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Mental Health Response to Mass Violence and Terrorism
CHAPTER VII: Comprehensive Training Course Outline
The comprehensive training course requires 2.4 days, depending on the depth
and scope of material presented. It has nine major content areas, organized
into "modules," each requiring from 1.4 hours. Each of the nine
modules has five components:
- Topics Covered;
- Objectives;
- Time Required;
- Materials Required; and
- Procedures.
Most of the modules include a balance of lectures, overheads, videos, and
experiential activities. Module 9, Stress Prevention, Management, and Intervention,
includes group and individual exercises that can be used throughout the training
to vary the teaching method and pace of the training. Examples of overheads
and references for videotapes are included at the end of this chapter. Handouts
and lecture content may be drawn from Chapters II.V of this manual. Trainers
are encouraged to develop their own disaster and crisis response stories and
case examples to bring the training to a more personal and specific level.
This comprehensive training may be held weeks or months after crisis impact.
The specific lecture content for each topic will need to be adapted to the
current stage in the recovery process, the appropriate response activities,
and current and anticipated criminal justice proceedings. Chapter VIII describes
training topics for subsequent in-service training and training modules during
the long-term response phase.
Trainers are encouraged to become knowledgeable about the current incident.
Media coverage, consultation with managers of the immediate mental health
response, emergency response reports, and grant applications for funding of
mental health programs can provide essential information. Local information
can be woven into the training and used as examples throughout the more general
discussions of common issues. Videos from local news coverage or special reports
are an effective component of training.
Content experts may conduct portions of the training (e.g., a child specialist,
a representative from law enforcement, a resource person from a cultural group,
a crime victim assistance educator, and an emergency manager).
Course Overview
The following overview lists course objectives, training content areas,
and suggested time requirements. The training content is not further divided
into daily agendas, because it is assumed that the trainer's preferences,
training class' composition and needs, timing of the training, and current
local issues will dictate this level of specificity.
Course Objectives
- Understand human reactions to incidents of mass violence and terrorism
including incident-related risk factors, at-risk survivor groups, post-traumatic
stress, traumatic bereavement, and key events affecting the recovery process;
- Identify the key concepts and principles of mental health intervention,
the differences between natural and criminally, human-caused disasters,
the interplay of the criminal justice process and survivors' psychological
reactions, and the simultaneous and interacting community and individual
impacts;
- Learn and convey the organizational aspects of the local, State, and Federal
responses to mass violence and terrorism including the roles and responsibilities
of emergency services, law enforcement, the medical examiner's office,
voluntary agencies, and the supporting role of mental health services;
- Master methods for providing appropriate mental health assistance to survivors
and bereaved family members in community settings with emphasis on psychological
first-aid, crisis intervention, crime victim assistance, psychoeducation,
community outreach, psychological debriefing, group counseling, and stress
management techniques;
- Lay out key considerations for intervening effectively with special populations
including children and adolescents, the elderly, and local cultural and
ethnic groups and methods for adapting mental health services to fit particular
communities;
- Present methods for providing mental health services at the community
level including psychoeducation through the media and group presentations,
consultation with employers and social service agencies, and assistance
with community rituals and memorials; and
- Understand the dynamics of mental health worker stress and the strategies
for preventing, managing, and intervening with stress overload and vicarious
traumatization at the personal, group, and administrative levels.
The time and content emphasis devoted to each module varies according to
the audience. The time and content emphasis devoted to each module varies
according to the audience, the goals of the training, the amount of time after
the incident, and the total time allocated for the training session. For example,
a one-day training during the immediate response phase might briefly include
all topics but not include group exercises. The emphasis in Module 5 on immediate
interventions would provide practical guidance readily applicable to the current
disaster response. Each module is intended to expand or contract, be more
clinically oriented or more appropriate for a lay audience, and shift in focus
depending on the phase of the recovery process.
Overview of Comprehensive Training Course
Module 1:
Introduction: 1 hour
Module 2:
Criminal Mass Victimization: 1.5 hours
Module 3:
Adult Responses to Mass Violence and Terrorism: 2.5 hours
Module 4:
Organizational Response and Mental Health Roles: 1.5 hours
Module 5:
Community Crisis Response and Mental Health Interventions: 4 hours
Module 6:
Children's and Adolescents' Reactions and Interventions: 3 hours
Module 7:
Cultural and Ethnic Groups: Considerations and Interventions: 2 hours
Module 8:
Planning Workgroups: 1.5 hours
Module 9:
Stress Prevention, Management, and Intervention: 2 hours
Materials Required
- Training handouts
- Name tags
MODULE 1: Introduction
Topics Covered
- Distribution of materials
- Welcome and brief overview of the training
- Introductions
- Training objectives, agenda, and materials
Objectives
- Introduce trainers and participants
- Review training objectives, agenda, and values underlying the training
- Begin group building through participant disclosure
- Model listening skills
Time Required
1 hour
Procedures
Distribute Materials: Distribute name tags, handout materials,
booklets, etc.
Welcome and Brief Overview: Give a welcoming statement,
brief overview of the training day, and discuss logistics (e.g., breaks,
lunch, phones, bathrooms, etc.). Encourage group participation and questions.
Introductions: Trainers introduce themselves, highlighting
trauma, crisis, crime victim, disaster, and other related experience. Participants
introduce themselves giving name, agency affiliation, current job, description
of experience with current incident and prior crises or disasters, and expectations
for the training. The trainer needs to model active listening and may briefly
bring out points relevant to training content.
Training Goals and Objectives: Review the goals and objectives
for training. Trainer addresses participants' stated expectations, commenting
on what will and will not be included in the training and how other training
needs may be met.
Agenda and Training Techniques: Review overall training
agenda and discuss training techniques (e.g., short lecture, discussion,
videos, small group exercises, and role-plays). Discuss rationale and values
underlying techniques (e.g., people learn by doing, trauma response work
affects mental health providers personally so sharing and support is important,
balance learning new content with developing new skills).
MODULE 2: Criminal Mass Victimization
Topics Covered
- Definitions of terrorism and mass violence occurring in the United States
- Comparison of natural and criminally human-caused disasters
- Unique aspects of human reactions to mass violence and terrorism
- Current incident information
Objectives
- Acquaint participants with characteristics of traumatic exposure
- Compare the impact of natural and criminally human-caused disasters and
related implications for mental health intervention
- Provide orientation to the current incident.its scope, impact, populations
affected, emergency response efforts, and status of criminal justice activities
- Increase understanding of unique elements of the current incident that
may contribute to mental health effects
Time Required
1.5 to 2 hours
Materials Required
- Overheads #1.4
- Video of news coverage of current incident and response
Procedures
Definitions: Using Overheads #1 and #2, present definitions
for terrorism and mass violence. Discuss how mass violent incidents can
target a group of individuals, affect entire communities, and strain social
support systems.
Dimensions of Traumatic Exposure: Discuss these generic
dimensions (see Overhead #3) and their relationship to increased post-traumatic
stress in victims, responders, and the community-at-large. Focus presentation
on the current incident.
Comparison of Natural and Criminally Human-Caused Disasters:
Discuss the dimensions listed on Overhead #4. The lecture content is provided
in Chapter II and in Table 1.
Description of the Current Incident: Provide overview of
information about the current incident including nature of the event, number
of people killed and injured, scope of property damage, populations affected,
emergency response and recovery efforts, relief efforts, and status of criminal
investigation and criminal justice proceedings.
Processing Trainees' Reactions to the Incident: Depending
on the size of the group, facilitate small or large group discussions focusing
on questions such as the following: What did you think or feel as you watched
the video? What reactions might you expect the people who directly experienced
this incident to have? What aspects of this incident would you expect to be
related to mental health effects? What do you think will be the difficulties/challenges
for this community during the recovery/reconstruction process?
This discussion is not intended to be a "debriefing" for those
who had personal exposure to the incident. The discussion provides an opportunity
for trainers and/or program managers to continue assessing if there are participants
who may be too involved in their own reactions to assist others effectively.
Refer to Overhead #4 and review assumptions and predictions that participants
have regarding the community's response to each dimension. Begin fostering
the "anticipate and think-onyour- feet" approach to community trauma
response. This can become an exercise in connecting theory with real world
issues.
Display photographs, newspaper articles, and maps of impacted areas. This
can be a group activity, if some participants have been involved in the mental
health response immediately after the incident. It can give them an opportunity
to describe their experiences while educating new staff.
MODULE 3: Adult Responses to Mass Violence and Terrorism
Topics Covered
- Population Exposure Model
- Survivor risk and resiliency factors
- Model and phases of psychological response
- Physical, behavioral, emotional, and cognitive reactions
- Traumatic grief
Objectives
- Acquaint participants with the community impacts of mass victimization
- Orient participants to survivor risk and resiliency factors that can
assist with screening and prioritization of mental health services
- Present a phenomenological model of coping with phases of psychological
response
- Provide information about the normal range of reactions to trauma and
sudden bereavement including considerations for older adults
- Address the interplay of trauma and grief processes
- Explore participants' personal reactions to the video and begin discussing
countertransference and the importance of self-awareness
Time Required
2.5 hours
Materials Required
- Overheads #5.13
- Videotapes: "OVC Special
Award for Extraordinary
Response to International
Terrorism" and "Disaster
Psychology"
Procedures
Population Exposure Model: Use Overhead #5, or
Figure 1. Discuss collective trauma and the potential
widespread effects, emphasizing the differences between
individually experienced trauma and community trauma.
Involve participants in identifying the groups that compose
the various concentric circles and the potential nature of
impacts. Orient participants to think on the "macro"
community level.
Survivor Risk and Resiliency Factors: Pose the question "Why,
when faced with identical overwhelming traumatic circumstances,
do people have such different reactions, particularly
over time?" Continue with the public health perspective
initiated in the section above, and discuss screening and
allocation of limited mental health services. Present material
related to survivor vulnerability and resilience. Ask the group
to brainstorm implications for outreach and service delivery.
Use Overhead #6.
Model and Phases of Psychological Responses: Using Overhead
#7 or Figure 2, discuss the phenomenological process of
coping with trauma and sudden bereavement. Encourage
participants to share what they have seen clinically and ways
that they have helped survivors "understand" and tolerate
this "working through" process. Chapter II also provides
presentation material. Discuss the process in terms of phases
as well as the influence of predictable events in the criminal
justice process. Address the importance of denial. Connect
this presentation with survivor risk and resiliency factors.
Emphasize that each survivor is unique, and that a model is a
generalization. Use Overhead #8 to address phases in the
community. These are typically used following natural
disasters. Facilitate a group discussion regarding their current
applicability.
Show Videotape: Ask the group questions about survivor
reactions in the film and where these reactions "fit" or "didn't
fit" in the model just discussed. Begin discussing the physical,
behavioral, emotional, and cognitive symptoms of trauma and
bereavement portrayed in the video, and if they seemed to
change over time. If appropriate, ask participants to speculate
which survivors in the film would need more intensive mental
health services, and why. Provide short lectures on topics
relevant to current disaster and phase.
Participant Self-Reflection: Invite participants to explore what
touched them personally as they watched the film.which
survivors, what circumstances, and why they were impacted.
Use this discussion to model giving permission and control
(°Share what you feel comfortable talking about here."), good
listening skills, nonjudgmental acceptance, and normalization.
Continue with a lecture about countertransference in
very practical terms, and introduce the importance of selfawareness,
self-care, talking with others, stress management,
and staff consultation. As a wrap-up, ask the group to
comment on techniques and approaches used by the
facilitator and their applicability to work with survivors.
Range of Adult Reactions to Trauma and Bereavement: Use
Overheads #9.12 in this section. Use case examples,
examples from the film, participant examples from the current
disaster, and their other clinical experiences to make these
lists come alive. Focus on reactions that are relevant to the
timing of the training and what participants may deal with in
their work with survivors. Emphasize that for the majority of
survivors, these reactions are normal and will subside over
time.with episodic resurgences triggered by events in
criminal justice proceedings, media coverage, anniversaries,
holidays, and other traumatic reminders.
Considerations with Older Adults: Using Overhead #13, discuss
the challenges faced by older adults, particularly the elderly.
Discuss this population in relation to issues and needs
expressed in the current disaster. Review the section in
Chapter II and Table 3. Expand section if this is a highly
impacted group.
Interplay of Trauma and Grief: Review this section in Chapter
II. Survivors who suffered serious and disabling physical
injuries, those who had a loved one killed in the incident, and
those who were both involved and suffered the death of a
family member or close friend experience an intensification of
both trauma and grief responses. Often, post-trauma
reactions take precedence and must be dealt with before
grieving can take place. The process of "working through" is
more arduous and often takes longer, because of the overlay
of psychological processes. If traumatic grief is prevalent in
the current disaster, focused, in-service training, clinical
supervision, and consultation on this topic are strongly
encouraged.
MODULE 4: Organizational Response And Mental Health Roles
Topics Covered
- Federal, State, local, and volunteer agencies involved in
crisis response
- Incident Command System (ICS) and Unified Command (UC)
- Local crisis response and key area resources
- Glossary of acronyms
Objectives
- Acquaint participants with representatives from primary
responding agencies (e.g., emergency management, law
enforcement, crime victim assistance-witness program, State
crime victims compensation program, ARC, OVC, CMHS,
FEMA)
- Orient participants to the organizational context of
community crisis response and the role of mental health
- Provide an overview of Federal programs that supplement
State resources for mental health and crime victim services
- Inform participants of the chronology of emergency response
and criminal justice events involved in the current incident
- Increase knowledge of local resources, contacts, and how to access them
Time Required
1.5 hours
Materials Required
- Overheads #14 and #15
- Figure 4
- Handouts from agencies
represented
- Contact information for local resources
- Videotape: "Surviving the
Secondary Device"
Procedures
Organizational Aspects of Crisis Response: Local, State, or
Federal representatives may conduct much of this section.
Participants benefit from having names and faces to attach to
unfamiliar agencies. Review the background information and
figures provided in Chapter IV. Include key topics: the ICS, UC,
emergency response procedures, coordination between law
enforcement and mental health, the EOC, lead agencies, and
participating agencies. Use Overhead #14 and organizational
charts in the figures. Mental health responders need to
understand the big picture of emergency operations, the
organizational players, and their roles. Show the video to
graphically portray a bombing incident crime scene and some
of the issues and challenges associated with emergency
response. Ask participants to discuss the potential mental
health impacts of procedures described in the film.
Local, State, and Federal Response and Recovery Activities:
Present a chronology of emergency response and law
enforcement activities, highlighting aspects that might have
mental health implications. Plan the presentation according to
the current phase in the response so that participants become
informed about the history, as well as who the current key
players are, and current phase-related recovery issues and
activities. Representatives from Federal agencies that have
funds available for mental health and crime victim services
may provide information relevant to the incident, the phase,
timing, and the participants. If the ARC has been active
providing disaster mental health services (DMHS), a DMHS
volunteer or staff person could present information about
community reactions and needs.
Mental Health Roles in Crisis Response: Using Overhead #14,
briefly describe the various mental health roles as they relate
to this discussion of the larger organizational context during
the early response phase.
Emergency Response Lingo and Defining Acronyms: Distribute
the glossary of acronyms, or develop a similar list for the
current local, State, and Federal agencies.
MODULE 5: Community Crisis Response and Mental Health Interventions
Topics Covered
- Key concepts of community crisis response
- Mental health interventions
- Key events with mental health implications
- Community interventions
- Limits and boundaries of mental health intervention
Objectives
- Orient participants to normal stress reactions to mass violence and sudden bereavement
- Acquaint participants with mental health interventions used
following community disasters as distinct from traditional office-based clinical practice
- Increase understanding of the importance of community rituals and interventions and the mental health role
- Describe key events in emergency response and recovery
and the criminal justice process that have mental health implications
- Provide guidance regarding professional and ethical limits and boundaries
Time Required
Up to 4 hours
Materials Required
- Overheads #16.29
- Sample public information
brochures and
materials
- Case scenarios
- Videotapes: "Hope and
Remembrance," "Death
Notification," and "The
News Media's Coverage
of Crime and Victimization"
Procedures
Key Concepts of Community Crisis Response: Using Overheads
#16 and #17 and material in Chapter III, review basic orienting
principles for community response. Emphasize flexibility,
empowerment, respect for differences, and practicality.
Community Crisis Response vs. Traditional Office-Based
Practice: Discuss how community crisis response differs from
traditional therapy. Emphasize aspects such as the service
provider goes to the client, rather than the client coming to
the office (especially initially); early intervention focuses on
problem-solving rather than achieving insight; and terms like "mental health" and "counseling" are de-emphasized and
terms like "assistance with problem-solving" and "providing
support and an ®ear'" are emphasized.
Immediate Mental Health Interventions: Adapt this section to
the current phase of response, training participants in
attendance, survivor populations affected, and the needs of
the group. Overheads #18.27 provide information about a
range of interventions. Use concrete examples of appropriate
interventions, selecting from the material in the overheads.
Clearly describe each intervention and give examples of when
it is used. Demonstrate the intervention and then have the
group practice through role-plays. Including all of these steps
will enhance learning through hearing, seeing, and then
doing.
Role-Play Exercises: Facilitate brief role-play exercises
throughout this section. Develop case scenarios that
exemplify relevant situations and the approaches being
taught. The focus might be psychological first-aid, a
supportive conversation about a survivor's trauma experience,
or providing psycho-educational information through
reviewing a brochure and discussing coping strategies.
Participants need to have their performance anxieties relieved
while receiving feedback to enhance their learning.
Assessment and Referral: Provide program guidelines for
assessment and referral. Define when mental health providers
should consider the level of distress and symptoms to be such
that a referral, more formal assessment, and more "advanced"
intervention are indicated. Participants will need a program
procedure for case consultation and referral.
Long-Term Mental Health Interventions: The facilitator must
determine which interventions are most relevant. Community
outreach is often an important element of service delivery. A
section on strategies and skills for effective outreach may
assist with this less formal style of service delivery.
Crime Victim Assistance: Mental health workers must be
familiar with the criminal justice process and crime victim
rights and issues, as well as the role of crime victim
advocates. A specialist in this area may present this
information, as it relates specifically to the current criminal
justice response, if this is not in the trainer's background.
Limits and Boundaries of Mental Health Intervention: When
the incident has particularly tragic and heart-wrenching
consequences, mental health responders are often challenged
to maintain appropriate professional and ethical boundaries.
The common risks and pitfalls listed on Overhead #28 provide
a basis for lecture, discussion, and establishing clear service
or program guidelines. Using examples for each pitfall will
help participants apply them to their own practices.
Key Events with Mental Health Implications: The facilitator and
group may identify anticipated key events (see Overhead #29)
and discuss anticipated mental health needs. If specific skillbuilding
is called for, then focus section in that direction (e.g.,
for participation on death notification teams, for assisting
survivors with return to work anxieties). This could include
large group brainstorming of service delivery ideas. A small
group exercise could assign a key event to each small group,
and request that each group brainstorm creative mental
health service and outreach suggestions. The section
emphasizes thinking on the "macro" community level and
anticipating events that will send ripples of mental health
effects through the community, as well as at the "micro" level
of the specifics of what an intervention would look like.
Community Intervention: Provide a brief lecture on the
importance of disseminating information on trauma, stress,
and coping. Community education is essential. Show samples
of educational efforts (e.g., brochures, public information
media spots, Internet sites, newspaper articles, etc.). Mental
health providers may help plan community events or be
present as a support (Overhead #30). Again, fit this discussion
to real events and needs occurring in the community.
Often, mental health providers are asked to give presentations
to different audiences including survivor groups defined by
age, culture, needs, employment, or affiliation with an organization.
Other audiences might be service provider groups
such as primary care providers, health care professionals,
disaster workers, faith-based counselors, or school teachers.
Specific training modules need to be developed to address
these particular needs and groups. The facilitator should
address these topics in a way that fits the needs of the group.
However, additional in-service training is also recommended.
Show Videotape: The videotape "Hope and Remembrance"
deals with the importance of community ritual and
memorials. The video is moving and is likely to elicit reactions
and emotions. It can provide an opportunity for self-reflection,
facilitator modeling of good listening and "counseling" skills,
and discussion of countertransference vulnerabilities.
MODULE 6: Children's and Adolescents' Reactions and Interventions
Topics Covered
- Age-related reactions and concerns
- Age-appropriate interventions
- Coordination with the schools
- Special projects
Objectives
- Provide information about children's normal and problematic
responses to trauma, loss, and family stress
- Assist participants in understanding developmental
influences so they can design appropriate interventions
- Identify strategies for working with the local schools and
children's organizations
- Provide examples of creative projects and partnerships
- Brainstorm
Time Required
Up to 3 hours
Materials Required
- Overheads #5 and #31.36
- Handout: "Age Specific Interventions for Children and Adolescents"
- Videotape: "Children and Trauma: The School's Response"
- Examples of coloring books, expressive and commemorative school
projects (photos, journals, posters, drawings, and documentaries)
Procedures
Children's Reactions to Crisis and Trauma: Review background
material in Chapters II and III, and Recommended Reading.
Present a lecture on children's reactions emphasizing
developmental stages and the significant role of the family.
Identify features of the current event that have salience for
children (e.g., witnessing frightening events in person or on
the television, separation from family members, traumatic
reminders at school). Use Overheads #31.33 as a starting
point. Discuss observed expressions of distress and trauma in
children following the recent disaster and interventions with
children to date.
Risk Factors: Review Overhead #34. Discuss at-risk groups of
children in the community. Using the concentric circle model
(Overhead #5), identify groups of children and adolescents
with different levels of exposure.
Interventions: Present a lecture on appropriate interventions
with children for different phases. Emphasize the importance
of parent education, support and consultation. The handout
can provide a structure for this lecture. Encourage participants
to assess the child or group before initiating expressive or
reenactment activities and to use them only when confident
that they will not be retraumatizing. With highly exposed
children, many of these interventions are most appropriate in
the context of a therapy relationship. The lecture on
intervention options may be broken up by group discussion,
showing examples, role-plays, and demonstrations of
techniques. This presentation should fit the roles of the participants.
Show Videotape: "Children and Trauma" captures many of the
points discussed, demonstrates techniques, and emphasizes
the importance of school involvement in interventions.
Discuss relevant aspects of the film and participant reactions.
Systematic Strategy for Assessing the Needs of Children: If a
high rate of more serious trauma and grief reactions are
anticipated because of the presence of risk factors and the
dynamics of the incident and recovery efforts, a systematic
system for screening children is advised. Multiple strategies
including gathering assessment information from parents and
teachers and directly from children and adolescents should be
used. Overhead #35 provides guidance for topics to include in
an assessment. Checklists have been developed for this
purpose. The program must define procedures and protocols
for systematic screening. The participants may practice brief
screening interviews with parents, children, or teachers.
depending on the program's plan and their roles.
Psychological Tasks: Using Overhead #36, discuss the psychological
tasks that a child must accomplish to integrate the
traumatic experience and move on. Discuss how age and
developmental stage affect the child's capacity to accomplish
these tasks and how these affect intervention strategies.
Emphasize that children may harbor a distorted
understanding of the event, what caused it, or their role in it.
These idiosyncratic distortions must be uncovered and
corrected for the child to work through their experiences.
When children have been highly impacted, child specialists
may conduct specific in-service training for mental health
professionals on providing counseling for traumatized and
bereaved children and their families.
School Systems: Schools are a critical point of contact to reach
children, parents, caretakers, and school personnel who have
regular contact with children. However, gaining access to
schools can be challenging. Access may be facilitated through
coordination with the U. S. Department of Education, which
has a crisis intervention program, the State Department of
Education, or more local official entities that have vested
interests in children's welfare. Other, less official channels
include working with the school nurse or counseling staff,
presenting educational sessions at PTA meetings, and
conducting in-service training for teachers. Hiring former
school personnel as program staff can be helpful for gaining
credibility and acceptance.
Determine what angles would help to promote collaboration
and a working relationship. These might be referrals for atrisk
children and families (due to the disaster), consultation
and training with school counselors and nurses, or parent
presentations. The interventions listed in the handout may be
used for training teachers and mental health professionals for
classroom sessions.
Other organizations serving children may be more accessible
and welcoming of outside assistance. Possibilities include day
care centers, YMCA/YWCA youth programs, scout programs,
religious youth groups, summer camps, or community
centers.
School and Community Projects: The videotapes shown have
demonstrated numerous ways that children can participate in
community commemoration. Display samples of children's
projects. Expressive activities provide a vehicle for expression,
validation and normalization, gaining social support, and "working through" reactions. Engage participants to
brainstorm innovative projects for the current crisis to foster
community healing and survivorship.
MODULE 7: Cultural and Ethnic Groups: Considerations and Interventions
Topics Covered
- Cultural competency
- Cultural information about affected groups
Objectives
- Identify special populations including cultural, ethnic, racial,
immigrant, and refugee groups affected by the disaster
- Review unique issues associated with each group and
special considerations for intervention
- Understand how traumatic stress, grief, healing, and
recovery may be experienced and expressed by each group
Time Required
2 hours
Procedures
Cultural, Ethnic, Racial, Immigrant, and Refugee Groups: Staff
must acquire cultural competency with and earn the
acceptance of affected groups in the community. Chapters II
and III highlight important topics. Overhead #37 presents
components of cultural competence. Program managers
should strongly state the program's position regarding valuing
diversity and respecting differences, and that everyone in the
community should have access to high quality, appropriate
services. Managers may present steps that the mental health
program is taking to promote cultural awareness and
sensitivity and to ensure cultural competence.
Information about Local Affected Groups: Representatives
from local ethnic, cultural and racial groups may present
portions of this section. Overhead #38 may provide guidance
regarding topics to address in these presentations. They may
share information about their groups' experience with the
disaster and the crisis response. Ideally, a specialist in the
group's cultural experience can provide insights on how to
work most effectively with the group and avenues for credible
liaison and helpful collaboration. Additional training on
cultural issues and awareness may be provided as in-service
training.
Basic Cultural Sensitivity: The tips listed on Overhead #39 are
the basics of respectful engagement with all people, yet must
be especially emphasized when trying to bridge cultural
differences. If interpreters are being used, suggestions are
included in Chapter III.
Materials Required
- Overheads #37.39
- Handouts and resource
materials on specific
groups in community
- Videotapes about working
with particular groups in
the community
MODULE 8: Planning Workgroups
Topic Covered
- Program planning for special population groups
Objectives
- Develop specific program strategy plans for addressing the
mental health needs of each affected special population
group in the community
- Encourage a team approach to program planning
- Identify expertise and interests of mental health staff
relevant to special groups
- Identify strategies for outreach, relationship-building with
community leaders and agency resources, and culturally
sensitive interventions
Time Required
1.5 hours
Procedures
Identifying Special Populations: Identify groups requiring
special program focus. Examples are children; older adults;
traumatically bereaved family members; people who lost their
jobs as a result of the disaster; people with disabling injuries
resulting from the incident; people in institutions, people with
pre-existing disabilities; cultural, ethnic, and racial groups;
and people with serious and persistent mental illness. Human
service workers in the community might receive a different
set of interventions, as a target group for networking,
outreach and educational presentations.
Special Population Workgroups: Establish workgroups of
participants for each identified population group. Assign tasks
to the workgroups. Group tasks could include: (1) identifying
points of contact to reach the group; (2) identifying group
leaders, key people, and gatekeepers; (3) identifying future
significant events with mental health implications; (4)
reviewing effective program or outreach strategies to date;
and (5) brainstorming program ideas, intervention, or
outreach strategies for the future. Groups may take 45
minutes to discuss and generate ideas and then transcribe
them to the flip chart. Then each group may present their
ideas to the larger group for input and discussion.
The trainer further comments on groups or issues raised,
summarizes common themes and challenges, and recognizes
the work of each group. This exercise provides a welcome
opportunity to encourage teamwork and demonstrate the
benefits of a collective process.
The program manager may discuss how the workgroup ideas
will be addressed and incorporated into the program plan.
Materials Required
(For each workgroup)
- Flip chart
- Pens
- Questions
MODULE 9: Stress Prevention, Management, And Intervention
Topics Covered
- Sources and nature of worker stress
- Organizational and individual approaches
- Self-awareness
- Stress reduction strategies
Objectives
- Provide information regarding sources and symptoms of
worker stress and compassion fatigue
- Introduce and discuss specific organizational and individual
approaches to prevent and manage work-related stress
- Enhance team support and group cohesiveness
- Identify individual vulnerabilities to stress and personal
prevention and management strategies
Time Required
2 hours (Exercises can be interspersed throughout the training
course.)
Materials Required
- Overheads #40.44
- Flip chart
- Pens
Procedures
Sources of Stress: Using Overhead #40, discuss potential
sources of work-related stress. Use examples relevant to the
timing of the training. Engage participants to identify
examples in each category. This exercise could be made more
personal by asking participants to identify their top three
stressors. These work-related stressors could be compiled,
voted on, and tallied.arriving at the top 10 stressors
identified by the entire group. These results could be the basis
for subsequent problem-solving exercises addressing these
top stressors.
The trainer may lecture on sources of stress for workers,
adding to the material generated by the group. The lecture
might include topics such as participants' motivations for
helping and how these might also generate stress; discomfort
being with someone who is angry, tearful, grief stricken,
hopeless, depressed, emotionally shut down, etc.; identifying
images or events that are traumatic; and difficulties managing
the boundaries of the "helper-helpee" relationship.especially
under such tragic life circumstances.
Concept of Stress: Overhead #41 provides important
perspectives on stress.that it is both good and bad and, most
importantly, identifiable and manageable. In moderation,
stress can enhance performance and mental acuity. Too much
stress continuing over a period of time can erode well-being,
coping, and eventually health. The program managers,
supervisors, and individual staff members each have responsibility
to prevent and manage stress. Review Chapter V.
Symptoms of Worker Stress: Review list of worker stress
symptoms in Chapter V. Invite participants to identify
symptoms that they have experienced during the current crisis
response. Participants may complete an assessment checklist
to determine how they are doing and their personal areas of
vulnerability. Figley (2001) provides resources for assessment.
Coping Strategies: Invite participants to list coping strategies
that they use to reduce stress. Next, ask participants to identify three strategies
that they think they should use to reduce stress. Divide the group into groups
of three or four and ask them to share what they have identified. Also, remind
the group that this can be another opportunity to practice listening skills.
Then, ask the groups to consider how coworkers and the program as a whole
might support their staff's continuing efforts to do what is helpful to
them and to begin doing activities on their "should" lists. Ask each group to summarize and report ideas, and write on a flip chart. The
flip chart list will contain some ideas for assisting staff with follow through
on stress management. Model giving positive and encouraging feedback. Make
the point that giving positive feedback and saying "thank you" often
can be a powerful stress intervention. This exercise can specify methods of team support for stress management (e.g.,
group walks at lunch, reduced group rates at a nearby gym, on-site yoga classes
at lunch, a positive incentive system for stress-reducing activities with
"rewards," buddy support, and accountability system). Organizational and Individual Approaches to Preventing and Managing
Stress: Using Overheads #42 and #43, present information contained
in Tables 4 and 5. Program managers may discuss how organizational recommendations
are addressed and the plan for future stress management. They may make a strong
statement about the program's commitment to supporting workers and promoting
stress management. Stress reduction strategies generated in the previous exercise
may also provide examples. Team Building Exercise: Ask participants to jot down their best
team experiences (sports, clubs, jobs, etc.). Then, invite them to silently
reflect on the characteristics of those teams and the roles they had. List
these characteristics on a flip chart and lecture on what contributes to effective
work teams. Next, ask participants to consider how they want to work together and what
norms or principles they would like to see the group adopt. Examples might
include "We will encourage, initiate, and participate in direct communication;"
"We will discuss work issues with an involved third person as they occur;"
"We will responsibly manage our time and workload;" or "We
will treat each other with respect." Combine individual lists to generate
a list that reflects all of the input. After reviewing the combined list, each participant votes on his or her top
three. Narrow the list down to five to seven briefly stated items and ask,
"Is there anything on this list with which anyone cannot live?"
The agreed upon list can be written up and posted at program offices. At staff
meetings, groups can check back to determine how they are abiding by the principles.
A more formal evaluation can provide the basis for future team-building interventions.
This process may be started at the comprehensive training and then continued
at in-service training sessions. Self-Awareness Exercises: Self-awareness is an essential ingredient
in understanding and managing stress and addressing compassion fatigue. In
this initial training, it is important that participants do not feel pushed
to disclose personal information that they do not want to share. Over time,
it will be important for staff to understand and deal with their personal
reactions, countertransference, their own experiences of trauma and loss,
and their motivations for and vulnerabilities to helping survivors. This process
may occur through in-service workshops, group consultation, group debriefing
sessions, clinical supervision, or confidential individual counseling support.
Stress Reduction Exercises: These exercises can be incorporated
at different points during the training. Later, they can be used to start
or end staff meetings, group consultation sessions, or as scheduled activities:
- Invite the group to stand and stretch, reaching hands
toward the ceiling and breathing deeply with each stretch;
- Facilitate a guided imagery process. Ask participants to close their eyes
and sit comfortably. Dim the lights and encourage deep breathing, physical
relaxation, and visualization of a personal and peaceful place;
- Encourage participants to take a quiet 15-minute break by themselves. They
might walk outside, noticing vegetation, smells, etc., or sit and read or
write, or close their eyes and meditate. Suggest that the group maintain
silence during the break as an experiment; and
- As a homework exercise, encourage participants to do one self-care activity.
This could be exercising, reading a book, spending time with a friend or
family member, doing a crossword puzzle, working in the yard, taking a bath,
etc. The next morning in class, invite participants to share what they did.
Again, respond positively to participants' efforts. These activities
and the group encouragement help foster a workplace culture that supports
stress management.
TRAINING OVERHEADS
OVERHEAD 1: Terrorism within the United States
"An activity that involves a violent act or an act of dangerousness
to human life that is in violation of the criminal laws of the United States,
or of any State...and that appears to be intended to intimidate or coerce a
civilian population...or to influence the policy of government by assassination
or kidnapping."
[18 U.S.C. 3077]
OVERHEAD 2: Mass Violence within the United States
"An intentional violent criminal act, for which a formal investigation
has been opened by the FBI or other law enforcement agency, that results in
physical, emotional, or psychological injury to a sufficiently large number
of people as to significantly increase the burden of victim assistance for the
responding jurisdiction."
OVERHEAD 3: Dimensions of Traumatic Exposure
- Threat to life and limb
- Severe physical harm or injury
- Receipt of intentional harm or injury
- Exposure to the grotesque
- Violent/sudden loss of a loved one
- Witnessing or learning of violence to a loved one
(Green, 1993)
OVERHEAD 4: Comparing Criminally Human-Caused and Natural Disasters
- Causation
- Appraisal of Event
- Psychological Impact
- Subjective Experience
- Worldview/Basic Assumptions
- Stigmatization of Victims
- Phases of Recovery
- Media
- Secondary Injury
OVERHEAD 5: Population Exposure Model
A: Community victims killed and seriously injured Bereaved family members,
loved ones, close friends
B: Community victims exposed to the incident and disaster scene, but not injured
C: Bereaved extended family members and friends Residents in disaster zone
whose homes were destroyed First responders, rescue and recovery workers Medical
examiner's office staff Service providers immediately involved with bereaved
families, obtaining information for body identification and death notification
D: Mental health and crime victim assistance providers Clergy, chaplains Emergency
health care providers Government officials Members of the media
E: Groups that identify with the target-victim group Businesses with financial
impacts Community-at-large
OVERHEAD 6: Survivor Risk and Resiliency Factors
- Psychological
- Capacity to tolerate stress
- Prior trauma history
- Socioeconomic and educational level
- Family stability
- Social support
- Female gender
OVERHEAD 7: Model of Psychological Responses to Trauma and Traumatic Bereavement
OVERHEAD 8: Community Response Phases
- Impact
- Heroic
- Honeymoon
- Disillusionment
- Reconstruction
OVERHEAD 9: Physical Reactions
- Agitation, hyper-arousal
- Fatigue, exhaustion
- Hot or cold sensations
- Gastrointestinal distress
- Tightness in throat, chest
- Appetite change
- Worsening of health conditions
OVERHEAD 10: Behavioral Reactions
- Sleep problems, nightmares
- Jumpiness, easily startled
- Hyper-vigilance
- Crying and tearfulness
- Avoidance of reminders
- Increased family conflicts
- Isolation, social withdrawal
OVERHEAD 11: Emotional Reactions
- Shock, disbelief
- Anxiety, fear about safety
- Irritability, anger, rage
- Sadness, grief, depression
- Numbness, disconnection
- Hopelessness and despair
- Survivor guilt, self-doubt
OVERHEAD 12: Cognitive Reactions
- Confusion, disorientation
- Intrusive thoughts, images
- Recurring dreams, nightmares
- Memory and concentration difficulties
- Difficulty making decisions
- Focus on protecting loved ones
- Questioning spiritual beliefs
OVERHEAD 13: Considerations with Older Adults
- Physical vulnerability
- Chronic health conditions
- Medication needs
- Auditory, visual, mobility, or cognitive impairment
- Increased anxiety, confusion
- Loss of home health support
OVERHEAD 14: Incident Command System (ICS) Organizational Components
OVERHEAD 15: Mental Health Roles in Crisis Response
- Mental health consultation
- Liaison with key agencies
- Psycho-education through media
- Mental health services with survivors, families
- Mental health services with responders
- Stress management support
OVERHEAD 16: Key Concepts
- Normal reactions to an abnormal situation
- Avoid "mental health" terms and labels
- Assume competence and capability
- All who witness are affected
- Respect differences in coping
OVERHEAD 17: Key Concepts (continued)
- First, do no harm
- Assistance is practical and flexible
- Focus on strengths and potential
- Encourage use of support network
- Tailor for active, community fit
- Be innovative in helping
OVERHEAD 18: On-Scene Interventions
- Direct to medical care, safety, shelter
- Protect from trauma, media, onlookers
- Connect to family, information, comfort
(Myers and Wee, 2003)
OVERHEAD 19: Immediate Interventions
- Rapid assessment and triage
- Psychological first-aid
- Crisis intervention
- Crime victim assistance
- Psycho-education
OVERHEAD 20: Immediate Interventions (continued)
- Informational briefings
- Community outreach
- Participation in death notifications
- Mental health consultation
- Debriefing and community meetings
- Information and referral
OVERHEAD 21: Psychological First-Aid
- Provide comfort, empathy, an "ear"
- Address physical needs
- Provide concrete information about what will happen next
- Link to support systems
- Reinforce coping strengths
OVERHEAD 22: Crisis Intervention
- Promote safety and security
- Gently explore trauma experience
- Identify priority needs and solutions
- Assess functioning and coping
- Provide: Reassurance
- Psycho-education
- Practical assistance
OVERHEAD 23: Crime Victim Assistance
- Protect victims' rights
- Ensure control over media contacts
- Provide criminal justice information
- Facilitate access to compensation
- Streamline bureaucratic procedures
OVERHEAD 24: Community Outreach
- Initiate contact at gathering sites
- Set up 24-hour telephone hotlines
- Outreach to survivors through media, Internet
- Educate service providers
- Use bilingual and bicultural workers
OVERHEAD 25: Participation in Death Notification
Responsible notifier:
- Obtains critical information
- Notifies next-of-kin directly, simply, in person
- Expects intense reactions
- Provides practical assistance
- Mental health participates on team, provides support and information
OVERHEAD 26: Brief Trauma Intervention
- Factual information
- Thoughts during event
- Reactions and feelings
- Psycho-education
- Problem-solving and action
OVERHEAD 27: Long-Term Interventions
- Community outreach
- Brief counseling
- Support and therapy groups
- Crime victim assistance
- Psycho-education
OVERHEAD 28: Beware! Common Pitfalls And Risks
- Over-involvement, doing too much
- Confusing friend and counselor roles
- Becoming lax about confidentiality
- Providing services beyond competency
- "I'm the only one who can..." syndrome
- Disengaging from family and own life
OVERHEAD 29: Key Events with Mental Health Implications
- Death notification
- Ending rescue and recovery
- Applying for death certificates
- Criminal justice proceedings
- Returning to impacted areas
- Funerals and memorials
OVERHEAD 30: Community Interventions
- Memorials and rituals
- Usual community gatherings
- Anniversary commemorations
- Symbolic gestures
OVERHEAD 31: Preschool-Age Children's Reactions
- Sleep problems, nightmares
- Clinging, separation anxiety
- Helplessness, passivity
- Death not permanent
- Fearfulness
- Regression
- Repetitive play
OVERHEAD 32: School-Age Children's Reactions
- Sleep problems, nightmares
- Preoccupation with disaster, death
- Fears about safety
- Self blame, guilt, responsibility
- Angry outbursts
- Retelling and repetitious play
- Social withdrawal
- Somatic complaints
- School performance problems
OVERHEAD 33: Pre-Adolescents and Adolescents
- Sleep problems and nightmares
- Self blame, guilt, shame
- Self-consciousness
- Depression, social withdrawal
- Desire for revenge
- Somatic complaints
- Aggressive and risk-taking behavior
- School performance problems
OVERHEAD 34: Risk Factors for Children
- Exposure to direct life threat and injury
- Witnessing mutilating injuries
- Hearing unanswered cries for help
- Degree of brutality and violence
- Unexpectedness and duration
- Separation from family
(Pynoos, 1996;
Vogel and Vernberg, 1993)
OVERHEAD 35: Screening Checklist
- Trauma and loss exposure
- Current level of distress
- Social, academic, emotional, and behavioral changes
- Traumatic reminders at home and school
- Ongoing stressors at home and school
- Other trauma in the past year
OVERHEAD 36: Tasks for Psychological Recovery
- Regain a sense of safety and security
- Gain understanding of child's unique experience of the trauma
- Gain understanding of actual events that have occurred
- Identify and express reactions and emotions
- Grieve and cope with traumatic stress
- Resume age-appropriate roles and activities
(Pynoos and Nader, 1993;
Vernberg and Vogel, 1993)
OVERHEAD 37: Cultural Competence
- Recognize the importance of culture and respect diversity
- Maintain a current profile of the cultural composition of the community
- Recruit disaster workers who are representative of the community or service area
- Provide ongoing cultural competence training to disaster mental health staff
- Ensure that services are accessible, appropriate, and equitable
- Recognize the role of help-seeking behaviors, customs and traditions, and natural support networks
- Involve as "cultural brokers" community leaders and organizations representing diverse cultural groups
- Ensure that services and information are culturally and linguistically competent
- Assess and evaluate the program's level of cultural competence
(CMHS, 2003)
OVERHEAD 38: Cultural Group Information
- Meanings associated with the event
- Experience with emergency response
- Trauma and violence in country of origin
- Signs and symptoms of trauma, grief
- View about mental health, providers
- Tips for professional courtesy
OVERHEAD 39: Basic Cultural Sensitivity
- Convey respect, good will, courtesy
- Ask permission to speak with people
- Explain role of mental health worker
- Acknowledge differences in behavior due to culture
- Respond to concrete needs
(Paniagua, 1998; Young, 1998)
OVERHEAD 40: Sources of Stress
- Exposure to trauma
- High-intensity assignments
- Environmental factors
- Organizational factors
- Individual factors
OVERHEAD 41: Stress Is:
- Normal
- Necessary
- Productive and destructive
- Acute and delayed
- Cumulative
- Identifiable
- Preventable and manageable
OVERHEAD 42: Organizational Approaches
- Effective management structure
- Effective managers and supervisors
- Clear purpose and goals
- Functionally defined roles
- Team support
- Plan for stress management
OVERHEAD 43: Individual Approaches
- Management of workload
- Balanced lifestyle
- Stress reduction strategies
- Self-awareness
OVERHEAD 44: Compassion Fatigue
"The natural consequent behaviors and emotions resulting from
knowing about a traumatic event experienced by a significant other.the stress
resulting from helping or wanting to help a traumatized or suffering person."
(Figley, 1995)
HANDOUTS
AGE-SPECIFIC INTERVENTIONS FOR CHILDREN AND ADOLESCENTS
Age Group
|
At Home |
At School or Other Organizations For Children
|
Pre-Schoolers
|
- Maintain family routines
- Give extra physical comfort and
reassurance
- Avoid unnecessary separations
- Permit child to sleep in parents' room
temporarily
- Encourage expression of feelings through play
- Monitor media exposure to disaster trauma
- Develop disaster safety plan
|
- Draw expressive pictures
- Tell stories of disaster and recovery
- Use coloring books on disaster, loss,
coping with feelings
- Read books on related themes
- Use dolls, puppets, toys, blocks for reenactment
play
- Facilitate group activities that foster
empowerment and understanding
- Talk about safety and self protection
- Provide parent education and support
meetings
- Provide absenteeism outreach to families
and children*
- Identify stressed children for assessment
and referral*
- Provide in-service training on children and
disaster, trauma, and grief*
- Provide school-based crisis hotline*
- Provide educational brochure for parents*
- Encourage students to resume normal roles and routine activities*
|
Elementary-Age
Children
|
- Give additional attention and consideration
- Set gentle but firm limits for acting-out
behavior
- Listen to child's repeated telling of disaster
experience
- Encourage verbal and play expression of
thoughts and feelings
- Provide structured but undemanding home
chores and rehabilitation activities
- Rehearse safety measures for future disasters
|
- Encourage free drawing after discussion of
disaster
- Encourage free writing after discussion of
disaster, complete-a-sentence exercise
- Tell stories of disaster, loss, and recovery
- Read books on related themes that may
generate discussion or healing
- Create a play about related themes and
survivorship
- Facilitate school study or projects to
increase understanding, promote
discussion
- Talk about safety, family protection, school
and family preparedness*
- Teach calming techniques (deep breathing,
visualization)*
- Conduct small group or individual
interventions for at-risk children*
- Conduct group "debriefing" discussion to express and normalize reactions,
correct misinformation, and enhance coping and peer support*
|
Pre-Adolescents
And Adolescents
|
- Give additional attention and consideration
- Encourage discussion of disaster
experiences with peers, significant adults
- Avoid insistence on discussion of feelings
with parents
- Encourage physical activities
- Encourage resumption of regular social and recreational activities
|
- *All interventions starred above apply
- Conduct school programs for assisting
community with recovery, helping others
- Conduct projects for commemoration and
memorialization
- Encourage discussion of losses and
feelings with peers and adults
- Address rebellious, risk-taking, aggressive,
or isolating behaviors
- Resume sports, club, and social activities when appropriate
|
VIDEOTAPES
Death Notification. Mother's Against Drunk Drivers (MADD), 1996. Available:
www.madd.org
Disaster Psychology: Victim Response. Catonsville, MD: Instructional Media
Resources, University of Maryland, Baltimore County, 1985.
The Federal Emergency Management Agency (FEMA) funded the two videotape projects
listed below through the Crisis Counseling Program. Copies are available at
no charge from the Center for Mental Health Services, National Mental Health
Services Knowledge Exchange Network, P.O. Box 42490, Washington, DC 20015 or
by contacting www.mentalhealth. org or calling 1-800- 789-2647.
Children and Trauma: The School's Response. Alameda County Department
of Mental Health, Santa Cruz County Department of Mental Health, and California
Department of Mental Health, 1991.
Hope and Remembrance. Texas Department of Mental Health, 1997.
The Office for Victims of Crime (OVC), U.S. Department of Justice, funded
the two videotape projects listed below. Copies are available at no charge through
the OVC Resource Center at www.ncjrs.org or by calling 1-800-851-3420.
Special Award for Extraordinary Response to International Terrorism. Office
for Victims of Crime, 2001.
The News Media's Coverage of Crime and Victimization. National Victim
Assistance Academy, 2000.
The Bureau of Justice Assistance, U.S. Department of Justice, funded the videotape
project listed below. Copies are available at no charge through the OVC Resource
Center at www.ncjrs.org or by calling 1-800-851-3420.
Surviving the Secondary Device: The Rules Have Changed. Georgia Emergency
Management Agency, 1997.
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