A primer for mental health professionals

The immediate response to events such as disasters is stress, about which we have prepared information for the public, for health care professionals, and for public safety workers.  This fact sheet is an overview of stress-related disaster as it relates to health care and mental health care.

Stress is an elevation in a person's state of arousal or readiness, caused by some stimulus or demand. As stress arousal increases, health and performance actually improve. Within manageable levels, stress can help sharpen our attention and mobilize our bodies to cope with threatening situations.  As the following graph illustrates, “optimal” stress involving functional amounts of arousal contributes to effective task performance, including response to disaster.

But beyond that optimal level there is deterioration of health and performance begins to lessen, so it is important to manage stress in order to keep it in the “good” range.

Stress is mediated by appraisal, a cognitive “story” that we tell ourselves about the disaster circumstances and our response to them: Have we had this experience before? If so, how did we respond? What was the outcome? Can we cope with the situation now? If there's doubt as to any of these questions, the stress response elevates.

Here are some common stress reactions in response to disasters, experienced to varying degrees by everyone involved with them, and which you will experience as well.

• Remember that stress response, grieving, coping, and resiliency are all processes, not events, and therefore take place along a more or less predictable, but always dynamic, timetable.
  • Monitor yourself and others for signs that you may need stress management assistance, if any of the following become persistent and extreme:
  • Difficulty communicating thoughts
  • Difficulty remembering instructions
  • Difficulty maintaining balance
  • Uncharacteristically argumentative
  • Difficulty making decisions
  • Limited attention span
  • Unnecessary risk-taking
  • Tremors/headaches/nausea
  • Tunnel vision/muffled hearing
  • Colds or flu-like symptoms
  • Disorientation or confusion
  • Difficulty concentrating
  • Loss of objectivity
  • Easily frustrated
  • Unable to engage in problem-solving
  • Unable to let down when off duty
  • Refusal to follow orders
  • Refusal to leave the scene
  • Increased use of drugs/alcohol
  • Unusual clumsiness
  • Practice self-care and coping for yourself.
  • Be aware of more serious signs of stress in yourself and in your patients as they may indicate Post-Traumatic Stress Disorder:
  • Intrusions, such as flashbacks or nightmares, where the traumatic event is re-experienced.
  • Avoidance, where the person tries to reduce exposure to people or things that might bring on their intrusive symptoms.
  • Hyperarousal, meaning physiologic signs of increased arousal, such as hypervigilance or increased startle response.

  Although the effects of PTSD are serious and difficult to deal with, it can be treated by a variety of forms of psychotherapy and medication.

  Web Links

  This is the homepage for the National Center for Posttraumatic Stress Disorder. It has fact sheets and resources covering all aspects of PTSD, including information geared specifically toward mental health care providers.

  This is part of SAMHSA’s “Guide to Managing Stress in Crisis Response Professions”. It lists, explains, and differentiates between common and extreme responses to stress.

  This guide lists some helpful stress management techniques that both you and your clients can use following a disaster.

  This is an annotated bibliography of disaster mental health resources.

  This is a PowerPoint presentation on the mental health consequences following the World Trade Center disaster. It outlines the immediate and long term responses to the event and the therapeutic interventions utilized as well as a summary of their effectiveness.

  This FEMA fact sheet provides hints for recognizing stress and tips for relieving stress.

  This journal article examines research findings on the effects of stress and trauma on immune response and health behavior.

  This disaster resources website, by the University of Illinois, has information on preparing for disasters and coping in their aftermath.

   

  Coping and disaster recovery for mental health professionals

  During the recovery phase following the disaster, both you and your consumers or clients will continue to experience stress, grief, and perhaps even some symptoms of depression and anxiety (PDF).  During this recovery phase physical problems, such as changes in sleep and appetite, digestive problems, more susceptibility to colds or other illnesses, and increased use of alcohol and other drugs, are also common.  We as well as those we accompany clinically may also have emotional responses, such as fear, irritability, nightmares, difficulty concentrating, feelings of betrayal, and loss of interest in everyday activities. 

  What can you do to cope, and to facilitate in your clients or consumers coping, in your journey toward recovery from disaster?  Here are some helpful suggestions:

  • Use grounding (PDF), a technique designed to keep your experience in the “here and now” and remind you that you are alive and present to life.  Teach consumers or clients this technique as well.  
  • Take time every day to focus on your breathing (PDF) as a calming and centering strategy.  You can educate consumers or clients about the contribution of conscious breathing to wellness, and demonstrate this in your work as well.
  • Experiment with watching your thoughts (PDF) to identify those that may be catastrophic or lead to feelings of hopelessness and helplessness.  A healthy outlook on life, for both you and your consumers or clients, makes resiliency and recovery more achievable.

  • Challenge negative beliefs. Replace such thoughts as, "I always have bad luck...nothing will get better from now on...everything is going wrong," with, "Is there any real reason to think that...maybe things will change for the better."
  • Adjust self-talk. Convert negative messages into positive ones. For example, replace "I’ll never get through this," with "I can do this, but it’s normal and okay to feel scared and overwhelmed."
  • Use previous ordeals that have been successfully overcome as a "power base."
  • Consider alternative outcomes for worst-case scenarios. For example, "I can still see my friends, I can enjoy the little things in life."
  • Imagine how this event will be viewed in the future, remembering how things do change over time.

  Some consumers or clients will be resistant to these strategies and perceive you as suggesting that their struggles are “all in their heads.”  Educating them with some easily understood techniques and exampleswill tend to diminish this perception.

  • Learn to manage anxiety (PDF) through such strategies as guided imagery and relaxation (PDF).  Include information about anxiety and its management in your office literature and handouts (PDF)
  • Teach your consumers or clients about the need for support systems or groups (saved as Support Group) to reach out and connect with others, especially those who may have shared the stressful event.  Consider forming such groups for your clients or consumers and consider affiliating with a disaster-specific subgroup of your professional association such as these for psychologists (PDF), licensed professional counselors (PDF), psychiatrists (saved as Disaster Psychiatry), and licensed social workers (PDF).
  • Use empathic listening (PDF) in your interactions with consumers or clients around disaster, and seek out in your circle of friends, family, and spiritual community those who will listen in this way to you.
  • Teach consumers or clients the need for emotional expression (PDF), and practice this yourself.  “Getting things out” helps.
  • Physical exercise (PDF) can contribute to greater well-being following disaster.  Teach consumers or clients this principle (PDF) and help them to develop an appropriate exercise plan.  Practice it yourself.
  • Use prayer, meditation, or other spiritual practices as helpful coping strategies.
  • Understand that your service to others (PDF), even in the midst of your own response to the disaster, can help you cope with your struggles in a kinder and clearer way.
  • Use creativity (PDF) to fill your life with “food for your soul.”
  • Take planned breaks, such as going to the movies or doing some light reading, to remind yourself that you are recovering, that you are well.
  • Maintain relationships with your pets in order to give and be given coping gifts.
  • Nourish yourself through healthy eating and drinking, and avoid self-medication, alcohol, or other drugs.
  • Write about (PDF) your experience in detail, just for yourself or to share with others.

  Remember that people who engage fully in recovery from disaster discover unexpected benefits. As they gradually heal their wounds, survivors and mental health providers alike find that they are also developing inner strength, compassion for others, increasing self-awareness, and often the most surprising -- a greater ability to experience joy and serenity than ever before.

  Web Links

  This guide lists ten helpful stress management techniques, some of which are found above, that both you and your clients can use following a disaster. (PDF)

  This page lists the common physical and emotional responses to traumatic events and provides strategies for coping. (PDF)

  This page, entitled “Coping With Disasters,” is a complete guide to understanding and managing post-disaster stress. It links to helpful fact sheets from organizations such as the National Center for PTSD, the Center for Mental Health Services, and FEMA. (PDF)

  This article, entitled “Become a Survivor: How to Find Peace of Mind Following Life’s Traumas,” provides strategies for healing, relieving stress, and obtaining a healthy outlook after traumatic events. (PDF)

  This SAMHSA pamphlet addresses multiple aspects of life after a disaster and provides tips on dealing with stress, changes within the self and within relationships, as well as financial worries. (PDF)

  This page provides an in-depth view on different levels of stress and practical coping strategies that apply to various aspects of everyday living. (PDF)

  Mental health reactions after disaster: A guide for mental health providers

  Traumatic events, such as disasters, are characterized by a sense of horror, helplessness, serious injury, or the threat of serious injury or death.  Disasters affect survivors, public safety and health care workers, and friends and relatives of victims who have been directly involved. Elsewhere on this website we review common stress reactions to disasters in a way that is oriented toward the Georgia public.  Here we will discuss common stress reactions and mental health responses to them from the perspective of mental health professionals.   

  • Everyone who experiences a disaster is affected by it.  For most people, the outcome is recovery and resiliency, not psychopathology.

  • There are common stress-related reactions to disasters, experienced by everyone (including children and disaster rescue or relief workers). These may last for several days or even a few weeks and may include:

    • Emotional reactions: shock, fear, grief, sadness, anger, guilt, shame, feeling helpless, feeling numb
    • Cognitive reactions: confusion, indecisiveness, worry, shortened attention span, trouble concentrating
    • Physical reactions: tension, fatigue, edginess, insomnia, bodily aches or pain,
    startling easily, racing heartbeat, nausea, change in appetite, change in sex drive
    • Interpersonal reactions: distrust, conflict, withdrawal, work or school problems, irritability, loss of intimacy, feeling rejected or abandoned

  Psychological first-aid for these symptoms can help reduce their severity and duration.

  There are also more severe post-traumatic stress responses (saved as PTSD sources) to disasters, that may include symptoms such as:

  • Intrusive re-experiencing: terrifying memories, nightmares, or flashbacks
  • Extreme emotional numbing: completely unable to feel emotion, as if empty
  • Extreme attempts to avoid disturbing memories: such as through substance use
  • Hyperarousal: panic attacks, rage, extreme irritability, intense agitation, violence
  • Severe anxiety: debilitating worry, extreme helplessness, compulsions, and/or obsessions
  • Severe depression: loss of the ability to feel hope, pleasure, or interest; feeling worthless; suicidal ideation or intent
  • Dissociation: fragmented thoughts, spaced out, unaware of surroundings, amnesia

  These various responses may be understood as occurring along the dimensions of frequency and severity of response, as follows:

  

  Even more important than the symptoms an individual experiences is the individual’s functional capacity. Symptomatic individuals who can continue to function affectively at work or at home are at much lower risk (PDF) for developing psychiatric problems that those who are functionally incapacitated.

  Some people have a higher risk for severe stress symptoms than do others.  Risk factors for severe response to trauma include:

  • Level of disaster-related trauma and stress: Severe exposure to the disaster, especially injury, threat to life, and extreme loss. Living in a highly disrupted or traumatized community.
  • Survivor characteristics: Female gender; if an adult survivor, being ages 40-60; being an ethnic minority; low socioeconomic status; predisaster psychiatric history.
  • Family context: Children in the home; among children whose parents are experiencing distress; having a significantly distressed family member; interpersonal conflict or lack of support in the home
  • Resource Context: Lacking belief in one’s ability to cope; few, weak, or deteriorating social resources.

  Reactions that Signal Possible Need for Mental Health Referral

  • Disorientation (dazed, memory loss, unable to give date/time or recall recent events…)

  • Depression (pervasive feeling of hopelessness and despair, withdrawal from others…)

  • Anxiety (constantly on edge, restless, obsessive fear of another disaster…)

  • Mental Illness (hearing voices, seeing visions, delusional thinking…)

  • Inability to care for self (not eating, bathing, changing clothing or handling daily life)

  • Suicidal or homicidal thoughts or plans

  • Problematic use of alcohol or drugs

  • Domestic violence, child abuse, or elder abuse

  Knowledge of these typical mental health responses to disasters can help mental health professionals distinguish normative from severe responses, and refer for appropriate treatment as necessary.

  Web Links

  This fact sheet goes over the common and severe mental health reactions following disasters and assesses the risk factors that contribute to severe reactions. (PDF)

  This page has links to resources on posttraumatic stress disorder, traumatic stress, and responses to disasters. Some of the listed resources specifically address traumatic stress in children. (PDF)

  Post-Traumatic Stress Disorder: A primer for mental health  professionals

  Elsewhere on this website you will find fact sheets addressing disaster-related stress and resiliency.  Most people experiencing disasters will recover and resume normal functioning, but some will go on to develop a constellation of symptoms that collectively is referred to as Post-Traumatic Stress Disorder.  This fact sheet is intended to highlight some of the key points of this struggle and prepare mental health professionals to screen and refer for treatment patients experiencing this disorder. 

  • Disasters are sufficiently unusual and traumatic to predispose some people who experience them to post-traumatic stress disorder.
  • Some people will experience a short-term acute stress disorder (PDF) characterized by dissociation (PDF) and other PTSD-like symptoms, but not develop PTSD.
  • Vulnerability for PTSD (PDF) is complex and debated, but it is clear that no one predictor serves to discriminate who will develop PTSD from who will not.  In general, the likelihood of a person developing PTSD depends on:
    • Previous history of trauma
    • Intensity of the present trauma
    • Personal loss or injury
    • Proximity to the traumatic event
    • Degree of control and emotional response to the disaster
    • Amount of post-disaster support
  • Symptoms of PTSD (PDF) occur in the following dimensions:
    
    • re-living symptoms
    • avoidance symptoms
    • numbing symptoms
      
    • arousal symptoms
      

  1. Re-Living Symptoms:
  The traumatic event is persistently re-experienced in one or more of the following ways:

  • Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions.
  • Recurrent distressing dreams of the event.
  • Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated).
  • Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
  • Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

  2. Avoidance & Numbing Symptoms:
  The individual also has persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by 3 or more of the following:

  • Efforts to avoid thoughts, feelings, or conversations associated with the trauma.
  • Efforts to avoid activities, places, or people that arouse recollections of the trauma.
  • Inability to recall an important aspect of the trauma.
  • Significantly diminished interest or participation in significant activities.
  • Feeling of detachment or estrangement from others.
  • Restricted range of affect (e.g., unable to have loving feelings).
  • Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span).

  3. Arousal Symptoms:
  Persistent symptoms of increased arousal (not present before the trauma), as indicated by 2 or more of the following:

  • Difficulty falling or staying asleep.
  • Irritability or outbursts of anger.
  • Difficulty concentrating.
  • Hypervigilance.
  • Exaggerated startle response.

  The disturbance, which has lasted for at least a month, causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  • Comorbidity, or other problems commonly associated with PTSD, include:
    • Substance abuse (PDF), or dependence
    • Feelings of hopelessness, shame, or despair
    • Vocational problems
    • Relationships problems including divorce and violence
    • Physical symptoms, those typically associated with anxiety (PDF)
  • Children can develop PTSD too.  Young children may have separation difficulties, or suddenly regress around toilet training or other developmental tasks.  Children of early elementary school age (ages 6 to 9) may act out the trauma through play, drawings, or stories. They may complain of physical problems or become more irritable or aggressive. They also may develop fears and anxiety that don't seem to be caused by the traumatic event.  The presentation of PTSD in adolescence (PDF) is more similar to that in adults.
  • Onset of PTSD is also a bit complicated, as symptoms usually start soon after the traumatic event, but they may not emerge as the syndrome until months or years later. They also may come and go over many years.
  • The course of PTSD is also complicated, in that about half (40% to 60%) of those who develop it get better at some time. But about 1 out of 3 people who develop PTSD always will have some symptoms.
  • Various treatments (PDF) are available, including psychotherapy and medication. 

  Becoming acquainted with PTSD as a mental health professional can help you detect and respond to it as it presents in some patients who have experienced disasters.

  Additional Resources

  Part of SAMHSA’s Training Manual for Mental Health and Human Service Workers, this section explains how various age, socioeconomic, and ethnic groups react to disasters and assesses each group’s risks for long-term mental health implications. (PDF)

  This fact sheet by the National Center for Posttraumatic Stress Disorder provides a general overview of PTSD, including a summary of its causes, symptoms, and treatment. (PDF)

  This fact sheet gives more specific descriptions of the symptoms of PTSD as categorized by reliving, avoidance, and arousal. (PDF)

  This page has an annotated list of reference guides and articles on the treatment of PTSD. (PDF)

  Mental health screening for PTSD following disasters

  As a mental health professional, you are likely to see an increase in traumatized individuals after a disaster.  Many of these clients or consumers will present with physical rather than mental or emotional symptoms, and will be referred to you by their physicians after physical work-ups for stress.  In addition to being familiar with disaster-related stress and practicing psychological first-aid, you will want to educate yourself about PTSD and start to screen those you work with for its effects following major disasters.

  First, some general PTSD screening considerations:

  • In addition to disasters and other traumatic life events, life-threatening medical conditions such as heart attack, severe burns, severe injuries, and cancer can cause or exacerbate PTSD.
  • You will want to make certain that your clients or consumers have had a thorough physical examination to rule out other causes of stress.
  • Patients with PTSD experience a significant degree of functional impairment similar to that observed in patients suffering from major depression (PDF).
  • Anxiety disorders (PDF), of which PTSD is a subtype, often present as physical symptoms (PDF) that can impair functioning severely. Persistent anxiety also brings about hormonal, neurochemical, immune functioning, and autonomic nervous system changes that can affect physical health.
  • PTSD is associated with significant problems in living, including alcohol abuse, marital problems, unemployment, and suicidal ideation. PTSD is also associated with high levels of use of medical services.
  • PTSD often presents to physicians, but goes unrecognized. Few medical clinics systematically identify trauma survivors who have related mental-health problems.
  • Failure to identify and treat PTSD has adverse effects on the peoples’ physical and mental health, and mental health professionals are often the first to suggest this as a possible struggle.

  Thus, thorough and early screening for PTSD is essential to its diagnosis and treatment.

  Screen administration
  Of course, as with clinical practice in general, we have numerous options for how we begin to understand others’ struggles.  Here are several:

  • Familiarize yourself with the diagnostic features of PTSD (PDF) and include questions about these features in your initial intake for people with history of trauma and suspected PTSD symptoms. 
  • Administer the Primary Care PTSD Screen (PC-PTSD) (PDF), a brief verbal measure designed for use by physicians and mental health professionals.  The PC-PTSD is brief and problem-focused, and consists of the following four questions:

   

  In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you:

  1. Have had nightmares about it or thought about it when you did not want to?
  YES     NO

  2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?         
  YES     NO

  3. Were constantly on guard, watchful, or easily startled?           
  YES     NO

  4. Felt numb or detached from others, activities, or your surroundings?
  YES     NO

   

  A positive response to the screen (answering “YES” to any three items) does not necessarily indicate that a patient has Posttraumatic Stress Disorder.  It does suggest, however, trauma-related problems that should be investigated further.

  Those of you practicing in areas in which a disaster has occurred may even add these screening items to the standard history forms that your clients or consumers complete at first visits.

  • Perform specific PTSD assessment of people you suspect of struggling in this way.  Here is a PTSD-specific self-test (PDF), that is a more thorough measure of PTSD symptoms and related response.  This measure is in the public domain and you may print it out and give it to your clients or consumers to complete.  

  STRESS-RELATED SELF-TEST
  Please complete the following self-test by clicking the "yes or "no" boxes next to each question. 

  
  Yes or No?
  

  A.

  Yes No

  Have you experienced or witnessed a life-threatening event that caused intense fear, helplessness or horror?

  
  B.

  Yes No	Repeated, distressing memories and/or dreams?
  Yes No	Acting or feeling as if the event were happening again (flashbacks or a sense of reliving it)?
  Yes No	Intense physical and/or emotional distress when you are exposed to things that remind you of the event?

  C.

  Yes No	Avoiding thoughts, feelings, or conversations about it?
  Yes No	Avoiding activities, places, or people who remind you of it?
  Yes No	Blanking on important parts of it?
  Yes No	Losing interest in significant activities of you life?
  Yes No	Feeling detached from other people?
  Yes No	Feeling your range of emotions is restricted?
  Yes No	Sensing that your future has shrunk (for example, you don't expect to have a career, marriage, children, or a normal life span)?

  D.

  Yes No	Problems sleeping?
  Yes No	Irritability or outbursts of anger?
  Yes No	Problems concentrating?
  Yes No	Feeling "on guard"?
  Yes No	Being easily and unusually startled?

  
  Sometimes people have more than one struggle at a time.  Please take a minute to answer the following questions:

  Yes No

  Have you experienced changes in sleeping or eating habits?

  
  More days than not, do you feel:

  Yes No	Sad or depressed?
  Yes No	Disinterested in life?
  Yes No	Worthless or guilty?

  
  During the last year, has the use of alcohol or drugs:

  Yes No	Resulted in your failure to fulfill responsibilities with work, school, or family?
  Yes No	Placed you in a dangerous situation, such as driving a car under the influence?
  Yes No	Gotten you arrested?
  Yes No	Continued despite causing problems for you and/or your loved ones?

   

  Scoring of this measure is straightforward.  A positive response to “A” indicates experience of trauma.  Within the “B” re-experiencing cluster, at least one positive response is required.  The Avoidance items in “C” require three or more positive responses, and the Numbing questions in “D” are diagnostic as well with three or more.
  The remaining items are intended to elaborate depression and substance-related struggles.

  Discussion and referral

  After a review of the screening results and a discussion with your client or consumer, you may decide whether he or she is in need of further specialized mental-health evaluation or treatment.  People may be referred, depending on availability, to specialized PTSD treatment, behavioral medicine, or more general mental-health services for further evaluation and possible treatment.  Of course, some patients who screen "positive" will not actually be diagnosed with PTSD after more detailed clinical evaluation by you or another mental health professional. 

  Keep in mind, you should also be concerned with and assess for suicidal ideation http://www.ahrq.gov/clinic/3rduspstf/suicide/suiciderr.pdf (saved as Suicide Risk) for anyone you suspect is experiencing PTSD.

   

  ADDITIONAL RESOURCES

  This is the homepage for the National Center for Trauma-Informed Care, funded by SAMHSA. The Center’s goal is to provide training in the support and empowerment of trauma survivors. On the left-hand side of the page, you can access resources on trauma and trauma-informed care. (PDF)

  This page provides an overview of trauma, its causes, and coping strategies. There is also a section that specifically addresses PTSD. (PDF)

  This is the American Psychological Association’s website on Posttraumatic Stress Disorder. Within the site are general resources on PTSD, as well as the latest findings, research, and press releases concerning PTSD. (PDF)

  This page has four different screening tools that can be helpful in the assessment of PTSD. Besides the Primary Care Screen, the other screens, or checklists, are targeted either toward civilians, military personnel, or specific stressors. (PDF)

  Disaster Mental Health Training

  Mental Health Professionals play an essential role in disaster response and recovery. Disaster Mental Health counseling usually involves short-term, community-based, on-site interventions aimed at meeting the immediate psychological needs of people affected by disasters during and immediately following disaster events.
  Although disaster events differ widely, they invariably involve sudden tragedy and loss in peoples lives. We accompany them as they struggle to navigate the suffering and uncertainty they face. Our primary mission is to provide support, referral, assessment of strengths and limitations, crisis intervention, advocacy, and help to foster coping and resilience.
  

  There is no universally accepted training model or credentialing for Disaster Mental Health professionals. Usually, the minimal requirements are a professional license and a willingness to help (frequently on a pro bono basis). Nevertheless, your willingness to make Disaster Mental Health a part of your professional identity should involve specific training and registration with agencies responsible for disaster response. This will help to facilitate rapid deployment and decrease the chaos often associated with deployment.
  

  Disaster Mental Health Training ranges from on-line modules like those offered by the Federal Emergency Management Agency (FEMA).
  Training (PDF)
  Training Brochure (PDF)
  Training Courses (PDF)
  

  In addition, there are certificate programs and doctoral degrees such as those offered by the University of South Dakota Disaster Mental Health Institute. (saved as USK Mental Health Institute)
  

  The Substance Abuse and Mental Health Services Administration (SAMHSA) offers an excellent training manual for mental health professionals. (PDF)
  
  The Georgia Department of Human Resources training can be found on the “DHR Training” fact sheet.
  
  Other ways to better prepare yourself include volunteering with the American Red Cross by contacting your local ARC chapter (PDF) or by contacting your state professional organization:
  Georgia Psychiatry Organization (PDF)
  Georgia Psychologists Organization (PDF)
  Licensed Professional Counselors Association of Georgia (PDF)
  Georgia Association of School Psychologists (PDF)
  Georgia School Counselors Association (PDF)
  Georgia Association of Marriage and Family Therapists (PDF)
  Georgia Association of Social Workers (PDF)

  Additional Training Resources for Mental Health Professionals:

  • Field Manual for Mental Health and Human Service Workers in Major Disasters. 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. (PDF)
  • Emotional and Spiritual Care. (PDF)
  • Developing Cultural Competence in Disaster Mental Health Programs.
    Highlights important common issues relating to cultural competence and to disaster mental health. Disaster mental health providers and workers can use and adapt the guidelines set forth in this document to meet the unique characteristics of individuals and communities affected directly or indirectly by a full range of natural and human-made disasters. (PDF)
  • Crisis Counseling Programs for the Rural Community.  The goal of this publication is to improve crisis counseling services for rural populations following disaster. Determining the factors that account for the uniqueness of rural populations and communities and how those factors affect the implementation of disaster crisis counseling services are the central issues of this publication. (PDF)
  • Working with Children:
    • Psychosocial issues for children and families in disasters (PDF)
    • Children’s responses to terrorism (PDF)
  • Psychosocial Responses to Disaster-related Mental Health Problems (PDF)
  • Psychological First-Aid: How to Support Well-being in Disasters Victims (PDF)
  • Guidelines on notifying families of Dead or Missing Loved Ones (PDF)
  • Organizing Funerals or Memorials: A Part of Recovery (PDF)
  • Coping with Loss and Grief (PDF)
  • Helping families manage the stress of relocation (PDF)
  • Fostering resilience:
    • The Road to Resilience (El camino hacia la fortaleza) (PDF)
    • Fostering resilience in response to terrorism (PDF)
  • International Trauma Studies Program. The International Trauma Studies Program is committed to enhancing the natural resilience and coping capacities in individuals, families, and communities that have endured and/or are threatened by traumatic events -- domestic and political violence, war and natural disaster.  ITSP pursues its mission through providing professional training, conducting innovative research, offering technical assistance to international organizations, and helping build a global learning community in mental health and human rights.  (PDF)
  • Training Manual for Mental Health and Human Service Workers in Major Disasters. This training manual explains how survivors respond to, and recover from, disasters and highlights the importance of tailoring disaster response to individual communities and populations. Intended for use by instructors, it describes effective interventions for responding to disasters and strategies for stress prevention and management among mental health and human service workers. (PDF)
  • Community Crisis Response Team Training Manual (PDF)
  • Psychological First Aid Manual (PDF)
  • Psychological First Aid (PDF)
  • Disaster Mental Health Institute Academic Program (University of South Dakota) (PDF)

  Other Resources

  • Common Misconceptions about Disaster: Panic, “the Disaster Syndrome”, and Looting (PDF)
  • Guilt Following a Traumatic Event (PDF)
  • Disaster Mental Health Handouts (PDF)
  • Mental Health and Mass Violence: Evidence-based Intervention for Victims/Survivors of Mass Violence (PDF)
  • Mental Health in Emergencies (PDF)
  • Disaster Psychiatry Handbook (PDF)
  • A guidebook for psychosocial intervention (PDF)
  • Trauma Response Guide. This manual was originally written for people working in the field with women survivors of rape in Bosnia, but it can be used more broadly as a guide for helping anyone of either gender who has survived any kind of trauma. Since it is written from afar and based on experiences similar to but not the same as the ones you are dealing with, please use what is useful or helpful and ignore what is irrelevant or wrong for your circumstances, trusting more in your judgment and intuition than in anything contained herein. (PDF)
  • Post-Traumatic Stress Disorder Response Guide (PDF)
  • Role of Pastoral Crisis Intervention (PDF)
  • Resilience a comprehensive website discussing resiliency, its importance, and ways to foster resiliency in your own life. (PDF)
    
    • Introduction to Resiliency (PDF)
    • The Principles Underlying Life Experience: The Beauty of Simplicity (PDF)
    • Health Realization: an Innate Resiliency Paradigm for School Psychology (PDF)
    • A Framework for Practice: Tapping Innate Resilience (PDF)
    • A Guide to Promoting Resilience in Children: Strengthening the Human Spirit 
    • Articles in Spanish
      • Estado de arte en resilencia (PDF)
      • Fomentando la elasticidad en los ninos (PDF)

   

  Talking with Children When the Talking Gets Tough

  
  Wars, shooting in schools, natural disasters, deaths at sporting events -- as adults we hope that these and other tragic outcomes will never happen anywhere, and definitely will not impact the children and youth we care about. We would like to protect those young minds from the pain and horror of difficult situations. We would like to ensure that they have happy, innocent, and carefree lives.

  
  So what is a mental health professional, parent, teacher, or other caring adult to do when disasters fill the airwaves and the consciousness of society?

  • Don’t assume that the kids don’t know about it. They probably know more than you think. The reality of today’s world is that news travels far and wide. Adults and children learn about disasters and tragedies shortly after they occur, and live video footage with close-ups and interviews are part of the reports. Children and youth are exposed to the events as soon as they can watch TV or interact with others who are consumers of the news. Not talking about it does not protect children. In fact, you may communicate that the subject is taboo and that you are unavailable if you remain silent.
  • Be available and "askable". Let kids know that it is okay to talk about the unpleasant events. Listen to what they think and feel. By listening, you can find out if they have misunderstandings, and you can learn more about the support that they want and need. You do not need to explain more than they are ready to hear, but be willing to answer their questions.
  • Share your feelings. Tell young people if you feel afraid, angry or frustrated. It can help them to know that others also are upset by the events. They might feel that only children are struggling. If you tell them about your feelings, you also can tell them about how you deal with the feelings. Be careful not to overwhelm them or expect them to find answers for you.
  • Help children use creative outlets like art and music to express their feelings. Children may not be comfortable or skilled with words, especially in relation to difficult situations. Using art, puppets, music or books might help children open up about their reactions. They may want to draw pictures and then destroy them, or they could want to display them or send them to someone else. Be flexible and listen.
  • Reassure young people and help them feel safe. When tragic events occur, children may be afraid that the same will happen to them. Some young children may even think that it already did happen to them. It is important to let them know that they are not at risk – if they are not. Try to be realistic as you reassure them, however. You can try to support them and protect them, but you can not keep all bad things from happening to children. You can always tell them that you love them, though. You can say that, no matter what happens, your love will be with them. That is realistic, and often that is all the children need to feel better.
  • Support children’s concern for people they do not know. Children often are afraid not only for themselves, but also for people they do not even know. They learn that many people are getting hurt or are experiencing pain in some way. They worry about those people and their well being. In some cases they might feel less secure or cared for themselves if they see that others are hurting. It is heartwarming and satisfying to observe this level of caring in children. Explore ways to help others and ease the pain.
  • Look for feelings beyond fear. After reassuring kids, don’t stop there. Studies have shown that children also may feel sad or angry. Let them express that full range of emotions. Support the development of caring and empathy. Be careful not to encourage the kind of response given by one child: "I don’t care if there’s a war, as long as it doesn’t affect me and my family".
  • Help children and youth find a course of action. One important way to reduce stress is to take action. This is true for both adults and children. The action may be very simple or more complex. Children may want to write a letter to someone about their feelings, get involved in an organization committed to preventing events like the one that they are dealing with, or send money to help victims or interventionists. Let the young people help to identify the action choices. They may have some wonderful ideas.

  Take action and get involved in something. It is not enough to let children take action by themselves. Children who know that their parents, teachers or other significant caregivers are working to make a difference feel hope. They feel safer and more positive about the future. So, do something. It will make you feel more hopeful too. And hope is one of the most valuable gifts we can give children and ourselves.

  For more resources on supporting children through traumatic events, go here
  (saved as Talking with Children) and click on “Children in Trauma” at the top of the page. This page contains all the information found on this fact sheet.

  Secondary stress and the mental health provider

  Those individuals who interact with trauma survivors, such as mental health providers, are themselves exposed to a form of traumatic stress.  More recent diagnostic formulations of Post-Traumatic Stress Disorder such as those in DSM-IV have broadened the definition of trauma to include participation in others’ traumatic response.  As you see and treat clients or consumers who have experienced disaster, whether in the emergency period immediately following it or thereafter, you will be exposed to secondary stress and traumatization, the focus of this fact sheet.  

  • Secondary stress has also been termed Secondary Traumatic Stress Disorder (STSD), vicarious traumatization (PDF), compassion fatigue (PDF), or empathic strain.
  • Some helpers exposed to stress develop PTSD, but the experience of the full syndrome is only one of the ways in which professional helpers are affected by their exposure to secondary traumatic stress (PDF).
  • Your vulnerability to secondary stress (PDF) is influenced by:
  • personal history, current life circumstances, as well as proximity and personal connection to the events and people involved in the disaster
  • your level of empathic engagement with your clients’ or consumers’ experience of the disaster
  • your perceived similarity to the victims of the disaster
  • Secondary stress involves the following features:
  • A broadened sense of “what can happen,” sometimes experienced as a “loss of innocence” or as cynical detachment influencing your frame of reference and identity, worldview, and spirituality.
  • Cognitive distortion around normalcy and baseline rates.  Our awareness that planes actually do crash and that storms can turn into tornados can transform into an expectation that every plane is likely to crash and that each storm is a tornado.  When we lose our sense of perspective in this way, we enter the world of the traumatized.
  • Heightened arousal and vigilance, which is a way of being in which we are characteristically aroused and remain constantly on our guard because we anticipate danger at every turn.
  • Avoidance, in that we may find ourselves organizing our lives around what might happen, rather than what is happening.
  • Emotional consequences of involvement, experienced as:
  • Threats to self-capacities of emotional management and self-worth
  • Changes in basic beliefs about psychological needs, such as safety, trust, esteem, intimacy, and control
  • Loss of hope and meaning, as found in increased cynicism and pessimism, nihilism, and existential despair (PDF)
  • Anger at the disaster or the perceived causes
  • Symptoms similar to those of the patients being treated, or a blurring of what experiences are “ours” and what belongs to the victims (a process involving dissociation)
  • A sense of unworthiness and survival guilt (PDF)
  • A persistent and extreme sadness, or dysphoria (PDF)
  • A sense of mourning and grief (PDF)
  • Behavioral changes such as:
    • Becoming judgmental of others
    • Tuning out
    • Having a reduced sense of connection with loved ones and colleagues
    • Becoming cynical or angry and losing hope and/or a sense of meaning
    • Developing rescue fantasies, becoming over-involved, taking on others' problems
    • Developing overly rigid, strict boundaries
    • Feeling heightened protectiveness as a result of a decreased sense of the safety of loved ones
    • Avoiding social contact
    • Avoiding work contact
  • Secondary stress can affect your:
  • Relationship with meaning and hope
  • Ability to get your psychological needs met
  • Intelligence
  • Willpower
  • Sense of humor
  • Ability to protect yourself
  • Memory/Imagery
  • Existential sense of connection to others
  • Dangers of secondary stress lie in both direct negative effects (intrusive imagery, disrupted beliefs) and in our way of responding to it (numbing, over-generalized negative expectations, cynicism).

  Coping with secondary stress:

  • Self-assessment: Ask yourself, "How am I doing? What do I need? How have I changed?” Discuss the questions and answers with a colleague, friend, or therapist.
  • Protect yourself through awareness of your vulnerability and recognition of the negative consequences of your work as echoed in the voices of others (PDF).
  • Work to cultivate:
    • A sense of strength
    • Self-knowledge
    • Confidence
    • A sense of meaning
    • Spiritual connection
    • Respect for human resiliency

  Address the stress of your work through practicing self-care -- Nurture yourself by focusing on sources of pleasure and joy, and allow yourself time alone when necessary.
  
  Fortunately, mental health professionals have tools to manage secondary stress. We have knowledge of the ways in which trauma affects people, we have skills for soothing arousal and processing states of distress, and -- most importantly -- we have each other, a support system with the potential to help each of us maintain perspective and find understanding during those times when we get caught in the web of secondary traumatic stress. We are not invulnerable, but if we maintain a strong sense of community among ourselves, we can be resilient.

  
  Additional Resources
  

  This American Psychological Association fact sheet, entitled “Fostering Resilience in Response to Terrorism Among Mental Health Workers,” focuses on vicarious traumatization and secondary traumatic stress. It goes over the signs of secondary stress and provides tips for coping. (PDF)

  Entitled “Secondary Stress and the Professional Helper,” this is another article on secondary stress. It provides another perspective and explains the causes and impact of stress. (PDF)

  Unlike the previous two articles, this one titled “Secondary Traumatization in Mental Health Care Providers,” focuses on research findings related to secondary traumatization, including a literature review. It also discusses the assessment of stress in mental health care providers and the implications of stress on training and clinical practice. (PDF)

  This article defines and explains compassion fatigue and coping strategies. (PDF)

  This article is also on compassion fatigue. It is extremely helpful in that it lists the symptoms and relates through examples and personal stories. (PDF)

  This fact sheet from the National Center for PTSD explains the importance of understanding secondary stress and the mental health implications mental health care providers face. (PDF)

  A perspective on Secondary Trauma

  This perspective, offered by an ER physician, does not necessarily reflect the views of the division of mental health, developmental disabilities and addictive disease. It is offered as a point of view about the personal and professional costs of working with suffering.

  I think, perhaps, I have seen enough pain for one life.  I know, I know, I'm only 40 years old.  I'm soft now.  I used to love intubations and resuscitations; I used to love the thump of the defibrillator, the thrill of blood from deep wounds, the surprise of something horrible on a CT scan.  I was once thrilled by helicopter blades whirring and ambulance light bars flashing, by anxious voices over radios.  I wanted to see bullet holes and bullet fragments.  I was irresistibly drawn to the chaos of disaster.  But then, I used to be separate from it all, outside it, a young, powerful man with a kind of immortality and immunity to the suffering of this world.  But that is fading with the years, and fading fast.

  
  I wonder how much pain we have to witness, or be part of, to make an adequate career.  I have been informed that expertise in emergency medicine requires something like seven years, or 40,000 patient encounters.  But how much suffering is sufficient to say, "Thanks, that's plenty.  I quit"?  I don't know the number.

  
  I'm sure that it differs for every woman and man who practices medicine.  But we seldom admit it, because we equate that feeling with weakness.

  
  We walk through it as if it is nothing.  We put our clumsy hands into the bodies of the wounded, we take away their breath to give them synthetic airways.  We listen as they open a dark door into their dark worlds, where daughters are raped by fathers, where children are left with strangers while mothers get high, and the strangers beat them mercilessly. We sit by strangers and say things like, "I'm sorry, but your child's injuries were too severe, and despite everything we did, she died."

  
  She died.  We say that over and over.  He died, she died, they died.  He has a hemorrhage in his brain, she has a heart attack, they are in surgery, he will never walk again.  This is who we are.  We are the messengers of chaos, the wardens of entropy, where the dissolution of the universe takes the very personal appearance of death and wounds and terrible illnesses.  And where the technicalities of medicine's inadequacy simply mean loss, and loss becomes screams and sobbing before it becomes a sterile news clipping or obituary.

  
  At the sharp point of medicine, the very tip where all bad things go first, we balance our lives, and cover up our hard secret with science and research, with our desire 'to help the suffering, to save lives', and with the necessarily callous humor that no one else grasps.

  
  Our secret, brothers and sisters, is that for every bit of pain we see, a little bit stays inside.  In some secret place in our hearts and minds, we accumulate it.  Sometimes, a professional will be knocked down and out by a single dose of it.  Like a nuclear weapon, it melts their circuits.  But most of us get accumulated small doses, and the effects are stochastic, unpredictable.

  
  But, I predict, the effects are greater than we know.  Thanks to the politics and rules of modern medicine, we see more pain, more rapidly, with less chance to process it than ever before.  It comes in great waves in some centers, day after day of violence and tragedy, death, pain and misery.  And all those who face it are like Caligula's guards, ordered to drive back the sea with swords and shields.

  
  In some places, like mine, it comes in smaller waves, but no less devastating.  Worse, perhaps, since the longer I live here in one small place, the more likely I will see friends and family and co-workers and others I know, lying supine on the gurney before me, with cancers, accidents, assaults and death.

  
  That's the thing.  Love makes it all harder.  When we are younger, we love intensely, passionately, but not with the depth, or desperation, of our years.  Now, husband of my lovely wife, father of my perfect children, I fear for them.  Or maybe, I fear for me, for the possibility that I might lose them, or that I might have to face their suffering.
  And this love makes me feel the loss of other spouses and parents more acutely. I imagine myself in their situations.  I hurt for them.  Maybe I'm doing the right thing, 'mourning with those who mourn', but it takes so much out of me, out of all of us, when we do it over and over and over again, and when we put a little more inside us each time, one more artifact of someone else's agony, one more memory of a scream, of a look, of a sob.

  
  As I grow older, I realize that some wounds will always be with us.  I can call up images that I will never be rid of, at least not in this life.  All I can hope is that in heaven, where suffering is not even a memory, I will see my patients, and they will see me, and the best we will be able to do is, "don't I know you?"  I won't remember their troubles, they won't associate my face with their former pain, as people in this life certainly must.

  
  That's my hope, for me and for all who labor in a job that casts us daily into all the troubles of humanity. And if you don't want to wait around for heaven to ease your pain, it's OK to say, 'enough'.

  Disasters and substance abuse/dependence

  
  In other places throughout this website you will find information on disaster-related stress, as well as usual and common responses during and following the immediate disaster. The amount and kind of stress and trauma that individuals experience in a disaster will vary from person to person; coping strategies and resiliency will vary as well.  Many people having experienced disasters may be vulnerable to abusing substances, resume previous patterns of use and abuse, or resume an addictive behavior because they are overwhelmed by their disaster experience.

  Here are some things to keep in mind about substance use, abuse, and dependence as they relate to disaster response:

  • Our relationship with substances (alcohol, tobacco, hallucinogens such as marijuana, stimulants such as caffeine or methamphetamines, or narcotics such as pain medication) can create problems for us (PDF) in our physical health, relationships, work, and spirituality.
  • We have to remember, though, that our involvement with substances is not just a problem, but an attempt at problem-solving (PDF).  In other words, people in the midst of or following disasters don’t use or abuse substances because they are evil or bad people, but because at the moment that is their best guess about how to solve problems of meaning-making, stress, and/or survival.  Seeing substance struggles this way helps us to remove guilt and morality from them and instead view them as an attempt at problem-solving (not an adaptive or healthy one, but an attempt regardless).  Some people, for example, talk about the role of self-medication (PDF) through substances.

  • Substance abuse is one of the most difficult disorders to assess and treat. Denial, ethnic and cultural views, legal factors, and stigma all contribute to this difficulty.

  • Substance use tends to increase in individuals with an experience of disaster-related trauma (PDF) as a coping and stress-management strategy.  Stress is a major contributor to the initiation and continuation of addiction to alcohol or other drugs, as well as to relapse or a return to drug use after periods of abstinence.  Some people are particularly vulnerable to unhealthy use of substances following disasters. Parental loss and child abuse have been associated with increased risk for depression, anxiety, impulsive behavior, and substance abuse in adulthood.

  • Prevention (PDF) is always more effective than treatment.  Here are some strategies for preventing substance struggles related to disasters:
    • Relying on your support network of friends and family, exercise, or any other healthy behavior to relieve stress (PDF) can reduce the desire to use alcohol or other drugs during or following disasters.
  • Avoiding triggers (PDF), which are things in our environment or in our thinking, behaviors, or feelings that lead to substance abuse, and developing alternatives.
  • Learning techniques that foster coping skills, problem-solving skills, and social support can reduce or eliminate drug use.
  • Some people may need medications for stress-related symptoms or for treatment of depression and anxiety. Physicians should be aware of what medications their patients are taking but should not discourage the use of medical prescriptions to help alleviate stress.

  • Treatment of substance-related struggles is available, even around disasters.
  • If you are experiencing the symptoms of PTSD, please see your physician or health care provider. Health care professionals should be reminded that PTSD frequently co-occurs with depression, anxiety disorders, and alcohol or other substance abuse.
  • If treatment is necessary, it is important that both PTSD and substance abuse are treated.
  • In some cases, medications such as antidepressants have been shown to be helpful in treating patients who suffer from PTSD and substance use disorders.
  • Group treatment is highly effective for substance-related struggles.  Consider contacting one of the following groups if this is part of your disaster response.

  Adult Children of Alcoholics (AcoA)
  P.O. Box 3216
  Torrance, CA 90510
  (310) 534-1815
  
  Al-Anon Family Group Headquarters
  1600 Corporate Landing Pkwy
  Virginia Beach, VA 23454
  Information Line 800-344-2666
  National Referral Line 888-4AL-ANON (M-F, 8AM to 6PM EST)
  
  Alcoholics Anonymous
  P.O. Box 459
  Grand Central Station
  New York, NY 10163
  Phone (212) 870-3400
  
  AlaTeen
  P.O. Box 459
  Grand Central Station
  New York, NY 10163
  Phone (212) 870-3400
  National Referral Line 888-4AL-ANON (M-F, 8AM to 6PM EST)
  
  Center for Substance Abuse Prevention
  1 Choke Cherry Road
  Room 4-1057
  Rockville, MD 20850
  Phone: 240-276-2420
  
  Children of Alcoholics Foundation
  33 West 60th Street, 5th Floor
  New York, NY 10023
  Phone (800) 359-2623
  
  Cocaine Anonymous
  3740 Overland Avenue, Ste C
  Los Angeles, CA 90034
  Phone (310) 559-5833
  National Referral Line 800-347-8998
  
  Nar-Anon Family Group Headquarters
  P.O. Box 2562
  Palos Verdes Peninsula, CA 90274
  Phone (310) 547-5800
  
  Narcotics Anonymous
  PO Box 9999
  Van Nuys, CA 91409
  Phone (818) 773-9999
  

  
  Web Links
  
  This is a fact sheet with data, statistics, and a literature review on substance abuse following disasters. (PDF)
  
  This is a thorough article that explains stress, PTSD, and risk factors for drug and alcohol abuse. It also lists strategies for prevention and intervention. (PDF)

  How do mental healthcare professionals volunteer during a disaster?

  We hope mental health professionals will take steps to receive appropriate training, and register with disaster response agencies (e.g., American Red Cross), before a disaster strikes. If you have not done so, but are willing to volunteer your time and expertise during a disaster, the best way to do so is to directly contact your state professional association listed below. On this website, you will also find resources to enhance your understanding of disaster mental health counseling.

  • Georgia Psychiatry Organization 
  • Georgia Psychological Organization
  • Licensed Professional Counselors Association
  • Georgia Association of School Psychologists
  • Georgia School Counselors Association
  • Georgia Association of Marriage and Family Therapists
  • Georgia Association of Social Workers

  Web Links

  This article, targeted toward social workers, covers the legal requirements for disaster volunteering on the federal and state levels. It provides an overview on disaster relief, licensing, liability, and confidentiality. (PDF)

  Titled “Standing Together,” this is a guide to disaster planning for the entire community. (PDF)

  This pamphlet by the American Academy of Pediatrics gives information on disaster preparedness. Though pediatricians are the target audience, it has practical advice and suggestions on preparing for and providing aid during emergency situations. Topics include office preparedness, evacuation, transportation, communication, and insurance.

  The National Board for Certified Counselors website has a list of resources for professionals who wish to volunteer in the aftermath of disasters. (PDF)

  The American Academy of Pediatrician’s CHILDisaster Network is made up of health care professionals who volunteer in disaster relief on short-term notice. This webpage provides detailed information on applying for and participating in the network. (PDF)
  
  This article comprehensively outlines the phases of disaster planning and the factors that need to be taken into account during the planning process. (PDF)

  The Center for Disease Control's web page for disaster preparedness covers the materials that might be beneficial in a disaster. This article addresses responses to disasters and the phases of recovery. (PDF)

  This page lists, describes, and links to numerous domestic and international organizations and agencies that work in disaster relief.

  How do mental health care professionals contribute to community disaster preparedness?

  Based on a very helpful set of principles of preparedness, we offer the following specific ways in which mental health care professionals might contribute to community planning for disasters in ways that will allow you to respond personally and also be able to do your important work in your communities.  Some of this information is based on a document prepared by the American Psychological Association Disaster Response Network (PDF) and the Social Work Disaster Resource Network website, which you may want to consult in their entirety.

  • Educate yourself using the resources of your professional organization,and this website, about the mental health components of disasters as they relate to health care.  Professional organizations for mental health practitioners in Georgia include:    
  • Georgia Psychiatry Organization 
  • Georgia Psychologists Organization
  • Licensed Professional Counselors Association
  • Georgia Association of School Psychologists
  • Georgia School Counselors Association
  • Georgia Association of Marriage and Family Therapists
  • Georgia Association of Social Workers www.naswga.org
  • Bring your perspectives to a disaster mental health plan (PDF) through consideration of:

  Community Demographic Characteristics

  • Who are the most vulnerable people in the community? Where do they live? What are their specific health care needs?
  • What kinds of families live in the community (i.e., single-parent households)?
  • How could individuals be identified and reached in a disaster?
  • Are policies and procedures in place to collect, maintain, and review current demographic data for any area that might be affected by a disaster?

  Cultural Groups

  • What cultural groups (ethnic, racial, and religious) live in the community?
  • Where do they live, and what are their special needs?
  • What are their values, beliefs, and primary languages as they relate to health care and to mental health disaster preparedness?
  • Who is knowledgeable about the culture or is an informal leader in the community?

  Socioeconomic Factors

  • Are there recognizable socioeconomic groups with special needs?
  • How many live in rental property? How many own their own homes?
  • Does the community have any special economic considerations that might affect people’s vulnerability to disaster and their health care needs?

  Mental Health Resources

  • What mental health service providers serve the community?
  • What skills and services does each provider offer?
  • What gaps, including lack of cultural competence, might affect disaster services?
  • How could the community’s mental health resources be used in response to different types of disasters?
  • What is the relationship between the health care and the mental health care communities?

  Nongovernmental Organizations’ Roles in a Disaster

  • What are the roles of the American Red Cross (ARC), interfaith organizations, and other disaster relief organizations?
  • What resources do nongovernmental agencies offer, and how can local mental health services be integrated into their efforts?
  • What mutual aid agreements exist?
  • How can mental health providers collaborate with private disaster relief efforts?

  Community Partnerships

  • What resources and support would community and cultural/ethnic groups provide during or following a disaster?
  • Do the groups hold pre-existing mutual aid agreements with any state or county agencies?
  • Who are the key informants/gatekeepers of the impacted community?
  • Has a directory of cultural resource groups, potential volunteers, and community informants who have knowledge about diverse groups been developed?
  • Are the community partners involved in all phases of disaster preparedness, response, and recovery operations?

  • Emphasize the mental health care implications of disasters (PDF) in your contribution to preparedness. Although this may seem obvious, bringing to the public some specific mental health care perspectives (PDF) is an essential contribution to disaster preparedness.   Remember that in many disasters the obvious victims are only the tip of the iceberg:

  
  The Impact Pyramid

  Individual victims Family and social networks Rescue workers, mental health care providers, their families and social networks Vulnerable populations and impacted businesses Ordinary people and their communities

  • Help disaster preparedness and planning groups, tailor disaster planning to the local risk situation. Hurricanes, tornadoes, and floods (saved as Natural Disaster Brochures), for example, are far more likely in Georgia than are earthquakes.
  • Collaborate with other professionals working in the mental health field, such as physicians, nurses, and especially school personnel. 

  Emphasize the psychosocial implications of disasters (PDF) in your planning, as systems of health care delivery are disrupted.  Make yourself available to community and school boards and as a guest speaker, taking advantage of disaster-specific lecture materials (PDF) to lend your perspectives on the health care components of preparedness.

  Volunteer (PDF) through your professional organization or through the Red Cross (PDF) to enhance your familiarity with disaster preparedness and your contribution to community planning.

   

  Web Links

  Titled “Standing Together,” this is a guide to disaster planning for the entire community.

  This pamphlet by the American Psychiatric Association has practical and useful information on creating and implementing a disaster plan. (PDF)

  This is a lengthy, but thorough, article titled “Disaster Preparedness: Is Your Unit Ready.” Although focused specifically on hospital dialysis units, the aspects of disaster planning it addresses apply to the general community as well.

  This article comprehensively outlines the phases of disaster planning and the factors that need to be taken into account during the planning process. (PDF)

  The Center for Disease Control's web page for disaster preparedness covers the materials that might be beneficial in a disaster. This article addresses responses to disasters and the phases of recovery. (PDF)

   

  Making disaster preparedness part of your professional identity
  

  Licensed social workers, psychiatrists, counselors, psychologists, and other mental health professionals have numerous responsibilities and areas of potential professional emphasis.  Including disaster preparedness as one of these areas of emphasis can help you respond to disasters in a helpful and professional way.  Here are some suggestions, based on helpful principles of preparedness and planning, for enhancing your preparedness for disasters.

  • In addition to affiliating with the disaster preparedness and intervention components of your professional organization, you may consider becoming part of a disaster-specific group such as these for psychologists (PDF), licensed professional counselors (PDF), psychiatrists (PDF), and licensed social workers (PDF).

  • Allocate some of your continuing educationto development of core competencies for disaster practice (PDF).  Doing an internet search on disaster-specific continuing education courses (PDF) will reveal numerous options in this category.

  • Educate yourself about various disasters, mental health care responses, and the mental health implications of each, through review of websites such as this one (PDF).

  • Volunteer, consulting Georgia disaster information clearinghouses such as Georgia911 to identify immediate and long-term needs.  Personal stories of mental health care volunteers (PDF) suggest that such volunteering can provide important personal and professional benefits.

  Making disaster preparedness part of your professional identity (PDF) can have significant benefits not only for you but for those you serve.

   

  Web Links
  
  This is an accredited online training module created by the University of Washington and the Center for Disease Control. It covers how a community responds to disasters and the short-term needs and long-term impacts of disasters.

  
  The Disaster Psychiatry Outreach is a non-profit organization of volunteer psychiatrists committed to disaster mental health services. They provide training courses, organize volunteers, and conduct extensive research in disaster mental health. This website has a variety of resources and literature. (PDF)

  
  This is an article on the psychological implications and lessons learned from Hurricane Katrina. On the page are links to articles written by social workers on grief, stress, and the impact on children. (PDF)

  
  The International Society for Traumatic Stress Studies (ISTSS) (PDF), with headquarters in Northbrook Illinois, is a professional association focused on research and practice in the area of traumatic-stress. Membership and other information is available via the ISTSS web site, or from their email address: istss@istss.org. The Society sponsors an annual convention (saved as Annual Meeting) each November, as well as an international conference. ISTSS also sponsors a variety of publications: the quarterly printed Journal of Traumatic Stress (saved as ISTSS journal), with peer-reviewed articles on biopsychosocial aspects of trauma, as well as a newsletter -- Traumatic StressPoints (saved as ISTSS traumatic stress points). [Note: Usually, the Conference on Innovations in Trauma Research Methods immediately follows the ISTSS convention, in the same city.

  
  The International Society for the Study of Dissociation (ISSD) (PDF) is a nonprofit professional society that "promotes research and training in the identification and treatment of dissociative disorders, provides professional and public education about dissociative states, and serves as a catalyst for international communication and cooperation among clinicians and researchers working in this field." ISSD often holds their annual convention nearby and shortly before that of ISTSS. Information about their annual convention (frequently held close to the ISTSS meeting), is available at their site, as well as psychotherapy training (saved as ISSD training) for clinical work with dissociative disorders. ISSD also sponsors the Journal of Trauma and Dissociation (saved as ISSD journal).

  
  Another annual conference important in the field of Psychological Trauma, the Boston Trauma Conference, is co-sponsored by Dr Bessel van der Kolk's Trauma Center (saved as Trauma Center) and the University of Boston Medical School.

  
  The American Academy of Experts in Traumatic Stress (PDF) (AAETS), in New York, is a multidisciplinary network of professionals committed to the advancement of intervention for survivors of trauma. With a diverse professional membership in the United States and over 24 other countries (representing over 140 specialties in the health-related fields, emergency services, criminal justice, forensics, law and education), the Academy seeks to increase awareness of the effects of trauma and ultimately to improve treatment for survivors. To this end, members may obtain Board Certification, Diplomate and Fellow Credentials, and listing in the National Registry of The American Academy of Experts in Traumatic Stress.

  
  The Association of Traumatic Stress Specialists (ATSS), founded in 1989, has a web site and offers three distinct certifications to individuals providing support, education, intervention, and treatment in the field of traumatic stress. These are Certified Trauma Specialist (CTS), Certified Trauma Responder (CTR), and Associate in Trauma Support (ATS). ATSS also offers continuing education trainings that are relevant for traumatic stress responders.
  A training and certification program is available at Florida State University for Certified Traumatologists, under the direction of Charles Figley, PhD. The Traumatology Institute (saved as Traumatology Institute) at FSU offers classes for those who assist trauma victims, and awards CEU's for licensed mental health professionals. Membership in the Traumatology Institute is available, by application, to qualified professionals experienced in reducing the distress and emotional trauma of others.

   

  Self-care for Mental Health Professionals During Disaster Response
  

  Taking care of yourself will help you to stay focused on taking care of others.  Often mental health professionals and other responders do not recognize the need to take care of themselves and to monitor their own emotional and physical health during their involvement with disasters—especially when recovery efforts stretch into several weeks, and they experience unnecessary consequences such as burnout or compassion fatigue (PDF).

  
  The following guidelines contain simple methods for self-care during disaster response.  Read them while you are involved in health care disaster work, and during the period after the disaster.

  • Pace yourself. Rescue and recovery efforts at the site may continue for days or weeks.

  • Take frequent rest breaks (PDF). Rescue and recovery operations take place in extremely dangerous work environments. Mental fatigue over long shifts can place health care workers at greatly increased risk for poor decision-making and treatment lapses.

  • Watch out for each other. Approach the disaster as a team (PDF) and rely on other professionals for consultation and perspective and support.

  • Be conscious of those around you.  Mental health care responders who are exhausted, feeling stressed, or even temporarily distracted may place themselves and others at risk.

  • Maintain as normal a schedule as possible: regular eating and sleeping are crucial. Adhere to the team schedule and rotation.

  • Maintain adequate nutrition (PDF) and try to eat a variety of foods. Particularly, try to increase your intake of complex carbohydrates (for example, breads and muffins made with whole grains, or granola bars).

  • Stay hydrated (PDF), with clean water and juices.

  • Whenever possible, distance yourself from the disaster site (PDF) to maintain boundaries and achieve perspective.  Eat and drink in the cleanest area available. Communicate with your loved ones at home as frequently as possible.

  • Give yourself permission to feel rotten: You are in a difficult situation.

  • Recurring thoughts, dreams, or flashbacks are normal—do not try to fight them. These responses to trauma will decrease over time and paying less attention to them (PDF) will break the cycle of anxiety.

  • Recognize and accept what you cannot change—the chain of command, organizational structure, waiting, equipment failures, etc.  Practice spirituality even in this difficult time.

  • Accept that, as you respond to the disaster, your “hidden wounds and hidden healing” (PDF) are yours. Keep appropriate boundaries in the ways you involve others in your experience.  There are some pieces of your experience that you will want to share, and some that you will want to forget.  If the disaster facility includes mental health support for mental health providers, consider using it.

  • Participate in memorials, rituals, and use of symbols (PDF) as ways to express feelings.

   

  Web Links

  This information sheet for emergency response workers prepared by the CDC covers the symptoms of stress and provides tips (some of which are above) for self-care on site and at home. (PDF)

  This is a comprehensive handbook for mental health professionals that encompasses all aspects of disaster relief. (PDF)

  This SAMHSA fact sheet, titled “Tips for Managing and Preventing Stress,” explains stress reactions and ways of managing them. (PDF)

  Building resiliency in yourself and others following disasters

  Mental health professionals have spent a long time studying post-traumatic stress disorder (PDF) as a response to disaster.  But more recently they have focused on resiliency (PDF), defined professionally as “the ability to spring back from and successfully adapt to adversity,” and by a 15 year-old high school student as, "Bouncing back from problems and stuff with more power and more smarts."  Resiliency is also sometimes referred to as psychological hardiness (PDF), wellness (PDF), and positive psychology (PDF).  Regardless of the name we give it, resiliency and the ability to “bounce back from (disasters) with more power and more smarts” is an important goal of mental health, and mental health providers can do a lot to facilitate resiliency in those we accompany.
  
  Each of us has a built-in capacity for resiliency, "a self-righting tendency" (PDF) that operates best when we cultivate and practice it. 

  Here are some suggestions for building resiliency, excerpted and modified from a very comprehensive American Psychological Association website (PDF).

  10 Ways to Build Resilience in yourself and others:

  1. Make connections. Good relationships with close family members, friends, colleagues, or others are important (PDF), especially following disasters.  Accepting help and support from those who care about you and will listen to you strengthens resilience. Some people find that being active in civic groups, faith-based organizations, or other local groups provides social support and can help with reclaiming hope. Assisting others in their time of need also can benefit the helper.
  2. Avoid seeing crises as insurmountable problems. You can't change the fact that disasters events happen, but you can change how you interpret and respond to these events. Try looking beyond the present to how future circumstances may be a little better. Note any subtle ways in which you might already feel somewhat better as you deal with difficult situations.  Punctuate time: write for publication or keep a journal to remind yourself that time is passing.
  3. Accept that change is a part of living. Acceptance of the fact of trauma (PDF) is an important element of resiliency. Certain ways of being human, for you and for those you work with, may no longer be attainable as a result of the circumstances around the disaster. Accepting circumstances that cannot be changed can help you and your consumers or clients focus on circumstances that you can alter.
  4. Move toward small and tangible goals. Develop some realistic goals. Do something regularly -- even if it seems like a small accomplishment -- that enables you to move toward your goals. Instead of focusing on large and abstract tasks, ask yourself, "What's one thing I know I can accomplish today that helps me move in the direction I want to go?"  What Bertrand Russell termed “tranquilization by the trivial” is certainly relevant in disaster resiliency.
  5. Take decisive actions. Emerging ecological models of trauma recovery (PDF) emphasize the need for action and empowerment.  Act on the adverse situations associated with the disaster as much as possible.  Take decisive actions, rather than detaching completely from problems and stresses and wishing they would just go away. And encourage those with whom you work to do the same.
  6. Look for opportunities for self-discovery.  There is some interesting work on the role of insight in trauma and disaster resiliency (PDF). Focus on what we can learn about ourselves, and how we have grown in response to loss, as an important feature of resiliency.  Many people who have experienced tragedies and hardship have reported better relationships, greater sense of strength even while feeling vulnerable, increased sense of self-worth, a more developed spirituality, and heightened appreciation for life.
  7. Nurture a positive view of yourself. Developing confidence in your ability to solve problems (PDF) and trusting your instincts helps build resilience.
  8. Keep things in perspective. One of the effects of trauma is to shrink our perspective on time and space.  It is helpful to nurture in ourselves and our clients and consumers the ability to keep the disaster in perspective. Try to consider it in a broader context and keep a long-term perspective.
  9. Maintain a hopeful outlook. (PDF) An optimistic outlook enables you and those you work with to expect that good things will happen in your life. Try visualizing what you want, rather than worrying about what you fear.
  10. Take care of yourself and encourage self-care in your clients or consumers. Pay attention to your own needs and feelings. Engage in activities that you enjoy and find relaxing. Exercise regularly. Taking care of yourself helps to keep your mind and body primed to deal with situations that require resilience.

  The key is to identify ways that are likely to work well for you, and for your clients and consumers, as part of your own personal strategy for fostering resilience.

  Web Links
  
  This pamphlet by the American Psychological Association, titled “Road to Resilience,” is a great guide that introduces resiliency, how it is developed, and strategies for developing it. (PDF)
  
  This website on resiliency has a Resiliency Quiz that presents the principles behind resiliency, assesses individual factors that contribute to resiliency, and gives tips on building resiliency. The site also has literature that can be ordered and a resources page with links to relevant outside articles. (PDF)
  
  This is an article reporting the findings of research conducted at the Illinois Bell Telephone company in relation to resiliency of people who work in highly stressful work conditions. The study found that certain individuals are able to thrive despite adversity, leading to the understanding of the set of principles that operate behind resiliency, or “hardiness.” (PDF)

  Returning home from a disaster assignment

  
  Disaster work can be a unique and very rewarding experience as disaster response workers feel part of a family and all work toward a common goal. There is a sense of adventure as we face the unique problems of each disaster setting, a sense of shared pride as we ease the suffering of survivors, and a sense of personal satisfaction in our ability to help.

  
  But we also experience things that most people -- including our families, friends, and co-workers -- could not begin to understand or appreciate, things far apart in time, space, and power from our everyday lives.  One of my practicum students spoke of an “airlock” between the hospital entrance and the psychiatric inpatient ward, in which he experienced the distance between that space and the space in which he ordinarily lived, both going into and coming out of that space.  Here are some suggestions, excerpted and elaborated from this document (PDF), on how to ease the airlock transition from the disaster place to your home place.

  
  Return is a Process, Not an Event.  I think in my own work about the process of atmospheric reentry (PDF): too direct an approach to returning home and you burn up, too indirect and you bounce off.  Try to get it just right. Be patient with yourself.
  

  Rest. Often, you may not get enough rest while working on a disaster, and when you return home you will feel exhausted. It may take several days to catch up, and both family members and employers need to understand that you need time to yourself before beginning a full schedule of normal activities.
  

  Pace. On a disaster relief operation, you perform your job as fast as possible to provide the greatest amount of assistance in the shortest possible time. It may take time to return to the more relaxed pace of your co-workers and family members.
  

  Sharing. You will want to talk to family members and co-workers about your experiences, and they will be eager to tell you about theirs. What you were doing may seem much more exciting and significant, but remember that their experiences are as important to them as yours are to you. If they seem to accuse you of being away when the washer overflowed, or the kids threw up, it’s only their way of saying, “We missed you.”
  

  Emotions. When you return home, some feelings or emotional swings associated with disaster-related stress may surprise or frighten you. If you anticipate some of these emotions, you can manage them better.
  

  Disappointment. You may find that others are not interested in hearing about your experiences, or that your reunion with your family and co-workers does not live up to your expectations. You may expect they will be happy to have you home and be surprised to find they are angry at your absence.  Anticipating this response will help you in managing it.
  

  Frustration and conflict. Your needs may not match those of family or colleagues. Although you may want nothing more than a good home-cooked meal, your family may be looking forward to going out to eat. Try to be kind in expressing your needs and frustrations.
  

  Anger. Problems presented by your family, friends, or co-workers may seem very trivial compared to those facing the disaster victims you just left. Try to remember that the folks at home feel that their problems are just as important to them right now.  Appreciate how your own anger and grief affect your ability to see the relativity of life events.
  

  Survivor identification. The actions or characteristics of people at home may remind you of your experience with disaster victims. You may experience emotional reactions that can surprise and confuse not only you, but also them. Try to make others understand the reasons behind your reactions.
  

  Daydreaming.  This is a part of response to trauma, and is healthy dissociation and part of your own response to trauma. You may find yourself wishing you could return to the disaster you just left, or be sent out again right away. Remember you are more important to the folks at home than you can imagine; they may just express their appreciation differently.
  

  Mood swings. These are normal after returning home, as they one of the ways to resolve conflicting feelings you have experienced on the operation. You may change from happy to sad, tense to relaxed, or outgoing to quiet without much warning. When you have time to put your disaster work into perspective, noticeable alterations in mood will pass.
  

  Children. It can be hard to explain to children why you must be away. If you tell them why you are leaving, and call home while you are away, it will help calm their fears. When you return home, try not to frighten them with stories about what you have seen and done. Tell them about the disaster in a way that is appropriate to their level of development, and involve them in preparedness efforts for your family. This will help them feel as if they are part of what you have been doing and reduce their fears about similar disasters at home.
  

  Your participation in disaster relief work is a gift to the world.  Practicing self-care and developing resiliency during the process of your return will allow you to continue giving your gifts.
  

   

  Web Links
  

  This is a PDF version of the fact sheet “Coping with Disaster: Returning Home from a Disaster Assignment.” It addresses much of the topics found above. (PDF)

  This is an article from the British Medical Journal, titled “Selection, Training, and Support of Relief Workers: An Occupational Health Issue,” that cites research findings on the mental health implications for relief workers during and after disasters. It addresses a need for and encourages increased training and awareness in stress management, self-care, and resiliency. (PDF)

   

  Psychological First Aid Field Operations Guide (PDF)

   

  National Consensus Statement on Mental Health Recovery

  Our approach to mental health recovery is consistent with the U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration (SAMHSA) which has developed the following guidelines:
  

  The 10 Fundamental Components of Recovery

  Mental health recovery is a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential.

  Self-Direction: Consumers lead, control, exercise choice over, and determine their own path of recovery by optimizing autonomy, independence, and control of resources to achieve a self-determined life. By definition, the recovery process must be self-directed by the individual, who defines his or her own life goals and designs a unique path towards those goals.

  Individualized and Person-Centered: There are multiple pathways to recovery based on an individual’s unique strengths and resiliencies as well as his or her needs, preferences, experiences (including past trauma), and cultural background in all of its diverse representations. Individuals also identify recovery as being an ongoing journey and an end result as well as an overall paradigm for achieving wellness and optimal mental health.

  Empowerment: Consumers have the authority to choose from a range of options and to participate in all decisions—including the allocation of resources—that will affect their lives, and are educated and supported in so doing. They have the ability to join with other consumers to collectively and effectively speak for themselves about their needs, wants, desires, and aspirations. Through empowerment, an individual gains control of his or her own destiny and influences the organizational and societal structures in his or her life.

  Holistic: Recovery encompasses an individual’s whole life, including mind, body, spirit, and community. Recovery embraces all aspects of life, including housing, employment, education, mental health and healthcare treatment and services, complementary and naturalistic services, addictions treatment, spirituality, creativity, social networks, community participation, and family supports as determined by the person. Families, providers, organizations, systems, communities, and society play crucial roles in creating and maintaining meaningful opportunities for consumer access to these supports.

  Non-Linear: Recovery is not a step-bystep process but one based on continual growth, occasional setbacks, and learning from experience. Recovery begins with an initial stage of awareness in which a person recognizes that positive change is possible. This awareness enables the consumer to move on to fully engage in the work of recovery.

  Strengths-Based: Recovery focuses on valuing and building on the multiple capacities, resiliencies, talents, coping abilities, and inherent worth of individuals. By building on these strengths, consumers leave stymied life roles behind and engage in new life roles (e.g., partner, caregiver, friend, student, employee). Th e process of recovery moves forward through interaction with others in supportive, trust-based relationships.

  Peer Support: Mutual support—including the sharing of experiential knowledge and skills and social learning—plays an invaluable role in recovery. Consumers encourage and engage other consumers in recovery and provide each other with a sense of belonging, supportive relationships, valued roles, and community.

  Respect: Community, systems, and societal acceptance and appreciation of consumers —including protecting their rights and eliminating discrimination and stigma—are crucial in achieving recovery. Self-acceptance and regaining belief in one’s self are particularly vital. Respect ensures the inclusion and full participation of consumers in all aspects of their lives.

  Responsibility: Consumers have a personal responsibility for their own self-care and journeys of recovery. Taking steps towards their goals may require great courage. Consumers must strive to understand and give meaning to their experiences and identify coping strategies and healing processes to promote their own wellness.

  Hope: Recovery provides the essential and motivating message of a better future— that people can and do overcome the barriers and obstacles that confront them. Hope is internalized; but can be fostered by peers, families, friends, providers, and others. Hope is the catalyst of the recovery process. Mental health recovery not only benefi ts individuals with mental health disabilities by focusing on their abilities to live, work, learn, and fully participate in our society, but also enriches the texture of American community life. America reaps the benefi ts of the contributions individuals with mental disabilities can make, ultimately becoming a stronger and healthier Nation.

  Resources
  www.samhsa.gov
  National Mental Health Information Center
  1-800-789-2647, 1-866-889-2647 (TDD)
  Original Link