MENTAL HEALTH RESPONSE TO MASS VIOLENCE AND TERRORISM: A FIELD GUIDE

CHAPTER III: Psychological First Aid and Counseling Skills

Establishing Rapport

Active Listening

Some Possible Do's and Definite Don'ts

Psychological First Aid

Problem Solving

A Word of Caution

Confidentiality

Workers should approach survivors and family members with compassion and regard for their humanity and dignity. This includes honoring families' and survivors' wishes to be left alone or deal privately with their suffering. Workers enhance survivors' sense of control over their situation through recognizing and reinforcing their coping strengths, providing clear information, and offering choices when appropriate. When survivors feel more secure and in control, they can better address immediate challenges. Crisis support involves guiding, listening, reassuring, and providing practical assistance. The following section provides "nuts-and-bolts" suggestions.

Establishing Rapport

When making initial contact, workers should introduce themselves and briefly explain their roles. They may ask permission to sit down, since standing over people when they are seated may seem intimidating. Workers convey genuine interest and concern through eye contact, the assurance of safety, offering a warm beverage, and a calm presence. They provide comfort, support, and nonjudgmental response to expressed immediate needs. Trust and safety are enhanced when workers listen to what distressed survivors and family members choose to discuss and avoid asking intrusive questions.

Active Listening

Workers listen most effectively when they absorb information through their ears, eyes, and hearts. Some tips for effective listening are:

Support personal "pacing"—Many survivors and family members want to talk about their traumatic experiences. Putting terrifying and tragic experiences into words and having them heard while receiving emotional support can contribute to the healing process. Others may choose to focus on concrete tasks or seemingly inconsequential matters, temporarily avoiding direct discussion of their trauma and loss. Workers should look for cues regarding comfort levels, coping style, and appropriate pacing, and allow survivors and family members to take the lead with personal sharing.
Allow silence—Silence can give a person time to reflect and become aware of feelings. Silence may help survivors identify what is most important to them at the moment, or be a prompt for elaboration on thoughts and reactions. Simply "being with" the survivor or family member can be supportive.
Attend nonverbally—Eye contact, head nodding, caring facial expressions, and being at the same physical level (e.g., sitting, standing) let the person know that the worker is listening. Observing and heeding cultural differences with regard to nonverbal communication conveys cultural sensitivity and can enhance acceptance of help.
Paraphrase—The worker conveys understanding, interest, and empathy by repeating portions of what the person has said. Paraphrasing also checks for accuracy, clarifies misunderstandings, and lets the person know that he or she is being heard. Good lead-ins are: "So you are saying that...," "It sounds like you...," or "I have heard you say that...." Paraphrasing may seem awkward at first, but is an effective tool for building trust.
Reflect feelings—The worker may notice that the person's tone of voice or nonverbal gestures suggest emotions such as anger, sadness, or fear. Possible responses are, "You seem afraid of spending the night at home alone. Is that true?" This helps the person to identify and articulate emotions and needs.
Allow expression of emotions—Communicating intense emotions through tears or venting is an important part of healing. It often helps the survivor or family member work through feelings so that he/she can better address the immediate tasks at hand. Workers should stay relaxed and let the person know that it is okay to feel and express emotions. [Suggestions in the "Stress Prevention, Management, and Intervention" section may be helpful.]

Some Possible Do's and Definite Don'ts

Do say:

You have temporarily lost your sense of safety and security. You will feel better over time.
It is understandable that you feel this way.
This is your body's and mind's way of dealing with what has happened to you. Your reactions are normal.
Feeling intense emotions and having thoughts that you have never had before is normal. You are not going crazy.
You didn't do anything wrong. It wasn't your fault. You did the best you could.
Things will never be the same as they were, but you will gradually feel better.

Don't say:

It could have been worse. You're lucky that….
It's best if you just stay busy.
You should count your blessings, it will make you feel better.
I know just how you feel.
He/she is in a better place now.
You need to get on with your life.

While the human desire is to try to "fix" the survivor's or family member's painful situation or to make them feel better, hearing comments in the preceding "Don't Say," however, can make a person feel discounted, judged, misunderstood, or more alone. Workers may find it difficult not to overidentify with survivors and families. They should allow survivors and families the space for their own experiences, feelings, and perspectives—whatever they are. Simply listening with respect, concern, and calmness can comfort them.

Psychological First Aid

During and immediately after an act of mass violence or terrorism, those most affected may experience shock, confusion, fear, numbness, panic, and anxiety. They may "shut down."

Witnessing or suspecting the death of loved ones or friends can be emotionally overwhelming. Some people may be locked in disbelief. When the perpetrators have not been apprehended or the event is considered terrorism, all may experience a sense of continued threat and danger. Workers have seven immediate tasks and purposes:

Identify those in need of medical attention for intense stress reactions.
Provide protection from further harm, and assistance to a safe environment.
Ensure that survivors are warm/cool enough and are being given fluids and food.
Promote a sense of security through orienting and reassurance.
Connect survivors with family, friends, and loved ones.
Provide information about the crime scene and perpetrators, status of rescue efforts, and what will happen next.
Connect survivors and family members with resources for immediate help (e.g., voluntary agencies, crime victim assistance, systems for locating missing persons, emergency shelter and food, faith-based resources, and disaster mental health and psychiatry).

Problem Solving

Stress resulting from trauma, crime victimization, and sudden bereavement often causes disorganized thinking, concentration problems, and difficulty planning and making decisions. Some people react by feeling overwhelmed and may become either immobilized or unproductively overactive. Workers can encourage survivors and family members to participate in simple concrete tasks to help them focus and assume a more active role in coping. Also, workers can guide individuals through the following problem-solving steps to help prioritize and address immediate issues.

Identify current priority needs and problems and possible solutions

"Describe the problems/challenges that you are facing right now."

Selecting one solvable problem and then successfully addressing it can help restore a sense of control and capability. Avoid picking a complex problem first. Support the person in identifying a task that is easily completed.
Assess functioning and coping

"How are you doing? How do you feel about how you are coping?"

"How have you handled stressful life events in the past?"

Through observation, gently asking questions, and reviewing the magnitude of the person's problems and loss, the worker develops an impression of the person's capacity to address current challenges. Based on this assessment, the worker may point out coping strengths, facilitate the person's engagement with social supports, or make referrals. The worker may also seek consultation from a medical or mental health professional.
Evaluate available resources

"Who might be able to help you with this task/problem?"

"What resources and options might be helpful?"

Explore existing sources of assistance and support such as immediate and extended family, loved ones, friends, neighbors, coworkers, religious leaders, and healthcare providers. Connect the survivor or family member with the appropriate community, crime victim assistance, and disaster relief resources and assess if he/she is able to make the calls and complete the required paperwork. Assist with accessing resources when necessary.
Develop and implement a plan

"What steps will you take to address this problem?"

Encourage the survivor or family member to say out loud what they plan to do and how. Offer to check in for support and to see how he/she is doing. If the worker has agreed to perform a task or get information, it is very important to follow through. A plan may focus on a very short timeframe or limited actions. For example, a plan could be to make two phone calls. Being reliable and following up, even when there is no new information, helps survivors gain control. Workers should promise only what they can do, not what they would like to do.

A Word of Caution

When confronted with a survivor's or family member's seemingly overwhelming and heart-wrenching needs, workers can feel the understandable impulse to help in every way possible. Workers may become over-involved and do too much for the survivor or grieving family, which is usually not in the survivor's or family's best interest. While being helpful and available, workers should also convey their confidence in the individual's coping abilities and resilience. When survivors and families are empowered to address their own problems, they feel more capable to tackle the next challenge.

Confidentiality

The privilege of helping others carries ethical responsibilities. Helping people in need involves learning their problems, concerns, fears, and anxieties-sometimes with very personal details. This sharing must be done with a sense of trust, built upon mutual respect, and the understanding that all discussions are confidential. No person's situation or "case" should be discussed elsewhere without the consent of the person being helped, except in extreme situations when the worker believes the person might harm him/herself or others. Under those circumstances, workers should report concerns to their supervisors so that the appropriate authorities may be contacted.

Workers should avoid discussing information in public places, such as restaurants, that might give the impression that privacy is not being protected. Only by maintaining the trust and respect of the survivor or family member can the privilege of helping continue.

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