Sept. 11, Hurricane Katrina, Virginia Tech, Newtown, Superstorm Sandy, Pulse nightclub … It is only a partial list, but this roll call of places and events seared into public memory makes it obvious: The 21st century has provided counselors with many unfortunate opportunities to exercise disaster mental health counseling skills.
Post-9/11, the practice of disaster mental health has been shifting and evolving as practitioners have continued to gain a better understanding of how people recover from traumatic events. Disasters, whether natural or human-caused, can be life-altering and psychologically scarring, but counselors and other experts say that most survivors will recover without major psychological trauma. And it is now widely recognized that in most cases, brief targeted treatments work better with survivors of disasters than does extended therapy.
Historically, counselors would show up in the wake of a disaster and engage in talk therapy, says Gerard Lawson, president of the American Counseling Association. Today there is an understanding that the immediate aftermath of a disaster is not the time to engage people in traditional psychotherapy. Survivors need something much more immediate — psychological first aid, which Lawson describes as a kind of mental health version of medical first aid. Responders try to “stop the bleeding” in a sense by treating survivors’ immediate stress and assessing who might be a threat to themselves or others, he says.
“One of the foundations of psychological first aid is that we assume not everybody [who experiences a disaster] is going to develop severe mental health problems,” Lawson says. He notes that research has shown that a fairly low percentage of disaster survivors — approximately 10 percent — will go on to develop posttraumatic stress disorder. Although in a different context the psychological distress that many survivors experience might seem indicative of mental health problems, in the wake of a disaster, this emotional (and sometimes physical) dysregulation is normal, he explains.
“These are people having normal reactions to abnormal events,” says ACA member J. Barry Mascari, an associate professor in the Department of Counselor Education at Kean University, where he teaches, studies and writes about trauma and disasters. “Therefore you cannot look at their reactions through a traditional mental health lens. The reactions are often situation specific and transient.”
In fact, says Mascari, who is certified in New Jersey in disaster response crisis counseling, the practices used in the past — engaging in talk therapy and focusing on the details of the disaster — can cause survivors to “relive” the event, which can be retraumatizing.
Indeed, the help that survivors need most is often practical as much as psychological, notes Laura Shannonhouse, an ACA member and a licensed professional counselor who has worked with survivors of multiple disasters. She says that psychological first aid is designed to provide information, comfort and practical support, all tailored to the individual needs of each survivor in a structured manner.
This support consists of eight core actions: contact and engage, provide safety and comfort, stabilize, gather information, offer practical assistance, connect individuals to social supports, give coping information and provide links to needed services, says Shannonhouse, an assistant professor in the clinical mental health school and the counselor education and practice doctoral programs at Georgia State University.
Disaster survivors are grappling with a substantial number of difficulties, notes ACA member Karin Jordan, who has worked directly with disaster survivors and is the coordinator of ACA’s Traumatology Interest Network. “Immediately after and in the wake of the disaster event, emotions tend to be very strong,” she says. “People are often put in a position in which they need to act in a heroic way to save their own or others’ lives and get themselves and others to safety. So safety of self and others is very important. This would include safety from the disaster and aftereffects.”
Safety concerns can involve anything from downed power lines to a disconnected gas line to earthquake aftershocks, notes Jordan, professor and director of the University of Akron School of Counseling. “Returning to damaged homes might be unsafe, which might mean that people will spend some time in a shelter or tent. Being displaced might also mean that some families are scattered across different camps.”
Counselors should keep all of this in mind when engaging with survivors, says Lawson, whose areas of expertise include disaster mental health and response and resilience. He explains that after introducing themselves to and establishing a basic rapport with survivors, counselors should assess for safety and comfort. For instance, if the person is having a panic attack or hyperventilating, the goal is to try to stabilize them, he says. Counselors should then gather information about survivors’ needs and concerns, such as whether they know the location of their loved ones, have a place to stay and have or know where to get items such as clothing and other supplies. Helping survivors identify resources to meet their needs can help them feel more in charge, Lawson notes.
Counselors also play a very important role in normalizing what survivors are feeling and how they are reacting to tragedy, Lawson points out. “We want to help them feel competence so they are not waiting for someone to come in and rescue them. We want to move them toward being in charge of what comes next,” says Lawson, who previously chaired an ACA Task Force on Crisis Response Planning.
“We hope for them [survivors] to be able to return to something like pre-trauma functioning,” Lawson says. “It won’t be the same, but similar. We talk about a ‘new normal.’ Your life isn’t going to be exactly the same as before, but you can get to a new normal.”
It is also crucial to get survivors reconnected with social supports such as family members, friends, their spiritual communities and the community in general, Lawson says. These natural support networks are particularly important to the long-term well-being of those who experience disasters, he adds. “As helpful as it is to have counselors there, they are ultimately going to go away,” Lawson points out.
ACA member Laura Captari, who has a background in community mental health and has counseled survivors of disasters in the United States and internationally, agrees. “Disasters often uproot social networks just like they do trees,” she says. “Isolation is a strong predictor of negative mental health outcomes. … Responders should listen for signs of isolation, loss of relationships and/or disconnection from community resources, and be looking for ways to facilitate reconnection with neighbors, family members and faith communities.”
“For survivors, acting on and celebrating interdependence on others can ease feelings of loneliness and isolation,” continues Captari, who is earning her doctorate in counseling psychology at the University of North Texas, where she works in the Family Attachment Lab studying the role that spirituality and attachment play in facilitating posttraumatic growth and resilience.
When survivors of disasters come together to support one another, in many cases they gain not only practical assistance and the comfort of being with people who understand what they have endured, but also a variety of emotional benefits, Captari says. She notes that research has associated altruism with increased gratitude and well-being among those who practice it.
Although most survivors will not need long-term treatment, counselors should be alert to certain signs and symptoms. “Disaster can lead to feeling hopeless and desperate,” Captari says. “Responders should listen for any indication of harm to self or others, as well as impulsive or risky behaviors. It is important to recognize when a survivor may need additional follow-up services from another professional, agency or organization, and [then to] provide this referral.”
Lawson adds that signs such as hypervigilance and difficulty sleeping can indicate trouble if they are present for weeks or months at a time.
Calling on a higher power
The Humanitarian Disaster Institute at Wheaton College in Illinois is a research center that studies the role that faith plays in helping people cope with disasters. Shannonhouse is a fellow at the institute, where she is part of a team that is developing a program of spiritual first aid.
“Survivors [of disasters] often turn to their faith to make sense of suffering, and there is more than 40 years of scholarship on religious and spiritual variables in coping and making sense of suffering,” Shannonhouse says. “Unfortunately, most of this knowledge is left out of disaster mental health programming.”
Captari is also working with Shannonhouse and others at the Humanitarian Disaster Institute to develop general spiritual first aid practices. “In working with professionals of diverse cultural backgrounds, I have learned so much about resilience in the wake of systemic trauma … and have seen, time and again, that for many individuals, their personal faith and spiritual community buffer against negative psychological outcomes,” Captari says.
Captari points out that multiple studies have indicated that the majority of Americans (an estimated 89 percent, according to the Pew Research Center) express a belief in God or some other higher power. In part for this reason, Captari contends that counselors have an obligation to understand and integrate survivors’ cultural, religious and spiritual values into treatment.
Shannonhouse, who also works at Georgia State University’s Center for the Study of Stress, Trauma and Resilience, notes that although spiritual beliefs can be a source of strength for survivors, disasters can also cause feelings of spiritual distress, such as feeling abandoned or punished by God. These feelings can lead to a loss of hope. Spiritual first aid is intended to help promote positive spiritual coping, Shannonhouse says.
“SFA [spiritual first aid] is an evidence-informed, early disaster, spiritual- and emotional-care intervention that promotes fortitude and resilience through spiritually oriented support, resources and interventions,” she explains. “[It] is designed to help triage survivors immediately following a disaster by reducing spiritual distress, fostering spiritual support [and] improving access to spiritual resources.”
Some of the aspects of spiritual first aid are based on general coping behaviors, such as practicing self-care and understanding common stress reactions. In addition, spiritual first aid involves working with survivors to help them identify what rituals or beliefs connected to their religious or spiritual traditions might bring them comfort. Disaster mental health workers then encourage survivors to turn to these practices as a way of coping, Shannonhouse explains.
Says Captari, “This could include attending religious services, vigils [or] support groups; meeting with spiritual leaders; yoga, meditation and mindfulness practices; reading sacred texts; listening to religious or spiritual music; prayer; journaling — the possibilities are endless, but they should be guided by the client.”
“SFA is not a step-by-step manualized intervention,” she continues, “but rather provides a simple, flexible model to help facilitate therapeutic interactions with survivors in a variety of short-term contexts through empathic listening and support.” She explains that when talking with survivors, counselors and community responders can hold in mind the acronym S.O.U.L.S. to assess how the individual or family has been affected and what the survivor’s greatest needs are:
O: Other support
U: Ultimate concerns
L: Loss of resources
S: Self-harm and harm to others
Another acronym, C.H.A.T, describes the helping process taught in spiritual first aid:
C: Connect through presence
H: Help with humility
A: Assess by observing and questioning
T: Triage with spiritually oriented interventions
S.O.U.L.S. and C.H.A.T. will be featured in a spiritual first aid manual currently being written by Shannonhouse, Jamie Aten (founder and director of the Humanitarian Disaster Institute) and Don Davis, an assistant professor at Georgia State.
Both Shannonhouse and Captari caution that no one-size-fits-all approach exists for spiritual first aid. Like any counseling method, it must be practiced with cultural humility.
“Be curious and seek to understand the survivor’s unique experience and needs,” Captari says. “Some survivors may be reticent to talk about spiritual issues due to fear of judgment or criticism. Counselors can use SFA to ask about, encourage and validate the importance of existential questions and struggles that may be present rather than shying away [from them].”
Captari also emphasizes the importance of counselors maintaining an open, interested and accepting attitude toward the beliefs and faith tradition of survivors. “For example, if the survivor identifies as religious or spiritual, explore how the disaster has impacted their relationship with the sacred or their connection with their faith community,” she advises. “Spirituality for many people is a profoundly physical and emotional experience, and people who have lived through disaster are likely experiencing acute stress reactions. It is often difficult to connect with the divine when one is in a state of hyperarousal. Normalize feelings of anger or confusion toward their higher power. Do not minimize, trivialize or pass over the very real negative impact of the disaster, and do not try and correct, challenge or ‘fix’ survivors’ theology, assumptions or beliefs.”
Counselors can help disaster survivors who identify as religious or spiritual in a number of ways, Captari says. These include:
- Helping them to draw on their sacred texts to normalize their feelings
- Exploring themes of mercy and protection with them
- Facilitating gratitude
- Encouraging the practice of daily spiritual routines such as prayer, yoga or meditation
- Encouraging them to identify and reflect on hope-filled mantras, positive imagery and stories of overcoming adversity
Says Shannonhouse, “Counselors don’t need to identify as religious or spiritual themselves in order to utilize the assessment [S.O.U.L.S.] and intervention [C.H.A.T.] strategies included in SFA. Nor do they need to be well-versed in the survivor’s faith tradition or spiritual beliefs. An attitude of humility, curiosity, empathy and acceptance is what is important, rather than coming in as the mental health expert who has all the answers.
“Joining with survivors and entering into their experience is the key to the therapeutic presence offered by SFA. This model provides a framework for talking about and exploring how the disaster has impacted a survivor’s sense of well-being and helps providers critically consider ways to connect survivors with spiritual resources that are in line with their faith tradition to help facilitate grief, adjustment and restoration of stability.”
Spiritual first aid isn’t just for counselors or other mental health professionals. Clergy and other professionals and volunteers such as emergency management professionals, humanitarian aid workers, first responders, and health and public health professionals may also find it helpful, Shannonhouse notes.
Resilience and growth
Helping people with the immediate negative aftermath of a disaster is important, but it is also crucial to note survivors’ capacity for resilience and growth, say Lawson and Mascari.
“Human resilience is amazing,” says Mascari, who studies disaster response and co-edited the third edition of the ACA book Terrorism, Trauma and Tragedies: A Counselor’s Guide to Preparing and Responding with Jane Webber. “People come out of disasters feeling stronger.”
Adds Lawson, “We focus an awful lot on posttraumatic stress, but there is also the potential for posttraumatic growth.”
Survivors of disasters often emerge with a new appreciation for life, value their relationships in a new way, feel a new sense of community or are strengthened spiritually, Lawson explains. In some instances, survivors even experience a renewed sense of power and purpose that they devote to a cause related to the disaster.
Lawson notes that the organization Mothers Against Drunk Driving emerged out of traumatic experiences. “They could have stayed in the victim stage, feeling helpless and distressed,” Lawson says, “but those people connected with others who had been through the same thing and resolved to do something about it.”
Shannonhouse points to the concept of spiritual fortitude. “Spiritual fortitude is … a process of facing adversity in which one intentionally engages redemptive narratives and the sacred in order to metabolize the difficulty of suffering and loss. Spiritual fortitude does not imply conquering adversity or returning to a state of previous functioning, nor is it simply enduring suffering. Rather, spiritual fortitude is about leaning into the suffering and undertaking virtuous action.”
Counselors can help encourage posttraumatic growth by assisting clients with the meaning-making process, say Shannonhouse and Captari.
“Invite them to view their present adversity from a transcendent perspective,” Captari suggests. “Ask them to think about how their life is part of something bigger.” Counselors can also help survivors create a “spiritual life map” or history to rediscover insights, strengths and resources that they have gained from their beliefs over the life span.
When people experience posttraumatic growth, it can allow them to say, “I’m not a victim. I didn’t just survive, I thrived,” Lawson concludes.
To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:
ACA Disaster Mental Health webpage (counseling.org/knowledge-center/trauma-disaster)
Includes information on the U.S. Substance Abuse and Mental Health Services Administration’s Disaster Distress Helpline and 15 fact sheets compiled by the ACA Traumatology Interest Network covering topics such as one-to-one crisis counseling, disaster and trauma responses of children and parents, helping survivors with stress management skills, grief reactions over the life span and intrusive memories.
Counseling Today (ct.counseling.org)
- Terrorism, Trauma and Tragedies: A Counselor’s Guide to Preparing and Responding, third edition, edited by Jane Webber & J. Barry Mascari
ACA Interest Networks
Laurie Meyers is the senior writer for Counseling Today. Contact her at firstname.lastname@example.org.
Letters to the editor: email@example.com
Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.