team" of facilitators so that participants can practice conducting portions of the group session.

ACTIVITY 7

CHILDREN IN DISASTER

Topics Covered

• Age-related reactions
• Age-appropriate interventions
• Coordination with the schools
• Coloring books and special projects

Objectives

1. To provide information about children's "normal" and problematic responses to disaster and family stress and methods for assessment
2. To assist participants in understanding developmental influences so they can appropriately design interventions
3. To identify strategies for working with the local schools and children's organizations
4. To provide examples of creative projects from other recovery programs

Time Required

2.5 hours

Materials Required

• Training handouts
• Overheads
• Films ("Children and Trauma: The School's Response", "Hurricane Blues")
• Examples of coloring books, expressive and commemorative school projects (photos, posters, drawings, journals)

Procedures

1. Children's Reactions to Disasters: Review background material in Section 3 of this manual and the Manual for Child Health Workers in Major Disaster, (second edition pending, CMHS, 2000). Recommended reading referenced at the end of Section 3 includes additional resource materials. Present lecture on children's reactions to disaster emphasizing developmental stages and the significant role of the family. Identify features of the current disaster that have salience for children (e.g., witnessing frightening events, high level of life threat, separation from family members, loss of school community). See Overheads #16, 17, and 18.
   
   
2. Risk Factors for Children: Discuss children's manifestations of stress from the current disaster observed by participants. Discuss interventions with children to date. Use Overhead #19 to discuss risk factors for children.
   
   
3. Interventions: Present lecture on appropriate interventions with children for the various phases. See Handout #2 for an overview of strategies.
   
   
4. Demonstration of Children's Reactions and Interventions: Show "Children and Trauma." If the group has already seen this film and this is a later training session, "Hurricane Blues" depicts more long-term recovery issues for children and families. Discuss relevant aspects of the film and thoughts/reactions that arose for participants.
   
   
5. Systematic Program Strategy for Assessing the Needs of Children: If a high prevalence of serious post-disaster stress among children is anticipated because of the dynamics of the disaster (e.g., high death rate, large numbers of children witnessing grotesque scenes of destruction), a systematic program strategy for assessing children needs to be developed. Since children tend not to disclose the extent of their post-disaster stress to parents (Vogel & Vernberg, 1993), alternate strategies should be included. Several checklists have been developed for this purpose. Participants can practice through role-plays asking parents, teachers, and children assessment questions, or conducting a brief interview.
   
   
6. Psychological Tasks: Using Overhead #20, discuss the psychological tasks that a child must accomplish to integrate the disaster experience and move on. Discuss how age/developmental stage will affect the child's capacity to accomplish these tasks and how this affects intervention strategies.
   
   
7. School Systems: Discuss methods for developing collaborative relationships with the schools for local children affected by the disaster. Gaining access to the schools can be challenging, especially several months after the disaster. First, determine likely entry points (e.g., school nurses, counselors, teachers, PTA, principals, superintendent). Utilize program staff's and agency's contacts and relationships with school personnel.
   
   Determine what would be a good "angle" or service to facilitate a working relationship. These might be: referral resource for disaster high risk children and families, consultation/training with counselors and nurses, in-service training for teachers, or a presentation at a PTA meeting. The interventions listed on Handout #2 can be used for teacher training or mental health professional facilitated classroom interventions. FEMA (1991a and 1991b) has some useful publications on school interventions developed by California programs.
   
   Other organizations serving children can be more accessible. Possibilities include: day care programs, YMCA/YWCA, 4-H, scout programs, church youth programs, community centers, or summer camps.
   
   
8. School and Community Projects: Display coloring books, expressive and commemorative school projects, and compilations of writings or drawings from different mental health recovery programs and communities. Engage participants to creatively brainstorm innovative project ideas for current disaster.

ACTIVITY 8

SPECIAL POPULATIONS IN DISASTER

Topics Covered

1. Older adults
2. Cultural and ethnic groups
3. Low socioeconomic groups
4. Persons with disabilities

Objectives

1. To identify special population groups affected by current disaster
2. To review unique issues associated with each potentially at-risk group
3. To understand how disaster stress may be experienced and expressed by each group

Time Required

Materials Required

1. Training handouts
2. Film "Voices of Wisdom"

Procedures

1. Older Adults: Review Section 3, "older adults" portion and Psychosocial Issues for Older Adults in Disasters: A Guide for Health and Mental Health Professionals (CMHS, 1999). The chart in Section 3 can be used as a handout and basis for discussion. Also, see Handout #3.
   
   Show selected portions or all of "Voices of Wisdom." Use the film to raise issues and generate discussion of needs.
   
   
2. Cultural and Ethnic Groups: When there are particular ethnic or cultural groups affected by the disaster, staff must acquire cultural competency and earn acceptance with those groups. See Section 3 for a brief discussion of issues. Handout #4 provides some additional information. As mentioned previously, representatives from the group may assist with training. Community members may share their disaster experiences and insights about cultural sensitivity. Additional training on cultural issues and awareness may be provided as in-service training.
   
   
3. Low Socioeconomic Groups: When people with low socioeconomic resources are involved in a disaster, they are frequently faced with immediate financial crisis. Section 3 briefly discusses these concerns. Staff need to learn generally about Federal, State, and local resources for all types of assistance, who to call, and how to refer.
   
   
4. People with Disabilities: Disabilities that involve difficulty with mobility, hearing or vision impairments, and dependence on special equipment or procedures can contribute to the survivor's sense of vulnerability and helplessness. Being unable to hear warnings, or physically leave one's home and having to be evacuated by strangers often is deeply distressing. People with disabilities may be especially anxious about future disasters and benefit from problem-solving discussions about disaster preparedness.

ACTIVITY 9

PLANNING WORKGROUPS

Topics Covered

1. Program planning for special population groups

Objectives

1. To develop specific program strategy plans for addressing the disaster mental health needs of each group identified in Activity 8
2. To encourage team approach to program planning
3. To identify expertise and interest areas of staff relevant to special groups
4. To identify strategies for outreach, relationship building with community leaders and key agency resources, and group-sensitive interventions

Time Required

1. 1.5 hours

Materials Required

1. Handout
2. Flip chart
3. Pen

Procedures

1. Identifying Special Populations: Identify groups requiring special program focus. Examples are children, older adults, people in institutions, people with disabilities, and cultural or ethnic groups. A workgroup might focus on training for human service workers in the community.
   
   
2. Special Population Workgroups: Establish "workgroups" of participants for each population group. Distribute task assignment handouts (See Handout #5). Give groups 45 minutes to discuss issues and brainstorm strategies and intervention ideas. Groups transcribe their ideas to flip chart paper for group presentation. Groups report their considerations and ideas and request input from the larger group.
   
   Trainer further comments on groups or issues raised (utilizing "teaching moments") and enthusiastically recognizes the work of each group.
   
   Trainer and/or program administrator discusses how the workgroup ideas will be addressed or incorporated into the program plan in the future.

ACTIVITY 10

STRESS PREVENTION AND MANAGEMENT

Topics Covered

1. Stressors and worker stress
2. Organizational and individual approaches
3. Self awareness
4. Stress reduction strategies

Objectives

1. To provide information regarding worker stress and burnout
2. To introduce and discuss specific organizational and individual approaches to prevent and mitigate stress
3. To enhance team support and group cohesiveness
4. To identify individual vulnerabilities to stress and personal prevention and management strategies

Time Required

1. 2 hours (Exercises should be interspersed throughout the training course.)

Materials Required

1. Training handouts
2. Overheads
3. Flip chart
4. Pen

Procedures

1. Disaster Work Stressors: Discuss stressors inherent in disaster mental health work. Using Overhead #21, discuss the three potential sources of stress as they pertain to the timing of this training. Engage the group in identifying examples in each category.
   
   
2. Concept of Stress: Present the concept of "stress" as neither intrinsically good or bad. People experience stress when they start a new job, get married, go to a foreign country, take on a professional challenge, etc. At optimal levels, stress can enhance performance. When it is too much, it can erode well being and coping. Use Overhead #22 to illustrate that stress can be prevented and managed.
   
   
3. Symptoms of Worker Stress: Review list of symptoms of worker stress in Handout #6. Invite participants to identify symptoms that they have experienced with the current disaster, or in the past with other intensive human service activities. Next, encourage them to list what coping or stress reduction strategies they used, and what was helpful. Divide participants into groups of three and invite them to discuss their responses to the above questions. This can be a good time for listening and paraphrasing skill practice as well, if that has previously been addressed in the course.
   
   
4. Coping Strategies: Generate a group list of coping strategies on the flip chart, by asking a member of each trio to report to the class. Model giving positive and encouraging feedback. Make the point that giving positive feedback and saying "thank you" often is a powerful group stress intervention.
   
   
5. Organizational and Individual Approaches to Preventing and Managing Stress: Using Overheads #23 and 24, present material included in Section 4 on organizational and individual approaches to prevent and manage stress. The charts provide specific examples of interventions. Stress reduction strategies generated in the previous exercise by the group can be used as examples as well. When discussing the "organizational approaches," the trainer or program administrator may describe methods that the current program is adopting. This also could be addressed in Activity 11. Throughout the presentation, encourage group participation, suggestions, and ideas.
   
   
6. Team Building: Facilitate team building exercise. First, have participants jot down their best team experiences (sports, club, service, job, etc.). Next, ask them to silently reflect on the characteristics of the team and the role they played on that team. Trainer lists characteristics on flip chart and summarizes with lecturette about what contributes to effective work teams.
   
   This next phase of the team building exercise may require that the work units form small groups. Adaptations will need to be made to allow for the size of the group. Discuss "principles of how we want to work together." Examples might be: we will encourage, initiate and participate in direct communication; we will discuss work issues with involved person as they occur; we will responsibly manage our time and workload; or we will treat each other with respect and consideration. First, participants write three to four principles that they'd like adopted. Then, the lists get read and combined so that a list of possibilities is generated that reflects all of the input. Next, participants vote on their top three. The list should get narrowed down to 5-7 briefly stated items. The trainer then asks "Is there anything on this list that anyone can not live with?" Later, the list is written up and posted prominently at program offices. At meetings, groups can check back with how they are doing. A more formal evaluation can provide the basis for future team building interventions.
   
   
   1. Self-Awareness Exercises: The following self-awareness exercises can be incorporated at different points in the training or as a part of in-service training.

      A. Invite participants to complete the questionnaire on Handout #7. Responses can be shared in small groups with immediate coworkers or in work units. This can be informative for supervisors to facilitate with their employees.
      
      B. In groups of 10-15 participants, facilitate discussions of question #2, "What are (or do you expect to be) the most stressful and the most rewarding aspects of doing disaster work?" The leader respectfully listens and paraphrases as participants share their responses, normalizing and describing common themes. Topics that might be addressed are: motivations for helping, personal prejudices or stereotypes, discomfort with intense emotions, feelings of personal or professional inadequacy, difficulties with the "helper-helpee" relationship, feelings associated with setting limits, or feeling powerless to "make enough of a difference." Some of these topics may not be relevant at this point in the program, but will inevitably surface.

   2. Stress Reduction Exercises: The following stress reduction exercises can also be incorporated at different points in the training.
      
      

      A. Invite the group to stand and stretch, reaching hands toward the ceiling and breathing deeply with each stretch.
      
      B. Facilitate guided imagery process, with participants' eyes closed, seated comfortably, dim lights, deep breathing, physical relaxation and visualization of a personal and peaceful place.
      
      C. Encourage participants to take a quiet fifteen-minute break by themselves. Participants might walk outside-noticing vegetation, smells, etc., or sit and read or write, or close their eyes and meditate. Suggest that the group maintain silence during the break as an experiment.
      
      D. As a "homework" exercise, encourage participants to do one "self-care" activity. This could be exercising, reading a book, taking a bath, writing in a journal, doing yoga, working in the yard, etc. The next morning in class, invite participants to share what they did. Again, positively respond to participants' efforts.

   ---

ACTIVITY 11

PROGRAM IMPLEMENTATION

Topics Covered

1. Program goals and structure
2. CMHS Program Guidance publications
3. Data collection and reporting

Objectives

1. To orient staff to program service priorities, organizational structure and management plan for the program
2. To review and discuss CMHS Program Guidance publications as they pertain to the current disaster program
3. To review all program forms for data collection to assure consistency in reporting
4. To describe program reporting requirements for services and expenditures and responsibilities of staff

Time Required

1. 1.5 hours

Materials Required

1. Handouts (program goals, organizational structure, roles and responsibilities of each job in program, CMHS Program Guidance publications, data collections forms, schedule for meetings, timeline for program reports, etc.)

Procedures

1. Program Structure and Goals: Program administrator presents content described above to staff. Trainer may be able to assist with explaining program elements and why they are important (e.g. clarification of Program Guidance, avoiding data collection problems).
   
   
2. Breakout for Supervisors: If there are several geographically dispersed "program units," with supervisors for each sub-group, these groups might each convene at this time to discuss some of the above issues. The supervisors may want to discuss operational and logistical issues.
   
   
3. Team Building: Team building exercises that were described in Activity 10 might be appropriate here.
   
   
4. Course Wrap-up and Evaluation

   ---

   Overheads

   Listing of Overheads:

   Overhead #1: Overhead #2: Overhead #3: Overhead #4: Overhead #5: Overhead #6: Overhead #7: Overhead #8: Overhead #9: Overhead #10: Overhead #11: Overhead #12: Overhead #13: Overhead #14: Overhead #15: Overhead #16: Overhead #17: Overhead #18: Overhead #19: Overhead #20: Overhead #21: Overhead #22: Overhead #23: Overhead #24:

   Definition of Disaster Characteristics of Disasters Types of Disasters Phases of Disaster Reactions Psychological Reactions to Disaster Physical Reactions Emotional Reactions Cognitive Reactions Behavioral Reactions Chronic Stressors in Disaster Effects of Long-term Disaster Stress Key Concepts Disaster Mental Health Interventions Post-Disaster Mental Health Interventions Brief Trauma Intervention Preschool-age Children's Reactions School-age Children's Reactions Pre-adolescents and Adolescents Risk Factors for Children Psychological Tasks for Recovery Stressors in Disaster Work Stress Basics Organizational Approaches Individual Approaches

   ---

   
   
   
   

   OVERHEAD #1
   DEFINITION OF DISASTER
   

   ---

   A disaster is an occurrence such as a hurricane, tornado, flood, earthquake, explosion, hazardous materials accident, war, transportation accident, fire, famine, or epidemic that causes human suffering or creates collective human need that requires assistance to alleviate.

   ---

   
   
   
   OVERHEAD #2
   CHARACTERISTICS OF DISASTERS

   ---

   Natural vs. human-caused Degree of personal impact Size and scope Visible impact/low point Probability of recurrence

   ---

   
   
   
   OVERHEAD #3
   TYPES OF DISASTERS
   

   ---

   Natural Technological Health Social

   ---

   
   
   
   OVERHEAD #4
   PHASES OF DISASTER REACTIONS
   

   ---

   Warning of Threat Impact Rescue or Heroic Remedy or Honeymoon Inventory Disillusionment Reconstruction and Recovery

   ---

   
   
   
   OVERHEAD #5
   PSYCHOLOGICAL REACTIONS
   TO DISASTER
   

   ---

   
   
   
   OVERHEAD #6
   PHYSICAL REACTIONS
   

   ---

   Fatigue, exhaustion Gastrointestinal distress Appetite change Tightening in throat, chest, or stomach Worsening of chronic conditions Somatic complaints

   ---

   
   
   
   OVERHEAD #7
   EMOTIONAL REACTIONS
   

   ---

   Depression, sadness Irritability, anger, resentment Anxiety, fear Despair, hopelessness Guilt, self-doubt Unpredictable mood swings

   ---

   
   
   
   OVERHEAD #8
   COGNITIVE REACTIONS
   

   ---

   Confusion, disorientation Recurring dreams or nightmares Preoccupation with disaster Trouble concentrating or remembering things Difficulty making decisions Questioning spiritual beliefs

   ---

   
   
   OVERHEAD #9
   BEHAVIORAL REACTIONS

   ---

   Sleep problems Crying easily Avoiding reminders Excessive activity level Increased conflicts with family Hypervigilance, startle reactions Isolation or social withdrawal

   ---

   
   
   
   OVERHEAD #10
   CHRONIC STRESSORS IN DISASTER
   

   ---

   Family disruption Work overload Gender differences Bureaucratic hassles Financial strain

   ---

   
   
   
   OVERHEAD #11
   EFFECTS OF LONG-TERM
   DISASTER STRESS
   

   ---

   Anxiety and vigilance Anger, resentment and conflict Uncertainty about the future Prolonged mourning of losses Diminished problem-solving Isolation and hopelessness Health problems Physical and mental exhaustion Lifestyle changes

   ---

   
   
   
   OVERHEAD #12
   KEY CONCEPTS
   

   ---

   Normal reactions to abnormal situation Avoid "mental health" terms and labels Assistance is practical Assume competence Focus on strengths and potentials Encourage use of support network Active, community fit Innovative in helping

   ---

   
   
   
   OVERHEAD #13
   DISASTER MENTAL HEALTH INTERVENTIONS
   

   ---

   Rapid assessment and triage Crisis intervention Supportive listening Problem-solving immediate issues Education about disaster stress Debriefing and community meetings Information and referral

   ---

   
   
   
   OVERHEAD #14
   POST-DISASTER MENTAL HEALTH INTERVENTIONS
   

   ---

   Casefinding Letters and phone calls Community Outreach Brief counseling (individual and group) Case management Public education through media Information and referral

   ---

   
   
   
   OVERHEAD #15
   BRIEF TRAUMA INTERVENTION
   

   ---

   Fact Phase Thought Phase Reaction and Feelings Phase Education Phase Action/Re-entry Phase

   ---

   
   
   
   OVERHEAD #16
   PRESCHOOL-AGE CHILDREN'S REACTIONS
   

   ---

   Sleep problems, nightmares Separation anxiety Fearfulness Clinging Regression Repetitive play

   ---

   
   
   
   OVERHEAD #17
   SCHOOL-AGE CHILDREN'S REACTIONS
   

   ---

   Sleep problems, nightmares Fears about safety Preoccupation with disaster Physical complaints Depression, guilt Angry outbursts School performance decline Withdrawal from peers

   ---

   
   
   
   OVERHEAD #18
   PRE-ADOLESCENTS AND ADOLESCENTS
   

   ---

   Sleep problems Physical complaints Depression, guilt Withdrawal, isolation Aggressive behavior Decline at school Risk-taking behavior

   ---

   
   
   
   OVERHEAD #19
   RISK FACTORS FOR CHILDREN
   

   ---

   Death or serious injury of family member or close friend Witnessing grotesque destruction Exposure to life threat Separation from parents High level of family stress Recent stressful life events Prior functioning problems

   ---

   
   
   
   OVERHEAD #20
   PSYCHOLOGICAL TASKS FOR RECOVERY
   

   ---

   Acceptance of the disaster and losses Identification, labeling, and expression of emotions Regaining sense of mastery and control Resumption of age-appropriate roles and activities (Pynoos & Nader, 1988)

   ---

   
   
   
   OVERHEAD #21
   STRESSORS IN DISASTER WORK
   

   ---

   Event-related Occupational Organizational

   ---

   
   
   
   OVERHEAD #22
   STRESS BASICS
   Stress is:
   

   ---

   Normal Necessary Productive and destructive Acute and delayed Cumulative Identifiable Preventable and manageable

   ---

   
   
   
   OVERHEAD #23
   ORGANIZATIONAL APPROACHES
   

   ---

   Effective management structure and leadership Clear purpose and goals Functionally defined roles Team support Plan for stress management

   ---

   
   
   
   OVERHEAD #24
   INDIVIDUAL APPROACHES
   

   ---

   Management of workload Balanced lifestyle Stress reduction strategies Self-awareness

   ---

   
   
   
   

   Handouts

   Listing of Handouts:

   Handout #1: Handout #2: Handout #3: Handout #4: Handout #5: Handout #6: Handout #7:

   Disaster Mental Health Course Objectives Age-Specific Interventions for Children in Disaster Special Concerns of Older Adults in Disaster Cultural Sensitivity and Disaster Planning Workgroup Common Disaster Worker Stress Reactions Professional Self-Care

   
   
   

HANDOUT #1
Disaster Mental Health Course Objectives

1. Understand human behavior in disaster, including factors affecting individual's response to disaster, phases of disaster, "at-risk" groups, concepts of loss and grief, postdisaster stress, and the disaster recovery process.
   
   
2. Understand the organizational aspects of disaster response and recovery, including key roles, responsibilities, and resources; local, State, Federal, and voluntary agency programs; and how to link disaster survivors with appropriate resources and serv-ices.
   
   
3. Understand the key concepts and principles of disaster mental health, including how disaster mental health services differ from traditional psychotherapy; the spectrum and design of mental health programs needed in disaster; and appropriate sites for delivery of mental health services.
   
   
4. Understand how to intervene effectively with special populations in disaster, including children, older adults, people with disabilities, ethnic and cultural groups indigenous to the area, and the disenfranchised or people living in poverty with few resources.
   
   
5. Provide appropriate mental health assistance to survivors and workers in community settings, with emphasis on crisis intervention, brief treatment, post-traumatic stress strategies, age-appropriate child interventions, debriefing, group counseling, support groups, and stress management techniques.
   
   
6. Provide mental health services at the community level, with emphasis on casefinding, outreach, mental health education, public education, consultation, community organization, and use of the media.
   
   
7. Understand the stress inherent in disaster work and recognize and manage that stress for themselves and with other workers.

(CMHS, 1994)

HANDOUT #2
Age-Specific Interventions for Children in Disaster

Age Group
At Home
At School or Other Organization for Children

• Maintain family routines
• Give extra physical comfort and reassurance
• Avoid unnecessary separations
• Permit child to sleep in parents' room temporarily
• Encourage expression of feelings through play
• Monitor media exposure to disaster trauma
• Develop disaster safety plan
• Draw expressive pictures
  
  
• Tell stories of disaster and recovery
• Use coloring books on disaster
• Read books on disaster and loss
• Use dolls, puppets, toys, blocks for reenactment play
• Facilitate group games
• Talk about disaster safety and self protection
• Absenteeism outreach to families and children*
• Teachers, school nurses, and providers identify stressed children for assessment and referral*
• In-service training on children and disaster*
• School-based crisis hotline*
• Provide educational brochure for parents*
• Encouragement to eventually resume normal roles as students*

• Give additional attention and consideration
• Set gentle but firm limits for acting out behavior
• Listen to child's repeated telling of disaster experience
• Encourage verbal and play expression of thoughts and feelings
• Provide structured but undemanding home chores and rehabilitation activities
• Rehearse safety measures for future disasters
• Free drawing after discussion of disaster
• Free writing after discussion of disaster, complete a sentence exercise
• Tell stories of disaster and recovery
• Read books on disaster and loss
• Role-play games about disaster
• Create a play about disaster
• School study or science projects to increase understanding and mastery
• Talk about disaster safety, family protection, family preparedness*
• Teach calming techniques (i.e., deep breathing, visualization)*
• Field visit to disaster-affected area*
• Small group or individual interventions for high risk children*
• Group "debriefing" discussion to express and normalize reactions, correct misinformation, and enhance coping and peer support*

Age-Specific Interventions for Children in Disaster (Continued)
Age Group
At Home
At School or Other Organization for Children

• Give additional attention and consideration
• Encourage discussion of disaster experiences with peers, significant adults
• Avoid insistence on discussion of feelings with parents
• Suggest involvement with community recovery work
• Encourage physical activities
• Encourage resumption of regular social and recreational activities
• Rehearse family safety measures for future disasters
• *All interventions starred above apply.
• School programs for assisting community with recovery, helping others
• Projects to commemorate and memorialize disaster gains and losses
• Encourage discussion of disaster losses with peers and adults
• Resume sports, club, and social activities when appropriate

HANDOUT #3
Special Concerns of Older Adults in Disaster

Reluctance to evacuate - Research shows that older adults are less likely to heed warnings, may delay evacuation, or resist leaving their homes during disasters. Disaster planning and preparedness is especially critical with this group.

Vulnerable housing - Due to limited income, older adults tend to live in dwellings that are susceptible to disaster hazards due to the location and age of buildings.

Fear of institutionalization - Many older adults fear that if their diminished physical or emotional capabilities are revealed, they will risk loss of independence or institutionalization. They may under-report the full extent of their problems and needs.

Multiple losses - An older person may have lost their income, job, home, loved ones, and/or physical capabilities prior to the disaster. For some, these prior losses may build coping strength and resilience. For others, these losses compound each other. Disasters sometimes provide a final blow that makes recovery especially difficult.

Significance of losses - As a result of a disaster, irreplaceable possessions such as photograph albums, mementos, valued items, or sacred objects passed on through generations may be destroyed. Pets or gardens developed over years may be lost. The special meaning of these losses must be recognized to assist with grieving.

Sensory deprivation - An older person's sense of smell, touch, vision, and hearing may be less acute than the general population. As a result, they may feel especially anxious about leaving familiar surroundings. They may not be able to hear what is said in a noisy environment or may be more apt to eat spoiled food.

Chronic health conditions - Higher percentages of older persons have chronic illnesses that may worsen with the stress of a disaster, particularly when recovery extends over months. Arthritis may prevent an older person from standing in line for long periods of time. Problems with thinking and memory may affect the person's ability to remember or process information.

Medications - Older adults are more likely to be taking medications that need to be replaced quickly following disaster. Medications may cause problems with confusion or memory, or cause a greater susceptibility to problems such as dehydration.

Hyper/hypothermia vulnerability - Older persons are often more susceptible to the effects of heat and cold. This becomes critical in disasters when furnaces and air conditioning may be unavailable.

Transfer and relocation trauma - Frail adults who are dislocated without use of proper procedures may suffer illness or even death. Relocation to unfamiliar surroundings and loss of community may result in depression and disorientation.

Delayed response syndromes - Older persons may not react as fast to a situation as younger persons. In disasters, this may mean that deadlines for applications or eligibility timelines may need to be extended.

Mobility impairment or limitation - Older persons may not be able to use automobiles or have access to public or private transportation. This may limit the opportunity to relocate, go to shelters, Disaster Recovery Centers, or to obtain food, water, or medications when necessary.

Financial limitations - Because many older adults live on fixed and limited incomes, they can't take out a loan to fully repair their homes. They are unable to "start over" due to lack of money and time, as is more possible for younger people.

Literacy - Older persons have lower educational levels than the general population. This may present difficulties in completion of applications or understanding directions. Public information targeting this group must be disseminated in multiple ways, including by non-written means.

Isolation - Some older adults have limited social support systems and are not associated with local senior centers or churches. Their isolation may contribute to not learning about available resources. They may not have access to help with clean-up or repairs. Disaster outreach efforts should prioritize reaching these individuals. Crime victimization - Con artists target older people, particularly after a disaster. These issues need to be addressed in shelters, housing arrangements, and when contractors are being selected to repair homes.

Bureaucracy unfamiliarity - Older adults often have not had experience working through bureaucratic systems. This is especially true for those who had a spouse who dealt with these areas.

Welfare stigma - Many older persons will not use services that have the connotation of being welfare or a "handout." They may need to be convinced that disaster services are available as a government service that their taxes have purchased.

Mental health stigma - Older persons may feel ashamed because they experience mental health problems, or they may be unfamiliar with counseling as a form of support. Psychological stress may be manifested in physical symptoms, which some find as more acceptable. Mental health services should emphasize "support," "talking," and "assistance with resources," and de-emphasize diagnosis or psychopathology.
(Deborah J. DeWolfe, Ph.D., 1995)

Resource Materials

Diane Myers, R.N., M.S.N. Older Adults' Reactions to Disaster Handout. 1990.

U.S. Department of Health and Human Services. Action Plan of the Administration on Aging to Strengthen the Disaster Response Capacity to Serve Older People, 1994.

HANDOUT #4
Cultural Sensitivity and Disaster

Disaster mental health recovery programs must respond specifically and sensitively to the various cultural groups affected by a disaster. In many disasters, ethnic and racial minority groups may be especially hard hit because of socioeconomic conditions which force the community to live in low income, sub-standard housing that is particularly vulnerable to destruction. Language barriers, suspicion of governmental programs due to prior experiences, rejection of outside interference or assistance, and differing cultural values often contribute to disaster outreach programs' difficulty in establishing access and acceptance.

Cultural diversity includes social class, gender, race, and ethnicity. Each family or individual receiving disaster mental health services should be viewed within the context of their cultural/ethnic/racial group and their experience of being a part of that group. The degree and nature of acculturation is relevant, in that bicultural influences are manifested by variation within each group.

To be culturally sensitive and provide appropriate services, disaster mental health professionals must be aware of their own values, attitudes, and prejudices (we all have them), be committed to learning about cultural differences, and be flexible, creative, and respectful in our intervention and outreach approaches.

Some Considerations When Establishing Contact With Ethnic Groups

Language/degree of fluency in English and literacy - Program cultural sensitivity is conveyed when information is translated into primary languages and/or available in non-written forms. When English is a person's second language, emotions are frequently experienced and expressed in their language of origin. Use of trained translators, especially with mental health backgrounds, is preferable to family or neighbors because of issues of privacy and confidentiality.

Immigration experience and status - The number of generations and years in the U.S., degree of acculturation, and citizenship status are relevant to consider when defining outreach strategies. Also, war, living conditions, and trauma in the country of origin as well as conditions of immigration may impact coping with the current disaster.

Family values - Determine who is included in the "family." Often, elders and extended family members are considered part of the family unit and form the primary avenue of support. Learn who the family decision-makers are, what the relative roles of women and men, parents and children, and the older generation are. Establish who should be included in outreach or "counseling" sessions.

Cultural values and traditions - Cultural groups have considerable variation regarding views of loss, death, grieving, property, home, rebuilding, religion, spiritual practices, mental health, healers, and helping. The disaster itself may be viewed as punishment, an act of God or other deity, or the result of another event or action.

Suggestions for Intervention

Learn from local leaders, social service workers, and community members from the cultural group about values, family norms, traditions, community politics, etc.

Involve mental health staff and community outreach workers who are bilingual and bicultural whenever possible. Involve trusted community members to enhance credibility.

Allow time and devote energy to gaining acceptance, be wary of aligning your efforts with agency/organizations that are mistrusted by the communities you're trying to reach. Take advantage of association with valued and accepted organizations.

Be dependable, non-judgmental, genuine, respectful, well-informed, and credible to the community. Listen for verbal and non-verbal cues and modify efforts accordingly.

Determine most appropriate and acceptable ways to introduce yourself and define your program and services to be culturally sensitive.

Recognize cultural variation in expression of emotions, manifestation, and description of psychological symptoms, mental health problems, and view of "counseling."

Provide community education information in multiple languages and via radio, TV, and church announcements if there is low literacy level.

Focus on problem-solving and concrete solutions. Be action-oriented and empower clients through education and skill-building.

Assist in eliminating barriers to help: interpret facts, policies, and procedures, provide advocacy and resource assistance in dealing with barriers.

(Deborah J. DeWolfe, Ph.D., 1993)

Resource Materials

Diane Myers, R.N., M.S.N. and Josie Romero, L.C.S.W. Task Force on the Delivery of Services to Ethnic Minority Populations, American Psychological Association. Guidelines for Providers of Psychological Services to Ethnic, Linguistic, and Culturally Diverse Populations. 1990.

Bolin, R. C. & Bolton, P. Race, Religion and Ethnicity in Disaster Recovery. Institute of Behavioral Science, University of Colorado, 1986.

HANDOUT #5
Planning Workgroup

Discuss the needs of your population group over time. Brainstorm a range of intervention possibilities that serve your group directly as well as secondary groups including gatekeepers.

Have a group recorder write down (legibly!) responses to the following questions so that they can be reported back to the larger group and compiled into a program-wide resource directory.

1. What are the points of contact to reach your group (e.g., churches, schools, clinics, etc.)?
2. Who are the key people, group leaders, and gatekeepers?
3. What significant events or milestones do you anticipate over time?
4. What programs or outreach efforts have been effective so far?
5. Brainstorm program ideas and outreach strategies. Consider #1, 2 and 3 as you generate possibilities.

HANDOUT #6
Common Disaster Worker Stress Reactions

• Feeling heroic, invulnerable, euphoric
• Denial
• Anxiety and fear
• Worry about safety of self and others
• Anger
• Irritability
• Restlessness
• Sadness, grief, depression, moodiness
• Distressing dreams
• Guilt or "survivor guilt"
• Feeling overwhelmed, hopeless
• Feeling isolated, lost, or abandoned
• Apathy
• Identification with survivors Cognitive
  
  • Memory problems
  • Disorientation
  • Confusion
  • Slowness of thinking and comprehension
  • Difficulty calculating, setting priorities, making decisions
  • Poor concentration
  • Limited attention span
  • Loss of objectivity
  • Unable to stop thinking about the disaster
  • Blaming
  Behavioral
  
  • Change in activity
  • Decreased efficiency and effectiveness
  • Difficulty communicating
  • Increased sense of humor
  • Outbursts of anger, frequent arguments
  • Inability to rest or "letdown"
  • Change in eating habits
  • Change in sleeping patterns
  • Change in patterns of intimacy, sexuality
  • Change in job performance
  • Periods of crying
  • Increased use of alcohol, tobacco, or drugs
  • Social withdrawal, silence
  • Vigilance about safety or environment
  • Proneness to accidents
  • Avoidance of activities or places that trigger memories
  Physical
  
  • Increased heartbeat, respiration
  • Increased blood pressure
  • Upset stomach, nausea, diarrhea
  • Change in appetite, weight loss or gain
  • Sweating or chills
  • Tremors (hands, lips)
  • Muscle twitching
  • "Muffled" hearing
  • Tunnel vision
  • Feeling uncoordinated
  • Lower back pain
  • Feeling a "lump in the throat"
  • Exaggerated startle reaction
  • Fatigue
  • Menstrual cycle changes
  • Change in sexual desire
  • Decreased resistance to infection
  • Flare-up of allergies and arthritis
  • Hair loss
  • Headaches
  • Soreness in muscles

  (CMHS, 1994)

  ---

HANDOUT #7
Professional Self-Care

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 the most rewarding aspects of disaster work?
3. How do you know when you are stressed?
4. How might your co-workers know when you are stressed?
5. What can others do for you when you are stressed?
6. What can you do for yourself?

Remember: You are a far less effective helper of others when you are not taking care of yourself.

Good teamwork means encouraging each other to manage stress.
(Deborah J. DeWolfe, Ph.D., 1996)

Videotapes

Beyond the Ashes. City of Berkeley Mental Health Division, California Department of Mental Health, 1992.

Disaster Psychology: Victim Response. Catonsville, MD: Instructional Media Resources, University of Maryland, Baltimore County, 1985.

_________________________________

FEMA funded the videotape projects listed below through the Crisis Counseling Program. Copies are available at no charge from the Center for Mental Health Services, National Mental Health Information Center, P.O. Box 42557, Washington, DC 20015 or by contacting any of the following:

Children and Trauma: The School's Response. Alameda County Department of Mental Health, Santa Cruz County Department of Mental Health, and California Department of Mental Health, 1991.

Faces in the Fire: One Year Later. Santa Barbara County Department of Mental Health, California Department of Mental Health, 1991.

Hope and Remembrance. Texas Department of Mental Health, 1997.

Hurricane Blues. South Carolina Department of Mental Health, 1990.

Voices of Wisdom: Seniors Cope With Disaster. San Bernardino County Department of Mental Health and the California State Department of Mental Health, 1992. (Available in Spanish.)

References and Recommended Reading

Center for Mental Health Services. Disaster Response and Recovery: A Handbook for Mental Health Professionals. Washington, D.C.: U.S. Department of Health and Human Services, Publication No. (SMA) 94-3010, 1994.

Center for Mental Health Services. Manual for Child Health Workers in Major Disaster. Washington, D.C.: U.S. Department of Health and Human Services; Publication No. (ADM) 86-1070. (Rev. ed. in press.)

Center for Mental Health Services. Psychosocial Issues for Older Adults in Disasters. Washington, D.C.: U.S. Department of Health and Human Services, Publication No. (SMA) 99-3323, 1999.

Federal Emergency Management Agency. How to Help Children After a Disaster: A Guidebook for Teachers. Washington, D.C.: FEMA Publication No. 219, 1991.

Federal Emergency Management Agency. School Intervention Following a Critical Incident. (Project COPE). Washington, D.C.: FEMA Publication No. 220, 1991.

LaGreca, A. M., Vernberg, E. M., Silverman, W. K., Vogel, A. L. & Prinstein, M. J. Helping Children Prepare for and Cope with Natural Disasters: A Manual for Professionals Working with Elementary School Children. BellSouth Corporation, 1994. (To obtain copies: Contact Dr. LaGreca, Department of Psychology, University of Miami, P.O. Box 248185, Coral Gables, FL 33124.)

Mitchell, J. & Bray, G. Emergency Services Stress: Guidelines for Preserving the Health and Careers of Emergency Services Personnel. New Jersey: Prentice-Hall, 1990.

Pynoos, R. S. & Nader, K. Psychological first aid and treatment approach to children exposed to community violence: Research implications. Journal of Traumatic Stress, 1988, 1, 445-473.

Vernberg, E. M. & Vogel, J. M. "Interventions with children after disasters." Journal of Clinical and Child Psychology, 1993, 22(4), 485-498.

Vogel, J. M. & Vernberg, E. M. "Children's psychological responses to disasters." Journal of Clinical and Child Psychology, 1993, 22(4), 464-484.

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