Mental Health Response to Mass Violence and Terrorism

CHAPTER VIII: Additional Training Needs and Options

This section addresses training needs beyond the comprehensive training outlined in Chapter VII. Training options included in this chapter are:

In the immediate phase of crisis response, training quickly provides necessary logistical and intervention information. The training is action-oriented, brief, and repeated as new mental health staff join the operation. Several months after the disaster, program managers assemble a group of more permanent workers. When the mental health response program's organizational structure and procedures have become further defined, they resemble an established program, as opposed to a rapid-response mobilization.

The comprehensive disaster mental health training presented in Chapter VII may be conducted at this point in the implementation process, or may have been offered earlier. This comprehensive training provides extensive disaster mental health and crime victim background and intervention information, and also addresses team development and worker stress management. Over the duration of the mental health program, in-service continuing education is essential, as new training needs are identified and phase-related issues emerge.

Paraprofessional peer counselors can be valuable members of disaster mental health recovery programs.

While bringing varied and salient life experiences to their disaster work, paraprofessionals need additional training on counseling skills, mental health assessment and referral, and ethical issues.

Training for Paraprofessional Staff

Paraprofessional counseling staff may be recruited from existing community programs such as crime victim advocacy and service programs, senior outreach services, faith-based programs, cultural grouporiented service programs, or disaster response volunteer organizations. These workers often reflect the demographic characteristics and ethnic and cultural groups present in the disaster-affected community. Solid interpersonal communication skills, the ability to work cooperatively with others, the psychological capacity to help others without judgment, and the ability to maintain confidentiality are desired qualities for paraprofessional counselors.

When paraprofessional staff have participated in a training session on counseling skills before the program's comprehensive disaster mental health training, they are able to engage with the material from a broader context and foundation. An initial two or three-day training course with regular weekly or biweekly continuing education and supervision sessions is suggested.

Newly trained paraprofessional counselors should initially work in teams with mental health professionals. It is critically important that roles and limits are clearly defined for paraprofessional counselors and that they have ready access to clinical supervisors.

The following topics are recommended for inclusion in training for paraprofessional staff:

Counseling Skill Development

Active listening: Using nonverbal cues, giving minimal encouragement (nods and "uh-huhs"), conveying empathy, paraphrasing, reflecting feelings, summarizing, differentiating content and feelings.

Asking questions: Interviewing techniques, asking open and closed questions, focusing with questions, avoiding using questions to give advice or make judgments.

Providing support and encouragement: Establishing rapport, empowering the survivor, giving positive feedback about coping strengths, offering suggestions, avoiding communication blocks and unhelpful phrases.

Counseling Interventions

Crisis intervention: Assessing capacity to live independently, evaluating suicide and dangerousness risk, giving reassurance, building hope, protocols for immediate response, procedures for consultation, referral and follow-up.

Listening to disaster experiences: Active listening to the telling (and retelling) of traumatic and loss experiences, exploring feelings and reactions, educating about traumatic stress and healthful coping strategies.
Problem-solving: Identifying and defining the problem, exploring feelings, brainstorming solutions and resources, setting realistic goals, taking action, evaluating results.

Self-Awareness

Motivations for helping: Exploring personal experiences, understanding helping relationships versus friendships, over-identifying with survivors.

Awareness of feelings: Identifying and articulating feelings, becoming familiar with range of "feeling words," tolerating expressions of intense emotions that may be uncomfortable.

Stereotypes and values: Exploring personal biases and prejudices, avoiding judgmental attitudes, promoting respect for differences.

Assessment of Mental Health and Other Problems

Basic overview of post-traumatic stress, grief and loss, depression, anxiety, alcohol and drug abuse, child and elder abuse, mental illness, cognitive impairment/dementia. symptom recognition, initial assessment strategies, procedures for consultation, referral and follow-up.

Legal, Ethical, and Program Considerations

Confidentiality, State law, and reporting requirements and procedures;
Record keeping, program reporting and monitoring;
Boundaries of relationship with clients;
Stress prevention and management (Chapter V); and
Consultation, supervision, and continuing education.

Paraprofessional staff training emphasizes that the helping person is in a privileged position. Helping someone in need implies a sharing of problems, concerns, and anxieties.sometimes with very personal details. This sharing cannot be done without a trust built upon mutual respect and the explicit understanding that all discussions are confidential and private. This mutual respect also involves acceptance of the survivor's experience, thoughts, and feelings. Judging, moralizing, or telling survivors how to feel only alienates and undermines the helping relationship.

Counseling skill-building through role-playing, observing role models, discussing case examples, and giving and receiving feedback helps paraprofessional staff gain competency. Having clear guidelines for assessment and referral helps counselors function within the boundaries of their training. Training facilitators must be adept at identifying and processing feelings, evaluating and promoting counseling skill development, and providing clear and concise procedures for handling challenging situations. Training for paraprofessional counselors should be ongoing and integrated with case consultation and practicing counseling skills.

Training for Human Service Workers

Human service workers may be directly involved in the disaster relief effort through Federal, State or local agencies, emergency services, law enforcement, crime victim services agencies, the American Red Cross, the Salvation Army, or local religious organizations. Most will benefit from focused training on disaster mental health issues geared to their respective roles. Developing a good working relationship with these entities for mutual referrals is a valuable byproduct of such training. The companion Field Manual is a helpful resource as an adjunct to training.

This training can be accomplished in several ways. Representatives from the various agencies and organizations may attend the comprehensive mental health course described in Chapter VII. When this occurs, the trainer should rearrange the training schedule so that representatives from outside agencies attend for the first day, or mornings. The training agenda should efficiently address these representatives' needs, while meeting the diverse training needs of the mental health program staff.

Another alternative is providing on-site disaster mental health training with each group. The training then can specifically address each group's needs. Activities, overheads, videos, and handouts can be used from the comprehensive training as needed. However, losing exposure to the entire mental health program staff is a trade-off.

Disaster relief and recovery workers compose one type of human service worker involved with survivors. Other human service workers encounter survivors in the course of conducting business or providing services. Examples are home health nurses, public assistance workers, school personnel, building permit inspectors, faith-based staff, or primary health care providers. Disaster mental health training and educational materials can assist these individuals in better serving survivors and to refer those in need for mental health services. Also, these individuals can distribute disaster stress and coping brochures to survivors.

The program may establish a task group to design outreach strategies, training presentations, and educational materials for these collateral providers and human service workers in the community. Since experience has shown that many survivors are more likely to talk with their physician, faith-based counselor, or someone already known to them before talking with a professional, outreach and education with these groups is extremely important.

Topics and Considerations For In-Service Training

The comprehensive training course provides staff with an overview of mental health interventions following incidents involving mass violence and terrorism. Because of the significant psychological and physical impact of these events, additional training and clinical supervision on group and individual counseling interventions with survivors and family members is necessary. As staff engage with the various disasteraffected communities over time, additional phase-related training needs become apparent. These identified training needs may involve particular population groups, specific community issues, or needed modifications of intervention strategies. Timing or phase-related topics, such as the one-year anniversary of the disaster, may become relevant.

SINCE EXPERIENCE HAS SHOWN THAT MANY SURVIVORS ARE MORE LIKELY TO TALK WITH THEIR PHYSICIAN, FAITH - BASED COUNSELOR, OR SOMEONE ALREADY KNOWN TO THEM BEFORE TALKING WITH A PROFESSIONAL, OUTREACH AND EDUCATION WITH THESE GROUPS IS EXTREMELY IMPORTANT.

In-service training also brings the staff together to strengthen group cohesion, social support, morale, and creativity. The focus of the session may be tending to the emotional challenges of disaster work through personal sharing and problem-solving new solutions. Some of the suggestions and exercise ideas in Chapter V, "Stress Prevention, Management and Intervention," can be included in the training. A skilled facilitator may identify organizational issues or procedures that may interfere with staff well-being or program effectiveness that can be addressed through teambuilding interventions.

The following are examples of in-service training topics:

Media policies, relations, and dissemination of public information;
Public speaking skills for disaster mental health presentations;
Stress management interventions for survivors, disaster workers, and program staff;
Addressing compassion fatigue and secondary traumatization;
Outreach, support, and interventions with emergency responders and other high-exposure occupational groups and their families;
More extensive training on serving children, elder adults, or ethnic/cultural groups in the community;
Long-term family stress issues, family counseling, and intervention;
Criminal justice process and impact on survivors and families;
Mental health program role and interventions with post-traumatic stress disorder, traumatic bereavement, anxiety disorders, depression, adjustment to disabling injuries, and alcohol and drug abuse problems;
Expressive intervention approaches (art, music, drama, writing, community projects) with adults and children;
Individual and group trauma and grief counseling with at-risk children;
Models for therapy and support groups;
Community organizing to address unmet disasterrelated needs;
Anniversary reactions and commemorative events;
Steps for program phasedown and termination of program and services; and
Final celebration of program success and lessons learned.

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