1. Crisis Counseling Assistance and Training Program Transition to Regular Services Program Training

2. Objectives After training, participants will be able to: Identify ISP-to-RSP transition issues. Define the goals and objectives of the RSP. Identify ongoing and emerging disaster reactions related to transition. Review crisis counseling services related to transition. Practice crisis counseling skills for transition. Complete data collection forms. Update strategies for managing stress.

3. Table of Contents Section 1—Transition from ISP to RSP Section 2—Disaster Reactions Related to Transition Section 3—Crisis Counseling During Transition Section 4—Data Collection and Program Evaluation Section 5—Stress Management Section 6—Team Building

4. Section 1—Transition from ISP to RSP Goals and Objectives of the RSP Administrative Issues Program Management Issues Program Services Issues

5. Goals and Objectives of the RSP In transition training it is important to emphasize: Services of lower intensity and higher volume. Ongoing needs assessment for this particular disaster and program. Moving from basic, supportive to community and strengths-based counseling. Continued identification of at-risk populations.

6. Goals and Objectives of the RSP (cont.) In transition training it is important to emphasize (cont.): Broader outreach to target populations. Increased community networking. Thorough assessment and referral. Maximization of resource linkage. Preparation of the community to rely on resilience and existing resources.

7. Goals and Objectives of the RSP (cont.) In transition training it is important to emphasize (cont.): Development of a thorough training plan that includes stress management. Use of program data to adjust the CCP. More detailed and comprehensive quality assurance. Development and use of legacy materials. Preparation of the community for the eventual phasedown of the CCP.

8. Administrative Issues CCP typical timeline:

9. RSP grant administration partnerships: Administrative Issues (cont.)

10. Program Management Issues These components should be considered in relation to the transition to RSP: Needs assessment and outreach strategy Staffing plan Training Supervision and team meetings Crisis counseling services

11. Program Management Issues (cont.) These components should be considered in relation to the transition to RSP (cont.): Stress management Fiscal management Quality assurance Data collection and evaluation Program media and marketing

12. Program Services Issues Survivors’ reactions will change over time, resulting in the need for programmatic changes in the RSP. There may be an increased need and opportunity for group crisis counseling and public education. Survivors may experience deepened anxiety or depression as the new reality of life after disaster sets in. While every disaster is different, there are some reactions that can be anticipated.

13. Section 2—Disaster Reactions Related to Transition Key Concepts Individual Reactions Collective Reactions Resilience

14. Key Concepts Everyone who experiences a disaster is affected by it in some way. People pull together during and after a disaster. Stress and grief are common reactions to uncommon situations. People’s natural resilience will support individual and collective recovery.

15. Key Concepts (cont.) Typical outcomes of disaster: –Some will have severe reactions. –Few will develop diagnosable conditions. –Most do not seek treatment. –Survivors often reject help.

16. Key Concepts (cont.) Adapted from DeWolfe, 2002. A.Injured survivors, bereaved family members B.Survivors with high exposure to disaster trauma, or evacuated from disaster zone C.Bereaved extended family and friends, first responders D.People who lost homes, jobs or possessions; people with preexisting trauma; at-risk groups; other disaster responders E.Affected people from community at large Risk Factors-Population Exposure Model:

17. Key Concepts (cont.) Two types of trauma: Individual trauma: –May cause stress and grief. –May cause fatigue, irritability, hopelessness, and relationship conflicts. Collective trauma: –May damage community support. –May affect individual coping.

18. Individual Reactions Types of individual reactions: Physical Emotional Cognitive Behavioral

19. Individual Reactions (cont.) Anticipated reactions over time might include: Anger around the limits of governmental assistance and insurance (e.g., “the system,” “red tape”). Increased substance use. Evolution of unaddressed trauma into diagnosable conditions such as posttraumatic stress disorder (PTSD) or depression. Stress from financial hardship as resources run out. Frustration and disillusionment at the pace of repairs. Continued anxiety around dislocation and separation.

20. Individual Reactions (cont.) Spiritual beliefs influence how people make sense of the world: Survivors may seek the comfort that comes from spiritual beliefs. Spiritual beliefs will assist some survivors with coping and resilience. Survivors may question their beliefs and life structure.

21. Individual Reactions (cont.) The severity of reactions is affected by the type of, level of exposure to, and casualties associated with the disaster. Pre-existing trauma may increase the risk of severe reactions. CCP staff members identify and refer for treatment anyone experiencing severe reactions. Pre-existing levels of support will affect the severity of reactions.

22. Individual Reactions (cont.) Severe reactions: How do you recognize when a reaction becomes severe? When does a severe reaction warrant referral?

23. Individual Reactions (cont.) Disorders that may result from severe reactions: Depressive disorders Suicidal behavior Substance abuse Acute stress disorder PTSD Dissociative disorders Anxiety disorders Paranoia Social isolation

24. Collective Reactions Typical phases of disaster: Pre-disaster phase Impact phase Heroic phase Honeymoon phase Disillusionment phase Reconstruction phase

25. Collective Reactions (cont.) Typical phases of disaster (cont.): Adapted from CMHS, 2000.

26. Resilience What is resilience? Resilience is an ability to recover from or adjust easily to misfortune or change. Merriam-Webster Online Dictionary

27. Resilience (cont.) Factors affecting resilience: Life situation Individual traits and coping styles Disaster and trauma experience Family and social support Spiritual beliefs Presence of perceived control, and hope Availability of accurate information An effective and caring emergency response

28. Resilience (cont.) To foster resilience, crisis counselors should assist survivors in: Making realistic plans and taking the steps to carry them out. Maintaining a positive self-image and confidence in their own abilities. Accessing their skills in communication and problem solving. Managing strong feelings and impulses. Adapted from The Road to Resilience, American Psychological Association (2006). www.apa.org

29. Resilience (cont.) Ten ways survivors can build resilience: Make connections. Avoid seeing crises as insurmountable problems. Accept change as a part of living. Move toward your goals. Take decisive actions. Look for opportunities for self-discovery. Nurture a positive view of yourself. Keep things in perspective. Maintain a hopeful outlook. Take care of yourself. Adapted from The Road to Resilience, American Psychological Association (2006). www.apa.org

30. Resilience (cont.) Personal growth can occur as a result of surviving disaster. Examples of personal growth include: –Becoming closer to loved ones. –Having faith in the ability to rebuild one’s life. –Becoming more spiritual or religious. –Finding a deeper meaning and purpose in life. –Discovering inner strength. Kessler et al., 2006

31. Section 3—Crisis Counseling During Transition Where Are We Now? Where Do We Go from Here?

32. Where Are We Now? How is your program: Strengths based? Culturally competent? Diagnosis free? Community based? Outreach oriented?

33. Where Are We Now? (cont.) How does your program: Bolster community support systems? Assume natural resilience and competence?

34. Where Are We Now? (cont.) How do crisis counselors assist people to: Understand their situations and reactions? Regain a sense of mastery and control? Identify, label, and express emotions? Adjust to the disaster and losses? Manage stress? Make decisions and take action? Develop coping strategies? Use community resources?

35. Where Are We Now? (cont.) Outreach: What populations have you targeted? What have your outreach strategies been? How successful have these strategies been?

36. Where Do We Go from Here? Ongoing needs assessment: What populations were not reached? What new populations need to be targeted? What strategies are we going to use?

37. Where Do We Go from Here? (cont.) What can be done in the following areas to develop culturally competent programming? Staff Program Community

38. Where Do We Go from Here? (cont.) CCP reach of services:

39. Where Do We Go from Here? (cont.) All services are provided throughout the CCP, however: Higher intensity, lower volume services are typically done in the ISP. Lower intensity, higher volume services are done in the RSP. Group-oriented services are important in the RSP.

40. Where Do We Go from Here? (cont.) At-risk populations: What services have been most effective with specific at-risk populations? What service needs remain? How will the program deliver needed services?

41. Where Do We Go from Here? (cont.) Group crisis counseling is characterized by: Services that help group members understand their current situations and reactions to the disaster. A need that may increase later in the CCP as people are ready to connect with others. Group members who should have had similar levels of exposure. Participants gaining mutual support from other group members. Psycho-education areas that include stress management, coping with triggers, expressing emotions, and problem solving.

42. Where Do We Go from Here? (cont.) Support groups: Are less structured than psychotherapy groups. Increase the social support network. Facilitate exchange of information on life situations. Help develop new ways of adapting and coping. Can be member facilitated.

43. Where Do We Go from Here? (cont.) Self-help groups: Are appropriately facilitated by a professional or paraprofessional crisis counselor. Can be cofacilitated by a group member to encourage transition to a member-facilitated group process. Are no longer a CCP service once the group has transitioned to a member-facilitated process.

44. Where Do We Go from Here? (cont.) Psycho-educational groups: Provide tools to obtain and process new information. Usually have limited duration and scope. Provide practical and concrete assistance. Use handouts and factual information relevant to the group’s discussion. Use speakers relevant to content area and group members’ needs.

45. Where Do We Go from Here? (cont.) Practical concerns in group crisis counseling: Assess your own knowledge and skills related to the content of the group. Be aware of your own values, biases, and beliefs, and how these affect the group. Respect and maintain confidentiality. Facilitate—do not dominate—the conversation or the group. Ask for feedback from the group. Rappin & Kell, 1998.

46. Where Do We Go from Here? (cont.) Community support and networking: Promote familiarity with disaster relief resources. Create a seamless system for referral. Create opportunities for shared resources and training.

47. Where Do We Go from Here? (cont.) Through community support and networking, the CCP: Partners with community support systems. Participates in community gatherings and rituals. Reaches out to community groups and leaders. Maintains a compassionate presence. Bolsters, but does not replace, systems in place.

48. Typical partners: Where Do We Go from Here? (cont.)

49. Community support and networking—other potential partners: Emergency management Law enforcement Substance abuse prevention community Office for Victims of Crime Community-based cultural organizations Native American tribal community leaders Refugee organizations Suicide prevention organizations Mental health and substance abuse consumer groups

50. Where Do We Go from Here? (cont.) Public education: Can be informational and educational presentations and materials. Is likely to increase during the course of the CCP. Is designed to: –Build resilience. –Promote constructive coping skills. –Educate about disaster reactions. –Help people access support and services. –Leave a legacy of educational materials.

51. Where Do We Go from Here? (cont.) Distribution of educational materials: Should be culturally competent. Includes flyers, brochures, tip sheets, guidances, and Web site content. Includes the following topics: –Basic disaster information –Key concepts of disaster behavioral health –Disaster reactions –Coping skills –Individual and community resilience

52. Where Do We Go from Here? (cont.) Media messaging: Continue to connect with media partners to: –Promote the services of the RSP, such as the helpline, ongoing individual and group crisis counseling, public education, and assessment and referral. –Educate the public on common reactions and effective coping skills. –Deliver a clear message regarding response and recovery.

53. Where Do We Go from Here? (cont.) Media messaging (cont.): Important things to consider when developing talking points: –The CCP emphasizes resilience and hope. –Help is available through a variety of services provided by the CCP. –The CCP provides education on common reactions and effective coping skills. –Cultural diversity is respected in providing assistance. –If appropriate, and while maintaining confidentiality, highlight stories of people who have been helped by the CCP.

54. Where Do We Go from Here? (cont.) Service provision in the RSP relies on: Assessing the needs of survivors at this phase of the disaster. Ensuring that survivors access appropriate services based on current assessments. Continually updating knowledge of community resources.

55. Where Do We Go from Here? (cont.) Assessment, referral, and resource linkage are likely to increase in the RSP because: Repeat individual crisis counseling contacts often trigger an assessment. Lingering reactions may now be cause for concern. Community recovery may make new resources available.

56. Where Do We Go from Here? (cont.) Assess and refer in relation to the following behavioral health risk factors and reactions: Safety Level of exposure to the traumatic event Prior trauma or physical or behavioral health concerns Presence of severe reactions Current level of functioning Alcohol and drug use

57. Where Do We Go from Here? (cont.) Adult Assessment and Referral Tool: This is used to facilitate referrals to more intensive behavioral health services. It is first used during a third individual crisis counseling encounter. It measures risk categories and event reactions using a structured interview approach. If a person scores three or more “intense” reactions (ones scored 4 or 5), then referral for more intensive services should be discussed.

58. Where Do We Go from Here? (cont.) Emergency treatment referral: Alert the team leader if: –There is intent or means to harm self or others. –Person experiences severe paranoia, delusions, or hallucinations. –Functioning is so poor that person’s (or dependent’s) safety is in danger. –Excessive substance use is placing person or others at risk. When in doubt, call 911, or refer for immediate psychiatric or medical intervention.

59. Where Do We Go from Here? (cont.) Nonemergency treatment referral: Reduce perceived stigma: –Demystify mental health or substance abuse treatment by explaining it. –Explore referral options, and give choices. Increase compliance: –Explore obstacles to accepting services. –Encourage person to call for the appointment while the counselor is there. –Accompany person to first appointment, if necessary and appropriate.

60. Where Do We Go from Here? (cont.) Traditional Case ManagementCCP Resource Linkage Provides services to individuals who may have a serious and persistent mental illness or other disability of indefinite duration. Provides services to disaster survivors regardless of level of functioning. Advocates for and influences the provision of services for clients. Empowers disaster survivors to advocate for their own services and resources. Includes filling out forms and arranging appointments for clients. Assists disaster survivors to access services by guiding them through typical application and referral processes. Assumes responsibility for ensuring clients access needed services and may follow up with service providers to ensure compliance with appointments. Assists disaster survivors to identify services and may follow up with survivors, while empowering survivors to be responsible for accessing their own services. Has a responsibility to ensure continuity of care for clients. Assists the disaster survivor to access disaster-related services, as prioritized by the survivor. Involves long-term relationship with clients.Involves short-term relationships with disaster survivors. CCP resource linkage:

61. Where Do We Go from Here? (cont.) The CCP model facilitates resource linkage through: Role modeling. Reinforcing. Empowering.

62. Where Do We Go from Here? (cont.) Ethical considerations: Maintain confidentiality. Follow State and local reporting regulations in cases of suicidal or homicidal intent. Follow the State and local regulations on mandatory reporting for child or elder abuse and neglect. Safeguard interests and rights of individuals who lack decisionmaking abilities. Treat all individuals in a nonbiased manner with regard to race, ethnicity, gender, religion, sexual orientation, and age.

63. Where Do We Go from Here? (cont.) Ethical considerations (cont.): Do no harm. Participation is voluntary. Consider reactions in relation to the disaster phase and context. Individual coping styles should be respected. Immediate interventions are supportive. Talking with a person in crisis does not always mean talking about the crisis. Be aware of the situational and cultural contexts of the survivor and the intervention itself.

64. Section 4—Data Collection and Program Evaluation Definition of Data Collection and Program Evaluation CCP Evaluation and Data Collection Toolkit Data Collection Tools Opportunities for Improvement

65. Definition of Data Collection and Program Evaluation What are data collection and program evaluation, and why do it? Program evaluation is a systematic effort to collect, analyze, and interpret information. We do it to understand and improve services based on observable and verifiable data.

66. Definition of Data Collection and Program Evaluation (cont.) How have the data: Assisted program management at the State level? Helped the field and the program understand trends and identify needs? Improved behavioral health disaster response? Improved behavioral health emergency preparedness? Documented the program’s accomplishments? Provided accountability to stakeholders (e.g., Congress, Government Accountability Office, Federal agencies)?

67. Definition of Data Collection and Program Evaluation (cont.) How are data used to evaluate the RSP? Are there additional ways that data can be used?

68. CCP Evaluation and Data Collection Toolkit Individual Crisis Counseling Services Log Group Encounter Log Weekly Tally Sheet (all services) Participant Feedback Survey (time-based sample of counseling recipients) Assessment and Referral Tool (intensive service users) Provider Survey (crisis counselors and supervisors)

69. Data Collection Tools Participant Feedback Surveys: Are used to obtain feedback about the program. Are conducted twice during an RSP. Survey all adults receiving individual or group crisis counseling. Provide some data about immediate outcomes of crisis counseling.

70. Data Collection Tools (cont.) Adult Assessment and Referral Tool: This is used to facilitate referrals to more intensive behavioral health services. It is first used during a third individual crisis counseling encounter. It measures risk categories and event reactions using a structured interview approach. If a person scores three or more “intense” reactions (ones scored 4 or 5), then referral for more intensive services should be discussed.

71. Data Collection Tools (cont.) Service Provider Feedback: It is used to capture crisis counselors’ opinions about their training, resources, supervision, workload, support, and overall quality of the CCP. It is collected anonymously from crisis counseling staff around 6 and 12 months post-disaster.

72. Data Collection Tools (cont.) How will we use data in the RSP? Data are used to assess: –Customer satisfaction. –Worker satisfaction. –Program changes. –Output outcomes. –Overall trends in the CCP. Are there other ways the data can be used?

73. Opportunities for Improvement Effective program management includes: Ongoing needs assessment. Outreach strategy. Program media and marketing. Staffing plan. Training. Staff stress management. Fiscal management. Evaluation. Quality assurance.

74. Section 5—Stress Management Typical Stressors Warning Signs of Excessive Stress Organizational Approaches to Stress Management Individual Approaches to Stress Management

75. Typical Stressors How stressful are these for you? Repeatedly hearing survivors’ distressing stories Approaching survivors who may reject help Feeling overwhelmed by the sadness of others Feeling helpless to alleviate the pain of others Working long hours Personal experience with the disaster

76. Warning Signs of Excessive Stress You cannot shake distressing images from your mind. Work consumes you at the expense of family and friends. You experience an increase in substance use or abuse. You are excessively irritable and impatient. You exhibit other serious or severe reactions.

77. Organizational Approaches to Stress Management Elements of organizational stress management: A clearly defined management and supervision structure Clearly defined purpose and goals that are articulated frequently Functionally defined roles that are reinforced through effective supervision Sound clinical consultation, support, and supervision Supportive peer relationships An active stress management program A comprehensive training plan

78. Organizational Approaches to Stress Management (cont.) Management responsibilities: Clearly articulate and often repeat the purpose, goals, scope, and limits of the program. Articulate and enforce policies related to work hours, holidays, supervision, and attendance at staff meetings and training events. Develop criteria for who is served and for how long, and require justification for continued counseling. Enforce safety policies, and enforce ethical conduct.

79. Organizational Approaches to Stress Management (cont.) Adequately prepare counselors for their tasks: Use simulation exercises to practice responses to highly distraught people. Develop a repertoire of introductory statements that are free of mental health references. Practice how to conclude a counseling relationship. Provide examples of signals that indicate whether talking about problems is bringing relief to the consumer; employ buddy systems. Educate about the differences between helping and “rescuing.”

80. Organizational Approaches to Stress Management (cont.) Adequately prepare counselors for their tasks: Address disillusionment and other midprogram stressors. Provide careful supervision. Enforce reasonable work hours and shifts. Monitor time off, and mandate, if necessary. Develop and enforce safety policies.

81. Individual Approaches to Stress Management What have you been doing to manage stress? Activity: Update your personal stress management plan.

82. Section 6—Team Building Use this section for: Practicing crisis counseling skills. Developing outreach strategies. Identifying training needs. Identifying other needs of the program during transition.

83. SAMHSA Disaster Technical Assistance Center SAMHSA DTAC supports SAMHSA’s efforts to prepare States, Territories, and local entities to deliver an effective behavioral health response during disasters. Toll-Free: 1-800-308-3515 E-Mail: dtac@esi-dc.com Web: www.mentalhealth.samhsa.gov/dtac