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

Crisis Counseling Assistance and Training Program

Transition to Regular Services ProgramTraining

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.

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

Section 1—Transition from ISP to RSP

• Goals and Objectives of the RSP

• Administrative Issues

• Program Management Issues

• Program Services Issues

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.

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.

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.

Administrative Issues

CCP typical timeline:

RSP grant administration partnerships:

Administrative Issues (cont.)

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

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

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.

Section 2—Disaster Reactions Related to Transition

• Key Concepts

• Individual Reactions

• Collective Reactions

• Resilience

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.

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.


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:


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.

Individual Reactions

Types of individual reactions:• Physical• Emotional• Cognitive• Behavioral

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.


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.


• 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.


Severe reactions:• How do you recognize when a reaction becomes

severe?• When does a severe reaction warrant referral?


Disorders that may result from severe reactions:• Depressive disorders• Suicidal behavior• Substance abuse• Acute stress disorder• PTSD• Dissociative disorders• Anxiety disorders• Paranoia• Social isolation

Collective Reactions

Typical phases of disaster:• Pre-disaster phase• Impact phase• Heroic phase• Honeymoon phase• Disillusionment phase• Reconstruction phase

Collective Reactions (cont.)

Typical phases of disaster (cont.):

Adapted from CMHS, 2000.

EmotionalHighs

EmotionalLows

Setback

Resilience

What is resilience?

Resilience is an ability to recover from or adjust easily to misfortune or change.

Merriam-Webster Online Dictionary

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

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

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

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

Section 3—Crisis Counseling During Transition

• Where Are We Now?

• Where Do We Go from Here?

Where Are We Now?

How is your program:• Strengths based?• Culturally competent?• Diagnosis free?• Community based?• Outreach oriented?

Where Are We Now? (cont.)

How does your program:• Bolster community support systems?• Assume natural resilience and competence?


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?


Outreach:• What populations have you targeted?• What have your outreach strategies been?• How successful have these strategies been?

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?

Where Do We Go from Here? (cont.)

What can be done in the following areas to develop culturally competent programming? • Staff• Program• Community


CCP reach of services:


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.


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?


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.


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.


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.


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.


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.


Community support and networking:• Promote familiarity with disaster relief resources.• Create a seamless system for referral.• Create opportunities for shared resources and

training.


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.

Typical partners:



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


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.


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


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.


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.


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.


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.


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


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.


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.


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.


Traditional Case Management CCP Resource LinkageProvides 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:


The CCP model facilitates resource linkage through:• Role modeling.• Reinforcing.• Empowering.


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.


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.

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

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.

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)?

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?

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 (crisis counselors and supervisors)and supervisors)

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.

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.


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.


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?

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.

Section 5—Stress Management

• Typical Stressors• Warning Signs of Excessive Stress• Organizational Approaches to Stress

Management• Individual Approaches to Stress Management

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

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.

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

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.


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.”


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.

Individual Approaches to Stress Management

What have you been doing to manage stress?

Activity:• Update your personal stress management plan.

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.

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: [email protected]

Web: www.mentalhealth.samhsa.gov/dtac

Documents

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