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

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Crisis Counseling Assistance and Training
ProgramTransition to Regular Services Program
Training
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Objectives

• Training will enable participants to
• Identify ISP-to-RSP transition issues.
• Define the goals and objectives of the RSP.
• Identify ongoing and emerging disaster reactions.
• Review crisis counseling services.
• Practice crisis counseling skills related to
  transition.
• Complete data collection forms.
• Update strategies for managing stress.

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Table of Contents

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

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Section 1Transition from ISP to RSP

• Goals and Objectives of the RSP
• Administrative Issues
• Program Management Issues
• Program Services Issues

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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.

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Goals and Objectives of the RSP (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.

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Goals and Objectives of the RSP (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.

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Administrative Issues
CCP typical timeline
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RSP grant administration partnerships
Administrative Issues (cont.)
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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.

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Program Management Issues (cont.)

• Stress management.
• Fiscal management.
• Quality assurance.
• Data collection and evaluation.
• Program media and marketing.

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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.

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Section 2Disaster Reactions Related to
Transition

• Key Concepts
• Individual Reactions
• Collective Reactions
• Resilience

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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.
• Peoples natural resilience will support
  individual and collective recovery.

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Key Concepts (cont.)

• Typical outcomes of disaster
• Some will have severe reactions
• Few will develop diagnosable conditions
• Most do not seek treatment and
• Survivors often reject help.

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Key Concepts (cont.)
Risk factors Population Exposure Model

• Injured survivors, bereaved family members
• Survivors with high exposure to disaster trauma,
  or evacuated from disaster zone
• Bereaved extended family and friends, first
  responders
• People who lost homes, jobs or possessions
  people with preexisting trauma at-risk groups
  other disaster responders
• Affected people from community at large

Adapted from DeWolfe, 2002.
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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 and
• May affect individual coping.

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Individual Reactions

• Types of reactions
• Physical.
• Emotional.
• Cognitive.
• Behavioral.

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Individual Reactions (cont.)

• Anticipated reactions over time might include the
  following
• Anger around the limits of governmental
  assistance and insurance (e.g., the system,
  red tape).
• Increased substance use.
• Unaddressed trauma leading to 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.

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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.

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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.

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Individual Reactions (cont.)

• Severe Reactions
• How do you recognize when a reaction becomes
  severe?
• When does a severe reaction warrant referral?

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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.

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Collective Reactions

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

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

• What is resilience?
• An ability to recover from or adjust easily to
  misfortune or change.
• Merriam-Webster
  Online Dictionary

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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.

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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

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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

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Resilience (cont.)

• Personal growth can occur as a result of
  surviving disaster.
• Examples of personal growth include
• Becoming closer to loved ones
• Faith in the ability to rebuild ones life
• Becoming more spiritual or religious
• Finding a deeper meaning and purpose in life and
• Discovering inner strength.

Kessler et al., 2006
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Section 3Crisis Counseling During Transition

• Where Are We Now?
• Where Do We Go from Here?

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Where Are We Now?

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

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Where Are We Now? (cont.)

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

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Where Are We Now? (cont.)

• How do crisis counselors assist people to
• Understand their situation 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?

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Where Are We Now? (cont.)

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

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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?

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Where Do We Go from Here? (cont.)

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

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

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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?

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Where Do We Go from Here? (cont.)

• Group crisis counseling is characterized by
• Services that help group members understand their
  current situation 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.

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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.

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Where Do We Go from Here? (cont.)

• Self-help groups
• It is a appropriate for a self-help group to be
  facilitated by a professional or paraprofessional
  crisis counselor.
• It can be cofacilitated by a group member to
  encourage transition to a member-facilitated
  group process.
• Once the group has transitioned to a
  member-facilitated process, it is no longer a CCP
  service.

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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 groups discussion.
• Use speakers relevant to content area and group
  members needs.

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Where Do We Go from Here? (cont.)

• Practical considerations
• 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.
• Facilitatedo not dominatethe conversation or
  the group.
• Ask for feedback from the group.
• Rappin Kell, 1998.

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Where Do We Go from Here? (cont.)

• Community support and networking
• Promotes familiarity with disaster relief
  resources.
• Creates a seamless system for referral.
• Creates opportunities for shared resources and
  training.

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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 already
  in place.

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Community support and networkingtypical partners
Where Do We Go from Here? (cont.)
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Where Do We Go from Here? (cont.)

• Community support and networkingother 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.

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Where Do We Go from Here? (cont.)

• Public education
• Includes 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 and
• Leave a legacy of educational materials.

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Where Do We Go from Here? (cont.)

• Educational material
• Should be culturally competent.
• Include flyers, brochures, tip sheets, guidances,
  and Web site content.
• Include the following topics
• Basic disaster information
• Key concepts of disaster behavioral health
• Disaster reactions
• Coping skills and
• Individual and community resilience.

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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 help
  line, ongoing individual and group crisis
  counseling, public education, and assessment and
  referral
• Educate the public on common reactions and
  effective coping skills and
• Deliver a clear message regarding response and
  recovery.

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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
• The CCP provides education on common reactions
  and effective coping skills
• Cultural diversity is respected and
• If appropriate, and while maintaining
  confidentiality, highlight stories of people who
  have been helped by the CCP.

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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.

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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.

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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.

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Where Do We Go from Here? (cont.)

• Adult Assessment and Referral Tool
• Used to facilitate referrals to more intensive
  behavioral health services.
• First used during a third individual crisis
  counseling encounter.
• 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.

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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 persons (or
  dependents) safety is in danger and
• Excessive substance use is placing person or
  others at risk.
• When in doubt, call 911, or refer for immediate
  psychiatric or medical intervention.

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Where Do We Go from Here? (cont.)

• Nonemergency treatment referral
• Reduce perceived stigma
• Demystify mental health or substance abuse
  treatment by explaining it and
• 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 and
• Accompany person to first appointment, if
  necessary and appropriate.

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Where Do We Go from Here? (cont.)
CCP resource linkage
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Where Do We Go from Here? (cont.)

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

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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.

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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.

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Section 4Program Evaluation and Data Collection

• Definition of Program Evaluation
• CCP Evaluation and Data Collection Toolkit
• Data Collection Tools
• Opportunities for Improvement

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Definition of Program Evaluation

• What is 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.

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Definition of 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 programs accomplishments?
• Provided accountability to stakeholders (e.g.,
  Congress, Government Accountability Office,
  Federal agencies)?

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Definition of Program Evaluation (cont.)

• How are data used to evaluate the RSP?
• Are there additional ways that data can be used?

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

• Participant Feedback Survey
• Used to obtain feedback about the program.
• Conducted twice during an RSP.
• Surveys all adults receiving individual or group
  crisis counseling.
• The survey provides some data about immediate
  outcomes of crisis counseling.

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Data Collection Tools (cont.)

• Adult Assessment and Referral Tool
• Used to facilitate referrals to more intensive
  behavioral health services.
• First used during a third individual crisis
  counseling encounter.
• 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.

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Data Collection Tools (cont.)

• Service Provider Feedback
• Used to capture crisis counselors opinions about
  their training, resources, supervision, workload,
  support, and overall quality of the CCP.
• The provider survey is collected anonymously from
  crisis counseling staff around 6 and 12 months
  post-disaster.

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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 and
• Overall trends in the CCP.
• Are there other ways the data can be used?

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Opportunities for Improvement

• Effective program management includes
• Ongoing needs assessment.
• Outreach strategy.
• Staffing plan.
• Training.
• Stress management.
• Fiscal management.
• Quality assurance.
• Evaluation.
• Program media and marketing

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Section 5Stress Management

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

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Typical Stressors

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

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Warning Signs of Excessive Stress

• How do you know when you are experiencing
  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.

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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.

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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.

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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.

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Organizational Approaches to Stress
Management (cont.)

• 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.
• Adequately prepare counselors for their work.

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Individual Approaches to Stress Management

• What have you been doing to manage stress?
• Activity
• Update your personal stress management plan.

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Section 6Team Building

• Use this section for
• Crisis counseling skills practice.
• Developing outreach strategies.
• Identifying training needs.
• Identifying other needs of the program during
  transition.

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SAMHSA Disaster Technical Assistance Center

• SAMHSA DTAC supports SAMHSAs 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_at_esi-dc.com
• Web www.mentalhealth.samhsa.gov/dtac