Mental Health Response to Mass Violence and Terrorism

CHAPTER VII: Comprehensive Training Course Outline

• Course Overview
  
• Course Objectives
  
• Overview of Comprehensive Training Course
  
• Module 1: Introduction
  
• Module 2: Criminal Mass Victimization
  
• Module 3: Adult Responses to Mass Violence and Terrorism
  
• Module 4: Organizational Response and Mental Health Roles
  
• Module 5: Community Crisis Response and Mental Health Interventions
  
• Module 6. Children's and Adolescents' Reactions and Interventions
  
• Module 7: Cultural and Ethnic Groups: Considerations and Interventions
  
• Module 8: Planning Workgroups
  
• Module 9: Stress Prevention, Management, and Intervention
  
• Training Overheads
  
• Handouts
  
• Videotapes

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:

1. Topics Covered;
2. Objectives;
3. Time Required;
4. Materials Required; and
5. 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:

1. Invite the group to stand and stretch, reaching hands toward the ceiling and breathing deeply with each stretch;
2. 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;
3. 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
4. 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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