PPSYCHOLOGICALSYCHOLOGICAL FFIRSTIRST AAIDID

Field Operations Guide 2nd Edition

National Child Traumatic Stress Network National Center for PTSD

This work was funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), US Department of Health and Human Services (HHS). Additional support was provided by the Robert Wood Johnson Foundation.

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Field Operations Guide 2nd Edition

National Child Traumatic Stress Network National Center for PTSD National Child Traumatic Stress Network Established by Congress in 2000, the National Child Traumatic Stress Network (NCTSN) is a unique collaboration of academic and community-based service centers whose mission is to raise the standard of care and increase access to services for traumatized children and their families across the United States. Combining knowledge of child development, expertise in the full range of child traumatic experiences, and attention to cultural perspectives, the NCTSN serves as a national resource for developing and disseminating evidence-based interventions, trauma-informed services, and public and professional education.

National Center for PTSD VA’s National Center for PTSD is a world leader in research and education programs focusing on PTSD and other psychological and medical consequences of traumatic stress. Mandated by Congress in 1989, the Center is a consortium of seven academic centers of excellence providing research, education and consultation in the field of traumatic stress.

The views, opinions, and content are those of the authors, and do not necessarily reflect those of SAMHSA or HHS.

Copyright © 2006 Brymer M, Jacobs A, Layne C, Pynoos R, Ruzek J, Steinberg A, Vernberg E, Watson P, (National Child Traumatic Stress Network and National Center for PTSD). All rights reserved. You are welcome to copy or redistribute this material in print or electronically provided the text is not modified, the authors and the National Child Traumatic Stress Network (NCTSN) and National Center for PTSD (NCPTSD) are cited in any use, and no fee is charged for copies of this publication. Unauthorized commercial publication or exploitation of this material is specifically prohibited. Anyone wishing to use any of this material for commercial use must request and receive prior written permission from the NCTSN. Permission for such use is granted on a case-by-case basis at the sole discretion of NCTSN. If you would like permission to adapt or license these materials, please contact Melissa Brymer, Psy.D. at [email protected]. Other inquires can be directed to the NCTSN National Resource Center at [email protected] or (919) 682-1552. Psychological First Aid

Table of Contents

Acknowledgements...... 1 Introduction and Overview...... 5 Preparing to Deliver Psychological First Aid...... 13 Core Actions...... 19 1. Contact and Engagement...... 23 2. Safety and Comfort...... 27 3. Stabilization (if needed)...... 49 4. Information Gathering: Needs and Current Concerns...... 57 5. Practical Assistance...... 65 6. Connection with Social Supports...... 69 7. Information on Coping...... 77 8. Linkage with Collaborative Services...... 93

LIST OF APPENDICES:...... 97

Appendix A: Overview of Psychological First Aid...... 99 Appendix B: Service Delivery Sites and Settings...... 103 Appendix C: Psychological First Aid Provider Care...... 109 Appendix D: Psychological First Aid Worksheets...... 119 Appendix E: Handouts for Survivors...... 125 Appendix F: Duplicate Handouts to Copy and Distribute

Psychological First Aid - Field Operations Guide 

This page intentionally left blank. Acknowledgements  . and www.ncptsd.va.gov This Psychological First Aid Field Operations Guide was developed by the National Child the National Child was developed by Guide Aid Field Operations First This Psychological the National Members of Center for PTSD. and the National Stress Network Traumatic as other Center for PTSD, as well Stress Network and the National Traumatic Child contributed in disaster response, have in coordinating and participating individuals involved to the current document. Christopher Layne, Melissa Brymer, (in alphabetical order) included: The principal authors and Patricia Vernberg, Eric Steinberg, Alan Pynoos, Josef Ruzek, Anne Jacobs, Robert Watson. Ford, Dora Black, Carrie Epstein, Julian included: Steve Berkowitz, Special contributors Jack Herrmann, Jessica Hamblen, Russell Jones, Robert Laura Gibson, Robin Gurwitch, Rose Betty Pfefferbaum, Merritt Schreiber, Shelby, Saltzman, Janine William Macy, Young. and Bruce Wirth, Whitham, Bonita Samuels, Cynthia Margaret Pfefferbaum, Guide was drawn Aid Field Operations First Additional material for this Psychological Reserve Corps (MRC). Principal authors for the MRC from an adaptation by the Medical John Hickey, Abbe Finn, Jack Herrmann, included: adaptation (in alphabetical order) by Additional content was provided Patricia Santucci, and James Shultz. Edward Kantor, Theological Seminary Adaptation Group, including from Fuller members of the Clergy Peter Kung, Cynthia Eriksson, David Foy, Augsburger, (in alphabetical order): David Dave Scott, and Jennifer Orona; from the HealthCare Doug McConnell, Kathy Putnam, Hasan, Martha Yusuf Handzo, George Nathan Goldberg, Chaplaincy (in alphabetical order): Treatment Trauma Adolescent Kim; and from the Jacobs, Jon Overvold, and Eun Joo Shore Long Island Jewish Health System (in alphabetical Development Center of the North and Juliet Turnbull, Ayme Labruna, Victor Kaplan, order): Christine DiBenedetto, Sandra of California, San Francisco Additional content was also provided by the University Vogel. Horn. Van and Patricia Alicia Lieberman, Ghosh Ippen, (in alphabetical order): Chandra March 31-April 1, 2005. SAMHSA-supported expert review panel was convened on A Those attending included: Miksha Nation, Participants made invaluable contributions. Dodgen, Darrin Cecilia Revera-Casale, Kerry Crawford, Rosemary Creeden, Daniel Gordon, Richard Gist, Ian Mary Fetchet, Ellen Gerrity, Eisenberg, William Donato, Jepson, Sandra Susan Hamilton, Seth Hassett, Jack Herrmann, Stevan Hobfoll, Stacia April Naturale, Kaplan, Susan Ko, Linda Ligenza, Steven Marans, Christina Mosser, and Robert Janine Shelby, Elana Newman, Bonnie O’Neill, Dori Reissman, Gilbert Reyes, Ursano. Vernberg A, A, Layne C, Pynoos R, Ruzek J, Steinberg For citation: Brymer M, Jacobs Stress Network and National Center for PTSD), Traumatic (National Child P, Watson E, on: Available 2006. Aid: Field Operations Guide, 2nd Edition. July, Psychological First www.nctsn.org Acknowledgements Psychological First Aid - Field Operations Guide Psychological

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 National Child Traumatic Stress Network National Center for PTSD Psychological First Aid Field Operations Guide 2nd Edition

Introduction and Overview:  What is Psychological First Aid?  Who is Psychological First Aid for?  Who Delivers Psychological First Aid?  When Should Psychological First Aid Be Used?  Where Should Psychological First Aid Be Used?  Strengths of Psychological First Aid  Basic Objectives of Psychological First Aid  Delivering Psychological First Aid

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National Child Traumatic Stress Network National Center for PTSD Introduction and Overview  modular approach to help children, modular approach  Consistent with research evidence on risk and resilience following trauma research evidence on risk and resilience Consistent with in field settings Applicable and practical across the lifespan Appropriate for developmental levels in a flexible manner Culturally informed and delivered 1. 2. 3. 4. adolescents, adults, and families in the immediate aftermath of disaster and terrorism. aftermath of disaster and terrorism. and families in the immediate adolescents, adults, the initial distress caused by traumatic Aid is designed to reduce Psychological First and functioning and coping. Principles short- and long-term adaptive events and to foster They are: basic standards. Aid meet four First techniques of Psychological develop severe mental Aid does not assume that all survivors will Psychological First based on an Instead, it is in recovery. health problems or long-term difficulties by such events will experience and others affected understanding that disaster survivors example, physical, psychological, behavioral, a broad range of early reactions (for will cause enough distress to interfere with adaptive spiritual). Some of these reactions by support from compassionate and caring disaster coping, and recovery may be helped responders. Psychological First Aid is designed for delivery by mental health and other disaster Psychological First children, families, and adults response workers who provide early assistance to affected These providers may be imbedded disaster response effort. as part of an organized command in a variety of response units, including first responder teams, incident health care, school crisis response teams, faith-based systems, primary and emergency Medical Reserve Corps, (CERT), Teams Response Community Emergency organizations, the Citizens Corps, and other disaster relief organizations. Psychological First Aid intervention strategies are intended for use with children, Aid intervention strategies are intended for Psychological First and adults exposed to disaster or terrorism. adolescents, parents/caretakers, families, and other disaster relief Aid can also be provided to first responders Psychological First workers. Psychological First Aid is an evidence-informed Psychological First Introduction Overview and Psychological First Aid is supported by disaster mental health experts as the “acute intervention of choice” when re- Psychological First Psychological First Aid - Field Operations Guide Psychological sponding to the psychosocial needs of children, adults and families affected by disaster and terrorism. At the time of this by disaster and terrorism. sponding to the psychosocial needs of children, adults and families affected because many of the components have been guided writing, this model requires systematic empirical support; however, ways to help survivors manage effective by research, there is consensus among experts that these components provide services. post-disaster distress and adversities, and to identify those who may require additional  Who Delivers Psychological First Aid? Who Delivers Psychological First Who is Psychological First Aid For? Who is Psychological First What is Psychological First Aid? First Psychological What is Introduction and Overview gency operations gency operations National Child Traumatic Stress Network National Center for PTSD Stress Network Center for National Child Traumatic National Establish a human connection in a non-intrusive, compassionate manner. Establish a human connection in a non-intrusive, compassionate and provide physical and emotional Enhance immediate and ongoing safety, comfort. Calm and orient emotionally overwhelmed or distraught survivors. and concerns are, Help survivors to tell you specifically what their immediate needs and gather additional information as appropriate. practical assistance and information to help survivors address their immediate Offer needs and concerns. Psychological First Aid includes basic information-gathering techniques to help Aid includes basic information-gathering Psychological First needs, and immediate concerns and of survivors’ providers make rapid assessments in a flexible manner. to implement supportive activities strategies that can Aid relies on field-tested, evidence-informed Psychological First settings. be provided in a variety of disaster appropriate Aid emphasizes developmentally and culturally Psychological First ages and backgrounds. interventions for survivors of various information for Aid includes handouts that provide important Psychological First use over the course of recovery. youth, adults, and families for their ...... Psychological First Aid is designed for delivery in diverse settings. Mental health and in diverse settings. Mental health Aid is designed for delivery Psychological First to provide Psychological First workers may be called upon other disaster response shelters, field hospitals and medical shelters, special needs Aid in general population staging areas Departments), care facilities (for example, Emergency triage areas, acute workers, emer for first responders or other relief or respite centers disaster assistance service or phone banks, feeding locations, centers, crisis hotlines centers, homes, businesses, and other community centers, family reception and assistance Aid in the challenges of providing Psychological First settings. For more information on Appendix B. various service settings, see Psychological First Aid is a supportive intervention for use in the immediate aftermath of aftermath use in the immediate intervention for is a supportive Aid First Psychological and terrorism. disasters  Basic Objectives of Psychological First Aid Basic Objectives of Psychological First Strengths of Psychological First Aid First Strengths of Psychological Where Should Psychological First Aid Be Used? Psychological First Where Should When Should Psychological First Aid Be Used? Aid First Should Psychological When Introduction and Overview  Operate only within the framework of an authorized disaster response system. Operate only within the framework and helpful. courteous, organized, Model healthy responses; be calm, Be visible and available. Maintain confidentiality as appropriate. expertise and your designated role. Remain within the scope of your additional expertise is needed or requested by the Make appropriate referrals when survivor. to issues of culture and diversity. Be knowledgeable and sensitive and physical reactions, and practice self-care. Pay attention to your own emotional Then ask simple respectful questions to intrude. Politely observe first; don’t determine how you may help. (food, water, Often, the best way to make contact is to provide practical assistance blankets). person or family, Initiate contact only after you have observed the situation and the and have determined that contact is not likely to be intrusive or disruptive. contact. Be prepared that survivors will either avoid you or flood you with Be patient, responsive, and sensitive. Speak calmly. Connect survivors as soon as possible to social support networks, including family including social support networks, as possible to survivors as soon Connect helping resources. and community friends, neighbors, members, and empower and strengths, efforts acknowledge coping adaptive coping, Support to take an active role in their adults, children, and families survivors; encourage recovery. with the psychological effectively that may help survivors cope Provide information impact of disasters. link the survivor to another and (when appropriate) availability, Be clear about your systems, mental health response team or to local recovery member of a disaster services, and organizations. services, public-sector ...... Psychological First Aid - Field Operations Guide Psychological Professional Behavior Aid Guidelines for Delivering Psychological First Delivering Psychological First Aid First Delivering Psychological Introduction and Overview National Child Traumatic Stress Network National Center for PTSD Stress Network Center for National Child Traumatic National Speak slowly, in simple concrete terms; don’t use acronyms or jargon. use acronyms terms; don’t in simple concrete Speak slowly, on hearing you listen, focus When be prepared to listen. want to talk, If survivors help. tell you, and how you can be of what they want to has done to keep safe. positive features of what the survivor Acknowledge the goals and clarify immediate that directly addresses the survivor’s Give information as needed. answers repeatedly for your audience. that is accurate and age-appropriate Give information to the look at and talk through a translator or interpreter, When communicating the translator or interpreter. person you are addressing, not at distress, assist with Aid is to reduce First Remember that the goal of Psychological functioning, not to elicit details of traumatic current needs, and promote adaptive experiences and losses. what survivors are experiencing or what they have Do not make assumptions about been through. to a disaster will be traumatized. Do not assume that everyone exposed are understandable and expectable given Do not pathologize. Most acute reactions have experienced. Do not label reactions as what people exposed to the disaster “diagnoses,” “conditions,” “pathologies,” or “symptoms,” or speak in terms of “disorders.” on his/her helplessness, or focus the survivor, Do not talk down to or patronize Focus instead on what the person has done weaknesses, mistakes, or disability. or may have contributed to helping others in need, both during the that is effective disaster and in the present setting. Often, being Do not assume that all survivors want to talk or need to talk to you. people feel safer and physically present in a supportive and calm way helps affected more able to cope. Do not “debrief” by asking for details of what happened. possibly inaccurate information. If you cannot answer a Do not speculate or offer question, do your best to learn the facts. survivor’s ......  Guidelines for Delivering Psychological First Aid - continued First Psychological for Delivering Guidelines Avoid Some Behaviors to Introduction and Overview  For young children, sit or crouch at the child’s eye level. crouch at the child’s children, sit or For young provide and questions; feelings, concerns verbalize their children Help school-age example, mad, sad, scared, common emotional reactions (for simple labels for may or “horrified” because this use extreme words like “terrified” worried). Do not increase their distress. sure you understand him/her. and check in with the child to make Listen carefully regression in their behavior and may show developmental Be aware that children use of language. children typically Younger level. developmental to the child’s Match your language concepts like “death.” Use direct and simple have less understanding of abstract language as much as possible. respect their to adolescents “adult-to-adult,” so you give the message that you Talk feelings, concerns, and questions. to help them provide parents/caregivers the child’s Reinforce these techniques with their child. appropriate emotional support to as vulnerabilities. Many older adults have Older adults have strengths as well of dealing with adversities. coping skills over a lifetime acquired effective a low pitch. speak clearly and in difficulty, For those who may have a hearing appearance or age, for example, make assumptions based only on physical Don’t reasoning, problems with memory, that a confused elder has irreversible confusion may include: disaster-related or judgment. Reasons for apparent poor disorientation due to change in surroundings; poor vision or hearing; problems with nutrition or dehydration; sleep deprivation; a medical condition or medications; social isolation; and feeling helpless or vulnerable. or confused An older adult with a mental health disability may be more upset to make in unfamiliar surroundings. If you identify such an individual, help arrangements for a mental health consultation or referral. or other When needed, try to provide assistance in an area with little noise stimulation. unless direct communication rather than the caretaker, Address the person directly, is difficult...... Psychological First Aid - Field Operations Guide Psychological Working with Older Adults with Older Working Survivors with Disabilities With Working Working With Children and Adolescents and Children With Working Introduction and Overview - continued National Child Traumatic Stress Network National Center for PTSD Stress Network Center for National Child Traumatic National If communication (hearing, memory, speech) seems impaired, speak simply and speak simply seems impaired, speech) memory, (hearing, If communication slowly. if the disability is who claims to have a disability–even the word of a person Take to you. not obvious or familiar can I do to help?” and trust what of how to help, ask, “What When you are unsure the person tells you. the person to be self-sufficient. When possible, enable him/her move about in person your arm to help a blind or visually impaired Offer unfamiliar surroundings. and make arrangements for the person to to write down information If needed, offer receive written announcements. oxygen tank, respiratory equipment, and Keep essential aids (such as medications, wheelchair) with the person...... 10 Working With Survivors with Disabilities with Disabilities Survivors With Working Psychological First Aid Field Operations Guide 2nd Edition

Preparing to Deliver Psychological First Aid:  Entering the Setting  Providing Services  Group Settings  Maintain a Calm Presence  Be Sensitive to Culture and Diversity  Be Aware of At-Risk Populations

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National Child Traumatic Stress Network National Center for PTSD Preparing to Deliver 13 Disoriented Confused Frantic or agitated . . . In some settings, Psychological First Aid may be provided in designated areas. In other Aid may be provided In some settings, Psychological First might need those who settings, providers may circulate around the facility to identify and interacting in the setting. assistance. Focus your attention on how people are reacting acute distress, including signs of Individuals who may need assistance include those showing individuals who are: Psychological First Aid begins when a disaster response worker enters an emergency an emergency worker enters Aid begins when a disaster response Psychological First for descriptions of Appendix B of a disaster (See management setting in the aftermath working within the framework of an entry involves various service delivery sites). Successful and decision-making are clearly (ICS) in which roles authorized Incident Command System all activities with authorized communication and coordinate defined. It is essential to establish entry also includes learning Effective the setting. that are managing personnel or organizations policies and organization, for example, leadership, as much as you can about the setting, information need to have accurate You and available support services. procedures, security, This and where they can be found. services are available, about what is going to happen, what that providing such information is soon as possible, given information needs to be gathered as coping. promoting adaptive often critical to reducing distress and In order to be of assistance to disaster-affected communities, the Psychological First Aid First the Psychological communities, to disaster-affected In order to be of assistance the event, current circumstances, and the knowledgeable about the nature of provider must be of relief and support services. type and availability provider. Aid a Psychological First as are important when working Planning and preparation of your incident command in disaster mental health and knowledge Up-to-date training may also be working You relief work. components in undertaking disaster structure are critical which require additional in-depth all of adults and special populations, with children, older response, you should consider your participate in disaster knowledge. In deciding whether to circumstances, work and family your health, current your work, of type this with level comfort C for more guidance in Appendix self-care. See and be prepared to engage in appropriate regard to these topics. Preparing to Deliver Preparing to Deliver First Aid Psychological Psychological First Aid - Field Operations Guide Psychological Providing Services Entering the Setting Preparing to Deliver

- continued - continued National Child Traumatic Stress Network National Center for PTSD Stress Network Center for National Child Traumatic National Tailor the discussion to the group’s shared needs and concerns. the discussion to the group’s Tailor strategies to immediate and applying coping Focus the discussion on problem-solving issues. lapse into complaints. Do not let discussion about concerns him/her after the group meet with to offer If an individual needs further support, discussion. Panicky or “shut down” withdrawn, apathetic, Extremely or angry Extremely irritable Exceedingly worried Providers of Psychological First Aid must be sensitive to culture, ethnic, religious, racial, and Aid must be sensitive to Providers of Psychological First you should be aware of your own Whether providing outreach or services, language diversity. community from those of the values and prejudices, and how these may agree with or differ this awareness. Helping to in cultural competence can facilitate Training being served. roles, and social structure, gender maintain or reestablish customs, traditions, rituals, family Information about of a disaster. bonds is important in helping survivors cope with the impact other psychological reactions are the community being served, including how emotions and People take their cue from how others are reacting. By demonstrating calmness and clear are reacting. By demonstrating People take their cue from how others you. Others may follow your lead thinking, you can help survivors feel that they can rely on or hopeful. Psychological effective, in remaining focused, even if they do not feel calm, safe, cannot always feel while they the sense of hope that survivors Aid providers often model First pressing concerns. are still attempting to deal with what happened and current While Psychological First Aid is primarily designed for working with individuals and with individuals and for working Aid is primarily designed First While Psychological such as when families gather can be used in group settings, families, many components The components of briefings. ones and for security together for information about loved applied to these spontaneous group and safety can be providing information, support, comfort, games for distraction can reduce adolescents, offering situations. For groups of children and days in a shelter setting. anxiety and concern after hours and following in mind: When meeting with groups, keep the ...... 14 Be Sensitive to Culture and Diversity Maintain a Calm Presence Group Settings Group Settings Providing Services Providing Preparing to Deliver 15 deportation), and lack of Separated from parents/caregivers died have family members, or friends Whose parents/caregivers, missing injured or are Whose parents/caregivers were significantly Involved in the foster care system     Those who have been injured and displacements Those who have had multiple relocations Medically frail children and adults Those with serious mental illness illness, or sensory deficit Those with physical disability, Adolescents who may be risk-takers abuse problems Adolescents and adults with substance Pregnant women Mothers with babies and small children Disaster response personnel home, pets, family Those with significant loss of possessions (for example, memorabilia) life threat Those exposed first hand to grotesque scenes or extreme Children, especially those: Children, especially Especially in economically disadvantaged groups, a high percentage of survivors may have Especially in economically disadvantaged groups, a high assault, disaster). a loved one, experienced prior traumatic events (for example, death of of pre- may have higher rates communities As a consequence, minority and marginalized for developing at greater risk existing trauma-related mental health problems, and are of Mistrust, stigma, fear (for example, problems following disaster. Individuals that are at special risk after a disaster include: Individuals that are expressed, attitudes toward government agencies, and receptivity to counseling, should be to counseling, and receptivity government agencies, attitudes toward expressed, understand represent and best who cultural leaders of community with the assistance gathered groups. local cultural knowledge about disaster relief services are important barriers to seeking, providing, and knowledge about disaster relief services are important barriers to regions are more Those living in disaster-prone receiving services for these populations. likely to have had prior disaster experiences...... Psychological First Aid - Field Operations Guide Psychological Be Aware of At-Risk Populations At-Risk of Aware Be

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16 National Child Traumatic Stress Network National Center for PTSD Psychological First Aid Field Operations Guide 2nd Edition

Core Actions:  Contact and Engagement  Safety and Comfort  Stabilization  Information Gathering: Current Needs and Concerns  Practical Assistance  Connection with Social Supports  Information on Coping  Linkage with Collaborative Services

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National Child Traumatic Stress Network National Center for PTSD Core Actions 19 specific (if needed) Linkage with Collaborative Services link survivors with available services needed at the time or in the future. To Goal: Goal: To offer practical help to survivors in addressing immediate needs and practical offer To Goal: concerns. Connection with Social Supports establish brief or ongoing contacts with primary support persons help To Goal: family members, friends, and community and other sources of support, including helping resources. Information on Coping provide information about stress reactions and coping to reduce distress To Goal: and promote adaptive functioning. Stabilization and orient emotionally overwhelmed or disoriented survivors. calm To Goal: Needs and Concerns Information Gathering: Current immediate needs and concerns, gather additional information, identify To Goal: Aid interventions. and tailor Psychological First Assistance Practical Contact and Engagement contacts in a non- initiated by survivors, or to initiate respond to contacts To Goal: and helpful manner. intrusive, compassionate, Safety and Comfort and and provide physical and ongoing safety, enhance immediate To Goal: emotional comfort. needs and concerns. 8. 7. Aid constitute the basic objectives of providing These core actions of Psychological First should be flexible, early assistance within days or weeks following an event. Providers survivors’ and base the amount of time they spend on each core action on the 6. 5. 4. 3. 2. 1. Core Actions Psychological First Aid - Field Operations Guide Psychological Psychological First Aid Core Actions Aid Core First Psychological

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20 National Child Traumatic Stress Network National Center for PTSD Psychological First Aid Field Operations Guide 2nd Edition

Contact and Engagement:  Introduce Yourself/Ask about Immediate Needs  Confidentiality

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National Child Traumatic Stress Network National Center for PTSD Contact and Engagement

23 , confidence, When you non- contacts in a to initiate The type of physical or personal contact considered appropriate may vary The type of physical or personal contact considered Alert: e by survivors, or initiated to contacts respond To Introduce yourself with your name, title, and describe your role. Ask for permission to Introduce yourself with your name, title, and describe your role. that you are there to see if you can be of help. Unless given and explain talk to him/her, Invite the person to permission to do otherwise, address adult survivors using last names. the person your full sit, try to ensure some level of privacy for the conversation, and give Refrain from looking around or being distracted. Find attention. Speak softly and calmly. Immediate out whether there is any pressing problem that needs immediate attention. medical concerns have the utmost priority. to first make a When making contact with children or adolescents, it is good practice role and seek permission. connection with a parent or accompanying adult to explain your a parent or caregiver as If you speak with a child in distress when no adult is present, find soon as possible to let him/her know about your conversation. identify such persons, timing is important. Do not interrupt conversations. Do not assume identify such persons, timing is important. outreach with immediate positive reactions. It may take that people will respond to your persons to feel some degree of safety time for some survivors or bereaved of help, respect his/her decision and indicate your offer and trust. If an individual declines on. Aid provider later First when and where to locate a Psychological from person to person and across cultures and social groups, for example, how close to from person to person and across contact to make or whether or not to touch someone, stand to someone, how much eye sex. Unless you are familiar with the culture of the especially someone of the opposite You make prolonged eye contact, or touch. you should not approach too closely, survivor, for “personal space,” and seek guidance about need should look for clues to a survivor’s cultural leaders who best understand local customs. cultural norms from community find out who is the spokesperson for the family and In working with family members, initially address this person. help, but may benefit from assistance. Some survivors may not seek your and helpful manner. compassionate, intrusive, and important. If managed in a respectful first contact with a survivor is Your and increase the helping relationship you can establish an effective compassionate way, should be to respond to survivors first priority Your to further help. receptiveness person’s with make contact you simultaneously, If a number of people approach who seek you out. be of interest and calm concern can as you can. Even a brief look as many individuals overwhelmed or confused. to people who are feeling grounding and helpful Cultur Goal: . Contact and Engagement1. Contact Psychological First Aid - Field Operations Guide Psychological Introduce Yourself/Ask about Immediate Needs Yourself/Ask Introduce Contact and Engagement Health - continued - continued (HIPAA) and the provisions related to and the Act (HIPAA) I’m checking in with people to see how they are doing, and with people to see how they are I’m checking in you for a Is it okay if I talk to in any way. to see if I can help before Williams, I ask your name? Mrs. few minutes? May like some something right now that you need, we talk, is there water or fruit juice? softly.) using her/his name and speaking and greet the child, here to try to help you and Hi Lisa, I’m ______and I’m There is Is there anything you need right now? your family. and we have a few blankets some water and juice over there, and toys in those boxes. National Child Traumatic Stress Network National Center for PTSD Stress Network Center for National Child Traumatic National Adult/Caregiver with ______. name is ______. I work Hello. My Adolescent/Child eye level, smile (Get on child’s And is this your daughter? Insurance Portability and Accountability Insurance Portability and Protecting the confidentiality of your interactions with children, adults, and families Protecting the confidentiality of especially given the lack of privacy in some post- after a disaster can be challenging, of confidentiality possible in maintaining the highest level disaster settings. However, survivors or disaster responders is extremely important. any conversation you have with to a category of mandated reporters, you should If you are a professional who belongs should also be aware of the You reporting laws. abide by state abuse and neglect disaster and terrorism. If you have questions about releasing information, discuss this disaster and terrorism. If you have Talking to co-workers about the challenges of charge. with a supervisor or an official in can be helpful, but any discussions organized working in the post-disaster environment for this purpose also need to preserve strict confidentiality. For example, in making initial contact, you might say: initial contact, you in making For example, 24 Confidentiality Introduce Yourself/Ask about Immediate Needs Needs about Immediate Yourself/Ask Introduce Psychological First Aid Field Operations Guide 2nd Edition

Safety and Comfort:  Ensure Immediate Physical Safety  Provide Information about Disaster Response Activities and Services  Attend to Physical Comfort  Promote Social Engagement  Attend to Children Who Are Separated from their Parents/ Caregivers  Protect from Additional Traumatic Experiences and Trauma Reminders  Help Survivors Who Have a Missing Family Member  Help Survivors When a Family Member or Close Friend has Died  Attend to Grief and Spiritual Issues  Provide Information about Casket and Funeral Issues  Attend to Issues Related to Traumatic Grief  Support Survivors Who Receive Death Notification  Support Survivors Involved in Body Identification  Help Caregivers Confirm Body Identification to a Child or Adolescent

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National Child Traumatic Stress Network National Center for PTSD Safety and Comfort 27 and physical and provide and ongoing safety, immediate enhance To Find the appropriate officials who can resolve safety concerns that are beyond your Find the appropriate officials who etc. control, such as threats, weapons, other objects that Remove broken glass, sharp objects, furniture, spilled liquids, and could cause people to trip and fall. they are Make sure that children have a safe area in which to play and that adequately supervised. that may be Be aware and ensure the safety of survivors in a particular subgroup religion, or other affiliations. for persecution based on their ethnicity, targeted adequate Help make the physical environment safer (for example, try to ensure lighting, and protect against slipping, tripping, and falling). wheelchairs, Ask specifically about his/her needs for eyeglasses, hearing aids, to ensure that all essential aids are kept with Try walkers, canes, or other devices. the person. Do things that are active (rather than passive waiting), practical (using available active (rather than passive waiting), Do things that are on past experience). resources), and familiar (drawing information, while avoiding survivors’ Get current, accurate and up-to-date or excessively upsetting. exposure to information that is inaccurate resources. Get connected with available practical are making the situation safer. Get information about how responders shared similar experiences. Get connected with others who have To promote safety and comfort for survivors who are elderly or disabled, you can: To Make sure that individuals and families are physically safe to the extent possible. If Make sure that individuals and families the immediate environment to increase physical and emotional reorganize necessary, For example: safety. comfort. emotional in the immediate aftermath of sense of safety is an important goal Restoration of a can reduce distress and worry. Promoting safety and comfort disaster and terrorism. death ones, death of loved ones, in circumstances of missing loved Assisting survivors component of providing emotional body identification is a critical notification and comfort and support. of ways, including helping survivors: can be supported in a number Comfort and safety . . Goal: ...... Safety and Comfort and 2. Safety Psychological First Aid - Field Operations Guide Psychological Ensure Immediate Physical Safety Ensure Immediate Physical Safety and Comfort - continued - continued whether and when to present information. Does the individual National Child Traumatic Stress Network National Center for PTSD Stress Network Center for National Child Traumatic National Ask whether the survivor needs help with health-related issues or daily activities (for or daily activities issues help with health-related the survivor needs Ask whether and meals). daily grooming, use of bathroom, assistance with dressing, example, or has a list of current medications Ask if he/she need for medication. Inquire about current has a readable copy of this he/she can be obtained, and make sure where this information during the post-disaster period. information to keep they can be checked on more so that a list of survivors with special needs Consider keeping frequently. medication, and nutrition, safety, if they are available, to further ensure Contact relatives, that are not being met. needs the authorities are aware of any daily rest. Make sure that may hurt themselves or others for signs that persons Threat of harm to self or others–Look or others, exhibits extreme intense anger towards self (for example, the person expresses management by medical, for containment and agitation). If so, seek immediate support assistance, or a security team. EMT skin; weak or rapid pulse; of shock (pale, clammy Shock–If an individual is showing signs lack of to communication; eyes; unresponsive dizzy; irregular breathing; dull or glassy medical support. immediate or confused), seek bladder or bowel control; restless, agitated, What to do next What is being done to assist them What is currently known about the unfolding event services Available Common stress reactions Self-care, family care, and coping Use your judgment as to appear able to comprehend what is being said, and is he/she ready to hear the content of the appear able to comprehend what is being said, and is he/she messages? If there are medical concerns requiring urgent attention or immediate need for medication, or immediate attention urgent If there are medical concerns requiring with the affected Remain immediately. medical professional contact the appropriate unit leader or help. Other safety concerns him/her until you can obtain person or find someone to stay with involve: To help reorient and comfort survivors, provide information about: reorient and comfort survivors, provide information help To In providing information: ...... 28 Providing Information about Disaster Response Activities and Services Activities Disaster Response Providing Information about Ensure Immediate Physical Safety Immediate Ensure Safety and Comfort 29

sponding as well as they can right now. I am not sure that the fire I am not sure that sponding as well as they can right now. are not in has been completely contained, but you and your family safety family’s your about concerns any have you Do here. danger right now? done to have any questions about what happened, or what is being keep everyone safe? Here’s what’s going to happen next. You and your mom are going and your mom You next. going to happen what’s Here’s a safe which really is just together soon to a place called a shelter, here and a place to rest. Stay building with food, clean clothing, time to go. close to your mom until it’s Your mom and dad are here, and many people are all working Your hard together so that you and your family will be safe. Do you have any questions about what we’re doing to keep you safe? From what I understand, we will start transporting people to the transporting people From what I understand, we will start food, There will be School in about an hour. High West shelter at mem- A Please stay in this area. clean clothing, and a place to rest. to go. when we are ready ber of the team will look for you here Use clear and concise language, while avoiding technical jargon. technical while avoiding and concise language, Use clear Address immediate needs and concerns to reduce fears, answer pressing questions, pressing reduce fears, answer and concerns to immediate needs Address adaptive coping. and support Child Adult/Caregiver re- I want to assure you that the authorities are Williams, Mrs. Adolescent you working hard to make you and your family safe. Do We’re Adult/Caregiver/ Adolescent Child Do not reassure people that they are safe unless you have definite factual information that this safe unless you have Do not reassure people that they are or services (for example, of goods Also do not reassure people of the availability is the case. that such goods and services will have definite information toys, food, medicines) unless you on your understanding of the current do address safety concerns based be available. However, situation. For example, you may say: . . Ask survivors if they have any questions about what is going to happen, and give simple to happen, and give simple is going have any questions about what Ask survivors if they special Also, ask whether he/she has any about what they can expect. accurate information Be on the best placement. to decide should know about in order needs that the authorities to Try in their new situation. and safety concerns regarding current danger sure to ask about If you do not have specific concerns. with information that addresses these connect survivors to provide reassurance. Instead, guess or invent information in order information, do not can gather the needed information. the person for ways you and he/she develop a plan with you might say include: Examples of what Psychological First Aid - Field Operations Guide Psychological Safety and Comfort National Child Traumatic Stress Network National Center for PTSD Stress Network Center for National Child Traumatic National Visual loss, which can limit awareness of surroundings and add to confusion loss, which can limit awareness of surroundings and add Visual understanding of what others are saying Hearing loss, resulting in gaps in   Cognitive problems, such as difficulty with attention, concentration, and memory Cognitive problems, such as difficulty Lack of mobility surroundings Unfamiliar or over-stimulating Noise that can limit hearing and interfere with hearing devices to wait in long Limited access to bathroom facilities or mass eating areas, or having needed a wheelchair before the event may need one person who has not lines (A now.) Concern for the safety of a service animal Health problems, such as physical illness, problems with blood pressure, fluid and Health problems, such as physical (supplemental oxygen dependency), frailty electrolyte balance, respiratory issues extremes) temperature and bruising, injuries, minor falls, to susceptibility (increased Age-related sensory loss: Facilitate group and social interactions as appropriate. It is generally soothing and Facilitate group and social interactions as appropriate. It is generally situation. On the reassuring to be near people who are coping adequately with the and emotionally other hand, it is upsetting to be near others who appear very agitated ...... Look for simple ways to make the physical environment more comfortable. If possible, more comfortable. environment make the physical simple ways to Look for how to furniture, and access air quality, lighting, things like temperature, consider of helplessness or dependency, In order to reduce feelings the furniture is arranged. needed for comfort (for example, to participate in getting things encourage survivors than retrieving supplies for area with the person rather to walk over to the supply offer and others around them. to soothe and comfort themselves him/her). Help survivors can hold and take care of can help like soft teddy bears that they For children, toys such toys if there are not enough avoid offering However, them to soothe themselves. can help children learn how to You children who may request them. to go around to all “care” for their toy (for example, by explaining how they can take care of themselves can and eat three meals a day–and you she needs to drink lots of water “Remember that do that, too”). people with disabilities, pay attention to factors that When working with the elderly or When attending to stress or worsen medical conditions. may increase their vulnerability be mindful of: to the physical needs of these survivors, 30 Promote Social Engagement Attend to Physical Comfort to Physical Attend Safety and Comfort 31 That man is so upset that he can’t calm down yet. Some people calm down yet. Some people that he can’t That man is so upset is team our down than others. Someone from take longer to calm impor- it is him calm down. If you feel upset, coming over to help can else who to your mom or dad, or someone tant for you to talk help you feel better. Help to create a designated child-friendly space, such as a corner or a room that is Help to create a designated child-friendly space, such as a corner safe, out of high traffic areas, and away from rescue activities. by caregivers with experience and skill in Arrange for this space to be staffed ages. working with children of different do not leave Monitor who comes in and out of the child area to ensure that children with an unauthorized person. Child/Adolescent Parents and caregivers play a crucial role in children’s sense of safety and security. safety and security. sense of role in children’s Parents and caregivers play a crucial caregivers, helping them reconnect quickly is a If children are separated from their (such as If you encounter an unaccompanied child, ask for information high priority. sibling names, address, and school), and notify the their name, parent/caregiver and accurate information in easy-to-understand appropriate authorities. Provide children them and what to expect next. Do not make any terms about who will be supervising they will see their promises that you may not be able to keep, such as promising that may also need to support children while their caregivers are being You caregiver soon. and not emotionally located or during periods when caregivers may be overwhelmed space. This support can include setting up a child-friendly accessible to their children. . . . As appropriate, encourage people who are coping adequately to talk with others who are As appropriate, encourage people Reassure them that talking to people, especially about distressed or not coping as well. example, coming from nearby neighborhoods or having things they have in common (for reduces This often help them support one another. children about the same age), can in both parties. For children, encourage social a sense of isolation and helplessness cards, board games, and playing a joint art activity, activities like reading out loud, doing or sports. overwhelmed. If survivors have heard upsetting information or been exposed to rumors, or been exposed information have heard upsetting If survivors overwhelmed. misinformation. and correct help to clarify adults for likely to look to are particularly adolescents, and to some extent Children, place children near adults When possible, and appropriate behavior. cues about safety to avoid putting them too close relatively calm, and when possible, or peers who appear to children and adolescents brief explanations are extremely upset. Offer individuals who extreme reactions in other survivors. who have observed Psychological First Aid - Field Operations Guide Psychological Set Up a Child-Friendly Space Attend to Children Who Are Separated from their Parents/Caregivers Attend to Children Who Safety and Comfort - continued You’ve been through a lot, and it’s a good idea to shield yourself a good idea to shield yourself been through a lot, and it’s You’ve and and your children from further frightening or disturbing sights disaster sounds as much as possible. Even televised scenes of the children may find that your You can be very disturbing to children. It feel better if you limit their television viewing of the disaster. coverage, hurt for adults to take a break from all the media doesn’t too. National Child Traumatic Stress Network National Center for PTSD Stress Network Center for National Child Traumatic National Stock the child-friendly space with materials for all age ranges. This can include This for all age ranges. space with materials child-friendly Stock the markers, books, crayons, balls, paper, board games, toys, playing cards, kits with and glue. safety scissors, tape, or wooden building blocks, calming include playing with Legos, Activities that are books (containing neutral scenes cut-outs, working on coloring play dough, doing playing team games. trees, or cute animals) and of flowers, rainbows, models for younger or adolescents to serve as mentors/role Invite older children group play can do this by helping you conduct They children, as appropriate. book to them or playing with them. children, or by reading a activities with younger to get together to talk about their concerns, Set aside a special time for adolescents activities like listening to music, playing games, and to engage in age-appropriate making a scrapbook. making up and telling stories, or Adult/Caregiver . survivors from it is also important to protect In addition to securing physical safety, traumatic events and trauma reminders, including unnecessary exposure to additional shield help protect their privacy, To be frightening. sights, sounds, or smells that may Advise personnel, onlookers, or attorneys. survivors from reporters, other media to be interviewed by the media, and that if they wish to adolescents that they can decline have a trusted adult with them. be interviewed, they may want to coverage (for example, television or radio broadcasts), If survivors have access to media of such coverage can be highly upsetting, especially point out that excessive viewing parents to monitor and limit their children’s for children and adolescents. Encourage any concerns after such viewing. Parents can let exposure to the media, and to discuss keeping track of information, and to come to them for their children know that they are about what they updates instead of watching television. Remind parents to be careful to them. For say in front of their children, and to clarify things that might be upsetting example, you might say: . . . 32 Protect from Additional Traumatic Experiences and Trauma Reminders and Trauma Experiences Additional Traumatic Protect from Set Up a Child-Friendly Space a Child-Friendly Set Up Safety and Comfort 33 s, etc.) and share these with . It provides a variety of tools and services needed to . It provides a variety of tools and services go to the internet after something like this, but doing this can be pretty be pretty doing this can like this, but internet after something go to the this programs that show or radio TV from best to stay away It’s scary. that dad if you see something can also tell your mom or You stuff. bothers you. www.redcross.org Adolescent/Child or TV to watch People often want lot already. a been through You’ve survivors. Just being member. a missing family extra time with survivors worried over may want to take You and answering in giving information hopes and fears, and being honest there to listen to survivors’ an you can make member, family help locate a missing To questions is often deeply appreciated. contact, including school or pre-disaster plans for post-disaster initial review with the family of any care; or co-workers for medical tracking transport of students workplace evacuation plans; plans for in case of emergency; or families used by schools, workplaces, out-of-state telephone numbers to be of relatives), both within and places (including homes and any pre-arranged or likely meeting outside the disaster perimeter. to find or rescue a missing loved Some family members may want to leave a safe area to attempt specific in the search area, one. In this case, inform the survivor about the current circumstances may be of first responders, and when updated information dangers, needed precautions, the efforts who recently an elderly parent available. Discuss specific concerns they may have (for example, to inform the appropriate offer and or a child who needs special medications), had hip surgery, authorities. to help the or other evidence In some cases, authorities may ask survivors to give information persons report or provide information Authorities may have family members file a missing search. else was there, and what he/she was about when and where the missing person was last seen, who to this process. wearing. It is best to limit the exposure of younger children communicate with loved ones during times of emergency. Try to identify other official sources Try times of emergency. communicate with loved ones during radio and television channel of updated information (police, official Coping while a loved one is missing is extremely difficult. Family members may experience a may experience members Family one is missing is extremely difficult. Coping while a loved between They may alternate shock, or guilt. hope, anger, denial, worry, feelings: number of different hopelessness evidence—and is alive—even in the face of contradictory certainty that the person for not trying hard enough, or for authorities for not having answers, They may blame and despair. responsible for locating their that they consider They may also feel vengeful against those delays. police, and children that the family, important to reassure missing relative or friend. It is extremely missing loved one. possible to find the other first responders are doing everything them obtain updated information loved one by helping Assist family members who have a missing and tell them the plan in locations for updated briefings, about missing persons, direct them to a “Disaster Cross has established American Red The place for connecting/reuniting survivors. a “Safe and and reunification, and System” to support family communication Information Welfare located at website Well” Psychological First Aid - Field Operations Guide Psychological Help Survivors Who Have a Missing Family Member Who Have a Missing Help Survivors Safety and Comfort - continued - continued Uncle Mario is missing. Everyone is working very hard to find out to Everyone is working very hard Uncle Mario is missing. to ask helping too and they need The police are what happened. okay if you do not remember something. you some questions. It’s some- Not remembering remember. Just tell them that you don’t you the will stay with mom Your thing will not hurt Uncle Mario. ques-any have Do you want. you if too, stay can I and time, whole tions? Beliefs and attitudes about death, funerals, and expressions of grief are Beliefs and attitudes about death, funerals, and expressions of grief National Child Traumatic Stress Network National Center for PTSD Stress Network Center for National Child Traumatic National Alert: Adolescent/Child It can be disturbing and confusing for a child to be present at a caregiver’s interview interview at a caregiver’s to be present confusing for a child disturbing and It can be to the might have happened about what adult speculations or to hear with authorities a loved one’s from member to collect DNA Authorities may ask a family missing person. cases, a child may need to be hair from a hairbrush. In rare for example, personal effects, health mental A the missing person. he/she was the last one to see interviewed because or should conduct the interview trained to interview children or forensic professional to the Talk or you should accompany the child. supportive family member A be present. say: For example, you might honestly. child simply and Culture strongly influenced by family, culture, religious beliefs, and rituals related to mourning. strongly influenced by family, leaders who best Learn about cultural norms with the assistance of community cultural belief and practices understand local customs. Even within cultural and religious groups, Do not assume that all members of a given group will believe or behave can vary widely. It is important for families to engage in their own traditions, practices, and the same way. of emotional responses rituals to provide mutual support, seek meaning, manage a range and death-related adversities, and honor the dead person. Sometimes in the case of missing persons, the evidence will strongly suggest that the Sometimes in the case of missing among family members about the status of There may be disagreement person is dead. (some giving members know that these differences should let family You their loved one. are common in a family when a loved one is missing, up hope, some remaining hopeful) can encourage You they love the person or each other. and not a measure of how much feelings until and respectful of each other’s family members to be patient, understanding, should not assume that it is better for a there is more definite news. Parents/caregivers is alive, but instead honestly share the concern that child to keep hoping that the person should check with children to make sure the loved one may be dead. Parents/caregivers what questions they have. that they have understood, and ask 34 Help Survivors When a Family Member or Close Friend has Died Help Survivors When a Family Member or Close Help Survivors Who Have a Missing Family Member Family Have a Missing Who Help Survivors Safety and Comfort 35 are likely to be intense and prevalent among those who have those who have prevalent among to be intense and are likely It is important to know that each family member may express their It is important to know that each family member may express a lot. while others might cry Some may not cry, grief differently. there is Family members should not feel badly about this or think respect What is most important is to something wrong with them. and ways each feels, and help each other in the days the different weeks ahead. Treat acutely bereaved children and adults with dignity, respect, and compassion. respect, and compassion. adults with dignity, acutely bereaved children and Treat from person to person. Grief reactions vary of grieving. There is no single “correct” course medications, increased of over-the-counter Grief puts people at risk for abuse Make survivors aware of these risks, the smoking, and consumption of alcohol. availability of professional help. importance of self-care, and the friends will each have their own special set Discuss how family members and grieving is right or wrong, and there is not a of reactions; no particular way of is most important for family members What “normal” period of time for grieving. how each may be experiencing their own and friends is to respect and understand course of grief. friends how culture or religious beliefs influence Discuss with family members and how rituals may or may not satisfy current how people grieve and especially feelings of each family member. of time each Keep in mind that children may only show their grief for short periods or engage in other positive activities, their grief and even though they may play day, can be just as strong as that of any other family member. Adult/Adolescent/ Child ...... Reactions Acute Grief suffered the death of a loved one or close friend. They may feel sadness and anger over sadness and They may feel close friend. of a loved one or the death suffered not providing regret about to prevent the death, having been able guilt over not the death, for reunion and wishing missing the deceased, leave-taking, or having a proper comfort, at first, Although painful to experience of seeing the person again). (including dreams Over time, the significance of the death. healthy responses that reflect grief reactions are and activities, such as telling to include more pleasant thoughts grief reactions tend You ways of remembering him/her. a loved one, and comforting positive stories about should remember: experienced the death of a family member or close In working with survivors who have friend, you can: emphasize how important is it for family members to understand and respect each To course of grief, you may say: other’s Psychological First Aid - Field Operations Guide Psychological Safety and Comfort - continued - continued National Child Traumatic Stress Network National Center for PTSD Stress Network Center for National Child Traumatic National say: I know how you feel. It was probably for the best. now. He is better off It was her time to go. At least he went quickly. talk about something else. Let’s should work towards getting over this. You are strong enough to deal with this. You should be glad he passed quickly. You kill us makes us stronger. That which doesn’t feel better soon. You’ll did everything you could. You need to grieve. You need to relax. You Reassure grieving individuals that what they are experiencing is understandable and is understandable individuals that what they are experiencing Reassure grieving expectable. as “the deceased.” to him/her name, rather than referring person’s Use the deceased periods of sadness, continue to experience Let them know that they will most likely loneliness, or anger. daily that affects them that if they continue to experience grief or depression Tell in grief is who specializes a counselor or the clergy functioning, talking to a member of advisable. mental health, or their local city or county department of their them that their doctor, Tell services. hospital can refer them to appropriate ...... Don’t Some children and adolescents will not have words to describe their feelings of grief and may of grief their feelings words to describe will not have and adolescents Some children be more will activities Sometimes, distracting how they feel. with others about resist talking wish etc. Some may to music, reading, for example, drawing, listening calming than conversation, does want to talk with you When a survivor provide them with some privacy. to be alone. If safe, compelled to talk a lot. Do not probe. and not feel you should listen quietly, about the loved one, Do: 36 Help Survivors When a Family Member or Close Friend has Died or Close Friend Member a Family When Help Survivors Safety and Comfort 37 varies depending on age and prior experience varies depending on age and prior affects children differently depending on their age. children differently affects death and adolescent understanding of death of a parent/caregiver Pre-school children may not understand that death is permanent, and may believe that and may believe that death is permanent, Pre-school children may not understand of a reality the physical help to confirm They need if they wish it, the person can return. has no feelings–and or having death–that he/she is no longer breathing, moving person’s bad happening to another something They may be concerned about discomfort or pain. family member. but may personify of death, the physical reality School-age children may understand they may experience for his/her return, death as a monster or skeleton. In longing anyone. but not tell presence of the lost person, upsetting feelings of the “ghostlike” Losing a family member or that death is irreversible. Adolescents generally understand or school, running away, decisions, such as quitting friend can trigger rage and impulsive the family or school. attention by These issues need prompt abusing substances. Pre-school children need consistent care and a predictable daily routine as soon as Pre-school children need consistent care and a predictable their special differently, They can be easily upset by change: food prepared possible. usual person or in a different blanket missing, or being put into bed at night without the the child if they are doing parent) should ask Caregivers (including the surviving way. “Am I not doing this the way or something “wrong” (for example, something differently Mommy did?”). but also the person who his/her primary caregiver, school-age child loses not only A Other activities. daily would normally be there to comfort him/her and help with Children may be angry at a as best they can, to assume these roles. caregivers should try, should acknowledge that the when disciplined. Caregivers especially substitute caregiver, extra comfort. and then provide child is missing his/her parent/caregiver, and protest over the death. Adolescents may experience an intense sense of unfairness, resent not being family and They may have to take on greater responsibilities within their It’s good that you are alive. that you are good It’s died. that no one else good It’s have a brother/sister/mother/father. worse; you still It could be plan. for the best according to a higher Everything happens we can bear. are not given more than We of the house now. are the man/woman You a child) (To have an answer. Someday you will . . . . . with death, and is strongly influenced by family, religious, and cultural values. and cultural religious, by family, with death, and is strongly influenced . The ...... If the grieving person says any of the above things, you can respectfully acknowledge the respectfully acknowledge the you can says any of the above things, If the grieving person yourself. initiate a statement like these but don’t feeling or thought, Child Psychological First Aid - Field Operations Guide Psychological Safety and Comfort - continued and talking with children for When Terrible Things Happen (Appendix E), Things When Terrible suggestions miss their father, like at mealtime or bedtime. If you say some- mealtime or bedtime. If you say like at miss their father, now,” thing like, “It is hard not to have daddy here with us right you can ease the discomfort everyone is feeling, make children feel less alone, and help them to better handle these difficult times. kind of When you see a sudden change in your children–looking lost or sad or even angry–and you suspect that they are missing you that you, too, have times when let them know their father, I’m won- seem really sad. Say something like, “You feel that way. very dering if you are thinking about your dad. Sometimes I feel bad okay to tell me when you are feeling sad about dad, too. It’s with so maybe I can help.” Help by giving them some time alone a hug. those feelings, sitting quietly with them, and giving them National Child Traumatic Stress Network National Center for PTSD Stress Network Center for National Child Traumatic National Assure children that they are loved and will be cared for. they are loved and will be cared Assure children that happened. what may be ready to talk about for signs that the child Watch or not wanting to talk. wanting child feel guilty or embarrassed about Do not make the to talk. Do not push children to their questions. answers Give short, simple, honest, and age-appropriate judgment. Listen carefully to their feelings without not their fault, and that it the death, that it was Reassure them that they did not cause that anyone did “wrong.” was not a punishment for anything and other rituals. burial, prayer, Answer questions honestly about funerals, questions over and over again. Be prepared to respond to the child’s a question. the answer to know Do not be afraid to say that you don’t able to have more independence or do the things that adolescents normally do. Over normally do. that adolescents or do the things more independence able to have needs. these different how to balance should discuss time, caregivers Parent/Caregiver will times when your children It can be helpful to think about describes common reactions to the death of a loved one and ways of coping. When speaking ways of coping. death of a loved one and describes common reactions to the to parents/caregivers, you can say: You should give information to parents/caregivers and children about reactions to the death about reactions to the death to parents/caregivers and children should give information You The handout, that they might experience. These include: death. adolescents about ...... You may give parents/caregivers some may give parents/caregivers some You 38 Help Survivors When a Family Member or Close Friend has Died or Close Friend Member a Family When Help Survivors Safety and Comfort 39 be so happy that we are all okay. You did not do anything wrong. wrong. did not do anything You are all okay. be so happy that we may not be enough; feelings of guilt Note: Saying this once provide to and again, and a parent may need may come up again and confusion ongoing worries with a child’s constant assistance about guilt. A good way to introduce this topic is to ask, “Do you have any religious or spiritual good way to introduce this topic is to ask, “Do you have any A to lead to a theological discussion or This question is not meant needs at this time?” If requested, you can refer them to a clergy to your engaging in spiritual counseling. member of their choice. religious Do not contradict or try to “correct” what a person says about his/her distress. beliefs, even if you disagree and think that it may be causing them to happen?” Do not try to answer religious questions like, “Why was this allowed than real requests These questions generally represent expressions of emotion rather for an answer. member of his/her If a person is clearly religious, ask if he/she wants to see a clergy faith. or sacred Many people rely on religious objects such as prayer beads, statues, this can help texts that they may have lost or left behind. Locating an object like member can clergy local A to increase their level of security and sense of control. often be of help in providing these items. Parent/Caregiver would Daddy could to try to save everybody. all did what we We In order to assist survivors with spiritual needs after a death, you should become familiar In order to assist survivors with spiritual response team on-site, and with ways to who may be part of the disaster with clergy religious groups to whom you can refer of local obtain contact information for clergy to rely on religious and spiritual beliefs/practices as a survivors. It is common for people one. Survivors may use religious language to talk way to cope with the death of a loved to engage in prayer or other religious practices. It is not about what is happening or want are not required to You beliefs in order to be supportive. necessary for you to share these own beliefs. Often, simply listening and attending is do or say anything that violates your include: Things to keep in mind all that is required. . . . . Children and adolescents sometimes feel guilty that they survived while other family survived while guilty that they sometimes feel and adolescents Children Families way. the death in some that they caused They may believe did not. members that, in events assure them responsibility and sense of dispel children’s need to help suggest that a you may For example, blame for what happened. they are not to like this, caregiver say: . Psychological First Aid - Field Operations Guide Psychological Attend to Grief and Spiritual Issues Attend to Grief and Spiritual Safety and Comfort - continued - continued National Child Traumatic Stress Network National Center for PTSD Stress Network Center for National Child Traumatic National Many times during disaster situations, well-meaning religious people Alert: Many times during disaster situations, well-meaning religious people

Survivors may want to pray alone or in a group. You may help by finding a suitable finding a suitable may help by You group. alone or in a may want to pray Survivors direction while facing in the proper For some people, them to do so. place for can help to orient them. You praying is important. regarding space and to officials in charge may also provide information You for religious observances. religious items needed Keep may decline if you feel uncomfortable. you to join in prayer, If you are asked If you are silence while they pray. may only involve standing in in mind that joining this can help your relationship in at the end with an “Amen,” comfortable joining the family. with the person and allowed in the If not or incense when they pray. Many people routinely light candles and assist them in finding a nearby place where an setting, explain this to survivors, open flame would be allowed. virtual certainty that survivor may voice hope for a miracle, even in the face of A take this as evidence that he/she has lost touch with their loved one has died. Do not way of continuing been said, but as the survivor’s reality or has not heard what has It is important to neither encourage or to function in devastating circumstances. discourage such hope. around death, particularly in regard to the care Every religion has specific practices complicated when the body is not These issues may be especially of dead bodies. may want a They Ask survivors about their religious needs in this area. recovered. member to advise them. clergy grief can be very loud and may seem out of In some cultures, expressions of families to a more private space to prevent them control. It may be helpful to move is upsetting to you, you should find someone from upsetting others. If the behavior else to assist the family. (a sign of If a survivor expresses anger associated with his/her religious beliefs Most people are not looking with him/her. spiritual distress), do not judge or argue If spiritual concerns are but a willing, non-judgmental listener. for an “answer,” you can ask if contributing to significant distress, guilt, or functional impairment, member. he/she would like a referral to a clergy ovider Pr seek out survivors in order to proclaim their own religious beliefs. If you become aware seek out survivors in order to proclaim their own religious beliefs. personnel or others in of activities like this, do not try to intervene; instead notify security charge...... 40 Attend to Grief and Spiritual Issues to Grief and Attend Safety and Comfort 41 attendance at a funeral, about children’s questions . In responding to questions, keep the following in mind: . In responding to questions, keep the gravesite Before asking children to choose, tell them what to expect if they attend, including attend, they if expect to what them tell choose, to children asking Before that there will be a be upset and crying. Explain letting them know that adults may Let them know (if that is to be arranged). special area for the family to sit together what will happen during the service. sit next to at the the person that they will Give them an opportunity to choose to them. can pay appropriate attention service. Make sure that this person that person, even to leave the service with Always provide a way for children if they become overwhelmed. temporarily, wish to attend, such as children about alternative arrangements if they do not Tell staying with a neighbor or friend of the family. on their something to say something or read If they choose not to attend, offer at a later time, behalf, and explain how they can participate in memorial activities including memorials of their own making.      It can be helpful for a child to attend a funeral. Although emotionally challenging, funerals Although emotionally a funeral. It can be helpful for a child to attend is part of grieving. If not of the death which help children accept the physical reality to the family. of something important included, children can feel left out not to attend a funeral or other a choice whether or Parents/caregivers should give children be pressured. They may be encouraged, but should not ritual. that they can explore the space. If possible, bring younger children to the location early so it. Caution should be Describe the casket and, if they wish, join them in approaching young child A touch the body. exercised in regard to allowing young children to view or can use a photograph of the person to help say goodbye. in distress. is not For younger children, reinforce that the deceased family member . . . . memorial service, or Local laws often govern the preparation of a body for burial and rules regarding caskets or rules regarding and body for burial preparation of a often govern the Local laws In many religious groups. of particular members for are made exceptions Sometimes internment. of or when the cause death traumatic of a requires autopsies for any victim jurisdictions, the law of religious groups to members may be upsetting, especially This requirement death is not clear. by requirements can be waived autopsy autopsies. In some jurisdictions, that normally prohibit out about should be helped to find autopsy Families who do not want an a Medical Examiner. local laws. with the suggest that–if it is in keeping may been significantly disfigured, you When a body has in on the casket of the deceased of the family–survivors place a photograph religious tradition was alive and pay their respects. to remember the person as he/she order to allow mourners can assist family members with their You Psychological First Aid - Field Operations Guide Psychological Provide Information about Casket and Funeral Issues and Funeral about Casket Information Provide Safety and Comfort - continued - continued bers may want to know details about what happened, but there what happened, but bers may want to know details about them. will be too upsetting for may be some details that you think help with a professional can Discussing what you went through you with family and also help you decide what to share with your your grief. National Child Traumatic Stress Network National Center for PTSD Stress Network Center for National Child Traumatic National Intrusive, disturbing images of the death that interfere with positive remembering and positive with images of the death that interfere Intrusive, disturbing reminiscing family and friends Retreat from close relationships with death the traumatic of usual activities because they are reminders of Avoidance circumstances the traumatic themes involving For children, repetitive play that includes of the death Adult/Adolescent mem- to have been there when Joe died. Other family It is awful Although it is unlikely that you will be asked to notify a family member of a death, you may member of a death, Although it is unlikely that you will be asked to notify a family FBI, may be asked by police, You assist family members who have been informed of a death. to be members (DMORT) Team hospital personnel or Disaster Mortuary Operational Response crashes, such as airline situations, present at the time of death notification. In some catastrophic before family members the accident the news media may report that there were no survivors of by the media or circulated sometimes As incorrect information is have been officially notified. confirmation from the authorities. other survivors–caution family members to wait for official . . . . After traumatic death, some survivors may stay focused on the circumstances of the death, of the death, the circumstances on some survivors may stay focused After traumatic death, been prevented, what the last have with how the death could including being preoccupied with grieving, making interfere may These reactions and who was at fault. moments were like, include: These reactions for survivors to adjust to the death. it more difficult course than time on a different often putting individuals These reactions can change mourning, to a family may want to speak privately You members. may be experienced by other family to advise him/her about the extra of the death in order member who was present at the time professional health to a mental him/her know that talking burden of witnessing the death. Let might say: you member may be very helpful. For example, or clergy You may be asked to attend funerals or other events. You may feel that this will help a family help a family this will may feel that You or other events. asked to attend funerals may be You of the family. and knowledge the permission funerals only with Attend or child. member 42 Support Survivors Who Receive Death Notification Attend to Issues Related to Traumatic Grief Related to Traumatic Attend to Issues Provide Information about Casket and Funeral Issues and Funeral about Casket Information Provide Safety and Comfort 43 if you want to cry or if you don’t want to cry. Anytime you want Anytime you want to cry. if you want to cry or if you don’t for to talk about her and what happened, I’m going to be here each can all help We see me have lots of feelings too. You’ll that. other. Don’t rush. Family members need time to process the news and ask questions. and need time to process the news rush. Family members Don’t over time. reactions: these will likely improve Allow for initial strong use the word “died,” not “lost” a person who is a confirmed fatality, When talking about or “passed away.” they (sympathy); YOU feel how members do not want to know Remember that family feel (empathy). THEY are trying to understand how want to know you need arises. personnel if a medical Seek assistance from medical support for hurting themselves or members are at risk Get help from the authorities if family others. or clergy. friends, neighbors, available, such as family, Make sure that social supports are are addressing large officials to work with individuals or family units. Even when Try their own tables with you assembled at crowds, it is better to have family members passenger manifests, ticket as reviewing present. Potentially traumatic activities–such with location, in a private groups, photos–should be done in family lists, or morgue do not see morgue that children and adolescents the appropriate authorities. Be careful photos. died, stay with the child or his/her caregiver has If an unaccompanied child is told that with other family is reunited the child until he/she ensure that another worker stays with worker. service child protective members or is attended to by an appropriate Parent/Caregiver okay Aunt Julia is really dead. It’s that It is awfully hard to hear ...... include: notification in dealing with death Active steps to help support survivors They may act of a loved one. death to being told of the Children may have a range of responses or they may not speak for an extended they may cry or protest the news, as if they did not hear, may suggest that the parent/ You They may be angry with the person who told them. period. caretaker say something like: After learning of the death of a family member or close friend, people may have psychological people may have or close friend, of a family member of the death After learning they must time, At the same agitation to numbness. that vary from reactions and physiological support, In providing environment. in the disaster of still being the continuing stress cope with following in mind: keep the Psychological First Aid - Field Operations Guide Psychological Safety and Comfort gue - continued - continued way. I’m going to go and make sure that it’s him, but I don’t him, but I don’t that it’s I’m going to go and make sure way. feel that you should go and see the body. National Child Traumatic Stress Network National Center for PTSD Stress Network Center for National Child Traumatic National Parent/Caregiversyou to see him that want Uncle Bobby wouldn’t know, You When the body is found, it is natural for families to want to know when and where it was When the body is found, it is natural for families to want to know may be more found, and what the person experienced before dying. Family members should You answered. disturbed by unanswered questions, than by having those questions including shock, numbness, expect a wide range of reactions after viewing the body, someone. fainting, vomiting, trembling, screaming, or hitting something or or an alternative location to view and identify the body. The Psychological First Aid The Psychological First and identify the body. or an alternative location to view in these activities, but may be of assistance prior provider will typically not participate Some individuals may feel that they must see the body to and after body identification. older children might ask Adolescents and is dead. before they can accept that the person most cases, children should be in however, to be present when the body is identified; the process. Children may not understand the extent discouraged from participating in or changed, and may find seeing the body extremely to which the body has deteriorated child: disturbing. Parents can say to the Where identifiable bodies have been recovered and family members have been asked to Where identifiable bodies have authorities may take family members to the mor assist in the identification process, For adolescents, you can advise parents to caution teens about doing something risky, like risky, about doing something caution teens advise parents to you can For adolescents, in out late, engaging news, staying with such while overwhelmed driving off, storming other reckless or other drugs, or acting in some using alcohol behavior, high-risk sexual to rage anger can turn an adolescent’s should also understand that Parents/caretakers way. some expressions of rage. However, they should be prepared to tolerate over the loss, and risks. Expression of any suicidal be firm in addressing any behavioral they should also additional assistance should be and appropriate taken seriously, thought should be Adolescents also be taken seriously. Expressions of revenge should immediately sought. to of revenge, and be encouraged to think about the consequences should be cautioned ways to respond to their feelings. consider constructive immediate questions from children and adolescents Family members should address may suggest that You and who will take care of them. about their living circumstances if at all possible. separation of siblings be avoided, 44 Support Survivors Involved in Body Identification Support Survivors Involved Support Survivors Who Receive Death Notification Who Receive Survivors Support Safety and Comfort 45 member him alive, and to think about the nice times we spent member him alive, and to think about You I remember going on hikes and going fishing. together. Then that you want, too. can pick any memory of Uncle Jack about him. we’ll both have good ways to think Parent/Caregivers want us to re- It was not easy to see Uncle Jack, and he would After a family member has identified the body of a loved one, a caregiver should convey should convey one, a caregiver body of a loved identified the member has After a family Since young children and assistance. to provide support may sit in You this to children. that should make it very clear that death is final, a family member do not understand that he/she is dead. If the identification body has been found, and the lost loved one’s to explain the certainty of the forensic methods, it is important was made through loved should reassure children that the simple direct language. Parents identification in taken care and that they will be were very loved by him/her, that they one is not suffering, them answer is not readily available–let to ask questions, and–if an Allow children of. should caution You information. or you will try to get additional know that the parent body. of the physical appearance of the about giving disturbing details parents/caretakers say: about the appearance, a parent can If the child asks Psychological First Aid - Field Operations Guide Psychological Help Caregivers Confirm Body Identification to a Child or Adolescent or to a Child Identification Body Confirm Help Caregivers

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46 National Child Traumatic Stress Network National Center for PTSD Psychological First Aid Field Operations Guide 2nd Edition

Stabilization:  Stabilize Emotionally Overwhelmed Survivors  Orient Emotionally Overwhelmed Survivors  The Role of Medications in Stabilization

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National Child Traumatic Stress Network National Center for PTSD Stabilization 49 shows survivors. disoriented disoriented to talk, or (if needed) consider: panic, is too upset, agitated, withdrawn, or or overwhelmed and orient emotionally calm To

Is the person with family and friends? If so, enlist them in comforting the distressed Is the person with family and friends? If so, enlist them in comforting speak may want to take a distressed individual to a quiet place, or You person. quietly with that person while family/friends are nearby. a What is the person experiencing? Is he/she crying, panicking, experiencing When intervening, “flashback,” or imagining that the event is taking place again? than simply rather immediate concern or difficulty, primary address the person’s of which trying to convince the person to “calm down” or to “feel safe” (neither tends to be effective). Looking glassy eyed and vacant–unable to find direction Looking glassy eyed and vacant–unable or commands Unresponsiveness to verbal questions behavior) in aimless disorganized Disorientation (for example, engaging uncontrollable crying, hyperventilating, Exhibiting strong emotional responses, rocking or regressive behavior reactions (shaking, trembling) Experiencing uncontrollable physical Exhibiting frantic searching behavior Feeling incapacitated by worry Engaging in risky activities or fear, anxiety, extreme Goal: Observe individuals for these signs of being disoriented or overwhelmed: Observe individuals for these signs If the person . . Most individuals affected by disasters will not require stabilization. Expressions of strong by disasters will not require stabilization. affected Most individuals spaced-out, or confused) indifferent, emotions (for example, numb, emotions, even muted signal the need for additional and do not of themselves are expectable reactions, of strong emotions, While expression ordinary supportive contact. intervention beyond to traumatic stress, extremely are normal and healthy responses numbing, and anxiety with sleep, eating, decision- or extreme anxiety can interfere high arousal, numbing, about those individuals should be concerned You and other life tasks. making, parenting, a they significantly interfere with are so intense and persistent that whose reactions ability to function. survivor’s ...... 3. Stabilization Psychological First Aid - Field Operations Guide Psychological Stabilize Emotionally Overwhelmed Survivors Stabilize Emotionally Overwhelmed Stabilization - continued - continued stabilize the majority of distressed to National Child Traumatic Stress Network National Center for PTSD Stress Network Center for National Child Traumatic National Intense emotions may come and go in waves. reactions in the Shocking experiences may trigger strong, often upsetting, “alarm” such as startle reactions. body, calming routines Sometimes the best way to recover is to take a few moments for practice muscle relaxation techniques). (for example, go for a walk, breathe deeply, calm down. Friends and family are very important sources of support to help Respect the person’s privacy, and give him/her a few minutes before you intervene. and privacy, Respect the person’s need you or that you will check back with them in Say you will be available if they doing and if there is anything you can do to help a few minutes to see how they are at that time. rather than trying to talk directly to the person, as Remain calm, quiet, and present, overload. Just remain available, while this may contribute to cognitive/emotional calm down. giving him/her a few minutes to survivors, do some paperwork, or other tasks Stand close by as you talk to other person need or wish to receive further help. while being available should the manageable feelings, thoughts, and support and help him/her focus on specific Offer goals. to the surroundings, such as how the setting is Give information that orients him/her steps he/she may consider. what will be happening, and what organized, Is the child or adolescent with his/her parents? If so, briefly make sure that the adult so, briefly make sure that the adult with his/her parents? If Is the child or adolescent role of calming their children. empowering the parents in their is stable. Focus on any comments that may for the parents, and avoid making Do not take over situation. Let them know that you authority or ability to handle the undermine their helpful. in any way that they find are available to assist are separated from their children or adolescents If emotionally overwhelmed below to the options for parents are not coping well, refer parents, or if their persons. stabilizing distressed Use these points to help survivors understand their reactions: Adults ...... individuals: . . . For children or adolescents, consider: or adolescents, For children help In general, the following steps will 50 Orient Emotionally Overwhelmed Survivors Stabilize Emotionally Overwhelmed Survivors Survivors Overwhelmed Emotionally Stabilize Stabilization 51 it may be a technique stabilize an agitated individual, to You can introduce grounding by saying: You crying, is experiencing ongoing intense to get support from adults that you trust. Is there anyone who to get support from adults that you to them? Maybe I can helps you feel better when you talk help you get in touch with them. of speech, seems to be losing agitated, shows a rush appears extremely After bad things happen, your body may have strong feelings that come and go like that come and have strong feelings your body may things happen, After bad to talk to your a good time really bad, that’s When you feel the ocean. waves in help you calm down. mom and dad to help at times like this. Even adults need happened, and to help people working together to help with what Many adults are recover. and start to make things better. help you deal with your feelings Staying busy can and look at you. Ask the individual to listen to you is, where he/she is, and what is happening. Find out if he/she knows who he/she and say where both of you are. Ask him/her to describe the surroundings, Sit in a comfortable position with your legs and arms uncrossed. Breathe in and out slowly and deeply. can see. For Look around you and name five non-distressing objects that you I see see a table, I see a chair, I see a shoe, I “I see the floor, example you could say, a person.” Breathe in and out slowly and deeply. Adolescent/Child like this happens, it is really important When something bad If the person may be helpful. called “grounding” or touch with the surroundings, Caution adolescents about doing something risky or impulsive, without discussing it with or impulsive, without discussing about doing something risky Caution adolescents say: adult. For example, you might a parent or trusted helpful to: help If none of these actions seems to overwhelmed with “After a frightening experience, you can sometimes find yourself can use a You emotions or unable to stop thinking about or imagining what happened. to feel less overwhelmed. Grounding works by turning your method called ‘grounding’ what you do….” attention from your thoughts back to the outside world. Here’s Children and Adolescents and Children ...... Psychological First Aid - Field Operations Guide Psychological Stabilization - continued - continued National Child Traumatic Stress Network National Center for PTSD Stress Network Center for National Child Traumatic National Next, name five non-distressing sounds you can hear. For example: “I hear a woman For example: “I you can hear. sounds five non-distressing Next, name I hear a someone typing, door close, I hear I hear a I hear myself breathing, talking, cell phone ringing.” slowly and deeply. Breathe in and out feel. For example: “I can feel this non-distressing things you can Next, name five inside my shoes, I can feel my with my hands, I can feel my toes wooden armrest my lips feel in my hands, I can blanket the feel I can my chair, pressing against back pressed together.” slowly and deeply. Breathe in and out Exposure to disaster may worsen pre-existing conditions (for example, Exposure to disaster may worsen pre-existing conditions (for example, pre-existing PTSD). schizophrenia, depression, anxiety, about Some survivors may be without their medications, or face uncertainty continued access to medications. may be Communication with their psychiatrists, physicians, or pharmacies disrupted. Monitoring of medication blood levels may be interrupted. You might have children name colors that they see around them. For example, say to the name colors that they see around them. For example, say to might have children You that you can see from where you are sitting. Can you child, “Can you name five colors yellow? Something green?” see something blue? Something in emotional stabilization, consult with medical or If none of these interventions aids may be needed. Modify these interventions for mental health professionals, as medication vision, hearing, or expressive language. a person who has difficulty with In most cases, the above-described ways of stabilizing survivors will be adequate. In most cases, the above-described reactions is not recommended as a routine way Medication for acute traumatic stress should be considered Aid, and medication First of meeting the goals of Psychological Any use of medication to other ways of helping. only if an individual has not responded (for example, sleep and control of panic target in survivors should have a specific Medications may be necessary when the survivor is attacks), and should be time-limited. anxiety and panic, psychosis, or is dangerous to experiencing extreme agitation, extreme self or others. should be mindful of the following: You ...... 52 The Role of Medications in Stabilization The Role of Medications Orient Emotionally Overwhelmed Survivors Overwhelmed Emotionally Orient Stabilization 53 List of current medications medications List of current a physician monitoring by require ongoing medications that Current and dispensing pharmacy prescribed medications, doctors, Access to currently with medication compliance The survivor’s issues Substance abuse/recovery and mental health conditions Ongoing medical You may obtain more information about current medications from family and friends if current medications from family may obtain more information about You to give an accurate report. the survivor is too distressed or confused Gather information that will be helpful when referring to a physician, including: referring to will be helpful when that Gather information ...... Psychological First Aid - Field Operations Guide Psychological

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54 National Child Traumatic Stress Network National Center for PTSD Psychological First Aid Field Operations Guide 2nd Edition

Information Gathering:  Nature and Severity of Experiences during the Disaster  Death of a Loved One  Concerns about Immediate Post-Disaster Circumstances and Ongoing Threat  Separation from or Concern about the Safety of Loved Ones  Physical Illness, Mental Health Conditions, and Need for Medications  Losses (Home, School, Neighborhood, Business, Personal Property, and Pets)  Extreme Feelings of Guilt or Shame  Thoughts about Causing Harm to Self or Others  Availability of Social Support  Prior Alcohol or Drug Use  Prior Exposure to Trauma and Death of Loved Ones  Specific Youth, Adult, and Family Concerns over Developmental Impact

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National Child Traumatic Stress Network National Center for PTSD Information Gathering 57 . Psychological First Aid Psychological First and additional information, Aid interventions. You’ve been through a lot of difficult things. May I ask you You’ve some questions about what you have been through? Where were you during the disaster? Did you get hurt? Did you see anyone get hurt? How afraid were you? (Appendix D), may be helpful in documenting Survivor Current Needs (Appendix D), may be helpful in concerns, gather identify immediate needs and To Psychological First Need for immediate referral Need for additional services a follow-up meeting Offering Aid that may be helpful First Using components of Psychological Needs and Current and Needs Concerns tailor . . . . Survivors who experienced direct life-threat to self or loved ones, injury to self, or Survivors who experienced direct life-threat to self or loved ones, severe and prolonged those who witnessed injury or death are at increased risk for more difficulty in Those who felt extremely terrified and helpless may also have more distress. experiences, you may ask: recovering. For information about the survivor’s Goal: You should be flexible in providing Psychological First Aid, and should adapt Aid, and Psychological First should be flexible in providing You Gather needs and concerns. specific individuals, and their identified interventions for your interventions to meet so that you can tailor and prioritize enough information and begins immediately after contact and clarifying information these needs. Gathering Aid. Psychological First continues throughout ability to gather Aid settings, your First Remember that in most Psychological other factors. needs and priorities, and survivors’ information will be limited by time, not appropriate, you may ask about: Although a formal assessment is The form, survivors. Likewise, the the basic information gathered from (Appendix D) may be useful in documenting services provided. (Appendix D) may be useful in documenting Worksheet Provider within an incident command system for evaluation These forms are designed for use safeguards for confidentiality purposes, and where there are proper to ask some questions to clarify the following: It may be especially useful for you 4. InformationGathering: Psychological First Aid - Field Operations Guide Psychological Nature and Severity of Experiences during the Disaster Nature and Severity of Experiences during the Information Gathering basic - continued - continued Do you need any information to help you better understand what has happened? Do you need information about how to keep you and your family safe? Do you need information about what is being done to protect the public? Did someone close to you get hurt or die as a result of the Did someone close to you get hurt Who got hurt or died? disaster? National Child Traumatic Stress Network National Center for PTSD Stress Network Center for National Child Traumatic National In clarifying disaster-related traumatic experiences, avoid asking for avoid asking for experiences, traumatic disaster-related Alert: In clarifying

For those with these concerns, help them obtain information about safety and protection. For those with these concerns, help them obtain information about For those who experienced the death of a loved one, provide emotional comfort, For those who experienced the death a follow-up meeting. support, and acute grief, and offer information about coping, social Survivors may be highly concerned about immediate and ongoing danger. You may ask You danger. Survivors may be highly concerned about immediate and ongoing questions like: The death of loved ones under traumatic circumstances is devastating, and over time The death of loved ones under traumatic of loved ones with a Ask about the death process. can greatly complicate the grieving question like: Provider lead distress. Follow the survivor’s that may provoke additional in-depth descriptions details of any trauma press survivors to disclose happened. Don’t in discussing what talk about their experiences, politely hand, if they are anxious to or loss. On the other helpful now is to get some tell them that what would be most and respectfully Let needs, and plan for future care. you can help with their current information so that be in a proper setting can the opportunity to discuss their experiences them know that future. arranged for the experiences, provide information about post-disaster For survivors with these kind of a follow-up meeting. For on Coping), and offer reactions and coping (see Information medical consultation as appropriate. those who were injured, arrange 58 Concerns about Immediate Post-Disaster Circumstances and Ongoing Threat Concerns about Immediate Death of a Loved One Nature and Severity of Experiences during the Disaster during of Experiences and Severity Nature Information Gathering 59 Was your home badly damaged or destroyed? Was Did you lose other important personal property? Did a pet die or get lost? your business, school, or neighborhood badly damaged or Was destroyed? Do you have any medical or mental health condition that Do you have any medical or mental needs attention? have? you don’t Do you need any medications that filled? Do you need to have a prescription Can you get in touch with your doctor? Are you worried about anyone close to you right now? about anyone close to you right Are you worried they are? Do you know where member or important like a family Is there anyone especially friend who is missing? For those with losses, provide emotional comfort, practical assistance to help link them For those with losses, provide emotional comfort, practical assistance support. with available resources, and information about coping and social For those with medical or mental health conditions, provide practical assistance in For those with medical or mental care and medication. obtaining medical or psychological For survivors with these concerns, provide practical assistance in connecting them with assistance in connecting them these concerns, provide practical For survivors with If survivors have extensive material losses and post-disaster adversities, their recovery If survivors have extensive material losses and post-disaster adversities, and hopelessness. For may be complicated with feelings of depression, demoralization, information about such loss, ask questions like: Pre-existing medical or mental heath conditions and need for medications are additional Pre-existing medical or mental heath a history of psychological problems may Those with sources of post-disaster distress. problems, as well as more severe and prolonged post- experience a worsening of these to immediate medical and mental health concerns. disaster reactions. Give a high priority Ask questions like: available information sources and registries that can help locate and reunite family members. family members. locate and reunite help sources and registries that can available information Supports. and Connection with Social See Safety and Comfort Separation from loved ones and concern about their safety is an additional source of is an additional about their safety and concern from loved ones Separation like these: with questions get information earlier, If not addressed distress. Psychological First Aid - Field Operations Guide Psychological Losses (Home, School, Neighborhood, Business, Personal Property, and Pets) Personal Property, Losses (Home, School, Neighborhood, Business, Physical Illness, Mental Health Conditions, and Need for Medications Physical Illness, Mental Separation from or Concern about the Safety of Loved Ones of Loved the Safety Concern about from or Separation Information Gathering Are there family members, friends, or community agencies that you can rely on for help with problems that you are facing as a result of the disaster? Sometimes situations like these can be very overwhelming. Sometimes situations like these can harming yourself? Have you had any thoughts about harming someone else? Have you had any thoughts about It sounds like you are being really hard on yourself about what are being really hard on yourself It sounds like you happened. feel that you could have done more. It seems like you National Child Traumatic Stress Network National Center for PTSD Stress Network Center for National Child Traumatic National For those lacking adequate social support, help them connect with available resources For those lacking adequate social support, help them connect with a follow-up and offer and services, provide information about coping and social support, meeting. For those with these thoughts, get medical or mental health assistance immediately. If medical or mental health assistance immediately. For those with these thoughts, get of hurting themselves or others, stay with him/her until the survivor is at immediate risk scene and assume management of the survivor. appropriate personnel arrive on the For those experiencing guilt or shame, provide emotional comfort and information about comfort and information guilt or shame, provide emotional For those experiencing Information on Coping. This can be found in the section, emotions. coping with these Family, friends, and community support can greatly enhance the ability to cope with friends, and community support can greatly enhance the ability Family, follows: Ask about social support as distress and post-disaster adversity. It is a priority to get a sense of whether an individual is having thoughts about causing It is a priority to get a sense of whether explore these thoughts and feelings, ask questions like: To harm to self or others. Extreme negative emotions can be very painful, difficult, and challenging, especially for especially for and challenging, difficult, can be very painful, negative emotions Extreme these feelings. to discuss may be ashamed Children and adults and adolescents. children you may further clarify, To comments. for signs of guilt or shame in their Listen carefully say: 60 Availability of Social Support Availability Thoughts about Causing Harm to Self or Others Thoughts about Causing Extreme Feelings of Guilt or Shame Feelings Extreme Information Gathering 61 Has your use of alcohol, prescription medications, or drugs Has your use of alcohol, prescription increased since the disaster? past with alcohol or drug Have you had any problems in the use? symptoms from Are you currently experiencing withdrawal drug use? Sometimes events like this can remind people of previous bad times. Have you ever been in a disaster before? Has some other bad thing happened to you in the past? Have you ever had someone close to you die? In clarifying prior history of substance use, prior trauma and loss, and use, prior trauma of substance prior history Alert: In clarifying

Adult/Caregiver/ Adolescent For those with potential substance use problems, provide information about coping and For those with potential substance a follow-up meeting. For those with services, and offer social support, link to appropriate referral. withdrawal symptoms, seek medical For those with prior exposure and/or loss, provide information about post-disaster and For those with prior exposure and/or loss, provide information about a follow-up offer grief reactions, information about coping and social support, and meeting. Those with a history of exposure to trauma or death of loved ones may experience more Those with a history of exposure reactions and a renewal of prior trauma and grief severe and prolonged post-disaster prior trauma, ask: reactions. For information about Exposure to trauma and post-disaster adversities can increase substance use, cause relapse cause use, substance increase can adversities post-disaster and trauma to Exposure new abuse. Get information about this by asking: of past substance abuse, or lead to prior mental health problems, you should be sensitive to the immediate needs of the the immediate needs be sensitive to you should health problems, prior mental for in-depth not appropriate, and avoid asking avoid asking for a history if survivor, can “Sometimes events like this clear reasons for asking (for example, description. Give to individuals who use alcohol of previous bad times . . .” “Sometimes remind individuals . . .”) following an event such as this will notice an increase in drinking cope with stress Provider Psychological First Aid - Field Operations Guide Psychological Prior Exposure to Trauma and Death of Loved Ones Prior Exposure to Trauma Prior Alcohol or Drug Use Alcohol Prior Information Gathering Is there anything else we have not covered that you are con- Is there anything else we have not me? cerned about or want to share with Were there any special events coming up that were disrupted coming up that were disrupted there any special events Were by the disaster? National Child Traumatic Stress Network National Center for PTSD Stress Network Center for National Child Traumatic National If the survivor identifies multiple concerns, summarize these and help to identify which If the survivor identifies multiple with the survivor to prioritize the order in which concerns Work issues are most pressing. should be addressed. For those with developmental concerns, provide information about coping and assist with information about coping and assist concerns, provide For those with developmental help. strategies for practical question to make sure that you have not It is also useful to ask a general open-ended missed any important information. Survivors can be very upset when the disaster or its aftermath interferes with upcoming interferes with or its aftermath when the disaster can be very upset Survivors birthdays, (for example, activities important developmental including special events, this, For information about of school or college, marriage, vacation). graduation, start ask: 62 Specific Youth, Adult, and Family Concerns over Developmental Impact Developmental Concerns over Family Adult, and Youth, Specific Psychological First Aid Field Operations Guide 2nd Edition

Practical Assistance:  Offering Practical Assistance to Children and Adolescents  Identify the Most Immediate Needs  Clarify the Need  Discuss an Action Plan  Act to Address the Need

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National Child Traumatic Stress Network National Center for PTSD Practical Assistance 65 needs and immediate in addressing help to survivors practical offer To Optimism (because they can have hope for their future) they can have hope for their Optimism (because life is predictable Confidence that be expected will work out as well as can reasonably Belief that things behalf (responsive on one’s Belief that outside sources act benevolently government) Strong faith-based beliefs me”) things usually work out for lucky, Positive belief (for example, “I’m financial Resources, including housing, employment, concerns. Like adults, children and adolescents benefit from clarifying their needs and concerns, Like adults, children and adolescents benefit from clarifying their Their ability to clarify what developing a plan to address them, and acting on the plan. follow through develops they want, think through alternatives, select the best option, and For example, many children can participate in problem-solving, but require the gradually. When appropriate, assistance of adolescents or adults to follow through with their plans. parents/caregivers share the plans you have developed with parents/caregivers, or involve to carry them through. in making the plans, so that they can help the child or adolescent practical assistance is composed of four steps: Offering Exposure to disaster, terrorism and post-event adversities is often accompanied by a loss adversities is often accompanied terrorism and post-event Exposure to disaster, are those who maintain to have more favorable outcomes Those who are likely of hope. following characteristics: one or more of the can increase a sense of empowerment, hope, and Providing people with needed resources problems Therefore, assisting the survivor with current or anticipated restored dignity. welcome a pragmatic Aid. Survivors may First is a central component of Psychological focus and assistance with problem-solving. As Aid contact. throughout a Psychological First Discussion of immediate needs occurs address the identified needs, as problem-solving may much as possible, help the survivor Teaching individuals to set of stress and adversity. be more difficult under conditions of failure and inability to cope, help individuals achievable goals may reverse feelings and help to reestablish a sense of environmental to have repeated success experiences, control necessary for successful disaster recovery. Goal: ...... 5. Practical Assistance Psychological First Aid - Field Operations Guide Psychological Offering Practical Assistance to Children and Adolescents Assistance to Children and Offering Practical Practical Assistance things, like what happened to your house, when your dad is com- house, when your dad things, like what happened to your important things, Those are all ing, and what will happen next. and then think about what is most important right now, but let’s make a plan. I understand from what you’re telling me, Mrs. Williams that your Williams me, Mrs. I understand from what you’re telling he’s husband and make sure main goal right now is to find your him. need to focus on helping you get in contact with We okay. make a plan on how to go about getting this information. Let’s National Child Traumatic Stress Network National Center for PTSD Stress Network Center for National Child Traumatic National Adolescent/Child It sounds like you are really worried about several different Adult/Caregiver Help the survivor to take action. For example, help him/her set an appointment with a Help the survivor to take action. For example, help him/her set an needed service or assist him/her in completing paperwork. Discuss what can be done to address the survivor’s need or concern. The survivor may The survivor may need or concern. Discuss what can be done to address the survivor’s know what a suggestion. If you say what he/she would like to be done, or you can offer or shelter, services are available ahead of time, you can help obtain food, clothing, help in locating medical care; mental health or spiritual care services; financial assistance; those who want to missing family members or friends; and volunteer opportunities for survivors what they can realistically expect in terms of Tell contribute to relief efforts. procedures. potential resources and support, qualification criteria, and application Talk with the survivor to specify the problem. If the problem is understood and clarified, with the survivor to specify the problem. If the problem is understood Talk steps that can be taken to address it. it will be easier to identify practical If the survivor has identified several needs or current concerns, it will be necessary to it will be or current concerns, several needs has identified If the survivor (for immediate solutions there will be For some needs, them one at a time. focus on the member to reassure them that something to eat, phoning a family example, getting to locating a lost loved one, returning Other problems (for example, survivor is okay). acquiring caregiving services securing insurance for lost property, previous routines, the survivor may be able to take but will not be solved quickly, for family members) report completing a missing persons address the problem (for example, concrete steps to applying for caregiving services). or insurance form, immediate help. help him/her select issues requiring with the survivor, As you collaborate might say: For example, you 66 Step 4: Act to Address the Need Act to Step 4: Step 3: Discuss an Action Plan Step 3: Discuss an Step 2: Clarify the Need Step 1: Identify the Most Immediate Needs Most Immediate Identify the Step 1: Psychological First Aid Field Operations Guide 2nd Edition

Connection with Social Supports:  Enhance Access to Primary Support Persons (Family and Significant Others)  Encourage Use of Immediately Available Support Persons  Discuss Support-Seeking and Giving  Special Considerations for Children and Adolescents  Modeling Support

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National Child Traumatic Stress Network National Center for PTSD Connection with Social Supports

69 persons and other support contacts with primary ongoing feeling like you fit in and have things in common with other people, with in and have things in common feeling like you fit having people reassure you that they will be there for you in case you will be there for you having people reassure you that they feeling that you are important to others, that you are valued, useful and that you are valued, feeling that you are important to others, Practical problem-solving Emotional understanding and acceptance Sharing of experiences and concerns Clarifying reactions Sharing information about coping      establish brief or help To hugs, a listening ear, understanding, love, acceptance understanding, love, ear, hugs, a listening Emotional Support: Social Connection: share activities having people to Feeling Needed: you productive, and that people appreciate in yourself and having people help you have confidence Reassurance of Self-Worth: the challenges you face your abilities, that you can handle Reliable Support: can rely on to help you need them, that you have people you something or give you Advice and Information: having people show you how to do that your way of reacting people help you understand information or good advice, having from about how to cope to learn having good examples to what has happened is common, in positive ways with what is happening fixing like carrying things, Assistance: having people help you perform tasks, Physical you do paperwork up your house or room, and helping food, clothing, shelter, Assistance: having people give you things, like Material medicine, building materials, or money recovery Increased opportunities for knowledge essential to disaster Opportunities for a range of social support activities, including: helping resources. and community members, friends, including family of support, sources Social support is related to emotional well-being and recovery following disaster and terrorism. following disaster and terrorism. recovery related to emotional well-being and Social support is (both to engage in supportive activities connected to others are more likely People who are well support can come in Social recovery. support) that assist with disaster receiving and giving These include: many forms. in developing and Fostering connections as soon as possible and assisting survivors include: connectedness Benefits of social maintaining social connections is critical to recovery...... Goal: . Connection with Social with 6. Connection Supports Psychological First Aid - Field Operations Guide Psychological Connection with Social Supports After National Child Traumatic Stress Network National Center for PTSD Stress Network Center for National Child Traumatic National Tic-tac-toe Folding “fortune tellers” Making paper balls and tossing them into an empty wastebasket it across the table Air hockey: wad up a piece of paper and have children try to blow can be used to practice deep breathing exercises). goal (Bonus: into the other team’s a drawing. Group drawing: have children sit in a circle, the first child begins 10 seconds, that child passes the drawing to the child on their right. Continue until 10 seconds, that child passes the drawing to the child on their right. Suggest Then show the group the final picture. everyone has added to the drawing. If individuals are disconnected from their social support network, encourage them to If individuals are disconnected from sources of social support (for example, yourself, other make use of immediately available while being respectful of individual preferences. It can relief workers, other survivors), magazines, newspapers, fact sheets), and reading materials (for example, help to offer are in a group, ask if they have questions. When people discuss the material with them. neighborhoods or communities, facilitate from different When members of the group are group discussions can provide a starting point for introductions among members. Small When working with the frail elderly, connectedness. further conversations and social if available, a younger adult or adolescent volunteer, you may try to connect them with assistance with daily activities. If appropriate, you who can provide social contact and by spending time with younger children them the opportunity to assist families may offer with them). or playing games while they play, (reading to them, sitting with them children together in a shared activity–as similar-age When working with youth, bring caregivers are. Provide art materials, coloring books, long as they know where their adult children engage in soothing, familiar activities. or building materials to help younger lead younger children in activities. Children may have Older children and adolescents can games that they have played at school. Several suggestions of songs to sing or classroom activities that can be done only with paper and pencil include: An immediate concern for most survivors is to contact those with whom they have with whom is to contact those most survivors concern for An immediate other family children, parents, example, spouse/partner, relationship (for a primary survivors to practical steps to assist Take friends, neighbors, and clergy). members, close e-mail, through web-based databases). (in person, by phone, by reach these individuals and hobby or club members social support may include co-workers Other sources of VFW). Survivors who or Rotary, club, bridge club, book club, (such as an afterschool supportive network that may have access to a valuable organizations belong to religious recovery. can help facilitate . . . . . 70 Encourage Use of Immediately Available Support Persons Available of Immediately Encourage Use Enhance Access to Primary Support Persons Primary Support Access to Others) and Significant (Family Enhance Connection with Social Supports 71 Not knowing what they need (and perhaps feeling that they should know). Not knowing what they need (and of needing help. Feeling embarrassed or weak because when others are in greater need. Feeling guilty about receiving help Not knowing where to turn for help. that they will be a burden or depress others. Worrying that they will lose control. Fearing that they will get so upset or helpful. Doubting that support will be available what I’m going through.” Thinking, “No one can understand there (feeling let down or that help wasn’t Having tried to get help and finding betrayed). will be angry or make them feel guilty for needing Fearing that the people they ask help. Think about the type of support that would be most helpful. Think about whom they can approach for that type of support. Choose the right time and place to approach the person. to the person and explain how he/she can be of help. Talk Afterwards, thank the person for his/her time and help. that the children draw something positive (not pictures of the disaster), something the disaster), something (not pictures of positive draw something that the children protection and safety. a sense of that promotes and their on the paper, makes a scribble one person game: pair up youth, Scribble to the scribble to turn it into something. partner has to add the child writes the name of doll chain or circle chain in which Making a paper adolescents, you can also ask support system on a link. For each person in their emotional support, advice and the type of support (for example, them to identify from each person. assistance, etc.) that they receive information, material In helping survivors to appreciate the value of social support and to engage with others, In helping survivors to appreciate the value of social support and you may need to address some of the above concerns. can be of assistance by For those who have become withdrawn or socially isolated, you helping them to: If individuals are reluctant to seek support, there may be many reasons, including: If individuals are reluctant to seek ...... Psychological First Aid - Field Operations Guide Psychological Discuss Support-Seeking and Giving Discuss Support-Seeking Connection with Social Supports

- continued want to be with the people you feel close to. You may find it may find You people you feel close to. want to be with the can You what each of you has been through. helpful to talk about about have to talk don’t You what to talk about. decide when and each with share to choose you what only occurred, that everything person. you need. feel like talking, be sure to ask for what don’t You are doing a great job letting grown-ups know what you are doing a great You people know how they need. It is important to keep letting you can make The more help you get, the more can help you. Even grown-ups need help at a time like this. things better. National Child Traumatic Stress Network National Center for PTSD Stress Network Center for National Child Traumatic National Identify ways that they can be helpful to others (volunteer in the shelter or Identify ways that they can be helpful help children or older adults). community, they can help. Identify a person or persons that to talk or to help them. Find an uninterrupted time and place Show interest, attention, and care. times as needed. to talk or spend time together as many Offer Talk with your parents/caregivers or other trusted adults about how you are feeling, Talk so that they better understand how and when to help you. games, board Do enjoyable activities with other children, including playing sports, games, watching movies, and so forth. Child Adolescent if you When something really upsetting like this happens, even Adult/Caregiver just Assistance Center you may When you’re able to leave the For those who would like to provide support to others, you can help them to: For those who would like to provide experiences or loss, but rather on The focus should not be on discussing disaster-related and concerns. providing practical assistance and problem-solving current needs You can help children and adolescents problem-solve ways in which they can ask for, and can help children and adolescents problem-solve ways in which they can ask for, You give support to, others around them. Here are some suggestions: ...... Let survivors know that, following a disaster, some people choose not to talk about their not to talk about some people choose following a disaster, know that, Let survivors talking can close to without people one feels time with and that spending experiences, your message might be: feel good. For example, 72 Special Considerations for Children and Adolescents Special Considerations for Children and Discuss Support-Seeking and Giving and Support-Seeking Discuss Connection with Social Supports 73 : : : “From what you’re saying, I can see how you would be . . .” “From what you’re saying, I can “It sounds like you’re saying . . .” “It seems that you are . . .” me if I’m wrong … it sounds like you . . .” “Tell . . .” “Am I right when I say that you “No wonder you feel . . .” “It sounds really hard . . .” “It sounds like you’re being hard on yourself.” “It is such a tough thing to go through something like this.” “I’m really sorry this is such a tough time for you.” can talk more tomorrow if you’d like.” “We got difficult?” “What have you done in the past to make yourself better when things “Are there any things that you think would help you to feel better?” difficult “I have an information sheet with some ideas about how to deal with for you.” situations. Maybe there is an idea or two here that might be helpful Spend time with your younger brothers or sisters. Help them to calm down, play to calm down, sisters. Help them brothers or with your younger Spend time company. and keep them with them, family and community. to support your or other chores cleaning, repairs, Help with toys. others, including activities and Share things with As a provider, you can model positive supportive responses, such as: you can model positive supportive responses, As a provider, Reflective comments Clarifying comments Supportive comments Empowering comments and questions: In some cases, children and adolescents will not feel comfortable talking with others. feel comfortable talking with others. and adolescents will not In some cases, children merely being present can be comforting. social or physical activities or Engaging them in game, walk, throwing a ball, playing a can be supportive by going for a Parents and you or simply sitting together. magazines together, thumbing through ...... Psychological First Aid - Field Operations Guide Psychological Modeling Support Connection with Social Supports Connecting with Others: Seeking Social Support and Others: Seeking Social Support Connecting with - continued - continued National Child Traumatic Stress Network National Center for PTSD Stress Network Center for National Child Traumatic National “People can be very different in what helps them to feel better. When things get When things feel better. helps them to in what can be very different “People would like that Do you think something helped me to . . . for me, it has difficult, work for you?” provided in Appendix E. These handouts are intended for adults These handouts are intended Appendix E. provided in Giving Social Support and older adolescents. . If appropriate, distribute handouts, If appropriate, distribute 74 Modeling Support Modeling Psychological First Aid Field Operations Guide 2nd Edition

Information on Coping:  Provide Basic Information about Stress Reactions  Review Common Psychological Reactions to Traumatic Experiences and Losses  Talking with Children about Body and Emotional Reactions  Provide Basic Information on Ways of Coping  Teach Simple Relaxation Techniques  Coping for Families  Assisting with Developmental Issues  Assist with Anger Management  Address Highly Negative Emotions  Help with Sleep Problems  Address Alcohol and Substance Abuse

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National Child Traumatic Stress Network National Center for PTSD Information on Coping 77 While it may be helpful to describe common stress reactions and to Alert.

and distress to reduce and coping reactions about stress information provide To What is currently known about the unfolding event What is currently What is being done to assist them are available What, where, and when services manage them Post-disaster reactions and how to Self-care, family care, and coping ovider note that intense reactions are common but often diminish over time, it is also important note that intense reactions are common but often diminish over time, Such disappear. to avoid providing “blanket” reassurance that stress reactions will takes to recover. reassurances may set up unrealistic expectations about the time it have sustained significant For survivors who have had significant exposure to trauma and can review You losses, provide basic psychoeducation about common distress reactions. Inform these, emphasizing that such reactions are understandable and expectable. to function survivors that, if these reactions continue to interfere with their ability The following adequately for over a month, psychological services should be considered. Aid provider so First basic information is presented as an overview for the Psychological post-disaster reactions. that you can discuss issues arising from survivors’ If appropriate, briefly discuss common stress reactions experienced by the survivor. Stress survivor. the by experienced reactions stress common discuss briefly appropriate, If will be frightened or alarmed by their own responses; reactions may be alarming. Some something negative ways (for example, “There’s some may view their reactions in take care to avoid pathologizing survivor should You wrong with me” or “I’m weak”). also see positive may You “symptoms” or “disorder.” responses; do not use terms like of spiritual and friends, or strengthening life, family, reactions, including appreciating beliefs and social connections. Pr functioning. adaptive promote risk for putting survivors at disorienting, confusing, and overwhelming, Disasters can be cope that they face. Feeling one can of competence to handle problems losing their sense and adversity is beneficial to recovery. stress with disaster-related and deal manage their stress reactions of information can help survivors types Various Such information includes: with problems. more effectively . . . . . Goal: 7. Information Coping on Psychological First Aid - Field Operations Guide Psychological Review Common Psychological Reactions to Traumatic Experiences and Losses Traumatic Review Common Psychological Reactions to Provide Basic Information about Stress Reactions Provide Basic Information Information on Coping are ways people use to keep away from, or are ways people National Child Traumatic Stress Network National Center for PTSD Stress Network Center for National Child Traumatic National are ways in which the traumatic experience comes back to back the traumatic experience comes are ways in which Intrusive reactions images of the event distressing thoughts or mental These reactions include mind. Among what happened. about what one saw), or dreams (for example, picturing Intrusive reactions disaster. the may not be specifically about children, bad dreams to reminders of the experi- emotional or physical reactions also include upsetting experiences is happen- worst may feel and act like one of their ence. Some people a “flashback.” This is called ing all over again. reactions and withdrawal Avoidance protect against, distress. These reactions include trying to avoid talking, thinking, trying to These reactions include protect against, distress. any reminders of the event, and avoiding and having feelings about the traumatic Emotions can connected to what happened. event, including places and people Feelings of detachment protect against distress. become restricted, even numb, to There may be a loss lead to social withdrawal. and estrangement from others may activities. of interest in usually pleasurable body react as if Physical arousal reactions are physical changes that make the being “on the lookout” constantly These reactions include danger is still present. having outbursts of anger, irritable or startling easily or being jumpy, for danger, or paying attention. and difficulty concentrating difficulty falling or staying asleep, 3. 2. 1. There are three types of posttraumatic stress reactions: stress three types of posttraumatic There are It is also useful to discuss the role of trauma reminders, loss reminders, change reminders, of trauma reminders, It is also useful to discuss the role and hardships in contributing to distress. the time of day, specific people, Reminders can be sights, sounds, places, smells, Trauma reminders can evoke Trauma afraid or anxious. situations, or even feelings, like being include the sound of what happened. Examples upsetting thoughts and feelings about people who were present at the or shouting, and specific wind, rain, helicopters, screaming earthquake, such as hurricane, time. Reminders are related to the specific type of event, it hard for people to can make flood, tornado, or fire. Over time, avoidance of reminders do what they normally do or need to do. of the time Loss Reminders can also be sights, sounds, places, smells, specific people, picture of a lost loved one, or include seeing a situations, or feelings. Examples day, bring to mind the absence of a seeing their belongings, like their clothes. Loss reminders sadness, nervousness, like loved one. Missing the deceased can bring up strong feelings, feeling alone or abandoned, or uncertainty about what life will be without them, anger, people want to do or things that hopelessness. Loss reminders can also lead to avoiding need to do. remind Change Reminders can be people, places, things, activities, or hardships that This can be something like someone of how life has changed as a result of the disaster. school, or being in a different bed in the morning, going to a waking up in a different 78 Review Common Psychological Reactions to Traumatic Experiences and Losses and Experiences Traumatic to Reactions Common Psychological Review - continued Information on Coping 79 Parent When Terrible Things Happen When Terrible are for adults to help themselves and their children. occur when children and adults have suffered the traumatic the traumatic suffered occur when children and adults have may be commonly experienced, even in the absence of any underlying may be commonly experienced, even in the absence of describes common adult and adolescent reactions, and positive/negative coping. describes common adult and adolescent reactions, and for Helping Preschool-Age Parent Tips and Toddlers; for Helping Infants Tips for Helping Parent Tips for Helping School-Age Children; Children; Parent Tips Adults for Adolescents; and Tips different place. Even nice things can remind a survivor of how life has changed, and make changed, and of how life has remind a survivor nice things can place. Even different been lost. miss what has the person difficult to recover. can make it more of disasters and in the wake often follow Hardships contribute to feelings of anxiety, can additional strains on survivors and Hardships place exhaustion. Examples of and mental and physical uncertainty, depression, irritability, shortages of food or money, of loss of home or possessions, lack hardships include: of obtaining the process health problems, separations from friends and family, water, to a new area, and lack of fun losses, school closures, being moved compensation for activities. grief, depression, and physical include grief reactions, traumatic Other kinds of reactions reactions. suffered have but disaster the survived who those among prevalent be will Reactions Grief and loss of home, possessions, death of loved ones, many types of losses, including the guilt or and anger, of sadness Loss may lead to feelings pets, schools, and community. and dreams of seeing the person longing for the deceased, regret over the death, missing or to survivors experiencing reactions and how to respond again. More information on grief and Comfort. in the section on Safety acute grief reactions can be found Grief Reactions Traumatic death of a loved one. Some survivors may stay focused on the circumstances of the death, may stay focused on the death of a loved one. Some survivors have been prevented, what the last how the death could including being preoccupied with may interfere with grieving, reactions These at fault. moments were like, and who was over time. More information to adjust to the death making it more difficult for survivors found in the section on Safety and to respond can be on traumatic grief reactions and how Comfort. related to the reactions and strongly Depression is associated with prolonged grief persistent depressed or Reactions include accumulation of post-disaster adversities. diminished interest or pleasure disturbance, greatly irritable mood, loss of appetite, sleep feelings of worthlessness or guilt, feelings energy, in life activities, fatigue or loss of is a common of hopelessness, and sometimes thoughts about suicide. Demoralization in post-disaster adversities and response to unfulfilled expectations about improvement resignation to adverse changes in life circumstances. Physical Reactions dizziness, stomachaches, These reactions include headaches, physical injury or illness. loss of appetite, muscle aches, rapid heart beat, tightness in the chest, hyperventilation, and bowel problems. Appendix E may be useful. Several handouts found in Psychological First Aid - Field Operations Guide Psychological Information on Coping When something really bad happens, kids often feel funny, kids often feel funny, When something really bad happens, fast, heart is beating really strange, or uncomfortable, like their arms their stomach hurts, or their legs or their hands feel sweaty, their Other times kids just feel funny inside feel weak or shaky. there, like they are watching heads, almost like they are not really bad things happening to someone else. even these feelings for a while Sometimes your body keeps having are feelings These are safe. after the bad thing is over and you was. way of telling you again how bad the disaster your body’s talk Do you have any of these feelings, or other ones that I didn’t feel about? Can you tell me where you feel them, and what they like? up when Sometimes these strange or uncomfortable feelings come things that remind them of what happened, or smell kids see, hear, It can like strong winds, glass breaking, the smell of smoke, etc. espe- be very scary for kids to have these feelings in their bodies, to do know why they are happening or what cially if they don’t yourself about them. If you like, I can tell you some ways to help Does that sound like a good idea? feel better. National Child Traumatic Stress Network National Center for PTSD Stress Network Center for National Child Traumatic National Don’t ask children directly to describe their emotions (like telling you that they feel to describe their emotions (like ask children directly Don’t a hard time finding the words. or angry), as they often have sad, scared, confused, for example: “How do to tell you about physical sensations, Instead, ask them all in your stomach or tight Do you feel something like butterflies you feel inside? over?” feelings and to suggest different talk about emotions, it is helpful If they are able to you feel okay?”) or scared, or do sad right now, ask them to pick one (“Do you feel (“How are you feeling?”). rather than asking open-ended questions the child to draw) an outline of a person and use this to help can draw (or ask You sensations. the child talk about his/her physical Adolescent/Child . . . Children vary in their capacity to make connections between events and emotions. Many emotions. Many events and between to make connections vary in their capacity Children experiences produce of how disaster-related a basic explanation will benefit from children for working with children and physical sensations. Suggestions upsetting emotions include: that helps children to talk about common The following gives a basic explanation to disaster. emotional and physical reactions 80 Talking with Children about Body and Emotional Reactions and Emotional about Body with Children Talking Information on Coping 81 tend to be ineffective in addressing problems. Such actions tend to be ineffective are those that help to reduce anxiety, lessen other distressing lessen other distressing to reduce anxiety, are those that help Talking to another person for support to another person Talking Getting needed information rest, nutrition, exercise Getting adequate activities (sports, hobbies, reading) Engaging in positive distracting possible to maintain a normal schedule to the extent Trying yourself that it is natural to be upset for some period of time Telling Scheduling pleasant activities Eating healthful meals breaks Taking Spending time with others Participating in a support group Using relaxation methods Using calming self talk Exercising in moderation Seeking counseling Keeping a journal the situation Focusing on something practical that you can do right now to manage better Using coping methods that have been successful for you in the past Using alcohol or drugs to cope from activities Withdrawing from family or friends Withdrawing You can discuss a variety of ways to effectively cope with post-disaster reactions and reactions and with post-disaster cope ways to effectively a variety of can discuss You adversity. actions Adaptive coping reactions, improve the situation, or help people get through bad times. In general, coping through bad times. In general, the situation, or help people get reactions, improve likely to be helpful include: methods that are Maladaptive coping actions include: ...... Psychological First Aid - Field Operations Guide Psychological Provide Basic Information on Ways of Coping of Ways on Basic Information Provide Information on Coping

Tips for Relaxation Tips - continued - continued When Terrible Things Happen (Appendix E), reviews positive and When Terrible National Child Traumatic Stress Network National Center for PTSD Stress Network Center for National Child Traumatic National Working too many hours too many Working angry Getting violently of self or others Excessive blaming Overeating or undereating computer games or playing too many TV too much Watching things Doing risky or dangerous etc.) yourself (sleep, diet, exercise, Not taking care of coping options Help survivors consider different coping strengths Identify and acknowledge their personal of maladaptive coping actions Think through the negative consequences goal-oriented choices about how to cope Encourage survivors to make conscious over coping and adjustment Enhance a sense of personal control Breathing exercises help reduce feelings of over-arousal and physical tension which, Breathing exercises help reduce feelings of over-arousal sleep, eating, and functioning. Simple breathing can improve if practiced regularly, is best to teach these techniques when the survivor is It exercises can be taught quickly. to prompt each calm and can pay attention. It may also be helpful for family members The handout, other to use and practice these techniques regularly. The aim of discussing positive and negative forms of coping is to: The aim of discussing positive and of coping, you can children and adolescents identify positive and negative forms help To Then talk with the the child is currently using to cope. write on slips of paper ways that coping strategies. Have the child sort the pieces child about adaptive and maladaptive discuss ways the child can increase their adaptive of paper into each category and then play a memory game in which each coping coping strategies. For younger children, and up, face paper each of sides blank the Place paper. of pieces two on written is strategy discuss with them if this is Once the child gets a pair, have the child find matching pairs. a good or bad strategy to feel better. The handout, negative coping for adult and adolescent survivors. (Appendix E), can be provided to reinforce the use and practice of relaxation techniques. (Appendix E), can be provided to reinforce the use and practice of teach a breathing exercise, you might say: To ...... 82 Teach Simple Relaxation Techniques Teach Provide Basic Information on Ways of Coping of Ways on Basic Information Provide Information on Coping 83 Let’s practice a different way of breathing that can help calm our way of breathing that can help calm a different practice Let’s [demon- one hand on your stomach, like this bodies down. Put When noses. going to breathe in through our we are strate]. Okay, our up with a lot of air and we breathe in, we are going to fill this [demonstrate]. stomachs are going to stick out like When we breathe our mouths. Then, we will breathe out through in and up like this [demon- out, our stomachs are going to suck with air, that we are a balloon, filling up can pretend We strate]. slow. and then letting the air out, nice and I’m to breathe in really slowly while I count to three. are going We breathe out really slowly. also going to count to three while we Great job! try it together. Let’s Inhale slowly (one-thousand one; one-thousand two; one-thou- one; one-thousand (one-thousand Inhale slowly all fill your lungs and comfortably through your nose, sand three) say to yourself, Silently and gently to your belly. the way down one; with calm.” Exhale slowly (one-thousand “My body is filling and mouth, one-thousand three) through your one-thousand two; abdomen. your lungs all the way down to your comfortably empty ten- say to yourself, “My body is releasing Silently and gently times slowly. sion.” Repeat five Child Adult/Caregiver/ Adolescent to the extent possible after a disaster is important for to the extent possible after a disaster Reestablishing family routines family routines such Encourage parents and caregivers to try to maintain family recovery. reading time, and play time, and to set aside time for as meal times, bedtime, wake time, the family to enjoy activities together. that has been If a family member has a pre-existing emotional or behavioral problem that they may have worsened by the current events, discuss with the family strategies that these strategies learned from a therapist to manage these problems. Discuss ways to have may be adapted for the current setting. If the family member continues difficulties, consider a mental health consultation. a mutual understanding It is especially important to assist family members in developing and to help develop a experiences, reactions, and course of recovery, of their different For example, you might say: family plan for communicating about these differences. If you find out that a survivor has previously learned some relaxation technique, try to If you find out that a survivor has learned rather than teaching new skills. reinforce what he/she has already Psychological First Aid - Field Operations Guide Psychological Coping for Families Information on Coping –such as earlier adolescents behaviors protective caregivers’ When disasters like this happen, parents/caregivers often become When disasters like this happen, parents/caregivers often more so they often have safety, more anxious about their kids’ on restrictions. So, while your parents feel the need to keep you some a tighter leash to make sure you are safe, try to give them and will probably decrease This is usually only temporary, slack. as things start to settle down. Often, due to differences in what each of you experienced dur- of you experienced in what each to differences Often, due different have member will each family the disaster, ing and after These differences of recovery. courses reactions and different not members deal with, and can lead to family can be difficult to each or not supporting getting into arguments, feeling understood, by more troubled one family member may be For example, other. than other family members. a trauma or loss reminder , and to talk about things that are bothering them, so the things that are bothering them, , and to talk about reactions - continued - continued National Child Traumatic Stress Network National Center for PTSD Stress Network Center for National Child Traumatic National Adolescent in their understand the increase without adult supervision, insisting by themselves off curfews, not letting adolescents go involve some or not letting adolescents do things that that they call in frequently, or doing skateboarding tricks. Remind adolescents that “everyday” risk, like driving a car unnecessary This will help them avoid temporary. this “strictness” is normal and usually say: You may conflict as the family recovers. and tolerant of to be understanding, patient, should encourage family members You in their differences to support them. Family members can help each other in others will know when and how and trying to understand, comforting with a hug, doing a number of ways, like listening things by playing a note, or getting his/her mind off something thoughtful like writing attention to how their children may be troubled by a game. Parents need to pay special how their children react and they can strongly affect reminders and hardships, because look like he/she is having a temper tantrum, when behave. For example, a child may of a friend who was hurt or killed. actually he/she has been reminded danger and loss, adolescents may find afterwards that When disasters confront adults with more anxious about their safety and, consequently, their parents/caretakers have become can help You adolescents to do. more restrictive in what they allow 84 Coping for Families Coping Information on Coping 85 learning to drive getting a first job dating going to college starting or changing a job or career getting engaged or married having a child having children leave home buying a new home or moving having a child leave home going through a separation or divorce experiencing the death of a grandparent graduations birthdays special events having friends of the opposite sex extracurricular activities pursuing organized activities outside of the striving for more independence and home becoming toilet trained becoming toilet or preschool entering daycare tricycle learning to ride a sleeping through the night learning or using language learning to read and do arithmetic of children being able to play by rules in a group scope of unsupervised handling themselves safely in a widening time • • • • • • • • • • • • • • • • • • • • • • • • • • Adults Families Ages All Older Adolescents Early Adolescents School-Age Children Examples of Developmental Milestones Examples of Developmental and Toddlers Preschool-Age Children Children, adolescents, adults, and families go through stages of physical, emotional, of physical, go through stages and families adolescents, adults, Children, of in the aftermath and adversities The many stresses and social development. cognitive, The loss or reversals in development. in key interruptions, delays, a disaster may result be a major consequence of the disaster. or achievements can of anticipated opportunities these milestones. is often measured by Developmental progression Psychological First Aid - Field Operations Guide Psychological Assist with Developmental Issues with Developmental Assist Information on Coping . Help find - continued - continued Were there things before the disaster that you were looking there Were or playing on a a school activity, forward to, like a birthday, sport team? Are there any special events that the family was looking forward forward events that the family was looking Are there any special important, like starting anyone about to do something Was to? from high school, or entering college? school, graduating this disas- you were working towards that Are there any goals at work or interfere with, like a promotion ter has, or might getting married? National Child Traumatic Stress Network National Center for PTSD Stress Network Center for National Child Traumatic National Postpone the event to a later date place Relocate the event to a different postponement becomes tolerable Change expectations, so that the Explain that feelings of anger and frustration are common to survivors after disaster. Explain that feelings of anger and frustration are common to survivors family their life (for example, relationship with Discuss how the anger is affecting members and friends, and parenting). while discussing how anger can increase Normalize the experience of anger, or potentially lead to violence. interpersonal conflict, push others away, address their Ask survivors to identify changes that they would like to make to anger. coping with, Compare how holding on to the anger can hurt them, versus how letting go of anger or directing it toward positive activities can help. much anger can Emphasize that some anger is normal and even helpful, while too undermine what they want to do. Child/Adolescent Parent/Caregiver Adult You should try to increase the family’s appreciation of these issues, so that they appreciation the family’s should try to increase You individual, as well as the whole family understand the challenge to each In helping to to handle the interruption or delay. alternative ways for family members consider whether the family can: develop a plan to address these concerns, Stressful post-disaster situations can make survivors feel irritable and increase their Stressful post-disaster situations you can: In addressing anger, difficulty in managing their anger...... Children and families should also be given an opportunity to attend to the disaster’s disaster’s to attend to the an opportunity also be given and families should Children and families directly: to ask children It can be helpful development. impact on 86 Assist with Anger Management Assist with Assist with Developmental Issues with Developmental Assist Information on Coping 87 How could you look at the situation that would be less upsetting and more helpful? How could you look at the situation that would be less upsetting another way of thinking about this? What’s Take a “time out” or “cool down” (walk away and calm down, do something else do something and calm down, (walk away out” or “cool down” a “time Take for a while). what is angering you. to a friend about Talk do pushups). exercise (go for a walk, jog, steam through physical Blow off and what you can do to change which you describe how you feel Keep a journal in the situation. achieve what you want, and that being angry will not help you Remind yourself relationships. may harm important like reading a book, praying or meditating, Distract yourself with positive activities to religious services or other uplifting group listening to upbeat music, going in need, etc. activities, helping a friend or someone viewpoint, or find see it from another’s way, Look at your situation in a different the top. reasons your anger may be over family member or other adult temporarily For parents/caregivers, have another angry or activities while you are feeling particularly supervise your children’s irritable. activities that help them express their feelings, Children and adolescents often like in a journal, playing out the situation with toys, such as drawing pictures, writing and composing a song. problem-solve a situation that is angering or Help children and adolescents to settle a dispute with another child, helping them frustrating them (like helping them obtain books or toys, etc.). In the aftermath of disasters, survivors may think about what caused the event, how they In the aftermath of disasters, survivors may think about what caused Attributing excessive blame to themselves or others reacted, and what the future holds. should listen for such negative beliefs, and help survivors You may add to their distress. might ask: You to look at the situation in ways that are less upsetting...... or becomes violent, seek immediate medical/ If the angry person appears uncontrollable mental health attention and contact security. Some anger management skills that you can suggest include: skills that you management Some anger ...... Psychological First Aid - Field Operations Guide Psychological Address Highly Negative Emotions (Guilt and Shame) Information on Coping - continued - continued emporary changes in sleeping T National Child Traumatic Stress Network National Center for PTSD Stress Network Center for National Child Traumatic National How might you respond if a good friend was talking to himself/herself like this? like was talking to himself/herself if a good friend you respond How might to yourself? say the same things Can you you say to him/her? What would Go to sleep at the same time and get up at the same time each day. Go to sleep at the same time and disrupts sleep. Reduce alcohol consumption, alcohol in the afternoon or evening. beverages Eliminate consumption of caffeinated not too close to bedtime. Increase regular exercise, though calming, like listening to soothing music, Relax before bedtime by doing something meditating, or praying. Limit daytime naps to 15 minutes and limit napping later than 4 PM. Tell the survivor that even if he/she thinks he/she is at fault, that does not make it true. If at fault, that does not make it true. even if he/she thinks he/she is the survivor that Tell at the situation. Help to some alternative ways of looking offer the survivor is receptive, that exacerbate distress, unwarranted rumors, and distortions clarify misunderstandings, have difficulty labeling thoughts, For children and adolescents who guilt, or shame. paper (for example, “I did something negative thoughts on a piece of you can write the them. and have the child add to it to happen,” “I was misbehaving”) wrong,” “I caused more helpful any misunderstandings, discuss can then discuss each one, clarify You at fault, or adolescent that he/she is not them down. Remind the child thoughts, and write these concerns. even if he/she has not expressed okay, as long as parents make a plan with their children to negotiate arrangements are have all “We might say, a return to normal sleeping arrangements. For example, a parent nights. of couple next the for bedroom our in stay can You happened. what by scared been bedroom for a while Then you will sleep in your bed, but we will sit with you in your we can talk about it.” before you go to sleep so you will feel safe. If you get scared again, ...... Sleep difficulties are common following a disaster. People tend to stay on alert at night, People tend a disaster. Sleep difficulties are common following about adversities Worries causing frequent awakenings. making it hard to fall asleep and hard to fall asleep. Disturbance in sleep can have a and life changes can also make it Ask whether and risk for injury. on mood, concentration, decision-making, major effect sleeping and about sleep routines and sleep-related the survivor is having any trouble sleep. For example the survivor might try to: habits. Problem-solve ways to improve reminders can make Discuss that worry over immediate concerns and exposure to daily get support from others it more difficult to sleep, and that being able to discuss these and can improve sleep over time. close to their parents at Remind parents that it is common for children to want to remain nighttime, and even to want to sleep in bed with them. . 88 Help with Sleep Problems Address Highly Negative Emotions (Guilt and Shame) (Guilt Emotions Highly Negative Address Information on Coping 89 Alcohol, Medication, and Drug Use after Disasters (Appendix E) gives an Alcohol, Medication, and Drug Explain to the survivor that many people (including adolescents) who experience adolescents) who experience that many people (including Explain to the survivor or drugs to reduce their bad to drink or use medications stress reactions choose feelings. the positives and negatives of to identify what he/she sees as Ask the individual drugs to cope. using alcohol or pattern of use. agree on abstinence or a safe Discuss and mutually difficulties in changing behavior. Discuss anticipated the person, make a referral for substance abuse If appropriate and acceptable to counseling or detoxification. treatment for substance abuse, encourage If the individual has previously received to get through the next few weeks and months. him/her to once again seek treatment overview of this information, and is intended for adults and adolescents with concerns in overview of this information, and this area. The handout, When use of alcohol and other substances is a concern: other substances of alcohol and When use ...... Psychological First Aid - Field Operations Guide Psychological Address Alcohol and Substance Use Substance Alcohol and Address

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90 National Child Traumatic Stress Network National Center for PTSD Psychological First Aid Field Operations Guide 2nd Edition

Collaborative Services:  Provide Direct Link to Additional Needed Services  Referrals for Children and Adolescents  Referrals for Older Adults  Promote Continuity in Helping Relationships

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National Child Traumatic Stress Network National Center for PTSD Collaborative Services 93 in the future. time or needed at the available services survivors with link To An acute medical problem that needs immediate attention An acute medical problem that needs that needs immediate attention An acute mental health problem of a pre-existing medical, emotional, or behavioral problem Worsening Threat of harm to self or others or drugs Concerns related to the use of alcohol or elder abuse (be aware of reporting laws) Cases involving domestic, child, When medication is needed for stabilization When pastoral counseling is desired (4 weeks or more after the disaster) Ongoing difficulties with coping about children or adolescents Significant developmental concerns When the survivor asks for a referral Mental health services Medical services Social support services Child welfare services Schools Drug and alcohol support groups As you provide information, also discuss which of the survivor’s needs and current the survivor’s also discuss which of As you provide information, Do what is necessary to ensure additional information or services. concerns require survivor over to an services (for example, walk the linkage with those effective set up a meeting with a community who can provide a service, agency representative a Examples of situations requiring may provide appropriate referrals). representative who referral include: before the In addition, reconnect survivors to agencies that provided them services disaster including: Goal: ...... 8. Linkage Serviceswith Collaborative Psychological First Aid - Field Operations Guide Psychological Provide Direct Link to Additional Needed Services Link to Provide Direct Collaborative Services - continued - continued National Child Traumatic Stress Network National Center for PTSD Stress Network Center for National Child Traumatic National A primary care physician A local senior center A Aging programs Council on Social support services Recommend that any follow-up services for the family include (at least) a brief Recommend that any follow-up adjustment. evaluation of child and adolescent and adolescents positive and supportive to Make your interactions with children towards future care providers. help them develop a positive attitude have an especially difficult time telling Remember that children and adolescents When working with youth, to traumatic events. and retelling information related about the event that you have gathered summarize in writing the basic information This will help to the receiving professional. and communicate this information of their minimize the number of times that they will have to retell the story experiences. Summarize your discussion with the person about his/her needs and concerns. discussion with the person about Summarize your of your summary. Check for the accuracy may help, and what will take of referral, including how this Describe the option goes for further help. place if the individual to the suggested referral. reaction Ask about the survivor’s make an appointment then and information, or if possible, Give written referral there. Help with plans for an elder who is going home or needs access to alternative housing. Help with plans for an elder who is going home or needs access to Make sure the elder has referral sources for the following, if needed: Remember that children and adolescents under the age of 18 will need parental consent Remember that children and adolescents may be less likely to self-refer Youth care. emergency for services outside of immediate and are less likely to follow through on referrals when they are experiencing difficulties, youth maximize the likelihood that To in the process. without an adult who is engaged you should: will follow through with a referral, ...... When making a referral: When making 94 Referrals for Older Adults Referrals for Older Referrals for Children and Adolescents Referrals for Children and Provide Direct Link to Additional Needed Services Needed Additional to Direct Link Provide Collaborative Services 95 Give the names and contact information for the local public health and public Give the names and contact information There may also be other local the community. mental health service providers in who have volunteered to provide post-disaster providers or recognized agencies volunteer (Be wary of referring to unknown follow-up services for the community. not be known for several hours or days, but once providers.) Such information may survivors. available, it can be helpful to disaster health, health care, family service, or relief Introduce survivors to other mental other helpers by name. workers, so that they know several Meals on Wheels Meals on living or assisted Senior housing services Transportation A secondary, but important concern for many survivors is being able to keep in contact survivors is being able to keep in but important concern for many secondary, A cases, continuing contact between who have been helpful. In most with responders family will leave triage sites or will not be possible because survivors survivors and you loss of contacts services. However, and go to other sites for continuing assistance centers or lead to a sense of abandonment acute aftermath of disasters can made during the a sense of continuing care if you: can create You rejection. succession of helpers, are meeting a never-ending Sometimes, survivors feel as if they their situation and telling their story to each one and that they have to go on explaining let the extent possible, minimize this. If you are leaving a response site, the To in turn. one who to another provider, and if possible, ensure a direct “hand-off” survivor know, an ongoing helping relationship with the person. Orient will be in a position to maintain needs to know about the person, and if possible, provide the new provider to what he/she an introduction...... Psychological First Aid - Field Operations Guide Psychological Promote Continuity in Helping Relationships Promote Continuity

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96 National Child Traumatic Stress Network National Center for PTSD Psychological First Aid Field Operations Guide 2nd Edition

LIST OF APPENDICES:

Appendix A: Overview of Psychological First Aid

Appendix B: Service Delivery Sites and Settings

Appendix C: Psychological First Aid Provider Care

Appendix D: Psychological First Aid Worksheets

Appendix E: Handouts for Survivors Appendix F: Handouts to Distribute and Copy

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National Child Traumatic Stress Network National Center for PTSD Psychological First Aid Field Operations Guide 2nd Edition

Appendix A:  Overview of Psychological First Aid

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National Child Traumatic Stress Network National Center for PTSD Overview of Psychological First Aid Section Headers Preparing to Deliver 1. Entering the setting Psychological First 2. Providing services Aid 3. Group settings 4. Maintain a calm presence 5. Be sensitive to culture and diversity 6. Be aware of at-risk populations

Contact and 1. Introduce yourself/ask about immediate needs Engagement 2. Confidentiality

Safety and Comfort 1. Ensure immediate physical safety 2. Provide information about disaster response activities and services 3. Attend to physical comfort 4. Promote social engagement 5. Attend to children who are separated from their parents/caregivers 6. Protect from additional traumatic experiences and trauma reminders 7. Help survivors who have a missing family member 8. Help survivors when a family member or close friend has died 9. Attend to grief and spiritual issues 10. Provide information about casket and funeral issues 11. Attend to issues related to traumatic grief 12. Support survivors who receive death notification 13. Support survivors involved in body identification 14. Help caregivers confirm body identification to a child or adolescent

Stabilization 1. Stabilize emotionally overwhelmed survivors 2. Orient emotionally overwhelmed survivors 3. The role of medications in stabilization

Information 1. Nature and severity of experiences during the disaster Gathering: Current 2. Death of a loved one Needs and Concerns 3. Concerns about immediate post-disaster circumstances and ongoing threat 4. Separations from or concern about the safety of loved ones 5. Physical illness, mental health conditions, and need for medications 6. Losses (home, school, neighborhood, business, personal property, and pets) 7. Extreme feelings of guilt or shame 8. Thoughts about causing harm to self or others 9. Availability of social support 10. Prior alcohol or drug use 11. Prior exposure to trauma and death of loved ones 12. Specific youth, adult, and family concerns over developmental impact

Psychological First Aid - Field Operations Guide 101 Overview of Psychological First Aid - continued Section Headers Practical Assistance 1. Offering practical assistance to children and adolescents 2. Identify the most immediate needs 3. Clarify the need 4. Discuss an action plan 5. Act to address the need

Connection with 1. Enhance access to primary support persons (family and significant others) Social Supports 2. Encourage use of immediately available support persons 3. Discuss support-seeking and giving 4. Special considerations for children and adolescents 5. Modeling support

Information on 1. Provide basic information about stress reactions Coping 2. Review common psychological reactions to traumatic experiences and losses • Intrusive reactions • Avoidance and withdrawal reactions • Physical arousal reactions • Trauma reminders • Loss reminders • Change reminders • Hardships • Grief reactions • Traumatic grief reactions • Depression • Physical reactions 3. Talking with children about physical and emotional reactions 4. Provide basic information on ways of coping 5. Teach simple relaxation techniques 6. Coping for families 7. Assist with developmental issues 8. Assist with anger management 9. Address highly negative emotions 10. Help with sleep problems 11. Address alcohol and substance use

Linkage with 1. Provide direct link to additional needed services Collaborative 2. Referrals for children and adolescents Services 3. Referrals for older adults 4. Promote continuity in helping relationships

102 National Child Traumatic Stress Network National Center for PTSD Psychological First Aid Field Operations Guide 2nd Edition

Appendix B:  Service Delivery Sites and Settings

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National Child Traumatic Stress Network National Center for PTSD Service Delivery Sites and Settings

Service Site Challenges in Delivering Psychological First Aid You can face many challenges in delivering services to disaster survivors and disaster relief work- ers. These challenges are often related to the specific disaster characteristics (for example, natural vs. human caused, size, location) and those of the individuals involved (for example, populations of special consideration–those with disabilities, youth, disadvantaged groups, individuals with pre-exist- ing medical or mental health conditions). Other challenges pertain to the multiple settings in which you may be deployed. The following information will be helpful in anticipating and understanding the unique challenges of some disaster-related service sites.

General Population Shelters When it is determined that a community or area of the community must be evacuated because of dan- gerous or threatening conditions, General Population Shelters are opened for the temporary housing of individuals. General Population Shelters are usually located in schools, community and recreation centers, or in other large facilities. Shelters usually have limited space for people to sleep, as well as an area for meals to be served. Typical challenges include establishing shelter rules (for example, lights out, regulated use of showers when in limited supply, meal times), addressing the socio-cultural and ethnic issues that arise when bringing diverse populations together, managing public health issues (for example, sanitation, medication dispensing, isolating the sick), and resolving disputes that arise among shelter residents or between shelter residents and staff.

Service Centers Service Centers may be opened by a local or federal governmental agency or by disaster relief orga- nizations to meet the initial needs of disaster survivors. These centers typically offer assistance with locating temporary housing or providing for the immediate personal needs of disaster survivors, such as food, clothing, and clean-up materials. Depending on the size and magnitude of the disaster, you may encounter large numbers of survivors seeking services, and anger and frustration expressed by survivors in circumstances where there are inadequate supplies.

Community Outreach Teams Community Outreach Teams are usually established in the event of disasters that affect a large geo- graphic area and/or a significant percentage of the population. These teams are often necessary to avoid long lines at Service Centers or when transportation services for the general population are limited. The teams are usually composed of two or more individuals that can provide comprehensive services to disaster survivors. For example, a disaster mental health or spiritual care professional may be teamed up with a representative from the American Red Cross who can provide assistance in meet- ing the survivors’ food, clothing, and shelter needs.

Psychological First Aid - Field Operations Guide 105 Family Reception Centers Family Reception Centers are typically opened in the immediate aftermath of a disaster involv- ing mass casualties or fatalities. There is a common recognition that after such disasters, indi- viduals may be trying to locate family or other loved ones specifically involved in the disaster or separated during the evacuation process. Often these are temporary holding sites until a more structured and operational Family Assistance Center can be opened. Family Reception Centers may be established in close proximity to the immediate disaster scene where individuals arrive in search of family and other loved ones involved in the incident, or in healthcare facilities where the injured have been transported.

Family Assistance Centers Family Assistance Centers are commonly opened in the event of a disaster involving mass casu- alties or fatalities. These centers usually offer a range of services in an effort to meet the needs of individuals under these circumstances. Mental health services, spiritual care, and crime victims’ services, as well as the services of law enforcement, the medical examiner, disaster relief agen- cies, and other local, state, and federal agencies are also offered on site. Family Assistance Centers are usually located away from the immediate disaster site. Family members may request visits to the affected site or memorial services. Therefore, the Family Assistance Centers should be close enough to facilitate those activities.

Points of Dispensing (POD) Centers PODs might be established by local, state, or federal public health agencies in the event of a pub- lic health emergency. These centers may be established to provide mass distribution of medica- tions or vaccinations in an effort to prevent or mitigate the spread of any communicable disease or other public health risk. Healthcare facilities may open PODs with the goal of vaccinating or distributing necessary medications to their own personnel or to reduce the burden on the commu- nity POD sites.

Phone Banks and Hotlines Communities and healthcare systems may wish to set up a Phone Bank to address and respond to numerous calls with questions that typically arise after a disaster. These Phone Banks are likely to be overwhelmed in the first few hours or days, with many questions regarding such issues as locating missing or injured family members or healthcare concerns. Community hotlines may encounter similar questions and address additional information such as the availability of shelter locations, mass food distribution sites, and other disaster relief services.

106 National Child Traumatic Stress Network National Center for PTSD Emergency First Aid Stations Emergency First Aid Stations provide basic medical services to disaster survivors as well as responders who may suffer minor injuries in the rescue and recovery efforts. They are usually located in close proximity to the direct impact of a disaster. In the event of a disaster resulting in mass casualties, makeshift emergency first aid stations may be set up near a healthcare facility in an effort to relieve the burden on emergency room services and ensure that such high level care is available to the seriously injured.

Hospitals and Hospital Emergency Room Settings During a mass casualty event, survivors who are triaged on site and listed as “immediate” will be brought to a hospital. In addition, many others will self-transport to the hospital wanting to be seen in the Emergency Room. This is likely to create a surge on medical resource capacity. Survivors may arrive in large numbers, many with both psychological and physical reactions. One important goal is to facilitate the treatment of injured survivors by removing individuals who do not require immediate medical care from the patient flow. However, increased physical symptoms have frequently been reported after disasters, particularly among those who witness injury and death, and those who may have had toxic exposure to a chemical or biological attack. As a result, differential diagnosis may at times be difficult, since signs and symptoms may be nonspecific and/or status may change over time. News or rumors of such an attack may generate an influx of those who fear they have been exposed, and rapidly overwhelm the system. Along with a system of triage, hospitals may set up a “support center” where Psychological First Aid providers can refer those in need to a spectrum of medical, psychological, behavioral, and phar- macological interventions.

Respite Centers Respite Centers are locations where first responders can rest and obtain food, clothing, and other basic support services. They are usually opened where prolonged rescue and recovery efforts are necessary. Respite Centers are usually located in close proximity to the direct impact of a disas- ter. Typical challenges for Psychological First Aid include limited time to interact with respond- ers who are extremely busy and tired, and feel a sense of urgency to continue working.

Psychological First Aid - Field Operations Guide 107

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108 National Child Traumatic Stress Network National Center for PTSD Psychological First Aid Field Operations Guide 2nd Edition

Appendix C:  Psychological First Aid Provider Care

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National Child Traumatic Stress Network National Center for PTSD Psychological First Aid Provider Care Providing care and support in the immediate aftermath of disaster can be an enriching professional and personal experience that enhances satisfaction through helping others. It can also be physically and emotionally exhausting. The following sections provide information to consider before, during, and after engaging in disaster relief work.

Before Relief Work In deciding whether to participate in disaster response, you should consider your comfort level with this type of work and your current health, family, and work circumstances. These considerations should include the following:

Personal Considerations Assess your comfort level with the various situations you may experience while providing Psychological First Aid: . Working with individuals who are experiencing intense distress and extreme reactions, including screaming, hysterical crying, anger, or withdrawal . Working with individuals in non-traditional settings . Working in a chaotic, unpredictable environment . Accepting tasks that may not initially be viewed as mental health activities (e.g., distributing water, helping serve meals, sweeping the floor) . Working in an environment with minimal or no supervision or conversely, micro- managed . Working with and providing support to individuals from diverse cultures, ethnic groups, developmental levels, and faith backgrounds . Working in environments where the risk of harm or exposure is not fully known . Working with individuals who are not receptive to mental health support . Working with a diverse group of professionals, often with different interaction styles

Health Considerations Assess your current physical and emotional health status, and any conditions that may influence your ability to work long shifts in disaster settings, including: . Recent surgeries or medical treatments . Recent emotional or psychological challenges or problems

Psychological First Aid - Field Operations Guide 111 Health Considerations - continued . Any significant life changes or losses within the past 6-12 months . Earlier losses or other negative life events . Dietary restrictions that would impede your work . Ability to remain active for long periods of time and endure physically exhausting conditions . If needed, enough medication available for the total length of your assignment plus some extra days

Family Considerations Assess your family’s ability to cope with your providing Psychological First Aid in a disaster setting: . Is your family prepared for your absence, which may span days or weeks? . Is your family prepared for you to work in environments where the risk of harm or exposure to harm is not fully known? . Will your support system (family/friends) assume some of your family responsibilities and duties while you are away or working long hours? . Do you have any unresolved family/relationship issues that will make it challenging for you to focus on disaster-related responsibilities? . Do you have a strong, supportive environment to return to after your disaster assignment?

Work Considerations Assess how taking time off to provide Psychological First Aid might affect your work life: . Is your employer supportive of your interest and participation in Psychological First Aid? . Will your employer allow “leave” time from your job? . Will your employer require you to utilize vacation time or “absence-without-pay time” to respond as a disaster mental health worker? . Is your work position flexible enough to allow you to respond to a disaster assignment within 24-48 hours of being contacted? . Will your co-workers be supportive of your absence and provide a supportive environment upon your return?

112 National Child Traumatic Stress Network National Center for PTSD Personal, Family, Work Life Plan If you decide to participate in disaster response, take time to make preparations for the following: . Family and other household responsibilities . Pet care responsibilities . Work responsibilities . Community activities/responsibilities . Other responsibilities and concerns

During Relief Work In providing Psychological First Aid, it is important to recognize common and extreme stress reactions, how organizations can reduce the risk of extreme stress to providers, and how best to take care of yourself during your work.

Common Stress Reactions Providers may experience a number of stress responses, which are considered common when working with survivors: . Increase or decrease in activity level . Difficulties sleeping . Substance use . Numbing . Irritability, anger, and frustration . Vicarious traumatization in the form of shock, fearfulness, horror, helplessness . Confusion, lack of attention, and difficulty making decisions . Physical reactions (headaches, stomachaches, being easily startled) . Depressive or anxiety symptoms . Decreased social activities

Psychological First Aid - Field Operations Guide 113 Extreme Stress Reactions Providers may experience more serious stress responses that warrant seeking support from a professional or monitoring by a supervisor. These include: . Compassion stress: helplessness, confusion, isolation . Compassion fatigue: demoralization, alienation, resignation . Preoccupation or compulsive re-experiencing of trauma experienced either directly or indirectly . Attempts to over-control in professional or personal situations . Withdrawal and isolation . Preventing feelings by relying on substances, becoming overly preoccupied by work, or drastic changes in sleep (avoidance of sleep or not wanting to get out of bed) . Serious difficulties in interpersonal relationships, including domestic violence . Depression accompanied by hopelessness (which has the potential to place individuals at a higher risk for suicide) . Unnecessary risk-taking

Organizational Care of Providers Organizations that recruit providers can reduce the risk of extreme stress by putting supports and policies in place. These include: . Limiting work shifts to no more than 12 hours and encouraging work breaks . Rotating of providers from the most highly exposed assignments to lesser levels of exposure . Mandating time off . Identifying enough providers at all levels, including administration, supervision, and support . Encouraging peer partners and peer consultation . Monitoring providers who meet certain high risk criteria, such as:  Survivors of the disaster  Those having regular exposure to severely affected individuals or communities  Those with pre-existing conditions  Those with multiple stresses, including those who have responded to multiple disasters in a short period of time

114 National Child Traumatic Stress Network National Center for PTSD . Establishing supervision, case conferencing, and staff appreciation events . Conducting trainings on stress management practices

Provider Self-Care Activities that promote self-care include: . Managing personal resources . Planning for family/home safety, including making child care and pet care plans . Getting adequate exercise, nutrition, and relaxation . Using stress management tools regularly, such as:  Accessing supervision routinely to share concerns, identifying difficult experiences, and strategizing to solve problems  Practicing brief relaxation techniques during the workday  Using the buddy system to share upsetting emotional responses  Staying aware of limitations and needs  Recognizing when one is Hungry, Angry, Lonely or Tired (HALT), and taking the appropriate self-care measures  Increasing activities that are positive  Practicing religious faith, philosophy, and spirituality  Spending time with family and friends  Learning how to “put stress away”  Writing, drawing, and painting  Limiting caffeine, tobacco, and substance use As much as possible, you should make every effort to: . Self-monitor and pace your efforts . Maintain boundaries: delegate, say no, and avoid working with too many survivors in a given shift . Perform regular check-ins with colleagues, family, and friends . Work with partners or in teams . Take relaxation/stress management/bodily care/refreshment breaks . Utilize regular peer consultation and supervision

Psychological First Aid - Field Operations Guide 115 Provider Self-Care - continued . Try to be flexible, patient, and tolerant . Accept that you cannot change everything You should avoid engaging in: . Extended periods of solo work without colleagues . Working “round the clock” with few breaks . Negative self-talk that reinforces feelings of inadequacy or incompetency . Excessive use of food/substances as a support . Common attitudinal obstacles to self-care:  “It would be selfish to take time to rest.”  “Others are working around the clock, so should I.”  “The needs of survivors are more important than the needs of helpers.”  “I can contribute the most by working all the time.”  “Only I can do x, y, and z.”

After Relief Work Expect a readjustment period upon returning home. You may need to make personal reintegration a priority for a while.

Organizational Care of Providers Organizations should: . Encourage time off for providers who have experienced personal trauma or loss. . Institute exit interviews to help providers with their experience–this should include information about how to communicate with their families about their work. . Encourage providers to seek counseling when needed, and provide referral information. . Provide education on stress management. . Facilitate ways providers can communicate with each other by establishing listservs, sharing contact information, or scheduling conference calls. . Provide information regarding positive aspects of the work.

116 National Child Traumatic Stress Network National Center for PTSD Provider Self-Care Make every effort to: . Seek out and give social support. . Check in with other relief colleagues to discuss relief work. . Increase collegial support. . Schedule time for a vacation or gradual reintegration into normal life. . Prepare for worldview changes that may not be mirrored by others in your life. . Participate in formal help to address your response to relief work if extreme stress persists for greater than two to three weeks. . Increase leisure activities, stress management, and exercise. . Pay extra attention to health and nutrition. . Pay extra attention to rekindling close interpersonal relationships. . Practice good sleep routines. . Make time for self-reflection. . Practice receiving from others. . Find activities that you enjoy or that make you laugh. . Try at times not to be in charge or the “expert.” . Increase experiences that have spiritual or philosophical meaning to you. . Anticipate that you will experience recurring thoughts or dreams, and that they will decrease over time. . Keep a journal to get worries off your mind. . Ask help in parenting if you feel irritable or are having difficulties adjusting to being back at home. Make every effort to avoid: . Excessive use of alcohol, illicit drugs, or excessive amounts of prescription drugs. . Making any big life changes for at least a month. . Negatively assessing your contribution to relief work. . Worrying about readjusting.

Psychological First Aid - Field Operations Guide 117 Provider Self-Care - continued . Obstacles to better self-care:  Keeping too busy  Making helping others more important than self-care  Avoiding talk about relief work with others

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Appendix D:  Psychological First Aid Worksheets

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National Child Traumatic Stress Network National Center for PTSD Provider Worksheets

Survivor Current Needs

Date: ______Provider: ______Survivor Name:______Location:______This session was conducted with (check all that apply):

 Child  Adolescent  Adult  Family  Group

Provider: Use this form to document what the survivor needs most at this time. This form can be used to communicate with referral agencies to help promote continuity of care. 1. Check the boxes corresponding to difficulties the survivor is experiencing.

Behavioral Emotional Physical Cognitive

 Extreme  Acute stress  Headaches  Inability to accept/ disorientation reactions  Stomachaches cope with death of loved one(s)  Excessive drug,  Acute grief  Sleep difficulties alcohol, or reactions  Distressing dreams  Difficulty eating prescription drug  Sadness, or nightmares  use tearfulness Worsening of  Intrusive thoughts health conditions  Isolation/  Irritability, anger or images withdrawal  Fatigue/exhaustion  Feeling anxious,  Difficulty   High risk behavior fearful Chronic agitation concentrating   Regressive  Despair, Other ______ Difficulty behavior hopelessness remembering  Separation anxiety  Feelings of guilt or  Difficulty making  Violent behavior shame decisions  Maladaptive  Feeling  Preoccupation with coping emotionally numb, death/destruction  Other ______disconnected  Other ______ Other ______

Psychological First Aid - Field Operations Guide 121 2. Check the boxes corresponding to difficulties the survivor is experiencing.  Past or preexisting trauma/psychological problems/substance abuse problems  Injured as a result of the disaster  At risk of losing life during the disaster  Loved one(s) missing or dead  Financial concerns  Displaced from home  Living arrangements  Lost job or school  Assisted with rescue/recovery  Has physical/emotional disability  Medication stabilization  Concerns about child/adolescent  Spiritual concerns  Other: ______

3. Please make note of any other information that might be helpful in making a referral. ______4. Referral

 Within project (specify) ______ Substance abuse treatment  Other disaster agencies  Other community services  Professional mental health services  Clergy  Medical treatment  Other: ______5. Was the referral accepted by the individual?

 Yes  No

122 National Child Traumatic Stress Network National Center for PTSD Provider Worksheets

Psychological First Aid Components Provided

Date: ______Provider: ______Location:______This session was conducted with (check all that apply):

 Child  Adolescent  Adult  Family  Group

Place a checkmark in the box next to each component of Psychological First Aid that you provided in this session.

Contact and Engagement  Initiated contact in an appropriate manner  Asked about immediate needs

Safety and Comfort  Took steps to ensure immediate physical  Gave information about the disaster/risks safety  Attended to physical comfort  Encouraged social engagement  Attended to a child separated from parents  Protected from additional trauma  Assisted with concern over missing loved one  Assisted after death of loved one  Assisted with acute grief reactions  Helped with talking to children about death  Attended to spiritual issues regarding death  Attended to traumatic grief  Provided information about funeral issues  Helped survivor after body identification  Helped survivors regarding death notification  Helped with confirmation of death to child

Stabilization  Helped with stabilization  Used grounding technique  Gathered information for medication referral for stabilization

Information Gathering  Nature and severity of disaster experiences  Death of a family member or friend  Concerns about ongoing threat  Concerns about safety of loved one(s)  Physical/mental illness and medications(s)  Disaster-related losses  Extreme guilt or shame  Thoughts of harming self or others  Availability of social support  Prior alcohol or drug use  History of prior trauma and loss  Concerns over developmental impact  Other ______

Psychological First Aid - Field Operations Guide 123 Practical Assistance  Helped to identify most immediate need(s)  Helped to clarify need(s)  Helped to develop an action plan  Helped with action to address the need

Connection with Social Supports  Facilitated access to primary support persons  Discussed support seeking and giving  Modeled supportive behavior  Engaged youth in activities  Helped problem-solve obtaining/giving social support

Information of Coping  Gave basic information about stress  Gave basic information on coping reactions  Taught simple relaxation techniques(s)  Helped with family coping issues  Assisted with developmental concerns  Assisted with anger management  Addressed negative emotions (shame/guilt)  Helped with sleep problems  Addressed substance abuse problems

Linkage with Collaborative Services  Provided link to additional service(s) ______ Promoted continuity of care ______ Provided handout(s) ______

124 National Child Traumatic Stress Network National Center for PTSD Psychological First Aid Field Operations Guide 2nd Edition

Appendix E:  Handouts for Survivors  Connecting with Others: Seeking Social Support (for adults and adolescents)  Connecting with Others: Giving Social Support (for adults and adolescents)  When Terrible Things Happen (for adults and adolescents)  Parent Tips for Helping Infants and Toddlers (for parents/caregivers)  Parent Tips for Helping Preschool-Age Children (for parents/caregivers)  Parent Tips for Helping School-Age Children (for parents/caregivers)  Parent Tips for Helping Adolescents (for parents/caregivers)  Tips for Adults (for adult survivors)  Basic Relaxation Techniques (for adults, adolescents, and children)  Alcohol and Drug Use after Disasters (for adults and adolescents)

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National Child Traumatic Stress Network National Center for PTSD Connecting with Others

Seeking Social Support . Making contact with others can help reduce feeling of distress . Children and adolescents can benefit from spending some time with similar-age peers . Connections can be with family, friends, or others who are coping with the same traumatic event

Social Support Options . Spouse/partner or parents . Clergy . Support group . Trusted family member . Doctor or nurse . Co-worker/Teacher/Coach . Close friend . Crisis/School counselor or . Pet other counselor

Do . . . . Decide carefully whom to . Start by talking about . Ask others if it’s a good talk to practical things time to talk . Decide ahead of time what . Let others know you need to . Tell others you appreciate you want to discuss talk or just to be with them them listening . Choose the right time and . Talk about painful thoughts . Tell others what you need place and feelings when you’re or how they could help–one ready main thing that would help you right now

Don’t . . . . Keep quiet because you don’t want to upset . Assume that others don’t want to listen others . Keep quiet because you’re worried about . Wait until you’re so stressed or exhausted being a burden that you can’t fully benefit from help

Ways to Get Connected . Calling friends or family on the phone . Getting involved with a support group . Increasing contact with existing . Getting involved in community/school acquaintances and friends recovery activities . Renewing or beginning involvement in religious group activities

Psychological First Aid - Field Operations Guide 127

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128 National Child Traumatic Stress Network National Center for PTSD Connecting with Others

Giving Social Support

You can help family members and friends cope with the disaster by spending time with them and lis- tening carefully. Most people recover better when they feel connected to others who care about them. Some people choose not to talk about their experiences very much, and others may need to discuss their experiences. For some, talking about things that happened because of the disaster can help those events seem less overwhelming. For others, just spending time with people they feel close to and accepted by, without having to talk, can feel best. Here is some information about giving social support to other people.

Reasons Why People May Avoid Social Support

. Not knowing what they need . Not wanting to burden others . Wanting to avoid thinking or feeling about the event

. Feeling embarrassed or . Doubting it will be helpful, or . Assuming that others will be “weak” that others will understand disappointed or judgmental

. Fearing they will lose control . Having tried to get help and . Not knowing where to get feeling that it wasn’t there help

Good Ways to Give Support

. Show interest, attention, and . Show respect for the person’s . Talk about expectable care reactions and ways of coping reactions to disasters, and healthy coping

. Find an uninterrupted time . Acknowledge that this type . Express belief that the person and place to talk of stress can take time to is capable of recovery resolve

. Be free of expectations or . Help brainstorm positive . Offer to talk or spend time judgments ways to deal with reactions together as many times as is needed

Psychological First Aid - Field Operations Guide 129 Behaviors That Interfere with Giving Support

. Rushing to tell someone the he/she will be okay . Acting like someone is weak or exaggerating or that they should just “get over it” because he or she isn’t coping as well as you are

. Discussing your own personal experiences . Giving advice without listening to the person’s without listening to the other person’s story concerns or asking the person what works for him or her

. Stopping people from talking about what is . Telling them they were lucky it wasn’t worse bothering them

When Your Support is Not Enough

. Let the person know that experts think that . Encourage the person to talk with a counselor, avoidance and withdrawal are likely to increase clergy, or medical professional, and offer to distress, and social support helps recovery. accompany them.

. Encourage the person to get involved in a . Enlist help from others in your social circle so support group with others who have similar that you all take part in supporting the person. experiences.

130 National Child Traumatic Stress Network National Center for PTSD When Terrible Things Happen - What You May Experience

Immediate Reactions

There are a wide variety of positive and negative reactions that survivors can experience during and immediately after a disaster. These include:

Domain Negative Responses Positive Responses

Cognitive Confusion, disorientation, worry, intru- Determination and resolve, sharper sive thoughts and images, self-blame perception, courage, optimism, faith

Emotional Shock, sorrow, grief, sadness, fear, an- Feeling involved, challenged, mobi- ger, numb, irritability, guilt and shame lized

Social Extreme withdrawal, interpersonal Social connectedness, altruistic helping conflict behaviors

Physiological Fatigue, headache, muscle tension, Alertness, readiness to respond, in- stomachache, increased heart rate, ex- creased energy aggerated startle response, difficulties sleeping

Common negative reactions that may continue include:

Intrusive reactions . Distressing thoughts or images of the event while awake or dreaming . Upsetting emotional or physical reactions to reminders of the experience . Feeling like the experience is happening all over again (“flashback”)

Avoidance and withdrawal reactions . Avoid talking, thinking, and having feelings about the traumatic event . Avoid reminders of the event (places and people connected to what happened) . Restricted emotions; feeling numb . Feelings of detachment and estrangement from others; social withdrawal . Loss of interest in usually pleasurable activities

Psychological First Aid - Field Operations Guide 131 Physical arousal reactions

. Constantly being “on the lookout” for danger, startling easily, or being jumpy

. Irritability or outbursts of anger, feeling “on edge”

. Difficulty falling or staying asleep, problems concentrating or paying attention

Reactions to trauma and loss reminders

. Reactions to places, people, sights, sounds, smells, and feelings that are reminders of the disaster

. Reminders can bring on distressing mental images, thoughts, and emotional/physical reactions

. Common examples include sudden loud noises, sirens, locations where the disaster occurred, seeing people with disabilities, funerals, anniversaries of the disaster, and television/radio news about the disaster

Positive changes in priorities, worldview, and expectations

. Enhanced appreciation that family and friends are precious and important

. Meeting the challenge of addressing difficulties (by taking positive action steps, changing the focus of thoughts, using humor, acceptance)

. Shifting expectations about what to expect from day to day and about what is considered a “good day”

. Shifting priorities to focus more on quality time with family or friends

. Increased commitment to self, family, friends, and spiritual/religious faith

When a Loved One Dies, Common Reactions Include:

. Feeling confused, numb, disbelief, bewildered, or lost

. Feeling angry at the person who died or at people considered responsible for the death

. Strong physical reactions such as nausea, fatigue, shakiness, and muscle weakness

. Feeling guilty for still being alive

132 National Child Traumatic Stress Network National Center for PTSD . Intense emotions such as extreme sadness, anger, or fear

. Increased risk for physical illness and injury

. Decreased productivity or difficulty making decisions

. Having thoughts about the person who died, even when you don’t want to

. Longing, missing, and wanting to search for the person who died

. Children are particularly likely to worry that they or a parent might die

. Children may become anxious when separated from caregivers or other loved ones

What Helps

. Talking to another person for support or spending time with others

. Engaging in positive distracting activities (sports, hobbies, reading)

. Getting adequate rest and eating healthy meals

. Trying to maintain a normal schedule

. Scheduling pleasant activities

. Taking breaks

. Reminiscing about a loved one who has died

. Focusing on something practical that you can do right now to manage the situation better

. Using relaxation methods (breathing exercises, meditation, calming self-talk, soothing music)

. Participating in a support group

. Exercising in moderation

. Keeping a journal

. Seeking counseling

Psychological First Aid - Field Operations Guide 133 What Doesn’t Help . Using alcohol or drugs to cope . Extreme avoidance of thinking or talking about the event or a death of a loved one . Violence or conflict . Overeating or failing to eat

. Excessive TV or computer games

. Blaming others

. Working too much

. Extreme withdrawal from family or friends

. Not taking care of yourself

. Doing risky things (driving recklessly, substance abuse, not taking adequate precautions)

. Withdrawing from pleasant activities

134 National Child Traumatic Stress Network National Center for PTSD Parent Tips for Helping Infants and Toddlers after Disasters If Your Child Understand Ways to Help . . has problems . When children are scared, they want to be with people . If you want, let your child sleep with you. Let him know this is just sleeping, doesn’t who help them feel safe, and they worry when you are not for now. want to go to bed, together. . Have a bedtime routine: a story, a prayer, cuddle time. Tell him the won’t sleep alone, . If you were separated during the disaster, going to bed routine (every day), so he knows what to expect. wakes up at night alone may remind your child of that separation. . Hold him and tell him that he is safe, that you are there and will not screaming. . Bedtime is a time for remembering because we are not leave. Understand that he is not being difficult on purpose. This may busy doing other things. Children often dream about take time, but when he feels safer, he will sleep better. things they fear and can be scared of going to sleep.

. . worries something . It is natural to have fears like this after being in danger. . Remind your child and yourself that right now you are safe. bad will happen to . These fears may be even stronger if your child was . If you are not safe, talk about how you are working to keep her safe. you. separated from loved ones during the disaster. . Make a plan for who would care for your child if something did (You may also have happen to you. This may help you worry less. worries like this.) . Do positive activities together to help her think about other things.

. . cries or complains . Children who cannot yet speak or say how they feel may . Try to stay with your child and avoid separations right now. whenever you leave show their fear by clinging or crying. . For brief separations (store, bathroom), help your child by naming his him, even when you . Goodbyes may remind your child of any separation you feelings and linking them to what he has been through. Let him know go to the bathroom. had related to the disaster. you love him and that this goodbye is different, you’ll be back soon. . Children’s bodies react to separations (stomach sinks, “You’re so scared. You don’t want me to go because last time I was . . can’t stand to be heart beats faster). Something inside says, “Oh no, I can’t gone you didn’t know where I was. This is different, and I’ll be right away from you. lose her.” back.” . Your child is not trying to manipulate or control you. He . For longer separations, have him stay with familiar people, tell him is scared. where you are going and why, and when you will come back. Let him . He may also get scared when other people (not just you) know you will think about him. Leave a photo or something of yours leave. Goodbyes make him scared. and call if you can. When you come back, tell him you missed him, thought about him, and did come back. You will need to say this over and over.

. . has problems . Stress affects your child in different ways, including her . Relax. Usually, as your child’s level of stress goes down, her eating eating, eats too much appetite. habits will return to normal. Don’t force your child to eat. or refuses food. . Eating healthfully is important, but focusing too much on . Eat together and make meal times fun and relaxing. eating can cause stress and tension in your relationship. . Keep healthy snacks around. Young children often eat on the go. . If you are worried, or if your child loses a significant amount of weight, consult a pediatrician.

Psychological First Aid - Field Operations Guide 135 Parent Tips for Helping Infants and Toddlers after Disasters If Your Child Understand Ways to Help . . is not able to do . Often when young children are stressed or scared, they . Avoid criticism. It makes him worried that he’ll never learn. things he used to do temporarily lose abilities or skills they recently learned. . Do not force your child. It creates a power struggle. (like use the potty). . This is the way young children tell us that they are not okay and . Instead of focusing on the ability (like not using the potty), help your child need our help. feel understood, accepted, loved, and supported. . . does not talk like he . Losing an ability after children have gained it (like starting to . As your child feels safer, he will recover the ability he lost. used to. wet the bed again) can make them feel ashamed or embarrassed. Caregivers should be understanding and supportive. . Your child is not doing this on purpose. . . is reckless, does . It may seem strange, but when children feel unsafe, they often . Keep her safe. Calmly go and get her and hold her if necessary. dangerous things. behave in unsafe ways. . Let her know that what she is doing is unsafe, that she is important, and you . It is one way of saying, “I need you. Show me I’m important by wouldn’t want anything to happen to her. keeping me safe.” . Show her other more positive ways that she can have your attention. . . is scared by things . Young children believe their parents are all-powerful and can . When your child is scared, talk to her about how you will keep her safe. that did not scare her protect them from anything. This belief helps them feel safe. . If things remind your child of the disaster and cause her to worry that it is before. . Because of what happened, this belief has been damaged, and happening again, help her understand how what is happening now (like rain without it, the world is a scarier place. or aftershocks) is different from the disaster. . Many things may remind your child of the disaster (rain, . If she talks about monsters, join her in chasing them out. “Go away, monster. aftershocks, ambulances, people yelling, a scared look on your Don’t bother my baby. I’m going to tell the monster boo, and it will get face), and will scare her. scared and go away. Boo, boo.” . It is not your fault–it was the disaster. . Your child is too young to understand and recognize how you did protect her, but remind yourself of the good things you did. . . seems “hyper,” . Fear can create nervous energy that stays in our bodies. . Help your child to recognize his feelings (fear, worry) and reassure your child can’t sit still, and . Adults sometimes pace when worried. Young children run, that he is safe. doesn’t pay attention to jump, and fidget. . Help your child get rid of nervous energy (stretching, running, sports, anything. . When our minds are stuck on bad things, it is hard to pay breathing deep and slow). attention to other things. . Sit with him and do an activity you both enjoy (throw a ball, read books, play, . Some children are naturally active. draw). Even if he doesn’t stop running around, this helps him. . If your child is naturally active, focus on the positive. Think of all the energy he has to get things done, and find activities that fit his needs. . . plays in a violent . Young children often talk through play. Violent play can be their . If you can tolerate it, listen to your child when he “talks.” way. way of telling us how crazy things were or are, and how they . As your child plays, notice the feelings he has and help him by naming feel inside. feelings and being there to support him (hold him, soothe him). . . keeps talking about . When your child talks about what happened, strong feelings . If he gets overly upset, spaces out, or he plays out the same upsetting scene, the disaster and the bad may come up both for you and your child (fear, sadness, anger). help him calm down, help him feel safe, and consider getting professional things he saw. help.

136 National Child Traumatic Stress Network National Center for PTSD Parent Tips for Helping Infants and Toddlers after Disasters If Your Child Understand Ways to Help . .is now very . Between the age of 18 months to 3 years, young children . Remember your child is not controlling or bad. This is normal, but demanding and often seem “controlling.” may be worse right now because she feels unsafe. controlling. . It can be annoying, but it is a normal part of growing up . Let your child have control over small things. Give her choices over and helps them learn that they are important and can make what she wears or eats, games you play, stories you read. If she has . . seems “stubborn” things happen. control over small things, it can make her feel better. Balance giving insisting that things . When children feel unsafe, they may become more her choices and control with giving her structure and routines. She will be done her way. controlling than usual. This is one way of dealing with feel unsafe if she “runs the show.” fears. They are saying, “Things are so crazy I need control . Cheer her on as she tries new things. She can also feel more in control over something.” when she can put her shoes on, put a puzzle together, pour juice. . . tantrums and is . Even before the disaster, your child may have had . Let him know you understand how hard this is for him. “Thing are cranky. tantrums. They are a normal part of being little. It’s really bad right now. It’s been so scary. We don’t have your toys or TV, frustrating when you can’t do things and when you don’t and you’re mad.” . .yells a lot – more have the words to say what you want or need. . Tolerate tantrums more than you usually would, and respond with love than usual. . Now, your child has a lot to be upset about (just like you) rather than discipline. You might not normally do this, but things are and may really need to cry and yell. not normal. If he cries or yells, stay with him and let him know you are there for him. Reasonable limits should be set if tantrums become frequent or are extreme. . . hits you. . For children, hitting is a way of expressing anger. . Each time your child hits, let her know that this is not okay. Hold her . When children can hit adults they feel unsafe. It’s scary to hands, so she can’t hit, have her sit down. Say something like, “It’s be able to hit someone who’s supposed to protect you. not okay to hit, it’s not safe. When you hit, you are going to need to sit . Hitting can also come from seeing other people hit each down.” other. . If she is old enough, give her the words to use or tell her what she needs to do. Tell her, “Use your words. Say, I want that toy.” . Help her express anger in other ways (play, talk, draw). . If you are having conflict with other adults, try to work it out in private, away from where your child can see or hear you. If needed, talk with a friend or professional about your feelings. . . says “Go away, I . The real problem is the disaster and everything that . Remember what your child has been through. He doesn’t mean hate you!” followed, but your child is too little to fully understand everything he is saying; he’s angry and dealing with so many difficult that. feelings. . . says “This is all . When things go wrong, young children often get mad . Support your child’s feeling of anger, but gently redirect the anger your fault.” at their parents because they believe they should have towards the disaster. “You are really mad. Lots of bad things have stopped it from happening. happened. I’m mad too. I really wish it didn’t happen, but even . You are not to blame, but now is not the time to defend mommies can’t make hurricanes not happen. It’s so hard for both of yourself. Your child needs you. us.”

Psychological First Aid - Field Operations Guide 137 Parent Tips for Helping Infants and Toddlers after Disasters If Your Child Understand Ways to Help . . doesn’t want to . Your child needs you. So much has happened and he may . Sit by your child and keep him close. Let him know you care. play or do anything. be feeling sad and overwhelmed. . If you can, give words to his feelings. Let him know it’s okay to feel . When children are stressed, some yell and others shut sad, mad, or worried. “It seems like you don’t want to do anything. I . . seems to not really down. Both need their loved ones. wonder if you are sad. It’s okay to be sad. I will stay with you.” have any feelings . Try to do things with your child, anything he might like (read a book, (happy or sad). sing, play together). . . cries a lot. . Your family may have experienced difficult changes . Allow your child to express feelings of sadness. because of the disaster, and it is natural that your child is . Help your child name her feelings and understand why she may feel sad. that way. “I think you’re sad. A lot of hard things have happened” . When you let your child feel sad and provide her with . Support your child by sitting with her and giving her extra attention. comfort, you help your child even if she remains sad. Spend special time together. . If you have strong feelings of sadness, it may be good for . Help your child feel hopeful about the future. Together think and talk you to get support. Your child’s well-being is connected about how your lives will continue and the good things you will do, to your well-being. like go for a walk, go to the park or zoo, play with friends. . Take care of yourself. . . misses people you . Even though young children do not always express how . For those that have moved away, help your child stay in touch in are no longer able to they feel, be aware that it is difficult for them when they some way (for example, sending pictures or cards, calling). see after the disaster. lose contact with important people. . Help your child talk about these important people. Even when we are . If someone close to your child died, your child may show apart from people, we can still have positive feelings about them by stronger reactions to the disaster. remembering and talking about them. . Young children do not understand death, and may think . Acknowledge how hard it is to not be able to see people we care for. that the person can come back. It is sad. . Where someone has died, answer your child’s questions simply and honestly. When strong reactions last longer than two weeks, seek help from a professional. . . misses things you . When a disaster brings so much loss to a family and . Allow your child to express feelings of sadness. It is sad that your have lost because of community, it is easy to lose sight of how much the loss child lost her toy or blanket. the disaster. of a toy or other important item (blanket) can mean to a . If possible, try to find something that would replace the toy or blanket child. that would be acceptable and satisfying to your child. . Grieving for a toy is also your child’s way of grieving for . Distract your child with other activities. all you had before the disaster.

138 National Child Traumatic Stress Network National Center for PTSD Parent Tips for Helping Preschool-Age Children after Disasters Reactions/Behavior Responses Examples of things to do and say Helplessness and passivity: Young children know . Provide comfort, rest, food, water, and . Give your child more hugs, hand holding, or time they can’t protect themselves. In a disaster, they feel opportunities for play and drawing. in your lap. even more helpless. They want to know their parents . Provide ways to turn spontaneous drawing or . Make sure there is a special safe area for your will keep them safe. They might express this by being playing about traumatic events to something that child to play with proper supervision. unusually quiet or agitated. would make them feel safer or better. . In play, a four year old keeps having the blocks . Reassure your child that you and other grownups knocked down by hurricane winds. Asked, “Can will protect them. you make it safe from the winds?” the child quickly builds a double block thick wall and says, “Winds won’t get us now.” A parent might respond with, “That wall sure is strong,” and explain, “We’re doing a lot of things to keep us safe.” General fearfulness: Young children may become . Be as calm as you can with your child. Try not to . Be aware when you are on the phone or talking more afraid of being alone, being in the bathroom, voice your own fears in front of your child. to others, that your child does not overhear you going to sleep, or otherwise separated from parents. . Help children regain confidence that you aren’t expressing fear. Children want to believe that their parents can protect leaving them and that you can protect them. . Say things such as, “We are safe from the them in all situations and that other grownups, such as . Remind them that there are people working to earthquake now, and people are working hard to teachers or police officers, are there to help them. keep families safe, and that your family can get make sure we are okay.” more help if you need to. . Say, “If you start feeling more scared, come and . If you leave, reassure your children you will be take my hand. Then I’ll know you need to tell me back. Tell them a realistic time in words they something.” understand, and be back on time. . Give your child ways to communicate their fears to you. Confusion about the danger being over: Young children . Give simple, repeated explanations as needed, . Continue to explain to your child that the disaster can overhear things from adults and older children, even every day. Make sure they understand the has passed and that you are away from the danger or see things on TV, or just imagine that it is happen- words you are using. . Draw, or show on a map, how far away you are ing all over again. They believe the danger is closer to . Find out what other words or explanations they from the disaster area, and that where you are is home, even if it happened further away. have heard and clarify inaccuracies. safe. “See? The disaster was way over there, and . If you are at some distance from the danger, it is we’re way over here in this safe place.” important to tell your child that the danger is not near you. Returning to earlier behaviors: Thumb sucking, bed- . Remain neutral or matter-of-fact, as best you can, . If your child starts bedwetting, change her clothes wetting, baby-talk, needing to be in your lap. as these earlier behaviors may continue a while and linens without comment. Don’t let anyone after the disaster. criticize or shame the child.

Psychological First Aid - Field Operations Guide 139 Parent Tips for Helping Preschool-Age Children after Disasters Reactions/Behavior Responses Examples of things to do and say Fears the disaster will return: When having remind- . Explain the difference between the event and . “Even though it’s raining, that doesn’t mean ers—seeing, hearing, or otherwise sensing something reminders of the event. the hurricane is happening again. A rainstorm that reminds them of the disaster. . Protect children from things that will remind is smaller and can’t wreck stuff like a hurricane them as best you can. can.” . Keep your child from television, radio, and computer stories of the disaster that can trigger fears of it happening again. Not talking: Being silent or having difficulty saying . Put common feelings into words, such as anger, . Draw simple “happy faces” for different feelings what is bothering them. sadness, and worry about the safety of parents, on paper plates. Tell a brief story about each one, friends, and siblings. such as, “Remember when the water came into . Do not force them to talk, but let them know they the house and you had a worried face like this?” can talk to you any time. . Say something like, “Children can feel really sad when their home is damaged.” . Provide art or play materials to help them express themselves. Then use feeling words to check out how they felt. “This is a really scary picture. Were you scared when you saw the water?” Sleep problems: Fear of being alone at night, sleep- . Reassure your child that he is safe. Spend extra . Provide calming activities before bedtime. Tell a ing alone, waking up afraid, having bad dreams. quiet time together at bedtime. favorite story with a comforting theme. . Let the child sleep with a dim light on or sleep . At bedtime say, “You can sleep with us tonight, with you for a limited time. but tomorrow you’ll sleep in your own bed.” . Some might need an explanation of the . “Bad dreams come from our thoughts inside difference between dreams and real life. about being scared, not from real things happening.” Not understanding about death: Preschool age chil- . Give an age-appropriate consistent explanation– . Allow children to participate in cultural and dren don’t understand that death is not reversible. that does not give false hopes–about the reality religious grieving rituals. They have “magical thinking” and might believe of death. . Help them find their own way to say goodbye by their thoughts caused the death. The loss of a pet may . Don’t minimize feelings over a loss of a pet or a drawing a happy memory or lighting a candle or be very hard on a child. special toy. saying a prayer for the deceased. . Take cues from what your child seems to want to . “No, Pepper won’t be back, but we can think know. Answer simply and ask if he has any more about him and talk about him and remember questions. what a silly doggy he was.” . “The firefighter said no one could save Pepper and it wasn’t your fault. I know you miss him very much.”

140 National Child Traumatic Stress Network National Center for PTSD Parent Tips for Helping School-Age Children after Disasters

Reactions Responses Examples of things to do and say Confusion about what happened . Give clear explanations of what happened . “I know other kids said that more tornadoes are whenever your child asks. Avoid details that would coming, but we are now in a safe place.” scare your child. Correct any misinformation that . Continue to answer questions your children have your child has about whether there is a present (without getting irritable) and to reassure them the danger. family is safe. . Remind children that there are people working to . Tell them what’s happening, especially about keep families safe and that your family can get issues regarding school and where they will be more help if needed. living. . Let your children know what they can expect to happen next. Feelings of being responsible: School-age children . Provide opportunities for children to voice their . Take your child aside. Explain that, “After a may have concerns that they were somehow at fault, or concerns to you. disaster like this, lots of kids–and parents too–keep should have been able to change what happened. They . Offer reassurance and tell them why it was not thinking, ‘What could I have done differently?’ or may hesitate to voice their concerns in front of others. their fault. ‘I should have been able to do something.’ That doesn’t mean they were at fault.” . “Remember? The firefighter said no one could save Pepper and it wasn’t your fault.” Fears of recurrence of the event and reactions to . Help identify different reminders (people, places, . When they recognize that they are being reminded, reminders sounds, smells, feelings, time of day) and clarify say, “Try to think to yourself, I am upset because the difference between the event and the reminders I am being reminded of the hurricane because it that occur after it. is raining, but now there is no hurricane and I am . Reassure them, as often as they need, that they are safe.” safe. . “I think we need to take a break from the TV right . Protect children from seeing media coverage of now.” the event, as it can trigger fears of the disaster . Try to sit with your child while watching TV. Ask happening again. your child to describe what they saw on the news. Clarify any misunderstandings. Retelling the event or playing out the event over and . Permit the child to talk and act out these reactions. . “You’re drawing a lot of pictures of what over Let him know that this is normal. happened. Did you know that many children do . Encourage positive problem-solving in play or that?” drawing. . “It might help to draw about how you would like your school to be rebuilt to make it safer.”

Psychological First Aid - Field Operations Guide 141 Parent Tips for Helping School-Age Children after Disasters

Reactions Responses Examples of things to do and say Fear of being overwhelmed by their feelings . Provide a safe place for her to express her fears, . “When scary things happen, people have strong anger, sadness, etc. Allow children to cry or be feelings, like being mad at everyone or being very sad; don’t expect them to be brave or tough. sad. Would you like to sit here with a blanket until you’re feeling better?” Sleep problems: Bad dreams, fear of sleeping alone, . Let your child tell you about the bad dream. . “That was a scary dream. Let’s think about some demanding to sleep with parents. Explain that bad dreams are normal and they will good things you can dream about and I’ll rub go away. Do not ask the child to go into too many your back until you fall asleep.” details of the bad dream. . “You can stay in our bedroom for the next couple . Temporary sleeping arrangements are okay; of nights. After that we will spend more time with make a plan with your child to return to normal you in your bed before you go to sleep. If you get sleeping habits. scared again, we can talk about it.” Concerns about the safety of themselves and others.. Help them to share their worries and give them . Create a “worry box” where children can write realistic information. out their worries and place them in the box. Set a time to look these over, problem-solve, and come up with answers to the worries. Altered behavior: Unusually aggressive or restless . Encourage the child to engage in recreational . “I know you didn’t mean to slam that door. It behavior. activities and exercise as an outlet for feelings must be hard to feel so angry.” and frustration. . “How about if we take a walk? Sometimes getting our bodies moving helps with strong feelings.” Somatic complaints: Headaches, stomachaches, . Find out if there is a medical reason. If not, . Make sure the child gets enough sleep, eats well, muscle aches for which there seem to be no reason. provide comfort and assurance that this is normal. drinks plenty of water, and gets enough exercise. . Be matter-of-fact with your child; giving these . “How about sitting over there? When you feel complaints too much attention may increase better, let me know and we can play cards.” them. Closely watching a parent’s responses and recovery: . Give children opportunities to talk about their . “Yes, my ankle is broken, but it feels better since Not wanting to disturb a parent with their own feelings, as well as your own. the paramedics wrapped it. I bet it was scary worries. . Remain as calm as you can, so as not to increase seeing me hurt, wasn’t it?” your child’s worries. Concern for other survivors and families. . Encourage constructive activities on behalf . Help children identify projects that are age- of others, but do not burden them with undue appropriate and meaningful (clearing rubble from responsibility. school grounds, collecting money or supplies for those in need).

142 National Child Traumatic Stress Network National Center for PTSD Parent Tips for Helping Adolescents after Disasters

Reactions Responses Examples of things to do and say Detachment, shame, and guilt . Provide a safe time to discuss with your teen the . “Many teens–and adults–feel like you do, angry events and their feelings. and blaming themselves that they could have . Emphasize that these feelings are common, done more. You’re not at fault. Remember even and correct excessive self-blame with realistic the firefighters said there was nothing more we explanations of what actually could have been could have done.” done. Self-consciousness: About their fears, sense of vul- . Help teens understand that these feelings are . “I was feeling the same thing. Scared and nerability, fear of being labeled abnormal. common. helpless. Most people feel like this when a . Encourage relationships with family and peers disaster happens, even if they look calm on the for needed support during the recovery period. outside.” . “My cell phone is working again, why don’t you see if you can get a hold of Pete to see how he’s doing.” . “And thanks for playing the game with your little sister. She’s much better now.” Acting out behavior: Using alcohol or drugs, sexu- . Help teens understand that acting out behavior . “Many teens–and some adults–feel out of ally acting out, accident-prone behavior. is a dangerous way to express strong feelings control and angry after a disaster like this. (like anger) over what happened. They think drinking or taking drugs will help . Limit access to alcohol and drugs. somehow. It’s very normal to feel that way–but . Talk about the danger of high-risk sexual it’s not a good idea to act on it.” activity. . “It’s important during these times that I know . On a time-limited basis, keep a closer watch where you are and how to contact you.” Assure on where they are going and what they are them that this extra checking-in is temporary, planning to do. just until things have stabilized. Fears of recurrence and reactions to reminders. Help to identify different reminders (people, . “When you’re reminded, you might try saying places, sounds, smells, feelings, time of day) to yourself, ‘I am upset now because I am being and to clarify the difference between the event reminded, but it is different now because there and the reminders that occur after it. is no hurricane and I am safe.’” . Explain to teens that media coverage of the . Suggest, “Watching the news reports could disaster can trigger fears of it happening again. make it worse, because they are playing the same images over and over. How about turning it off now?”

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Reactions Responses Examples of things to do and say Abrupt shifts in interpersonal relationships: Teens . Explain that the strain on relationships is . Spend more time talking as a family about how may pull away from parents, family, and even from expectable. Emphasize that everyone needs everyone is doing. Say, “You know, the fact peers; they may respond strongly to parent’s reac- family and friends for support during the that we’re crabby with each other is completely tions in the crisis. recovery period. normal, given what we’ve been through. I think . Encourage tolerance for different family we’re handling things amazingly. It’s a good members’ courses of recovery. thing we have each other.” . Accept responsibility for your own feelings. . You might say, “I appreciate your being calm when your brother was screaming last night. I know he woke you up, too.” . “I want to apologize for being irritable with you yesterday. I am going to work harder to stay calm myself.” Radical changes in attitude . Explain that changes in people’s attitudes after a . “We are all under great stress. When people’s disaster are common, but often return back over lives are disrupted this way, we all feel more time. scared, angry–even full of revenge. It might not seem like it, but we all will feel better when we get back to a more structured routine.” Premature entrance into adulthood: (wanting to . Encourage postponing major life decisions. . “I know you’re thinking about quitting school leave school, get married). Find other ways to make the teens feel more in and getting a job to help out. But it’s important control. not to make big decisions right now. A crisis time is not a great time to make major changes.” Concern for other survivors and families . Encourage constructive activities on behalf of . Help teens to identify projects that are age- others, but do not let them burden themselves appropriate and meaningful (clearing rubble with undue responsibility. from school grounds, collecting money or supplies for those in need).

144 National Child Traumatic Stress Network National Center for PTSD Tips for Adults

Reactions/Behavior Responses Examples of things to do and say High anxiety/arousal: Tension and anxiety are com- . Use breathing and/or other relaxation skills. . Breathing exercise: Inhale slowly through your mon after disasters. Adults may be excessively worried . Take time during the day to calm yourself through nose and comfortably fill your lungs all the way about the future, have difficulties sleeping, problems relaxation exercises. These can make it easier to down to your stomach, while saying to yourself, concentrating, and feel jumpy and nervous. These reac- sleep, concentrate, and will give you energy. “My body is filled with calm.” Exhale slowly tions can include rapid heart beat and sweating. through your mouth and empty your lungs, while silently saying to yourself, “My body is letting go.” Do this five times slowly, and as many times a day as needed. Concern or shame over your own reactions. Many . Find a good time to discuss your reactions with a . When talking with someone, find the right time people have strong reactions after a disaster, including family member or trusted friend. and place, and ask if it is okay to talk about your fear and anxiety, difficulty concentrating, shame about . Remember that these reactions are common and it feelings. how they reacted, and feeling guilty about something. takes time for them to subside. . Remind yourself that your feelings are expectable It is expectable and understandable to feel many emo- . Correct excessive self-blame with realistic and you are not “going crazy,” and that you are not tions in the aftermath of an extremely difficult event. assessment of what actually could have been done. at fault for the disaster. . If these feelings persist for a month or more, you may wish to seek professional help. Feeling overwhelmed by tasks that need to be accom- . Identify what your top priorities are. . Make a list of your concerns and decide what to plished (housing, food, paperwork for insurance, child . Find out what services are available to help get tackle first. Take one step at a time. care, parenting). your needs met. . Find out which agencies can help with your needs . Make a plan that breaks down the tasks into and how to access them. manageable steps. . Where appropriate, rely on your family, friends, and community for practical assistance. Fears of recurrence and reactions to reminders: It is . Be aware that reminders can include people, . When you are reminded, try saying to yourself, common for survivors to fear that another disaster will places, sounds, smells, feelings, time of day. “I am upset because I am being reminded of the occur, and to react to things that are reminders of what . Remember that media coverage of the disaster can disaster, but it is different now because the disaster happened. be a reminder and trigger fears of it happening is not happening and I am safe.” again. . Limit your viewing of news reports so you just get the information that you need. Changes in attitude, view of the world and of . Postpone any major unnecessary life changes in . Getting back to a more structured routine can help oneself: Strong changes in people’s attitudes after the immediate future. improve decision-making. a disaster are common, including questioning one’s . Remember that dealing with post-disaster . Remind yourself that going through a disaster can spiritual beliefs, trust in others and social agencies, difficulties increases your sense of courage and have positive effects on what you value and how and concerns about one’s own effectiveness, and effectiveness. you spend your time. dedication to helping others. . Get involved with community recovery efforts.

Psychological First Aid - Field Operations Guide 145 Tips for Adults

Reactions/Behavior Responses Examples of things to do and say Using alcohol and drugs, or engaging in gambling or . Understand that using substances and engaging . Remember that substance use and other addictive high-risk sexual behaviors: Many people feel out of in addictive behaviors can be a dangerous way to behaviors can lead to problems with sleep, control, scared, hopeless, or angry after a disaster and cope with what happened. relationships, jobs, and physical health. engage in these behaviors to feel better. This can espe- . Get information about local support agencies. cially be a problem if there was pre-existing substance abuse or addiction. Shifts in interpersonal relationships: People may feel . Understand that family and friends are a major . Don’t withdraw from others because you feel you differently towards family and friends; for example, form of support during the recovery period. might burden them. Most people do better after they may feel overprotective and very concerned for . It is important to understand and tolerate different disasters turning to others. each other’s safety, frustrated by the reactions of a courses of recovery among family members. . Ask your friends and family how they are doing, family member or friend, or they may feel like pulling . Rely on other family members for help with rather than just giving advice, or telling them away from family and friends. parenting or other daily activities when you are to “get over it.” Offer a supportive ear or lend a upset or under stress. helping hand. . Say, “We’re crabby with each other and that is completely normal, given what we’ve been through. I think we’re handling things amazingly. It’s a good thing we have each other.” Excessive anger: Some degree of anger is understand- . Find ways to manage your anger that help you . Take time to cool down, walk away from stressful able and expected after a disaster, especially when rather than hurt you. situations, talk to a friend about what is making something feels unfair. However, when it leads to you angry, get physical exercise, distract yourself violent behavior, extreme anger is a serious problem. with positive activities, or problem-solve the situation that is making you angry. . Remind yourself that being angry may harm important relationships. . If you become violent, get immediate help. Sleep difficulties: Trouble falling asleep and frequent . Make sure you have good sleep routines. . Go to sleep at the same time every day. awakening is common after a disaster, as people are on . Don’t have caffeinated drinks in the evening. edge and worried about adversities and life changes. . Reduce alcohol consumption. . Increase daytime exercise. . Relax before bedtime. . Limit daytime naps to 15 minutes, and do not nap later than 4 pm.

146 National Child Traumatic Stress Network National Center for PTSD Tips for Relaxation

Tips for Relaxation Tension and anxiety are common after disasters. Unfortunately, they can make it more dif- ficult to cope with the many things that must be done to recover. There is no easy solution to coping with post-disaster problems, but taking time during the day to calm yourself through relaxation exercises may make it easier to sleep, concentrate, and have energy for coping with life. These can include muscle relaxation exercises, breathing exercises, meditation, swimming, stretching, yoga, prayer, exercise, listening to quiet music, spending time in nature, and so on. Here are some basic breathing exercises that may help: For Yourself: 1. Inhale slowly (one-thousand one; one-thousand two; one-thousand three) through your nose and comfortably fill your lungs all the way down to your belly. 2. Silently and gently say to yourself, “My body is filled with calmness.” Exhale slowly (one-thousand one; one-thousand two; one-thousand three) through your mouth and comfortably empty your lungs all the way down to your stomach. 3. Silently and gently say to yourself, “My body is releasing the tension.” 4. Repeat five times slowly and comfortably. 5. Do this as many times a day as needed. For Children: Lead a child through a breathing exercise: 1. “Let’s practice a different way of breathing that can help calm our bodies down. 2. Put one hand on your stomach, like this [demonstrate]. 3. Okay, we are going to breathe in through our noses. When we breathe in, we are going to fill up with a lot of air and our stomachs are going to stick out like this [demonstrate]. 4. Then, we will breathe out through our mouths. When we breathe out, our stomachs are going to suck in and up like this [demonstrate]. 5. We are going to breathe in really slowly while I count to three. I’m also going to count to three while we breathe out really slowly. 6. Let’s try it together. Great job!” Make a Game of It: . Blow bubbles with a bubble wand and dish soap. . Blow bubbles with chewing gum. . Blow paper wads or cotton balls across the table. . Tell a story where the child helps you imitate a character who is taking deep breaths.

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148 National Child Traumatic Stress Network National Center for PTSD Alcohol, Medication, and Drug Use after Disaster

Alcohol, Medication, and Drug Use after Disaster Some people increase their use of alcohol, prescription medications, or other drugs after a disaster. You may feel that using drugs and alcohol helps you escape bad feelings or physical symptoms related to stress responses (for example, headaches, muscle tension). However, they can actually make these worse in the long term because they interrupt natural sleep cycles, create health problems, interfere with relationships, and create potential dependence on the substance. If your use of alcohol or drugs has increased since the disaster or is causing problems for you, it is important for you to reduce your level of use or seek help in gaining control over your use.

. Pay attention to any change in your use of . Consult with a healthcare professional about alcohol and/or drugs. safe ways to reduce anxiety, depression, muscle tension, and sleep difficulties. . Correctly use prescription and over-the- . If you find that you have greater difficulty counter medications as indicated. controlling alcohol/substance use since the disaster, seek support in doing so. . Eat well, exercise, get enough sleep, and use . If you believe you have a problem with your family and others for support. substance abuse, talk to your doctor or counselor about it. . If you feel like using larger amounts of either prescribed or over-the-counter medications, consult a healthcare professional. If you have had an alcohol, medication, or drug problem in the past For people who have successfully stopped drinking or using drugs, experiencing a disaster can sometimes result in strong urges to drink or use again. Sometimes it can lead them to strengthen their commitment to recovery. Whatever your experience, it is important to consciously choose to stay in recovery.

. Increase your attendance at substance abuse . Talk with family and friends about supporting support groups. you to avoid use of alcohol or substances. . If you are receiving disaster crisis counseling, . If you have a 12-Step sponsor or substance talk to your counselor about your past alcohol abuse counselor, talk to him or her about your or drug use. situation. . If you have been forced to move out of your . Increase your use of other supports that have local community, talk to disaster workers helped you avoid relapse in the past. about helping to locate nearby alcohol or drug recovery groups, or ask them to help organize a new support group.

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150 National Child Traumatic Stress Network National Center for PTSD Psychological First Aid Field Operations Guide 2nd Edition

Appendix F:  Duplicate Handouts to Copy and Distribute  For Psychological First Aid Providers  Overview of Psychological First Aid  Psychological First Aid Worksheets  Handouts for Survivors  Connecting with Others: Seeking Social Support (for adults and adolescents)  Connecting with Others: Giving Social Support (for adults and adolescents)  When Terrible Things Happen (for adults and adolescents)  Parent Tips for Helping Infants and Toddlers (for parents/caregivers)  Parent Tips for Helping Preschool-Age Children (for parents/caregivers)  Parent Tips for Helping School-Age Children (for parents/caregivers)  Parent Tips for Helping Adolescents (for parents/caregivers)  Tips for Adults (for adult survivors)  Basic Relaxation Techniques (for adults, adolescents, and children)  Alcohol and Drug Use after Disasters (for adults and adolescents)

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National Child Traumatic Stress Network National Center for PTSD Overview of Psychological First Aid Section Headers Preparing to Deliver 1. Entering the setting Psychological First 2. Providing services Aid 3. Group settings 4. Maintain a calm presence 5. Be sensitive to culture and diversity 6. Be aware of at-risk populations

Contact and 1. Introduce yourself/ask about immediate needs Engagement 2. Confidentiality

Safety and Comfort 1. Ensure immediate physical safety 2. Provide information about disaster response activities and services 3. Attend to physical comfort 4. Promote social engagement 5. Attend to children who are separated from their parents/caregivers 6. Protect from additional traumatic experiences and trauma reminders 7. Help survivors who have a missing family member 8. Help survivors when a family member or close friend has died 9. Attend to grief and spiritual issues 10. Provide information about casket and funeral issues 11. Attend to issues related to traumatic grief 12. Support survivors who receive death notification 13. Support survivors involved in body identification 14. Help caregivers confirm body identification to a child or adolescent

Stabilization 1. Stabilize emotionally overwhelmed survivors 2. Orient emotionally overwhelmed survivors 3. The role of medications in stabilization

Information 1. Nature and severity of experiences during the disaster Gathering: Current 2. Death of a loved one Needs and Concerns 3. Concerns about immediate post-disaster circumstances and ongoing threat 4. Separations from or concern about the safety of loved ones 5. Physical illness, mental health conditions, and need for medications 6. Losses (home, school, neighborhood, business, personal property, and pets) 7. Extreme feelings of guilt or shame 8. Thoughts about causing harm to self or others 9. Availability of social support 10. Prior alcohol or drug use 11. Prior exposure to trauma and death of loved ones 12. Specific youth, adult, and family concerns over developmental impact

Psychological First Aid - Field Operations Guide Overview of Psychological First Aid - continued Section Headers Practical Assistance 1. Offering practical assistance to children and adolescents 2. Identify the most immediate needs 3. Clarify the need 4. Discuss an action plan 5. Act to address the need

Connection with 1. Enhance access to primary support persons (family and significant others) Social Supports 2. Encourage use of immediately available support persons 3. Discuss support-seeking and giving 4. Special considerations for children and adolescents 5. Modeling support

Information on 1. Provide basic information about stress reactions Coping 2. Review common psychological reactions to traumatic experiences and losses • Intrusive reactions • Avoidance and withdrawal reactions • Physical arousal reactions • Trauma reminders • Loss reminders • Change reminders • Hardships • Grief reactions • Traumatic grief reactions • Depression • Physical reactions 3. Talking with children about physical and emotional reactions 4. Provide basic information on ways of coping 5. Teach simple relaxation techniques 6. Coping for families 7. Assist with developmental issues 8. Assist with anger management 9. Address highly negative emotions 10. Help with sleep problems 11. Address alcohol and substance use

Linkage with 1. Provide direct link to additional needed services Collaborative 2. Referrals for children and adolescents Services 3. Referrals for older adults 4. Promote continuity in helping relationships

National Child Traumatic Stress Network National Center for PTSD Provider Worksheets

Survivor Current Needs

Date: ______Provider: ______Survivor Name:______Location:______This session was conducted with (check all that apply):

 Child  Adolescent  Adult  Family  Group

Provider: Use this form to document what the survivor needs most at this time. This form can be used to communicate with referral agencies to help promote continuity of care. 1. Check the boxes corresponding to difficulties the survivor is experiencing.

Behavioral Emotional Physical Cognitive

 Extreme  Acute stress  Headaches  Inability to accept/ disorientation reactions  Stomachaches cope with death of loved one(s)  Excessive drug,  Acute grief  Sleep difficulties alcohol, or reactions  Distressing dreams  Difficulty eating prescription drug  Sadness, or nightmares  use tearfulness Worsening of  Intrusive thoughts health conditions  Isolation/  Irritability, anger or images withdrawal  Fatigue/exhaustion  Feeling anxious,  Difficulty   High risk behavior fearful Chronic agitation concentrating   Regressive  Despair, Other ______ Difficulty behavior hopelessness remembering  Separation anxiety  Feelings of guilt or  Difficulty making  Violent behavior shame decisions  Maladaptive  Feeling  Preoccupation with coping emotionally numb, death/destruction  Other ______disconnected  Other ______ Other ______

Psychological First Aid - Field Operations Guide 2. Check the boxes corresponding to difficulties the survivor is experiencing.  Past or preexisting trauma/psychological problems/substance abuse problems  Injured as a result of the disaster  At risk of losing life during the disaster  Loved one(s) missing or dead  Financial concerns  Displaced from home  Living arrangements  Lost job or school  Assisted with rescue/recovery  Has physical/emotional disability  Medication stabilization  Concerns about child/adolescent  Spiritual concerns  Other: ______

3. Please make note of any other information that might be helpful in making a referral. ______4. Referral

 Within project (specify) ______ Substance abuse treatment  Other disaster agencies  Other community services  Professional mental health services  Clergy  Medical treatment  Other: ______5. Was the referral accepted by the individual?

 Yes  No

National Child Traumatic Stress Network National Center for PTSD Provider Worksheets

Psychological First Aid Components Provided

Date: ______Provider: ______Location:______This session was conducted with (check all that apply):

 Child  Adolescent  Adult  Family  Group

Place a checkmark in the box next to each component of Psychological First Aid that you provided in this session.

Contact and Engagement  Initiated contact in an appropriate manner  Asked about immediate needs

Safety and Comfort  Took steps to ensure immediate physical  Gave information about the disaster/risks safety  Attended to physical comfort  Encouraged social engagement  Attended to a child separated from parents  Protected from additional trauma  Assisted with concern over missing loved one  Assisted after death of loved one  Assisted with acute grief reactions  Helped with talking to children about death  Attended to spiritual issues regarding death  Attended to traumatic grief  Provided information about funeral issues  Helped survivor after body identification  Helped survivors regarding death notification  Helped with confirmation of death to child

Stabilization  Helped with stabilization  Used grounding technique  Gathered information for medication referral for stabilization

Information Gathering  Nature and severity of disaster experiences  Death of a family member or friend  Concerns about ongoing threat  Concerns about safety of loved one(s)  Physical/mental illness and medications(s)  Disaster-related losses  Extreme guilt or shame  Thoughts of harming self or others  Availability of social support  Prior alcohol or drug use  History of prior trauma and loss  Concerns over developmental impact  Other ______

Psychological First Aid - Field Operations Guide Practical Assistance  Helped to identify most immediate need(s)  Helped to clarify need(s)  Helped to develop an action plan  Helped with action to address the need

Connection with Social Supports  Facilitated access to primary support persons  Discussed support seeking and giving  Modeled supportive behavior  Engaged youth in activities  Helped problem-solve obtaining/giving social support

Information of Coping  Gave basic information about stress  Gave basic information on coping reactions  Taught simple relaxation techniques(s)  Helped with family coping issues  Assisted with developmental concerns  Assisted with anger management  Addressed negative emotions (shame/guilt)  Helped with sleep problems  Addressed substance abuse problems

Linkage with Collaborative Services  Provided link to additional service(s) ______ Promoted continuity of care ______ Provided handout(s) ______

National Child Traumatic Stress Network National Center for PTSD Connecting with Others

Seeking Social Support . Making contact with others can help reduce feeling of distress . Children and adolescents can benefit from spending some time with similar-age peers . Connections can be with family, friends, or others who are coping with the same traumatic event

Social Support Options . Spouse/partner or parents . Clergy . Support group . Trusted family member . Doctor or nurse . Co-worker/Teacher/Coach . Close friend . Crisis/School counselor or . Pet other counselor

Do . . . . Decide carefully whom to . Start by talking about . Ask others if it’s a good talk to practical things time to talk . Decide ahead of time what . Let others know you need to . Tell others you appreciate you want to discuss talk or just to be with them them listening . Choose the right time and . Talk about painful thoughts . Tell others what you need place and feelings when you’re or how they could help–one ready main thing that would help you right now

Don’t . . . . Keep quiet because you don’t want to upset . Assume that others don’t want to listen others . Keep quiet because you’re worried about . Wait until you’re so stressed or exhausted being a burden that you can’t fully benefit from help

Ways to Get Connected . Calling friends or family on the phone . Getting involved with a support group . Increasing contact with existing . Getting involved in community/school acquaintances and friends recovery activities . Renewing or beginning involvement in religious group activities

Psychological First Aid - Field Operations Guide

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National Child Traumatic Stress Network National Center for PTSD Connecting with Others

Giving Social Support

You can help family members and friends cope with the disaster by spending time with them and lis- tening carefully. Most people recover better when they feel connected to others who care about them. Some people choose not to talk about their experiences very much, and others may need to discuss their experiences. For some, talking about things that happened because of the disaster can help those events seem less overwhelming. For others, just spending time with people they feel close to and accepted by, without having to talk, can feel best. Here is some information about giving social support to other people.

Reasons Why People May Avoid Social Support

. Not knowing what they need . Not wanting to burden others . Wanting to avoid thinking or feeling about the event

. Feeling embarrassed or . Doubting it will be helpful, or . Assuming that others will be “weak” that others will understand disappointed or judgmental

. Fearing they will lose control . Having tried to get help and . Not knowing where to get feeling that it wasn’t there help

Good Ways to Give Support

. Show interest, attention, and . Show respect for the person’s . Talk about expectable care reactions and ways of coping reactions to disasters, and healthy coping

. Find an uninterrupted time . Acknowledge that this type . Express belief that the person and place to talk of stress can take time to is capable of recovery resolve

. Be free of expectations or . Help brainstorm positive . Offer to talk or spend time judgments ways to deal with reactions together as many times as is needed

Psychological First Aid - Field Operations Guide Behaviors That Interfere with Giving Support

. Rushing to tell someone the he/she will be okay . Acting like someone is weak or exaggerating or that they should just “get over it” because he or she isn’t coping as well as you are

. Discussing your own personal experiences . Giving advice without listening to the person’s without listening to the other person’s story concerns or asking the person what works for him or her

. Stopping people from talking about what is . Telling them they were lucky it wasn’t worse bothering them

When Your Support is Not Enough

. Let the person know that experts think that . Encourage the person to talk with a counselor, avoidance and withdrawal are likely to increase clergy, or medical professional, and offer to distress, and social support helps recovery. accompany them.

. Encourage the person to get involved in a . Enlist help from others in your social circle so support group with others who have similar that you all take part in supporting the person. experiences.

National Child Traumatic Stress Network National Center for PTSD When Terrible Things Happen - What You May Experience

Immediate Reactions

There are a wide variety of positive and negative reactions that survivors can experience during and immediately after a disaster. These include:

Domain Negative Responses Positive Responses

Cognitive Confusion, disorientation, worry, intru- Determination and resolve, sharper sive thoughts and images, self-blame perception, courage, optimism, faith

Emotional Shock, sorrow, grief, sadness, fear, an- Feeling involved, challenged, mobi- ger, numb, irritability, guilt and shame lized

Social Extreme withdrawal, interpersonal Social connectedness, altruistic helping conflict behaviors

Physiological Fatigue, headache, muscle tension, Alertness, readiness to respond, in- stomachache, increased heart rate, ex- creased energy aggerated startle response, difficulties sleeping

Common negative reactions that may continue include:

Intrusive reactions . Distressing thoughts or images of the event while awake or dreaming . Upsetting emotional or physical reactions to reminders of the experience . Feeling like the experience is happening all over again (“flashback”)

Avoidance and withdrawal reactions . Avoid talking, thinking, and having feelings about the traumatic event . Avoid reminders of the event (places and people connected to what happened) . Restricted emotions; feeling numb . Feelings of detachment and estrangement from others; social withdrawal . Loss of interest in usually pleasurable activities

Psychological First Aid - Field Operations Guide Physical arousal reactions

. Constantly being “on the lookout” for danger, startling easily, or being jumpy

. Irritability or outbursts of anger, feeling “on edge”

. Difficulty falling or staying asleep, problems concentrating or paying attention

Reactions to trauma and loss reminders

. Reactions to places, people, sights, sounds, smells, and feelings that are reminders of the disaster

. Reminders can bring on distressing mental images, thoughts, and emotional/physical reactions

. Common examples include sudden loud noises, sirens, locations where the disaster occurred, seeing people with disabilities, funerals, anniversaries of the disaster, and television/radio news about the disaster

Positive changes in priorities, worldview, and expectations

. Enhanced appreciation that family and friends are precious and important

. Meeting the challenge of addressing difficulties (by taking positive action steps, changing the focus of thoughts, using humor, acceptance)

. Shifting expectations about what to expect from day to day and about what is considered a “good day”

. Shifting priorities to focus more on quality time with family or friends

. Increased commitment to self, family, friends, and spiritual/religious faith

When a Loved One Dies, Common Reactions Include:

. Feeling confused, numb, disbelief, bewildered, or lost

. Feeling angry at the person who died or at people considered responsible for the death

. Strong physical reactions such as nausea, fatigue, shakiness, and muscle weakness

. Feeling guilty for still being alive

National Child Traumatic Stress Network National Center for PTSD . Intense emotions such as extreme sadness, anger, or fear

. Increased risk for physical illness and injury

. Decreased productivity or difficulty making decisions

. Having thoughts about the person who died, even when you don’t want to

. Longing, missing, and wanting to search for the person who died

. Children are particularly likely to worry that they or a parent might die

. Children may become anxious when separated from caregivers or other loved ones

What Helps

. Talking to another person for support or spending time with others

. Engaging in positive distracting activities (sports, hobbies, reading)

. Getting adequate rest and eating healthy meals

. Trying to maintain a normal schedule

. Scheduling pleasant activities

. Taking breaks

. Reminiscing about a loved one who has died

. Focusing on something practical that you can do right now to manage the situation better

. Using relaxation methods (breathing exercises, meditation, calming self-talk, soothing music)

. Participating in a support group

. Exercising in moderation

. Keeping a journal

. Seeking counseling

Psychological First Aid - Field Operations Guide What Doesn’t Help . Using alcohol or drugs to cope . Extreme avoidance of thinking or talking about the event or a death of a loved one . Violence or conflict . Overeating or failing to eat

. Excessive TV or computer games

. Blaming others

. Working too much

. Extreme withdrawal from family or friends

. Not taking care of yourself

. Doing risky things (driving recklessly, substance abuse, not taking adequate precautions)

. Withdrawing from pleasant activities

National Child Traumatic Stress Network National Center for PTSD Parent Tips for Helping Infants and Toddlers after Disasters If Your Child Understand Ways to Help . . has problems . When children are scared, they want to be with people . If you want, let your child sleep with you. Let him know this is just sleeping, doesn’t who help them feel safe, and they worry when you are not for now. want to go to bed, together. . Have a bedtime routine: a story, a prayer, cuddle time. Tell him the won’t sleep alone, . If you were separated during the disaster, going to bed routine (every day), so he knows what to expect. wakes up at night alone may remind your child of that separation. . Hold him and tell him that he is safe, that you are there and will not screaming. . Bedtime is a time for remembering because we are not leave. Understand that he is not being difficult on purpose. This may busy doing other things. Children often dream about take time, but when he feels safer, he will sleep better. things they fear and can be scared of going to sleep.

. . worries something . It is natural to have fears like this after being in danger. . Remind your child and yourself that right now you are safe. bad will happen to . These fears may be even stronger if your child was . If you are not safe, talk about how you are working to keep her safe. you. separated from loved ones during the disaster. . Make a plan for who would care for your child if something did (You may also have happen to you. This may help you worry less. worries like this.) . Do positive activities together to help her think about other things.

. . cries or complains . Children who cannot yet speak or say how they feel may . Try to stay with your child and avoid separations right now. whenever you leave show their fear by clinging or crying. . For brief separations (store, bathroom), help your child by naming his him, even when you . Goodbyes may remind your child of any separation you feelings and linking them to what he has been through. Let him know go to the bathroom. had related to the disaster. you love him and that this goodbye is different, you’ll be back soon. . Children’s bodies react to separations (stomach sinks, “You’re so scared. You don’t want me to go because last time I was . . can’t stand to be heart beats faster). Something inside says, “Oh no, I can’t gone you didn’t know where I was. This is different, and I’ll be right away from you. lose her.” back.” . Your child is not trying to manipulate or control you. He . For longer separations, have him stay with familiar people, tell him is scared. where you are going and why, and when you will come back. Let him . He may also get scared when other people (not just you) know you will think about him. Leave a photo or something of yours leave. Goodbyes make him scared. and call if you can. When you come back, tell him you missed him, thought about him, and did come back. You will need to say this over and over.

. . has problems . Stress affects your child in different ways, including her . Relax. Usually, as your child’s level of stress goes down, her eating eating, eats too much appetite. habits will return to normal. Don’t force your child to eat. or refuses food. . Eating healthfully is important, but focusing too much on . Eat together and make meal times fun and relaxing. eating can cause stress and tension in your relationship. . Keep healthy snacks around. Young children often eat on the go. . If you are worried, or if your child loses a significant amount of weight, consult a pediatrician.

Psychological First Aid - Field Operations Guide Parent Tips for Helping Infants and Toddlers after Disasters If Your Child Understand Ways to Help . . is not able to do . Often when young children are stressed or scared, they . Avoid criticism. It makes him worried that he’ll never learn. things he used to do temporarily lose abilities or skills they recently learned. . Do not force your child. It creates a power struggle. (like use the potty). . This is the way young children tell us that they are not okay and . Instead of focusing on the ability (like not using the potty), help your child need our help. feel understood, accepted, loved, and supported. . . does not talk like he . Losing an ability after children have gained it (like starting to . As your child feels safer, he will recover the ability he lost. used to. wet the bed again) can make them feel ashamed or embarrassed. Caregivers should be understanding and supportive. . Your child is not doing this on purpose. . . is reckless, does . It may seem strange, but when children feel unsafe, they often . Keep her safe. Calmly go and get her and hold her if necessary. dangerous things. behave in unsafe ways. . Let her know that what she is doing is unsafe, that she is important, and you . It is one way of saying, “I need you. Show me I’m important by wouldn’t want anything to happen to her. keeping me safe.” . Show her other more positive ways that she can have your attention. . . is scared by things . Young children believe their parents are all-powerful and can . When your child is scared, talk to her about how you will keep her safe. that did not scare her protect them from anything. This belief helps them feel safe. . If things remind your child of the disaster and cause her to worry that it is before. . Because of what happened, this belief has been damaged, and happening again, help her understand how what is happening now (like rain without it, the world is a scarier place. or aftershocks) is different from the disaster. . Many things may remind your child of the disaster (rain, . If she talks about monsters, join her in chasing them out. “Go away, monster. aftershocks, ambulances, people yelling, a scared look on your Don’t bother my baby. I’m going to tell the monster boo, and it will get face), and will scare her. scared and go away. Boo, boo.” . It is not your fault–it was the disaster. . Your child is too young to understand and recognize how you did protect her, but remind yourself of the good things you did. . . seems “hyper,” . Fear can create nervous energy that stays in our bodies. . Help your child to recognize his feelings (fear, worry) and reassure your child can’t sit still, and . Adults sometimes pace when worried. Young children run, that he is safe. doesn’t pay attention to jump, and fidget. . Help your child get rid of nervous energy (stretching, running, sports, anything. . When our minds are stuck on bad things, it is hard to pay breathing deep and slow). attention to other things. . Sit with him and do an activity you both enjoy (throw a ball, read books, play, . Some children are naturally active. draw). Even if he doesn’t stop running around, this helps him. . If your child is naturally active, focus on the positive. Think of all the energy he has to get things done, and find activities that fit his needs. . . plays in a violent . Young children often talk through play. Violent play can be their . If you can tolerate it, listen to your child when he “talks.” way. way of telling us how crazy things were or are, and how they . As your child plays, notice the feelings he has and help him by naming feel inside. feelings and being there to support him (hold him, soothe him). . . keeps talking about . When your child talks about what happened, strong feelings . If he gets overly upset, spaces out, or he plays out the same upsetting scene, the disaster and the bad may come up both for you and your child (fear, sadness, anger). help him calm down, help him feel safe, and consider getting professional things he saw. help.

National Child Traumatic Stress Network National Center for PTSD Parent Tips for Helping Infants and Toddlers after Disasters If Your Child Understand Ways to Help . .is now very . Between the age of 18 months to 3 years, young children . Remember your child is not controlling or bad. This is normal, but demanding and often seem “controlling.” may be worse right now because she feels unsafe. controlling. . It can be annoying, but it is a normal part of growing up . Let your child have control over small things. Give her choices over and helps them learn that they are important and can make what she wears or eats, games you play, stories you read. If she has . . seems “stubborn” things happen. control over small things, it can make her feel better. Balance giving insisting that things . When children feel unsafe, they may become more her choices and control with giving her structure and routines. She will be done her way. controlling than usual. This is one way of dealing with feel unsafe if she “runs the show.” fears. They are saying, “Things are so crazy I need control . Cheer her on as she tries new things. She can also feel more in control over something.” when she can put her shoes on, put a puzzle together, pour juice. . . tantrums and is . Even before the disaster, your child may have had . Let him know you understand how hard this is for him. “Thing are cranky. tantrums. They are a normal part of being little. It’s really bad right now. It’s been so scary. We don’t have your toys or TV, frustrating when you can’t do things and when you don’t and you’re mad.” . .yells a lot – more have the words to say what you want or need. . Tolerate tantrums more than you usually would, and respond with love than usual. . Now, your child has a lot to be upset about (just like you) rather than discipline. You might not normally do this, but things are and may really need to cry and yell. not normal. If he cries or yells, stay with him and let him know you are there for him. Reasonable limits should be set if tantrums become frequent or are extreme. . . hits you. . For children, hitting is a way of expressing anger. . Each time your child hits, let her know that this is not okay. Hold her . When children can hit adults they feel unsafe. It’s scary to hands, so she can’t hit, have her sit down. Say something like, “It’s be able to hit someone who’s supposed to protect you. not okay to hit, it’s not safe. When you hit, you are going to need to sit . Hitting can also come from seeing other people hit each down.” other. . If she is old enough, give her the words to use or tell her what she needs to do. Tell her, “Use your words. Say, I want that toy.” . Help her express anger in other ways (play, talk, draw). . If you are having conflict with other adults, try to work it out in private, away from where your child can see or hear you. If needed, talk with a friend or professional about your feelings. . . says “Go away, I . The real problem is the disaster and everything that . Remember what your child has been through. He doesn’t mean hate you!” followed, but your child is too little to fully understand everything he is saying; he’s angry and dealing with so many difficult that. feelings. . . says “This is all . When things go wrong, young children often get mad . Support your child’s feeling of anger, but gently redirect the anger your fault.” at their parents because they believe they should have towards the disaster. “You are really mad. Lots of bad things have stopped it from happening. happened. I’m mad too. I really wish it didn’t happen, but even . You are not to blame, but now is not the time to defend mommies can’t make hurricanes not happen. It’s so hard for both of yourself. Your child needs you. us.”

Psychological First Aid - Field Operations Guide Parent Tips for Helping Infants and Toddlers after Disasters If Your Child Understand Ways to Help . . doesn’t want to . Your child needs you. So much has happened and he may . Sit by your child and keep him close. Let him know you care. play or do anything. be feeling sad and overwhelmed. . If you can, give words to his feelings. Let him know it’s okay to feel . When children are stressed, some yell and others shut sad, mad, or worried. “It seems like you don’t want to do anything. I . . seems to not really down. Both need their loved ones. wonder if you are sad. It’s okay to be sad. I will stay with you.” have any feelings . Try to do things with your child, anything he might like (read a book, (happy or sad). sing, play together). . . cries a lot. . Your family may have experienced difficult changes . Allow your child to express feelings of sadness. because of the disaster, and it is natural that your child is . Help your child name her feelings and understand why she may feel sad. that way. “I think you’re sad. A lot of hard things have happened” . When you let your child feel sad and provide her with . Support your child by sitting with her and giving her extra attention. comfort, you help your child even if she remains sad. Spend special time together. . If you have strong feelings of sadness, it may be good for . Help your child feel hopeful about the future. Together think and talk you to get support. Your child’s well-being is connected about how your lives will continue and the good things you will do, to your well-being. like go for a walk, go to the park or zoo, play with friends. . Take care of yourself. . . misses people you . Even though young children do not always express how . For those that have moved away, help your child stay in touch in are no longer able to they feel, be aware that it is difficult for them when they some way (for example, sending pictures or cards, calling). see after the disaster. lose contact with important people. . Help your child talk about these important people. Even when we are . If someone close to your child died, your child may show apart from people, we can still have positive feelings about them by stronger reactions to the disaster. remembering and talking about them. . Young children do not understand death, and may think . Acknowledge how hard it is to not be able to see people we care for. that the person can come back. It is sad. . Where someone has died, answer your child’s questions simply and honestly. When strong reactions last longer than two weeks, seek help from a professional. . . misses things you . When a disaster brings so much loss to a family and . Allow your child to express feelings of sadness. It is sad that your have lost because of community, it is easy to lose sight of how much the loss child lost her toy or blanket. the disaster. of a toy or other important item (blanket) can mean to a . If possible, try to find something that would replace the toy or blanket child. that would be acceptable and satisfying to your child. . Grieving for a toy is also your child’s way of grieving for . Distract your child with other activities. all you had before the disaster.

National Child Traumatic Stress Network National Center for PTSD Parent Tips for Helping Preschool-Age Children after Disasters Reactions/Behavior Responses Examples of things to do and say Helplessness and passivity: Young children know . Provide comfort, rest, food, water, and . Give your child more hugs, hand holding, or time they can’t protect themselves. In a disaster, they feel opportunities for play and drawing. in your lap. even more helpless. They want to know their parents . Provide ways to turn spontaneous drawing or . Make sure there is a special safe area for your will keep them safe. They might express this by being playing about traumatic events to something that child to play with proper supervision. unusually quiet or agitated. would make them feel safer or better. . In play, a four year old keeps having the blocks . Reassure your child that you and other grownups knocked down by hurricane winds. Asked, “Can will protect them. you make it safe from the winds?” the child quickly builds a double block thick wall and says, “Winds won’t get us now.” A parent might respond with, “That wall sure is strong,” and explain, “We’re doing a lot of things to keep us safe.” General fearfulness: Young children may become . Be as calm as you can with your child. Try not to . Be aware when you are on the phone or talking more afraid of being alone, being in the bathroom, voice your own fears in front of your child. to others, that your child does not overhear you going to sleep, or otherwise separated from parents. . Help children regain confidence that you aren’t expressing fear. Children want to believe that their parents can protect leaving them and that you can protect them. . Say things such as, “We are safe from the them in all situations and that other grownups, such as . Remind them that there are people working to earthquake now, and people are working hard to teachers or police officers, are there to help them. keep families safe, and that your family can get make sure we are okay.” more help if you need to. . Say, “If you start feeling more scared, come and . If you leave, reassure your children you will be take my hand. Then I’ll know you need to tell me back. Tell them a realistic time in words they something.” understand, and be back on time. . Give your child ways to communicate their fears to you. Confusion about the danger being over: Young children . Give simple, repeated explanations as needed, . Continue to explain to your child that the disaster can overhear things from adults and older children, even every day. Make sure they understand the has passed and that you are away from the danger or see things on TV, or just imagine that it is happen- words you are using. . Draw, or show on a map, how far away you are ing all over again. They believe the danger is closer to . Find out what other words or explanations they from the disaster area, and that where you are is home, even if it happened further away. have heard and clarify inaccuracies. safe. “See? The disaster was way over there, and . If you are at some distance from the danger, it is we’re way over here in this safe place.” important to tell your child that the danger is not near you. Returning to earlier behaviors: Thumb sucking, bed- . Remain neutral or matter-of-fact, as best you can, . If your child starts bedwetting, change her clothes wetting, baby-talk, needing to be in your lap. as these earlier behaviors may continue a while and linens without comment. Don’t let anyone after the disaster. criticize or shame the child.

Psychological First Aid - Field Operations Guide Parent Tips for Helping Preschool-Age Children after Disasters Reactions/Behavior Responses Examples of things to do and say Fears the disaster will return: When having remind- . Explain the difference between the event and . “Even though it’s raining, that doesn’t mean ers—seeing, hearing, or otherwise sensing something reminders of the event. the hurricane is happening again. A rainstorm that reminds them of the disaster. . Protect children from things that will remind is smaller and can’t wreck stuff like a hurricane them as best you can. can.” . Keep your child from television, radio, and computer stories of the disaster that can trigger fears of it happening again. Not talking: Being silent or having difficulty saying . Put common feelings into words, such as anger, . Draw simple “happy faces” for different feelings what is bothering them. sadness, and worry about the safety of parents, on paper plates. Tell a brief story about each one, friends, and siblings. such as, “Remember when the water came into . Do not force them to talk, but let them know they the house and you had a worried face like this?” can talk to you any time. . Say something like, “Children can feel really sad when their home is damaged.” . Provide art or play materials to help them express themselves. Then use feeling words to check out how they felt. “This is a really scary picture. Were you scared when you saw the water?” Sleep problems: Fear of being alone at night, sleep- . Reassure your child that he is safe. Spend extra . Provide calming activities before bedtime. Tell a ing alone, waking up afraid, having bad dreams. quiet time together at bedtime. favorite story with a comforting theme. . Let the child sleep with a dim light on or sleep . At bedtime say, “You can sleep with us tonight, with you for a limited time. but tomorrow you’ll sleep in your own bed.” . Some might need an explanation of the . “Bad dreams come from our thoughts inside difference between dreams and real life. about being scared, not from real things happening.” Not understanding about death: Preschool age chil- . Give an age-appropriate consistent explanation– . Allow children to participate in cultural and dren don’t understand that death is not reversible. that does not give false hopes–about the reality religious grieving rituals. They have “magical thinking” and might believe of death. . Help them find their own way to say goodbye by their thoughts caused the death. The loss of a pet may . Don’t minimize feelings over a loss of a pet or a drawing a happy memory or lighting a candle or be very hard on a child. special toy. saying a prayer for the deceased. . Take cues from what your child seems to want to . “No, Pepper won’t be back, but we can think know. Answer simply and ask if he has any more about him and talk about him and remember questions. what a silly doggy he was.” . “The firefighter said no one could save Pepper and it wasn’t your fault. I know you miss him very much.”

National Child Traumatic Stress Network National Center for PTSD Parent Tips for Helping School-Age Children after Disasters

Reactions Responses Examples of things to do and say Confusion about what happened . Give clear explanations of what happened . “I know other kids said that more tornadoes are whenever your child asks. Avoid details that would coming, but we are now in a safe place.” scare your child. Correct any misinformation that . Continue to answer questions your children have your child has about whether there is a present (without getting irritable) and to reassure them the danger. family is safe. . Remind children that there are people working to . Tell them what’s happening, especially about keep families safe and that your family can get issues regarding school and where they will be more help if needed. living. . Let your children know what they can expect to happen next. Feelings of being responsible: School-age children . Provide opportunities for children to voice their . Take your child aside. Explain that, “After a may have concerns that they were somehow at fault, or concerns to you. disaster like this, lots of kids–and parents too–keep should have been able to change what happened. They . Offer reassurance and tell them why it was not thinking, ‘What could I have done differently?’ or may hesitate to voice their concerns in front of others. their fault. ‘I should have been able to do something.’ That doesn’t mean they were at fault.” . “Remember? The firefighter said no one could save Pepper and it wasn’t your fault.” Fears of recurrence of the event and reactions to . Help identify different reminders (people, places, . When they recognize that they are being reminded, reminders sounds, smells, feelings, time of day) and clarify say, “Try to think to yourself, I am upset because the difference between the event and the reminders I am being reminded of the hurricane because it that occur after it. is raining, but now there is no hurricane and I am . Reassure them, as often as they need, that they are safe.” safe. . “I think we need to take a break from the TV right . Protect children from seeing media coverage of now.” the event, as it can trigger fears of the disaster . Try to sit with your child while watching TV. Ask happening again. your child to describe what they saw on the news. Clarify any misunderstandings. Retelling the event or playing out the event over and . Permit the child to talk and act out these reactions. . “You’re drawing a lot of pictures of what over Let him know that this is normal. happened. Did you know that many children do . Encourage positive problem-solving in play or that?” drawing. . “It might help to draw about how you would like your school to be rebuilt to make it safer.”

Psychological First Aid - Field Operations Guide Parent Tips for Helping School-Age Children after Disasters

Reactions Responses Examples of things to do and say Fear of being overwhelmed by their feelings . Provide a safe place for her to express her fears, . “When scary things happen, people have strong anger, sadness, etc. Allow children to cry or be feelings, like being mad at everyone or being very sad; don’t expect them to be brave or tough. sad. Would you like to sit here with a blanket until you’re feeling better?” Sleep problems: Bad dreams, fear of sleeping alone, . Let your child tell you about the bad dream. . “That was a scary dream. Let’s think about some demanding to sleep with parents. Explain that bad dreams are normal and they will good things you can dream about and I’ll rub go away. Do not ask the child to go into too many your back until you fall asleep.” details of the bad dream. . “You can stay in our bedroom for the next couple . Temporary sleeping arrangements are okay; of nights. After that we will spend more time with make a plan with your child to return to normal you in your bed before you go to sleep. If you get sleeping habits. scared again, we can talk about it.” Concerns about the safety of themselves and others.. Help them to share their worries and give them . Create a “worry box” where children can write realistic information. out their worries and place them in the box. Set a time to look these over, problem-solve, and come up with answers to the worries. Altered behavior: Unusually aggressive or restless . Encourage the child to engage in recreational . “I know you didn’t mean to slam that door. It behavior. activities and exercise as an outlet for feelings must be hard to feel so angry.” and frustration. . “How about if we take a walk? Sometimes getting our bodies moving helps with strong feelings.” Somatic complaints: Headaches, stomachaches, . Find out if there is a medical reason. If not, . Make sure the child gets enough sleep, eats well, muscle aches for which there seem to be no reason. provide comfort and assurance that this is normal. drinks plenty of water, and gets enough exercise. . Be matter-of-fact with your child; giving these . “How about sitting over there? When you feel complaints too much attention may increase better, let me know and we can play cards.” them. Closely watching a parent’s responses and recovery: . Give children opportunities to talk about their . “Yes, my ankle is broken, but it feels better since Not wanting to disturb a parent with their own feelings, as well as your own. the paramedics wrapped it. I bet it was scary worries. . Remain as calm as you can, so as not to increase seeing me hurt, wasn’t it?” your child’s worries. Concern for other survivors and families. . Encourage constructive activities on behalf . Help children identify projects that are age- of others, but do not burden them with undue appropriate and meaningful (clearing rubble from responsibility. school grounds, collecting money or supplies for those in need).

National Child Traumatic Stress Network National Center for PTSD Parent Tips for Helping Adolescents after Disasters

Reactions Responses Examples of things to do and say Detachment, shame, and guilt . Provide a safe time to discuss with your teen the . “Many teens–and adults–feel like you do, angry events and their feelings. and blaming themselves that they could have . Emphasize that these feelings are common, done more. You’re not at fault. Remember even and correct excessive self-blame with realistic the firefighters said there was nothing more we explanations of what actually could have been could have done.” done. Self-consciousness: About their fears, sense of vul- . Help teens understand that these feelings are . “I was feeling the same thing. Scared and nerability, fear of being labeled abnormal. common. helpless. Most people feel like this when a . Encourage relationships with family and peers disaster happens, even if they look calm on the for needed support during the recovery period. outside.” . “My cell phone is working again, why don’t you see if you can get a hold of Pete to see how he’s doing.” . “And thanks for playing the game with your little sister. She’s much better now.” Acting out behavior: Using alcohol or drugs, sexu- . Help teens understand that acting out behavior . “Many teens–and some adults–feel out of ally acting out, accident-prone behavior. is a dangerous way to express strong feelings control and angry after a disaster like this. (like anger) over what happened. They think drinking or taking drugs will help . Limit access to alcohol and drugs. somehow. It’s very normal to feel that way–but . Talk about the danger of high-risk sexual it’s not a good idea to act on it.” activity. . “It’s important during these times that I know . On a time-limited basis, keep a closer watch where you are and how to contact you.” Assure on where they are going and what they are them that this extra checking-in is temporary, planning to do. just until things have stabilized. Fears of recurrence and reactions to reminders. Help to identify different reminders (people, . “When you’re reminded, you might try saying places, sounds, smells, feelings, time of day) to yourself, ‘I am upset now because I am being and to clarify the difference between the event reminded, but it is different now because there and the reminders that occur after it. is no hurricane and I am safe.’” . Explain to teens that media coverage of the . Suggest, “Watching the news reports could disaster can trigger fears of it happening again. make it worse, because they are playing the same images over and over. How about turning it off now?”

Psychological First Aid - Field Operations Guide Parent Tips for Helping Adolescents after Disasters

Reactions Responses Examples of things to do and say Abrupt shifts in interpersonal relationships: Teens . Explain that the strain on relationships is . Spend more time talking as a family about how may pull away from parents, family, and even from expectable. Emphasize that everyone needs everyone is doing. Say, “You know, the fact peers; they may respond strongly to parent’s reac- family and friends for support during the that we’re crabby with each other is completely tions in the crisis. recovery period. normal, given what we’ve been through. I think . Encourage tolerance for different family we’re handling things amazingly. It’s a good members’ courses of recovery. thing we have each other.” . Accept responsibility for your own feelings. . You might say, “I appreciate your being calm when your brother was screaming last night. I know he woke you up, too.” . “I want to apologize for being irritable with you yesterday. I am going to work harder to stay calm myself.” Radical changes in attitude . Explain that changes in people’s attitudes after a . “We are all under great stress. When people’s disaster are common, but often return back over lives are disrupted this way, we all feel more time. scared, angry–even full of revenge. It might not seem like it, but we all will feel better when we get back to a more structured routine.” Premature entrance into adulthood: (wanting to . Encourage postponing major life decisions. . “I know you’re thinking about quitting school leave school, get married). Find other ways to make the teens feel more in and getting a job to help out. But it’s important control. not to make big decisions right now. A crisis time is not a great time to make major changes.” Concern for other survivors and families . Encourage constructive activities on behalf of . Help teens to identify projects that are age- others, but do not let them burden themselves appropriate and meaningful (clearing rubble with undue responsibility. from school grounds, collecting money or supplies for those in need).

National Child Traumatic Stress Network National Center for PTSD Tips for Adults

Reactions/Behavior Responses Examples of things to do and say High anxiety/arousal: Tension and anxiety are com- . Use breathing and/or other relaxation skills. . Breathing exercise: Inhale slowly through your mon after disasters. Adults may be excessively worried . Take time during the day to calm yourself through nose and comfortably fill your lungs all the way about the future, have difficulties sleeping, problems relaxation exercises. These can make it easier to down to your stomach, while saying to yourself, concentrating, and feel jumpy and nervous. These reac- sleep, concentrate, and will give you energy. “My body is filled with calm.” Exhale slowly tions can include rapid heart beat and sweating. through your mouth and empty your lungs, while silently saying to yourself, “My body is letting go.” Do this five times slowly, and as many times a day as needed. Concern or shame over your own reactions. Many . Find a good time to discuss your reactions with a . When talking with someone, find the right time people have strong reactions after a disaster, including family member or trusted friend. and place, and ask if it is okay to talk about your fear and anxiety, difficulty concentrating, shame about . Remember that these reactions are common and it feelings. how they reacted, and feeling guilty about something. takes time for them to subside. . Remind yourself that your feelings are expectable It is expectable and understandable to feel many emo- . Correct excessive self-blame with realistic and you are not “going crazy,” and that you are not tions in the aftermath of an extremely difficult event. assessment of what actually could have been done. at fault for the disaster. . If these feelings persist for a month or more, you may wish to seek professional help. Feeling overwhelmed by tasks that need to be accom- . Identify what your top priorities are. . Make a list of your concerns and decide what to plished (housing, food, paperwork for insurance, child . Find out what services are available to help get tackle first. Take one step at a time. care, parenting). your needs met. . Find out which agencies can help with your needs . Make a plan that breaks down the tasks into and how to access them. manageable steps. . Where appropriate, rely on your family, friends, and community for practical assistance. Fears of recurrence and reactions to reminders: It is . Be aware that reminders can include people, . When you are reminded, try saying to yourself, common for survivors to fear that another disaster will places, sounds, smells, feelings, time of day. “I am upset because I am being reminded of the occur, and to react to things that are reminders of what . Remember that media coverage of the disaster can disaster, but it is different now because the disaster happened. be a reminder and trigger fears of it happening is not happening and I am safe.” again. . Limit your viewing of news reports so you just get the information that you need. Changes in attitude, view of the world and of . Postpone any major unnecessary life changes in . Getting back to a more structured routine can help oneself: Strong changes in people’s attitudes after the immediate future. improve decision-making. a disaster are common, including questioning one’s . Remember that dealing with post-disaster . Remind yourself that going through a disaster can spiritual beliefs, trust in others and social agencies, difficulties increases your sense of courage and have positive effects on what you value and how and concerns about one’s own effectiveness, and effectiveness. you spend your time. dedication to helping others. . Get involved with community recovery efforts.

Psychological First Aid - Field Operations Guide Tips for Adults

Reactions/Behavior Responses Examples of things to do and say Using alcohol and drugs, or engaging in gambling or . Understand that using substances and engaging . Remember that substance use and other addictive high-risk sexual behaviors: Many people feel out of in addictive behaviors can be a dangerous way to behaviors can lead to problems with sleep, control, scared, hopeless, or angry after a disaster and cope with what happened. relationships, jobs, and physical health. engage in these behaviors to feel better. This can espe- . Get information about local support agencies. cially be a problem if there was pre-existing substance abuse or addiction. Shifts in interpersonal relationships: People may feel . Understand that family and friends are a major . Don’t withdraw from others because you feel you differently towards family and friends; for example, form of support during the recovery period. might burden them. Most people do better after they may feel overprotective and very concerned for . It is important to understand and tolerate different disasters turning to others. each other’s safety, frustrated by the reactions of a courses of recovery among family members. . Ask your friends and family how they are doing, family member or friend, or they may feel like pulling . Rely on other family members for help with rather than just giving advice, or telling them away from family and friends. parenting or other daily activities when you are to “get over it.” Offer a supportive ear or lend a upset or under stress. helping hand. . Say, “We’re crabby with each other and that is completely normal, given what we’ve been through. I think we’re handling things amazingly. It’s a good thing we have each other.” Excessive anger: Some degree of anger is understand- . Find ways to manage your anger that help you . Take time to cool down, walk away from stressful able and expected after a disaster, especially when rather than hurt you. situations, talk to a friend about what is making something feels unfair. However, when it leads to you angry, get physical exercise, distract yourself violent behavior, extreme anger is a serious problem. with positive activities, or problem-solve the situation that is making you angry. . Remind yourself that being angry may harm important relationships. . If you become violent, get immediate help. Sleep difficulties: Trouble falling asleep and frequent . Make sure you have good sleep routines. . Go to sleep at the same time every day. awakening is common after a disaster, as people are on . Don’t have caffeinated drinks in the evening. edge and worried about adversities and life changes. . Reduce alcohol consumption. . Increase daytime exercise. . Relax before bedtime. . Limit daytime naps to 15 minutes, and do not nap later than 4 pm.

National Child Traumatic Stress Network National Center for PTSD Tips for Relaxation

Tips for Relaxation Tension and anxiety are common after disasters. Unfortunately, they can make it more dif- ficult to cope with the many things that must be done to recover. There is no easy solution to coping with post-disaster problems, but taking time during the day to calm yourself through relaxation exercises may make it easier to sleep, concentrate, and have energy for coping with life. These can include muscle relaxation exercises, breathing exercises, meditation, swimming, stretching, yoga, prayer, exercise, listening to quiet music, spending time in nature, and so on. Here are some basic breathing exercises that may help: For Yourself: 1. Inhale slowly (one-thousand one; one-thousand two; one-thousand three) through your nose and comfortably fill your lungs all the way down to your belly. 2. Silently and gently say to yourself, “My body is filled with calmness.” Exhale slowly (one-thousand one; one-thousand two; one-thousand three) through your mouth and comfortably empty your lungs all the way down to your stomach. 3. Silently and gently say to yourself, “My body is releasing the tension.” 4. Repeat five times slowly and comfortably. 5. Do this as many times a day as needed. For Children: Lead a child through a breathing exercise: 1. “Let’s practice a different way of breathing that can help calm our bodies down. 2. Put one hand on your stomach, like this [demonstrate]. 3. Okay, we are going to breathe in through our noses. When we breathe in, we are going to fill up with a lot of air and our stomachs are going to stick out like this [demonstrate]. 4. Then, we will breathe out through our mouths. When we breathe out, our stomachs are going to suck in and up like this [demonstrate]. 5. We are going to breathe in really slowly while I count to three. I’m also going to count to three while we breathe out really slowly. 6. Let’s try it together. Great job!” Make a Game of It: . Blow bubbles with a bubble wand and dish soap. . Blow bubbles with chewing gum. . Blow paper wads or cotton balls across the table. . Tell a story where the child helps you imitate a character who is taking deep breaths.

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National Child Traumatic Stress Network National Center for PTSD Alcohol, Medication, and Drug Use after Disaster

Alcohol, Medication, and Drug Use after Disaster Some people increase their use of alcohol, prescription medications, or other drugs after a disaster. You may feel that using drugs and alcohol helps you escape bad feelings or physical symptoms related to stress responses (for example, headaches, muscle tension). However, they can actually make these worse in the long term because they interrupt natural sleep cycles, create health problems, interfere with relationships, and create potential dependence on the substance. If your use of alcohol or drugs has increased since the disaster or is causing problems for you, it is important for you to reduce your level of use or seek help in gaining control over your use.

. Pay attention to any change in your use of . Consult with a healthcare professional about alcohol and/or drugs. safe ways to reduce anxiety, depression, muscle tension, and sleep difficulties. . Correctly use prescription and over-the- . If you find that you have greater difficulty counter medications as indicated. controlling alcohol/substance use since the disaster, seek support in doing so. . Eat well, exercise, get enough sleep, and use . If you believe you have a problem with your family and others for support. substance abuse, talk to your doctor or counselor about it. . If you feel like using larger amounts of either prescribed or over-the-counter medications, consult a healthcare professional. If you have had an alcohol, medication, or drug problem in the past For people who have successfully stopped drinking or using drugs, experiencing a disaster can sometimes result in strong urges to drink or use again. Sometimes it can lead them to strengthen their commitment to recovery. Whatever your experience, it is important to consciously choose to stay in recovery.

. Increase your attendance at substance abuse . Talk with family and friends about supporting support groups. you to avoid use of alcohol or substances. . If you are receiving disaster crisis counseling, . If you have a 12-Step sponsor or substance talk to your counselor about your past alcohol abuse counselor, talk to him or her about your or drug use. situation. . If you have been forced to move out of your . Increase your use of other supports that have local community, talk to disaster workers helped you avoid relapse in the past. about helping to locate nearby alcohol or drug recovery groups, or ask them to help organize a new support group.

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National Child Traumatic Stress Network National Center for PTSD www.nctsn.org www.ncptsd.va.gov