To provide information about stress reactions and coping to reduce distress and promote adaptive functioning.
Disasters can be disorienting, confusing, and overwhelming, putting survivors at risk for losing their sense of competence to handle problems that they face. Feeling one can cope with disaster-related stress and adversity is beneficial to recovery.
Various types of information can help survivors manage their stress reactions and deal more effectively with problems. Such information includes:
If appropriate, briefly discuss common stress reactions experienced by the survivor. Stress reactions may be alarming. Some will be frightened or alarmed by their own responses; some may view their reactions in negative ways (for example, “There’s something wrong with me” or “I’m weak”). You should take care to avoid pathologizing survivor responses; do not use terms like “symptoms” or “disorder.” You may also see positive reactions, including appreciating life, family, and friends, or strengthening of spiritual beliefs and social connections.
Provider Alert: While it may be helpful to describe common stress reactions and to note that intense reactions are common but often diminish over time, it is also important to avoid providing “blanket” reassurance that stress reactions will disappear. Such reassurances may set up unrealistic expectations about the time it takes to recover.
For survivors who have had significant exposure to trauma and have sustained significant losses, provide basic psychoeducation about common distress reactions. You can review these, emphasizing that such reactions are understandable and expectable. Inform survivors that, if these reactions continue to interfere with their ability to function adequately for over a month, psychological services should be considered. The following basic information is presented as an overview for the Psychological First Aid provider so that you can discuss issues arising from survivors’ post-disaster reactions.
There are three types of posttraumatic stress reactions:
1. Intrusive reactions are ways in which the traumatic experience comes back to mind. These reactions include distressing thoughts or mental images of the event (for example, picturing what one saw), or dreams about what happened. Among children, bad dreams may not be specifically about the disaster. Intrusive reactions also include upsetting emotional or physical reactions to reminders of the experience. Some people may feel and act like one of their worst experiences is happening all over again. This is called a “flashback.”
2. Avoidance and withdrawal reactions are ways people use to keep away from, or protect against, distress. These reactions include trying to avoid talking, thinking, and having feelings about the traumatic event, and avoiding any reminders of the event, including places and people connected to what happened. Emotions can become restricted, even numb, to protect against distress. Feelings of detachment and estrangement from others may lead to social withdrawal. There may be a loss of interest in usually pleasurable activities.
3. Physical arousal reactions are physical changes that make the body react as if danger is still present. These reactions include constantly being “on the lookout” for danger, startling easily or being jumpy, irritable or having outbursts of anger, difficulty falling or staying asleep, and difficulty concentrating or paying attention.
It is also useful to discuss the role of trauma reminders, loss reminders, change reminders, and hardships in contributing to distress.
Trauma Reminders can be sights, sounds, places, smells, specific people, the time of day, situations, or even feelings, like being afraid or anxious. Trauma reminders can evoke upsetting thoughts and feelings about what happened. Examples include the sound of wind, rain, helicopters, screaming or shouting, and specific people who were present at the time. Reminders are related to the specific type of event, such as hurricane, earthquake, flood, tornado, or fire. Over time, avoidance of reminders can make it hard for people to do what they normally do or need to do.
Loss Reminders can also be sights, sounds, places, smells, specific people, the time of day, situations, or feelings. Examples include seeing a picture of a lost loved one, or seeing their belongings, like their clothes. Loss reminders bring to mind the absence of a loved one. Missing the deceased can bring up strong feelings, like sadness, nervousness, uncertainty about what life will be without them, anger, feeling alone or abandoned, or hopelessness. Loss reminders can also lead to avoiding things that people want to do or need to do.
Change Reminders can be people, places, things, activities, or hardships that remind someone of how life has changed as a result of the disaster. This can be something like waking up in a different bed in the morning, going to a different school, or being in a different place. Even nice things can remind a survivor of how life has changed, and make the person miss what has been lost.
Hardships often follow in the wake of disasters and can make it more difficult to recover. Hardships place additional strains on survivors and can contribute to feelings of anxiety, depression, irritability, uncertainty, and mental and physical exhaustion. Examples of hardships include: loss of home or possessions, lack of money, shortages of food or water, separations from friends and family, health problems, the process of obtaining compensation for losses, school closures, being moved to a new area, and lack of fun activities.
Other kinds of reactions include grief reactions, traumatic grief, depression, and physical reactions.
Grief Reactions will be prevalent among those who survived the disaster but have suffered many types of losses, including the death of loved ones, and loss of home, possessions, pets, schools, and community. Loss may lead to feelings of sadness and anger, guilt or regret over the death, missing or longing for the deceased, and dreams of seeing the person again. More information on grief reactions and how to respond to survivors experiencing acute grief reactions can be found in the section on Safety and Comfort.
Traumatic Grief Reactions occur when children and adults have suffered the traumatic death of a loved one. Some survivors may stay focused on the circumstances of the death, including being preoccupied with how the death could have been prevented, what the last moments were like, and who was at fault. These reactions may interfere with grieving, making it more difficult for survivors to adjust to the death over time. More information on traumatic grief reactions and how to respond can be found in the section on Safety and Comfort.
Depression is associated with prolonged grief reactions and strongly related to the accumulation of post-disaster adversities. Reactions include persistent depressed or irritable mood, loss of appetite, sleep disturbance, greatly diminished interest or pleasure in life activities, fatigue or loss of energy, feelings of worthlessness or guilt, feelings of hopelessness, and sometimes thoughts about suicide. Demoralization is a common response to unfulfilled expectations about improvement in post-disaster adversities and resignation to adverse changes in life circumstances.
Physical Reactions may be commonly experienced, even in the absence of any underlying physical injury or illness. These reactions include headaches, dizziness, stomachaches, muscle aches, rapid heart beat, tightness in the chest, hyperventilation, loss of appetite, and bowel problems.
Several handouts found in Appendix E may be useful. When Terrible Things Happen describes common adult and adolescent reactions, and positive/negative coping. Parent Tips for Helping Infants and Toddlers; Parent Tips for Helping Preschool-Age Children; Parent Tips for Helping School-Age Children; Parent Tips for Helping Adolescents; and Tips for Adults are for adults to help themselves and their children.
Talking with Children about Body and Emotional Reactions Children vary in their capacity to make connections between events and emotions. Many children will benefit from a basic explanation of how disaster-related experiences produce upsetting emotions and physical sensations. Suggestions for working with children include:
The following gives a basic explanation that helps children to talk about common emotional and physical reactions to disaster.
When something really bad happens, kids often feel funny, strange, or uncomfortable, like their heart is beating really fast, their hands feel sweaty, their stomach hurts, or their legs or arms feel weak or shaky. Other times kids just feel funny inside their heads, almost like they are not really there, like they are watching bad things happening to someone else.
Sometimes your body keeps having these feelings for a while even after the bad thing is over and you are safe. These feelings are your body’s way of telling you again how bad the disaster was.
Do you have any of these feelings, or other ones that I didn’t talk about? Can you tell me where you feel them, and what they feel like?
Sometimes these strange or uncomfortable feelings come up when kids see, hear, or smell things that remind them of what happened, like strong winds, glass breaking, the smell of smoke, etc. It can be very scary for kids to have these feelings in their bodies, especially if they don’t know why they are happening or what to do about them. If you like, I can tell you some ways to help yourself feel better. Does that sound like a good idea?
You can discuss a variety of ways to effectively cope with post-disaster reactions and adversity.
Adaptive copingactions are those that help to reduce anxiety, lessen other distressing reactions, improve the situation, or help people get through bad times. In general, coping methods that are likely to be helpful include:
Maladaptive coping actions tend to be ineffective in addressing problems. Such actions include:
The aim of discussing positive and negative forms of coping is to:
To help children and adolescents identify positive and negative forms of coping, you can write on slips of paper ways that the child is currently using to cope. Then talk with the child about adaptive and maladaptive coping strategies. Have the child sort the pieces of paper into each category and then discuss ways the child can increase their adaptive coping strategies. For younger children, play a memory game in which each coping strategy is written on two pieces of paper. Place the blank sides of each paper face up, and have the child find matching pairs. Once the child gets a pair, discuss with them if this is a good or bad strategy to feel better.
The handout, When Terrible Things Happen (Appendix E), reviews positive and negative coping for adult and adolescent survivors.
Breathing exercises help reduce feelings of over-arousal and physical tension which, if practiced regularly, can improve sleep, eating, and functioning. Simple breathing exercises can be taught quickly. It is best to teach these techniques when the survivor is calm and can pay attention. It may also be helpful for family members to prompt each other to use and practice these techniques regularly. The handout, Tips for Relaxation (Appendix E), can be provided to reinforce the use and practice of relaxation techniques. To teach a breathing exercise, you might say:
Inhale slowly (one-thousand one; one-thousand two; one-thou sand three) through your nose, and comfortably fill your lungs all the way down to your belly. Silently and gently say to yourself, “My body is filling with calm.” 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 abdomen. Silently and gently say to yourself, “My body is releasing tension.” Repeat five times slowly.
Let’s practice a different way of breathing that can help calm our bodies down. Put one hand on your stomach, like this [demonstrate]. 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]. 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].
Then, we will breathe out through our mouths. When we breathe out, our stomachs are going to suck in and up like this [demonstrate]. We can pretend that we are a balloon, filling up with air, and then letting the air out, nice and slow.
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. Let’s try it together. Great job!
If you find out that a survivor has previously learned some relaxation technique, try to reinforce what he/she has already learned rather than teaching new skills.
Reestablishing family routines to the extent possible after a disaster is important for family recovery. Encourage parents and caregivers to try to maintain family routines such as meal times, bedtime, wake time, reading time, and play time, and to set aside time for the family to enjoy activities together.
If a family member has a pre-existing emotional or behavioral problem that has been worsened by the current events, discuss with the family strategies that they may have learned from a therapist to manage these problems. Discuss ways that these strategies may be adapted for the current setting. If the family member continues to have difficulties, consider a mental health consultation.
It is especially important to assist family members in developing a mutual understanding of their different experiences, reactions, and course of recovery, and to help develop a family plan for communicating about these differences. For example, you might say:
Often, due to differences in what each of you experienced during and after the disaster, each family member will have different reactions and different courses of recovery. These differences can be difficult to deal with, and can lead to family members not feeling understood, getting into arguments, or not supporting each other. For example, one family member may be more troubled by a trauma or loss reminder than other family members.
You should encourage family members to be understanding, patient, and tolerant of differences in their reactions, and to talk about things that are bothering them, so the others will know when and how to support them. Family members can help each other in a number of ways, like listening and trying to understand, comforting with a hug, doing something thoughtful like writing a note, or getting his/her mind off things by playing a game. Parents need to pay special attention to how their children may be troubled by reminders and hardships, because they can strongly affect how their children react and behave. For example, a child may look like he/she is having a temper tantrum, when actually he/she has been reminded of a friend who was hurt or killed.
When disasters confront adults with danger and loss, adolescents may find afterwards that their parents/caretakers have become more anxious about their safety and, consequently, more restrictive in what they allow adolescents to do. You can help adolescents understand the increase in their caregivers’ protective behaviors–such as earlier curfews, not letting adolescents go off by themselves without adult supervision, insisting that they call in frequently, or not letting adolescents do things that involve some “everyday” risk, like driving a car or doing skateboarding tricks. Remind adolescents that this “strictness” is normal and usually temporary. This will help them avoid unnecessary conflict as the family recovers. You may say:
When disasters like this happen, parents/caregivers often become more anxious about their kids’ safety, so they often have more restrictions. So, while your parents feel the need to keep you on a tighter leash to make sure you are safe, try to give them some slack. This is usually only temporary, and will probably decrease as things start to settle down.
Children, adolescents, adults, and families go through stages of physical, emotional, cognitive, and social development. The many stresses and adversities in the aftermath of a disaster may result in key interruptions, delays, or reversals in development. The loss of anticipated opportunities or achievements can be a major consequence of the disaster. Developmental progression is often measured by these milestones.
Examples of Developmental Milestones
Toddlers and Preschool-Age Children
• becoming toilet trained
• entering daycare or preschool
• learning to ride a tricycle
• sleeping through the night
• learning or using language School-Age
• learning to read and do arithmetic
• being able to play by rules in a group of children
• handling themselves safely in a widening scope of unsupervised time
• having friends of the opposite sex
• pursuing organized extracurricular activities
• striving for more independence and activities outside of the home
• buying a new home or moving
• having a child leave home
• going through a separation or divorce
• experiencing the death of a grandparent
• special events
Children and families should also be given an opportunity to attend to the disaster’s impact on development. It can be helpful to ask children and families directly:
Are there any special events that the family was looking forward to? Was anyone about to do something important, like starting school, graduating from high school, or entering college?
Are there any goals you were working towards that this disaster has, or might interfere with, like a promotion at work or getting married?
Were there things before the disaster that you were looking forward to, like a birthday, a school activity, or playing on a sport team?
You should try to increase the family’s appreciation of these issues, so that they understand the challenge to each individual, as well as the whole family. Help find alternative ways for family members to handle the interruption or delay. In helping to develop a plan to address these concerns, consider whether the family can:
Stressful post-disaster situations can make survivors feel irritable and increase their difficulty in managing their anger. In addressing anger, you can:
Some anger management skills that you can suggest include:
If the angry person appears uncontrollable or becomes violent, seek immediate medical/ mental health attention and contact security.
In the aftermath of disasters, survivors may think about what caused the event, how they reacted, and what the future holds. Attributing excessive blame to themselves or others may add to their distress. You should listen for such negative beliefs, and help survivors to look at the situation in ways that are less upsetting. You might ask:
Tell the survivor that even if he/she thinks he/she is at fault, that does not make it true. If the survivor is receptive, offer some alternative ways of looking at the situation. Help to clarify misunderstandings, rumors, and distortions that exacerbate distress, unwarranted guilt, or shame. For children and adolescents who have difficulty labeling thoughts, you can write the negative thoughts on a piece of paper (for example, “I did something wrong,” “I caused it to happen,” “I was misbehaving”) and have the child add to them. You can then discuss each one, clarify any misunderstandings, discuss more helpful thoughts, and write them down. Remind the child or adolescent that he/she is not at fault, even if he/she has not expressed these concerns.
Sleep difficulties are common following a disaster. People tend to stay on alert at night, making it hard to fall asleep and causing frequent awakenings. Worries about adversities and life changes can also make it hard to fall asleep. Disturbance in sleep can have a major effect on mood, concentration, decision-making, and risk for injury. Ask whether the survivor is having any trouble sleeping and about sleep routines and sleep-related habits. Problem-solve ways to improve sleep. For example the survivor might try to:
Discuss that worry over immediate concerns and exposure to daily reminders can make it more difficult to sleep, and that being able to discuss these and get support from others can improve sleep over time.
Remind parents that it is common for children to want to remain close to their parents at nighttime, and even to want to sleep in bed with them. Temporary changes in sleeping arrangements are okay, as long as parents make a plan with their children to negotiate a return to normal sleeping arrangements. For example, a parent might say, “We have all been scared by what happened. You can stay in our bedroom for the next couple of nights. Then you will sleep in your bed, but we will sit with you in your bedroom for a while before you go to sleep so you will feel safe. If you get scared again, we can talk about it.”
When use of alcohol and other substances is a concern:
The handout, Alcohol, Medication, and Drug Use after Disasters (Appendix E) gives an overview of this information, and is intended for adults and adolescents with concerns in this area.