Trauma-informed

approach to Mental
Health and Psychosocial
Support During Disasters
A Training Manual for Counsellors
August 2024

By

RAHBAR, A FIELD ACTION PROJECT OF THE

SCHOOL OF HUMAN ECOLOGY, TATA INSTITUTE OF
SOCIAL SCIENCES

In Collaboration With

NATIONAL DISASTER MANAGEMENT AUTHORITY

RAHBAR
The authors would like to express
their sincere gratitude to all
those who contributed towards
the development of this training
manual.

First and foremost, we thank Shri. Krishna Vatsa, Member

Secretary, NDMA, and Shri. Safi Ahsan Rizvi, IPS, Advisor
(Mitigation), NDMA. It is their foresight and vision that
brought mental health support to the forefront of
disaster management services. Under their leadership,
NDMA launched a Psychosocial Care project for the state
of Sikkim from which subsequently this manual was
developed.

We are grateful to Chancellor and Pro-Vice chancellor

Tata Institute of Social Sciences, for extending her
support for this collaboration between NDMA and
Rahbar, a field action project of TISS.

The volunteer Tele-Manas counsellors from the state of

Sikkim associated with NDMA’s Psychosocial Reverse
Helpline who were a part of the training and supervision
sessions carried out by Rahbar contributed significantly
to the compilation of this manual. It is through our
interaction with them that we gained insights on
psychosocial concerns of people affected by disasters
and the needs of mental health professionals during
this time, which provided the conceptual and practical
framework for this manual.
In putting together this manual we drew upon evidence
based models and resources developed by various
international organizations and practitioners across the
world.

We are grateful to the team at the National Institute

for the Clinical Application of Behavioral Medicine,
Connecticut, United States for granting us permission
to use their resources in the manual. We have taken
due care to appropriately credit their work in relevant
chapters.

The compilation of this manual would not have been

possible without Ms. Teju Jhaveri. It is thanks to her
artistic expertise that endless pages of text were brought
to life through a creative visual layout and design.

We thank all the mental health professionals across

India who have been tirelessly working on the frontlines
of disasters to provide timely and responsive care to
individuals and families impacted by it. This manual
is dedicated to their efforts and we hope it serves as
an effective resource and guide for all mental health
professionals.
Contents

A. ABBREVIATIONS 6

B. AUTHOR BIOS 8

C. ABOUT THE MANUAL 11

SECTION 1: TRAUMA AND DISASTER MENTAL HEALTH 16

SECTION 2: TRAUMA RESPONSES IN DISASTERS. 33

SECTION 3: TRAUMA-INFORMED MENTAL HEALTH AND

PSYCHOSOCIAL SUPPORT (MHPSS) IN DISASTERS. 55

SECTION 4: ROLE OF MENTAL HEALTH PROFESSIONALS

IN DELIVERING TRAUMA-INFORMED MHPSS DURING
DISASTERS. 72

SECTION 5: PROVIDING TRAUMA-INFORMED MHPSS

DURING DISASTERS 92

SECTION 6: MHPSS FOR SPECIFIC TRAUMA RESPONSES

DURING DISASTERS 112
List of Abbreviations

ACEs: Adverse Childhood Experiences

ANS: Autonomic Nervous System

APA: American Psychological Association/ American Psychiatric Association

ASD: Acute Stress Disorder

CAPS-5: Clinician Administered PTSD Scale for DSM-5

CAPS-CA-5: Clinician-Administered PTSD Scale for DSM-5 - Child/Adolescent Version

CBT: Cognitive–behavioral therapies

CPT: Cognitive processing therapy

CSRC: Child Stress Reaction Checklist

DBT: Dialectic Behavioural Therapy

DMA: Disaster Management Act

DSM-5: Diagnostic and Statistical Manual of Mental Disorders, 5th Edition

EMDR: Eye Movement Desensitization and Reprocessing

IFS: Internal Family Systems model

ISTSS: International Society for Traumatic Stress Studies

MHPSS: Mental Health and Psychosocial Support

MoHFW: Ministry of Health and Family Welfare, Government of India

NCTSN: National Child Traumatic Stress Network

6
NDMA: National Disaster Management Authority, Government of India

NICABM: National Institute for the Clinical Application of Behavioral Medicine,

Connecticut, United States

NIMHANS: National Institute of Mental Health And NeuroSciences, India

NSESASDSS: National Stressful Events Survey Acute Stress Disorder Short Scale

PDS-5: Posttraumatic Diagnostic Scale

PSS-I-5: PTSD Symptom Scale - Interview for DSM-5

PTG: Post-Traumatic Growth

PTGI: Post-Traumatic Growth Inventory

PTSD: Post-Traumatic Stress Disorder

SAMHSA: Substance Abuse and Mental Health Services Administration

SI-PTSD: Structured Interview for PTSD

SS: Seeking Safety model

STAIR: Skills Training in Affective and Interpersonal Regulation

SUDS: Subjective Units of Distress

TISS: Tata Institute for Social Sciences, India

UNISDR: United Nations International Strategy for Disaster Reduction

WHO: World Health Organization

7
Author Bios

Dr. Chetna Duggal

is Associate Professor at the School of Human Ecology,
Tata Institute of Social Sciences (TISS), Mumbai. She has
completed her Ph.D. from TISS, Mumbai and her M.Phil.
in Clinical Psychology from NIMHANS, Bangalore. She
is a psychotherapist with over 20 years of experience
and has worked with children, adolescents, couples and
families. She teaches courses on psychotherapy and
counselling in the Masters programme and supervises
trainee counsellors and practitioners. She is the Project
Director for Rahbar, an initiative to promote training,
supervision and professional development for mental
health practitioners in India. She also heads the School
Initiative for Mental Health Advocacy (SIMHA), an
initiative that endeavours to promote well-being of
young people in schools through advocacy, research
and capacity building. She is the trustee of Apnishala,
an organisation working towards making life skills
education accessible to children from underprivileged
contexts. She has a keen interest in psychotherapists and
counsellors training, supervision and reflective practice,
and has conducted research and authored book chapters
and papers on the same.

8
Ms. Bakul Dua
is a Clinical Psychologist based in Bengaluru. She has
over 16 years of experience in clinical practice, research
and advocacy and has worked in clinical and community
contexts across Delhi, Mumbai and Bengaluru. She
comes from a multidisciplinary background in the
humanities, having completed her M.Sc. in Cultural
Studies from at the London School of Economics, M.A
in Counselling Psychology from the Tata Institute of
Social Sciences (Gold medalist) and M.Phil. in Clinical
Psychology from the National Institute of Mental Health
and Neurosciences (Gold medalist). She is currently a
doctoral scholar at the School of Human Ecology at TISS.
She is the Project Coordinator of Rahbar – a field action
project at TISS which provides training and supervision
to mental health professionals across India. She works as
a psychotherapist in independent practice in Bengaluru
and also leads programming at the India Mental Health
Alliance.

Ms. Mrinalini Mahajan

is a clinical psychologist working as a private practitioner
in New Delhi. She has experience of working with
individuals with psychiatric difficulties as well as children
who are survivors of sexual abuse. Her special interest
is in working with individuals with histories of trauma
which also aligns with her research interest. She has an
MPhil in Clinical Psychology from NIMHANS (Bangalore),
an MA in Clinical Psychology from TISS, Mumbai (Silver
Medalist) and a BA (Hons.) Psychology from Delhi
University (Gold Medalist). Her therapeutic work is
a reflection of her beliefs about acknowledging and
appreciating the role of social justice, intersectionality
and socio-political frameworks in the sphere of mental
health.

9
i
Introduction
About the Manual

BACKGROUND This manual has been developed by Rahbar in

collaboration with the National Disaster Management
Authority (NDMA). Rahbar (‘guide’ or ‘companion’ in
Urdu) is a field action project of the School of Human
Ecology, Tata Institute of Social Sciences (TISS), Mumbai.
Rahbar was established in 2019 as a platform for
promoting training and supervision for mental health
practice. Rahbar supports mental health professionals
and organisations across India and outside, especially
those in resource constrained contexts, to ensure access
to quality mental health care for all through supporting
professional development of mental health practitioners
and developing best practice guidelines and frameworks.
Rahbar also offers a flagship Post graduate Diploma in
Supervision for Mental Health Practice. The Rahbar team
also coordinated mental health and psychosocial support
for those affected by the train accident in Balasore,
Orissa.

In April 2020 Rahbar launched an initiative to train and

supervise mental health professionals supporting those
affected by the Covid-19 pandemic. In May 2020 the
National Disaster Management Authority collaborated
with Rahbar as a training partner to support volunteer
counsellors leading NDMA’s psychosocial helpline
for persons diagnosed with Covid-19. Between June
to August 2020, the Rahbar team provided training
sessions and sessions pro bono to NDMA’s counsellors
which aimed at building knowledge, skills and reflective
abilities of counsellors in carrying out psychosocial
first aid and telephonic support to those affected by
the pandemic. In September 2020 Rahbar and NDMA
collaborated for continuing supervision sessions for PSC
Helpline counsellors as well as developing a training
manual. Between September to December 2020 Rahbar
provided supervision sessions which covered case
discussions, peer de-debriefs, skill building, theoretical
discussions and experiential exercises. The discussions
informed the development of a training manual titled
‘Psychosocial Support during the COVID-19 pandemic:

11
A training manual for counsellors’ (https://ndma.gov.
in/sites/default/files/PDF/covid/RAHBAR_%20NDMA-
manual.pdf). NDMA and Rahbar also documented this
work through the research titled ‘Psychosocial Support
for Individuals Diagnosed with Covid-19: Experiences
of Volunteer Counsellors from India’ (https://ndma.gov.
in/sites/default/files/PDF/covid/Psychosocial-Support-
forIndividuals-Diagnosed-with-Covid-19.pdf). After the
helpline restarted in 2021, Rahbar supported NDMA
through training and supervision sessions. From March
to September 2023, Rahbar worked on updating the
National Disaster Management Guidelines on Mental
health and Psychosocial Support Services in Disasters
in keeping with the recent developments in the field
of disaster risk reduction and as well as psychosocial
care. The updated guidelines would provide a pathway
to integrate and mainstream psychosocial care in every
stage of the disaster management cycle in view of these
developments in the national and international scenario.

The NDMA and Rahbar collaborated once again in

November 2023, following the landslide in the state
of Sikkim. Rahbar provided support for psychosocial
work in the state by creating resources for community
sensitization and facilitating awareness programs for
school students to identify emotional responses during
disasters and sharing strategies for managing distress.
Tele-Manas counsellors from the state were trained in
trauma-informed practices for working with traumatic
responses commonly seen in the aftermath of disasters.
A reverse helpline was started in which the counsellors
contacted those most severely affected by the landslide
to provide psychosocial support. Rahbar provided
supervision and debriefing support to the counsellors
during this time.

This manual presents a trauma-informed framework of

psychosocial support to equip counsellors in addressing
the mental health concerns that arise in the context
of disasters. Integrating international best practice
guidelines with practice-based insights of trainers and
supervisors, as well as counsellor education frameworks,
the manual aims to be a resource for mental health
professionals not only in India, but across the world.

12
SCOPE This manual is aimed at helping mental health
professionals to provide trauma-informed care
to individuals who have survived disasters. The
interventions described in this manual can be used by
counsellors and other mental health professionals (e.g.,
social workers, psychologists, psychiatrists etc) who have
training in mental health. These brief interventions can
be applied in any modality ( in-person or remote)

What? For Whom?

Providing Survivors
trauma-informed of disasters
care

Scope

By Whom? How?
Mental health Through brief
professionals with intervention that can
basic training be delivered in person
or remotely

OVERVIEW This manual is divided into six sections:

SECTION 1: Trauma and Disaster Mental health. This

section defines trauma and its typologies with an
overview of mental health in disaster settings.

SECTION 2: Trauma responses in disasters. This section

highlights the different responses to traumatic events
and how these can be identified in disaster settings. It
also introduces the concept of post-traumatic growth.

13
 SECTION 3: Trauma-informed Mental health and
Psychosocial support (MHPSS) in disasters. This section
describes the neurobiology of trauma and its impact on
the brain and body.

SECTION 4: Role of Mental health professionals in

delivering trauma-informed MHPSS during disasters.
This section describes the role that mental health
professionals play at different stages of psychosocial
support in disaster settings. It also highlights the
principles of trauma-informed care and competencies of
mental health professionals who are trauma-informed.

SECTION 5: Providing Trauma-informed MHPSS during

disasters. This section describes the stages of trauma-
informed MHPSS and the interventions that can be
carried out at each stage.

SECTION 6: MHPSS for specific trauma responses during

disasters. This section describes the interventions that
can be carried out for different trauma responses during
disasters.

Throughout the manual, exercises for reflective practice and self-care have been woven
in to help counsellors to reflect on their work and promote professional development.
Additionally, each chapter also has tips for supervisors for carrying out trauma-
informed supervision.

14
 Trigger Warning

It is important to note that this manual covers very heavy and triggering
topics that may bring up difficult experiences for counsellors either from
their own life or those important to them, including their clients. Please feel
free to pause and step away from it as and when it becomes overwhelming.

All mental health professionals acknowledge that working with the realities of
trauma is an evolving competency. As counselors we are all continuously finding
our own ways to make meaning of the pain and suffering that we witness.

If it seems ‘too heavy’, that is because it is. It will become more bearable with
time, experience, supervision and support. Using the strategies mentioned in
the manual may be beneficial for us too.

15
1
CHAPTER 1

Trauma
and Disaster
Mental health
 Trauma has been defined in the Diagnostic and
1 Statistical Manual of Mental Disorders (5th ed.; DSM–5;
American Psychiatric Association, 2013), as “exposure
DEFINING to actual or threatened death, serious injury, or sexual
TRAUMA violence in one (or more) of the following ways: directly
experiencing the traumatic event(s); witnessing, in
person, the traumatic event(s) as it occurred to others;
learning that the traumatic event(s) occurred to a
close family member or close friend (in case of actual
or threatened death of a family member or friend,
the event(s) must have been violent or accidental);
or experiencing repeated or extreme exposure to
aversive details of the traumatic event(s)” ( DSM 5, APA,
2013). This definition focuses on the traumatic event.
The American Psychological Association (APA, 2017)
highlights the experience of trauma where it is seen
as an emotional response to a terrible event like an
accident, rape or natural disaster. Immediately after
the event, shock and denial are typical. Longer term
reactions include unpredictable emotions, flashbacks,
strained relationships and even physical symptoms
like headaches or nausea (APA, 2017). The definition
of trauma by Substance Abuse and Mental Health
Services Administration (SAMHSA) highlights the effect
of the traumatic event on the experience. SAMHSA
has specifically defined trauma as resulting “from
an event, series of events, or set of circumstances
that is experienced by an individual as physically or
emotionally harmful or life threatening and that has
lasting adverse effects on the individual’s functioning
and mental, physical, social, emotional, or spiritual
well-being” (SAMHSA, 2014). This definition of trauma
is sometimes used to define “psychological trauma” to
help differentiate it from other types of trauma such as
physical trauma like having a fractured limb or meeting
with a road traffic accident. The trauma in psychological
trauma is defined in terms of the event, the individual’s
experience of the event and the adverse long-lasting
effects of this experience.

CHAPTER 1: TRAUMA AND DISASTER MENTAL HEALTH 17

Thus, the 3 Es of trauma are (SAHMSA, 2014):

These are the single, multiple or extended situations

Events and circumstances posing an actual or extreme threat
of physical or psychological harm.

It is the unique and subjective experiences of

Experience individuals which determine whether events are

perceived as traumatic

These refer to the temporal nature of the experiences.

Effects Effects of the event may be immediate, or delayed;
short term, or long term.

Adverse childhood experiences (ACEs) are those

2 experiences occurring before the age of 18 years that can
be considered to be traumatic. These include exposure
TYPES OF to violence, abuse, or neglect, as well as any situation in
the environment that compromises a child’s sense of
TRAUMA safety and stability including but not limited to parental
separation, a family member having substance use
difficulties, and so on (SAMHSA, 2014). ACEs tend to have
a pervasive and long-range influence on the emotional,
cognitive, behavioral, and psychobiological functioning
of the child. It may lead to difficulties in managing
emotions, processing information, guilt and shame,
behavioural difficulties, difficulties in interpersonal
relationships and delay in biological development of the
child (APA, 2017).

Traumatic events may be interpersonal and

noninterpersonal events based on the intentionality to
inflict harm (Janoff-Bulman, 1992). Interpersonal traumas
are those in which a perpetrator harms another human
being with conscious intent. Examples of these events
include experiencing or witnessing physical, sexual and
emotional abuse, interpersonal violence to name a few.
These experiences are associated with dissociation,
shame, distress, lowered self-esteem, and changes in
beliefs about self, such as negative self-attributions and
a decrease in positive view of self; about others such

CHAPTER 1: TRAUMA AND DISASTER MENTAL HEALTH 18

 as they are not trust-worthy and the world such as it
is unsafe and unpredictable (Forbes et al., 2014; Ogle,
et al., 2013). Noninternpersonal traumas include those
events where such an intention is absent. Some common
examples of these noninterpersonal traumas are illness,
natural disasters and accidents. Noninterpersonal
traumatic events may elicit feelings of powerlessness and
feelings of loss of control (Lilly et al., 2011).

Experiences of trauma may also be transmitted as

a psychological consequence of an injury or attack,
poverty, and so forth, from one generation to next.
These reactions often include shame, increased anxiety
and guilt, a heightened sense of vulnerability and
helplessness, low self-esteem, depression, suicidality,
substance abuse, dissociation, hypervigilance, intrusive
thoughts, difficulty with relationships and attachment to
others, difficulty in regulating aggression, and extreme
reactivity to stress (APA, 2017).

3
The United Nations International Strategy for Disaster
DISASTERS AS Reduction [UNISDR] considers disaster as “a serious
TRAUMATIC EVENTS disruption of the functioning of a community or a society
involving widespread human, material, economic or
environmental losses and impacts, which exceeds the
ability of the affected community or society to cope using
its own resources” (UNISDR, 2009; pp.13). The Disaster
Management Act, 2005 [DMA, 2005] defines disaster as
“a catastrophe, mishap, calamity or grave occurrence in
any area, arising from natural or manmade causes or by
accident or negligence which result in substantial loss of
life or human sufferings or damage to, and destruction
of, property or damage to, or degradation of environment
and is of such a nature or magnitude as to be beyond the
coping capacity of the community of an affected area”.

Disasters differ from other types of traumas in significant

ways. Thus, it is important to discuss these separately
(Watson & Hamblen, 2008). Disasters tend to be
collective in nature, that is, a large number of individuals
are often affected at the same time. This may lead to
better mobilization of support and resources which may
not be accessible to individuals otherwise. At the same
time, it may lead to minimization of individual needs. It is
possible that the resources available may be insufficient.
The impact of disasters is widespread and includes

CHAPTER 1: TRAUMA AND DISASTER MENTAL HEALTH 19

 impacts on infrastructure and mental health. Basic
needs such as communication, transportation or housing
may get adversely impacted. Secondary impacts such as
homelessness and joblessness may get exacerbated. The
vulnerabilities in the communities may get magnified
in the context of disasters. This can be seen in the
results of a large-scale study which found that the loss
of lives in lower income countries was higher despite
experiencing fewer disasters (West et al., 2015). The
response to the disaster can also be an important factor
to the experience of trauma. If the systemic responses
are not attuned to the needs of the people who went
through the disaster, it may lead to increased feelings
of helplessness, abandonment, and insecurity among
affected individuals and communities (Schultz et al,
2005). Across different disasters such as hurricanes,
earthquakes and Tsunami, research has shown that
lack of timely rescue efforts, breakdown of healthcare
systems, difficulties in meeting the basic needs of the
people, and insufficient long-term support and recovery
planning can prove to be detrimental to the overall
recovery of the individuals and communities (Shreshtha
et al, 2018).

India is considered to be one of the most disaster-prone countries in the world because
of its unique geo-climatic conditions. Within the country, 27 out of the 36 States and
Union Territories have been deemed as being prone to disasters (NDMA, 2021). The
effects of disasters are further complicated by a large population, the social, economic,
and cultural diversity in communities, low literacy levels, high poverty, and inequitable
availability and distribution of resources.

4
PHASES OF The impact of disaster is often widespread and the needs
DISASTERS and reactions of individuals and communities change
over time. Thus, understanding the way in which post-
disaster events unfold is important. This period has
often been divided into four phases: impact, immediate,
intermediate, and long-term.

CHAPTER 1: TRAUMA AND DISASTER MENTAL HEALTH 20

 4.1 PHASE 1: IMPACT

This phase encompasses the hours, days or weeks

following a disaster, depending on the size and scope
of the event. The impact phase tends to be longer for
events that destroy people’s homes and create a housing
crisis, like a hurricane, earthquake, flood, or fire. During
this phase several stressors may occur such as injury, loss
(of loved ones, home, workplace, possessions), dislocation
(i.e., separation from loved ones, home, familiar settings,
neighborhood, community); even trying to understand
the fact that some disasters may be caused by human
error, neglect, or malevolence. People may feel a sense of
threat, shock, fear, helplessness or powerlessness, guilt,
and anxiety. People may also reach out to support each
other and prevent loss of life and property.

4.2 PHASE 2: IMMEDIATE - RESCUE

This is the phase in the days and weeks following disaster

when people start assessing the extent of damage to
home and community. They begin to deal with the
physical, emotional, and social impact of injury, loss, and
exposure to traumatic stress engendered by the event.
The focus is often on survival needs and the restoration
of safety and some semblance of order. Once stability is
achieved, people may start showing delayed emotional
reactions. These reactions depend on the personal
history, perceptions, and exposure to the disaster.

4.3 PHASE 3: INTERMEDIATE - RECOVERY

The intermediate phase may last from weeks to months,

depending on the size and scope of the event. This
phase is the prolonged period of adjustment or return
to equilibrium. It begins as rescue is completed and
individuals and communities face returning to fulfilling
routine tasks and roles. Much of what happens in this
phase will depend on the extent of devastation that
has occurred, as well as injuries, exposure to traumatic
stress, and lives lost. Once the basic safety is restored,
other psychosocial needs begin to emerge that had been
previously frustrated and unfulfilled.

4.4 PHASE 4: LONG-TERM - RECONSTRUCTION

This phase may last several months or years, as

communities rebuild and individuals deal with their

CHAPTER 1: TRAUMA AND DISASTER MENTAL HEALTH 21

 post-event problems. On the one hand, there may
be opportunities for positive social consequences
if communities collectively respond and rebuild.
However, if the community is unable to pull together
and overcome fragmentation, there may be increased
risk for ongoing stress reactions across the community.
This is further complicated by socioeconomic, cultural,
racial, and political factors associated with the disaster
response. The perception of the event and the meaning
assigned to it may also affect long-term psychosocial
adjustment. While the majority of affected individuals
will see a lessening of distress over time in the long-term
phase, vulnerable populations such as those with injury,
severe disaster exposure or ongoing adversities, may
continue to suffer for years after a large-scale disaster
event.

5
Disasters have a devastating impact on individuals,
IMPACT OF families, communities, and society as a whole. They
DISASTERS ON have wide-ranging effects on the individual such as
loss of life, injury, disability and on the community as a
MENTAL HEALTH whole such as costs to livelihood, property, purchasing
AND WELLBEING capacity, and financial security. Disasters tend to disturb
routines, cut-off social support systems, and lead to
forcible displacement of people. Basic needs may not be
met as access to water supply may get contaminated or
restricted, food supply chains may get obstructed, and
services, infrastructure and systems may get damaged
especially health services.

These consequences of disasters have cumulative and

far-reaching effects on the psychosocial and mental
health of people. There is a growing body of research that
indicates a surge in mental health concerns and stress-
related conditions in the aftermath of disasters, including
post-traumatic stress disorder, anxiety, substance
misuse, and depression (Makwana, 2019; Fergussson &
Boden, 2014). The psychological impact of disasters has
led to the development of policies focused on providing
psychosocial support and mental health services.

People respond to the immediate aftermath of trauma

by showing emotional distress ranging from transient
to severe. Emotional distress is defined as a range of
negative and/or painful emotions and experiences, both
physiological and psychological (APA, 2017). A large
scale review summarising findings from 160 studies
CHAPTER 1: TRAUMA AND DISASTER MENTAL HEALTH 22
 showed that nearly 51% of the samples of people who
had experienced disaster showed moderate impairment
indicating prolonged stress. The more extreme reactions
such as minimal or transient impairment were shown
by 11% of the sample while severe impairment and
very severe impairment indicating clinically significant
distress was shown by 21% and 18% respectively on the
other hand (Norris & Elrod, 2006). Results from a review
conducted in India showed that post disaster mental
health difficulties are highly variable, ranging from 5% to
as high as 80% (Kar, 2010).

Research in the field of mental health impact of disasters

indicate that the most common post-disaster negative
reactions are depression, anxiety, posttraumatic stress
disorder (with higher incidences of intrusion and arousal
reported as compared to avoidance), acute stress
disorder, dissociative responses, increases in the use
of alcohol and drugs, demoralization, negative affect,
perceived stress, physical health problems or somatic
concerns, poor sleep quality, and physiological indicators
of stress such as increased activation of the autonomic
nervous system and hypothalamic-pituitary-adrenal
axis (Goldmann & Galea, 2014; Lowe & Galea, 2015;
Morganstein et al., 2016). It is indicated that the first 6 to
12 months post disasters are crucial as these reactions
are more common during this period irrespective of the
nature of the disaster (Pietrzak et al., 2012). Complicated
grief which has a combination of symptoms of grief
and PTSD tends to cause greater and more prolonged
distress (Kristensen et al., 2012). With respect to suicide,
the rates vary with severity of the disasters. In large
scale disasters, the rates increase three to fouryears later
whereas in less severe disasters, the rates decrease as the
time moves on (Matsubayashi et al., 2013). With respect to
children, distress is often manifested as emotional lability,
difficulties in sleep, increased crying, fear and grief
especially around anniversaries and somatic complaints
which cannot be explained medically (Peek, 2008; Ronan
et al., 2008).

In this manual, we are particularly focusing on trauma

responses experienced by those affected by the disasters.
These include responses such as shock, numbness,
hyper-arousal, hypo-arousal, agitation, flashbacks, and
disorientation. During disasters, trauma responses
are seen in both individuals as well as communities.
Individual trauma as already described above, is said

CHAPTER 1: TRAUMA AND DISASTER MENTAL HEALTH 23

 to arise from an event, or a series of events or set of
circumstances that are experienced by an individual
as being physically or emotionally harmful or life
threatening. These tend to have lasting adverse effects
on their functioning as well as their mental, physical,
social, emotional, or spiritual well-being (SAHMSA, 2014).

Disasters may be experienced as collective trauma

by the affected communities. Collective trauma
refers to psychological reactions to a traumatic event
affecting the society at large. It is not just a historical
fact or a recollection that a terrible event happened
to a community. It highlights the representation and
ongoing reconstruction of the traumatic event in the
collective memory of the group so as to make sense
of it (Hirschberger, 2018). Communities which have
undergone collective trauma are more likely to be
passive, mistrustful, silent, dependent and leaderless
(Somasundaram, 2014). Other effects of collective trauma
may include breakdown in traditional family, and social
structures; changes in relationships, and child rearing
patterns; or widespread displacement,
and disenfranchisement.

6
Mr.R is a 43 year old man residing in a small town near
VULNERABLE a river. Due to unexpected heavy rains, the river flooded
GROUPS IN this year. His two-storey house was badly affected as
water entered the ground floor. Fortunately, he had
DISASTERS heard the warning that the Government was telecasting
on the news for two days and had shifted his family
members upstairs. He has lost some furniture and a
valuable watch that was a gift from his grandfather.
He is hoping that once the flood water recedes, he can
travel again for business and recover the cost of the
furniture. The watch is lost forever though.

Mrs. P is a 24 year old woman residing in the same town

in a one-room house in a temporary tenement. When
the flood came, they were caught completely off-guard
and had to rush home. They were able to reach safely
though. Since her house was on the upper floor, there
was no property damage but the children were very
scared with the running and sudden onslaught of water.
They have been crying incessantly and Mrs. P is finding
it difficult to comfort them. Her husband is getting very
angry about this and is shouting at her and them which
is making them even more upset. Along with being
CHAPTER 1: TRAUMA AND DISASTER MENTAL HEALTH 24
 distressed about this situation, she is very worried about
the ration as the food supply will end in a day or so.
The roads are still closed. She knows hunger makes her
husband angrier and more violent.

Reflective Exercise

· Did you notice any difference in MR. R’s experience and Mrs. P’s experience?

· Who do you think was more vulnerable and why?

Disasters do not affect all individuals equally. Some

individuals may be more vulnerable to the experiences
of disaster while others may be better protected
from their impact. Identity and intersectionality are
important contexts to consider. These contexts shape
the individual’s experiences as traumatic and help in
understanding why a particular event may be traumatic
for one person and not for the other. It includes the
person’s historical, caste and class oriented experiences,
and other intergenerational experiences which are
traumatic. (SAMHSA, 2014). Risk factors or vulnerabilities
increase the likelihood of experiencing more intense
emotional distress, trauma responses, and mental health
concerns during or after a disaster. Protective factors
are those variables that are likely to build resilience and
protect individuals from the likelihood of experiencing
emotional distress, trauma responses, and psychosocial
disabilities during or after a disaster.

6.1 PROTECTIVE AND RISK FACTORS

There have been some risk and protective factors that

have been consistently associated with disasters. It is
important to remember that there is no single factor
that puts a person at risk or protects that person; rather a
combination or additive total of these risk and protective
factors determine the outcome for the individual
(Bonanno et al., 2010; Masten & Narayan, 2012).
It is seen that most individuals (70-90%) affected
by disasters will not require support from mental
health professionals (Bonanno et al., 2010). Some
unique predictors of resilience include acquiring and
maintaining social and emotional resources (Felix & Afifi,
2015), certain personality factors, such as low negative
CHAPTER 1: TRAUMA AND DISASTER MENTAL HEALTH 25
 affectivity, high capacity for optimism, emotional
stability, agreeableness, and perceived coping self-
efficacy (Bosmans & van der Velden, 2015); and socio-
demographic variables such as male gender and
higher education level (Bonanno et al., 2010). Among
children, resilience is affected by various bio-psycho-
social factors such as presence of supportive adults,
posseeing problem solving skills, self-regulation and
social regulation skills, and having feelings of self-efficacy
and hope. This may help them feel safe, connected, and
display a sense of agency to make meaning of these
experiences (Masten & Narayan, 2012).

CERTAIN RISK FACTORS HAVE BEEN IDENTIFIED

IN LITERATURE:

Severity of exposure.
The severity of exposure to the disaster is described
in terms of the injury experienced, how much was
the threat to life, where was the person with respect
to the disaster, the type of disaster that occurred, the
displacement that the disaster caused and the severity
of loss. Research suggests that it consistently predicts
worse outcomes (Gruebner et al., 2015; Viswanath et al.,
2013).

1. Ongoing stressors and weak or deteriorating

psychosocial resources.
The stresses and adversities faced by the individuals
such as loss of employment, financial constraints, and
relationship difficulties (Cerdá et al., 2013) along with
inadequacy of psychosocial and practical support and
resources can pose as significant risk factors (Felix & Afifi,
2015; Goldmann & Galea, 2014; Norris & Elrod, 2006).

2. Demographic factors.
Certain demographic risk factors include female gender;
belonging to ethnic minority groups; poverty or low
socioeconomic status; and having psychiatric history
(Goldmann & Galea, 2014; Norris & Elrod, 2006).

3. Emotional and cognitive factors.

These factors include negative coping strategies, like
blaming self or others for negative events (Ehlers et al.,
2003; Pietrzak et al., 2013), negative appraisals about the
traumatic event, role of self and about the future (Ehlers
et al., 2003) and using avoidance as a coping mechanism.

CHAPTER 1: TRAUMA AND DISASTER MENTAL HEALTH 26

 4. Developmental factors.
Risk factors associated with children and adolescents
include their age, peer group, reactions of parents
towards disasters, separation from a primary caregiver
and other factors previously related to severity of
exposure (Brymer, et al, 2012; Eisenberg & Silver, 2011). On
the other side of the continuum are the older adults who
are at greater risk if they have previous health concerns
(Parker et al., 2016) along with other previous mentioned
factors.

5. Community-level factors.
Certain community level factors such as low community
social cohesion may also show worse outcomes
(Johns et al., 2012).

There is a need to focus on groups that are especially vulnerable during disasters. The
table below describes some vulnerable groups in the Indian context (NDMA, 2023).
There may be other groups which may not be covered in this list but may still be
vulnerable due to the influence of local power structures and contexts

Table 1.1: Vulnerable Groups in India

Factors Vulnerable groups

Age Children (unaccompanied children, orphans, child

labourers, children with physical and psychosocial
disabilities, children in conflict with law)

Older adults (those not cared for in families, living alone

and in elderly homes)

Gender and Sexuality Women (pregnant women, divorced women, widows)

Gender minorities (transgender and intersex people)
People identifying as lesbian, gay, bisexual, or other
sexualities

Occupation People in vulnerable occupations, informal sector, and

those who are unemployed or undocumented (like daily
wage workers, bonded labourers, sex workers, mine
workers)

Disaster responders including first responders,

government officials, media personnel, and health care
providers

CHAPTER 1: TRAUMA AND DISASTER MENTAL HEALTH 27

 Socio-economic status People who are socio-economically disadvantaged
(families below the poverty line, homeless persons, slum
dwellers)

Caste and Tribal Individuals from Scheduled Castes, Scheduled Tribes

communities

Disability People who have visual impairment, hearing impairment,

locomotor disabilities, developmental disabilities
(including autism, intellectual disability, speech and
language impairments), muscular and neurological
disabilities and mental illness

Health People with chronic medical conditions,

immunocompromised status, persons with limited life
span, and those in palliative care ; individuals with pre-
existing mental health concerns

Trauma People experiencing or having experienced intimate

partner violence, other community or domestic violence,
traumatic bereavement, survivors of sexual violence, and
other traumatic experiences

Family Single parent families, families with multiple dependent

individuals and caregiving responsibilities

Ethnicity Indigenous people and people belonging to cultural and

linguistic minorities

Displacement Immigrants, migrants, people who are internally

displaced and climate change refugees

Others Tourists, prisoners

As we have seen that some groups are more vulnerable than others, it is important
to understand the unique socio-political and economic context that clients will bring
into the sessions. The next chapter will focus on the role that we as mental health
professionals play in this context and the challenges that we may face.

CHAPTER 1: TRAUMA AND DISASTER MENTAL HEALTH 28

 Let’s avoid...

Understanding trauma as a unidimensional construct. It is important to

remember that trauma can be categorised as events, experiences and effects in
order to facilitate any help that the clients need.

Trying to generalise the experiences of the client without asking them about
it. Trauma responses are varied and depend on a large number of personal,
interpersonal and intrapersonal factors and we need to carefully understand the
context of the individual before planning any intervention.

Underestimating the influence of the client’s unique socio-cultural context on

their experience. Clients’ experiences occur in their socio-cultural context which
may serve as protective or risk factors. Discounting these and locating the
distress within the individual does not give a holistic perspective.

Negating the resilient reactions of the clients. Most of the clients show
moderate responses to traumatic situations which may recede on their own
time. We can look for stories of resilience and identify the protective factors that
they display.

Self-care Exercise

Speaking about trauma may bring up some difficult emotions for us. We can try
the following self-care strategies.

· Making a list of all coping strategies that help us relax and self-soothe
· Having interests outside of our work.
· Taking up training opportunities to hone our skills
· Taking periodic breaks
· Seeking social support and using strategies that we often teach clients.
· Accessing personal therapy.

CHAPTER 1: TRAUMA AND DISASTER MENTAL HEALTH 29

 Tips for Supervisors

Some general practices that can ensure a good supervisory relationship with
the supervisees while working with clients with histories of trauma may be:

· Hold regular supervision at a time and place that works for you both.

· Collaboratively create an agenda. Ask, “What would you like to discuss

today?”

· Outside of supervision sessions, transparently explain your availability and

boundaries. For example, we can say, “I am involved in other projects on
Tuesdays and Thursdays. I do not schedule supervision sessions on those
days. But you can email me anytime, and if I’m not available, I’ll get back to
you the next day.”

· Listen non-judgmentally, openly, and empathetically. We may want to say,

“I know the case would be very difficult for anybody. Would you like to start
there?”

· Use humility and self-disclosure to create an emotionally safe environment

for supervisees to share.

Specifically in the context of trauma, it may be helpful for supervisors to

understand how supervisees conceptualise trauma. We can ask, “What comes
to your mind when you think of the word trauma? What do you know about it?”

This chapter helps us in understanding disasters as traumatic events and their impact.
The next chapter describes the role of mental health professionals and trauma-informed
care in the context of disasters.

CHAPTER 1: TRAUMA AND DISASTER MENTAL HEALTH 30

References

American Psychiatric Association. (2013). Diagnostic and statistic manual of mental disorders (5th ed.). Washington,
DC: American Psychiatric Association.

American Psychological Association. Psychological distress [internet]. [cited 2024 January 11]. Available from https://
dictionary.apa.org/distress and https://dictionary.apa.org/psychological-distress

Bonanno, G. A., Brewin, C. R., Kaniasty, K., & La Greca, A. M. (2010). Weighing the costs of disaster: Consequences,
risks, and resilience in individuals, families, and communities. Psychological Science in the Public Interest, 11, 1–49.
http://dx.doi.org/10.1177/1529100610387086

Brymer, M. J., Steinberg, A. M., Watson, P. J., & Pynoos, R. S. (2012). Prevention and early intervention programs for
children and adolescents. In J. G. Beck & D. Sloan (Eds.), The Oxford handbook of traumatic stress disorders (pp.
381–392). http://dx.doi.org/10.1093/oxfordhb/9780195399066.013.0025

Cerdá, M., Bordelois, P. M., Galea, S., Norris, F., Tracy, M., & Koenen, K. C. (2013). The course of posttraumatic stress
symptoms and functional impairment following a disaster: What is the lasting influence of acute versus ongoing
traumatic events and stressors? Social Psychiatry and Psychiatric Epidemiology, 48, 385–395. http://dx.doi.
org/10.1007/s00127-012-0560-3

Ehlers, A., Clark, D. M., Hackmann, A., McManus, F., Fennell, M. J. V., Herbert, C., & Mayou, R. A. (2003). A randomized
controlled trial of cognitive therapy, a self-help booklet, and repeated assessments as early interventions for
posttraumatic stress disorder. Archives of General Psychiatry, 6, 1024–1032.

Eisenberg, N., & Silver, R. C. (2011). Growing up in the shadow of terrorism: Youth in America after 9/11. American
Psychologist, 66, 468–481. http://dx.doi.org/10.1037/a0024619

Felix, E. D., & Afifi, W. (2015). The role of social support on mental health after multiple wildfire disasters. Journal of
Community Psychology, 43, 156–170. http://dx.doi.org/10.1002/jcop.21671

Fergusson, D. M., & Boden, J. M. (2014). The psychological impacts of major disasters. The Australian and New
Zealand journal of psychiatry, 48(7), 597–599. https://doi.org/10.1177/0004867414538677

Forbes, D., Lockwood, E., Phelps, A., Wade, D., Creamer, M., Bryant, R. A., . . . O’Donnell, M. (2014). Trauma at the hands
of another: Distinguishing PTSD patterns following intimate and nonintimate interpersonal and noninterpersonal
trauma in a nationally representative sample. The Journal of Clinical Psychiatry, 75, 147–153. http://dx.doi.org/10.4088/
JCP.13m08374

Gold, S. N. (2017). APA handbook of trauma psychology: Foundations in knowledge, Vol. 1. American Psychological
Association. xxii-624

Goldmann, E., & Galea, S. (2014). Mental health consequences of disasters. Annual Review of Public Health, 35,
169–183. http://dx.doi.org/10.1146/annurev-publhealth-032013-182435

Gruebner, O., Lowe, S. R., Sampson, L., & Galea, S. (2015). The geography of post-disaster mental health: Spatial
patterning of psychological vulnerability and resilience factors in New York City after Hurricane Sandy. International
Journal of Health Geographics, 14, 16. http://dx.doi.org/10.1186/s12942-015-0008-6

Hirschberger G. Collective trauma and the social construction of meaning. Frontiers in psychology. 2018 Aug
10;9:1441.1

Janoff-Bulman, R. (1992). Shattered assumptions: Towards a new psychology of trauma. New York, NY: Free Press.

Johns, L. E., Aiello, A. E., Cheng, C., Galea, S., Koenen, K. C., & Uddin, M. (2012). Neighborhood social cohesion and
posttraumatic stress disorder in a community-based sample: Findings from the Detroit Neighborhood Health Study.
Social Psychiatry and Psychiatric Epidemiology, 47, 1899–1906. http://dx.doi.org/10.1007/s00127-012-0506-9

Kar N. Indian research on disaster and mental health. Indian journal of psychiatry. 2010 Jan;52(Suppl1):S286.

Kristensen, P., Weisæth, L., & Heir, T. (2012). Bereavement and mental health after sudden and violent losses: A review.
Psychiatry: Interpersonal and Biological Processes, 75, 76–97. http://dx.doi.org/ 10.1521/psyc.2012.75.1.76

Lilly, M. M., Valdez, C. E., & Graham-Bermann, S. A. (2011). The mediating effect of world assumptions on the
relationship between trauma exposure and depression. Journal of Interpersonal Violence, 26(12), 2499-2516.

31
Lowe, S. R., & Galea, S. (2015). The mental health consequences of mass shootings. Trauma, Violence, and Abuse
(June), 1–21. http://dx.doi.org/ 10.1177/1524838015591572

Makwana N. (2019). Disaster and its impact on mental health: A narrative review. Journal of family medicine and
primary care, 8(10), 3090–3095. https://doi.org/10.4103/jfmpc.jfmpc_893_19

Masten, A. S., & Narayan, A. J. (2012). Child development in the context of disaster, war, and terrorism: Pathways of risk
and resilience. Annual Review of Psychology, 63, 227–257. http://dx.doi.org/ 10.1146/annurev-psych-120710-100356

Matsubayashi, T., Sawada, Y., & Ueda, M. (2013). Natural disasters and suicide: Evidence from Japan. Social Science
and Medicine, 82, 126–133. http://dx.doi.org/10.1016/j.socscimed.2012.12.021

Morganstein, J. C., West, J. C., Huff, L. A., Flynn, B. W., Fullerton, C. S., Benedek, D. M., & Ursano, R. J. (2016).
Psychosocial responses to disaster and exposures: Distress reactions, health risk behavior, and mental disorders. In
J. Shigemura & R. K. Chhem (Eds.), Mental health and social issues following a nuclear accident (pp. 99–117). Tokyo,
Japan: Springer.

National Disaster Management Authority. Annual Report 2020-2021. [Internet]. [cited 2024 January 11]. Available from
https://ndma.gov.in/sites/default/files/PDF/Reports/NDMA-Annual-Report_20-21.pdf

Norris, F. H., & Elrod, C. L. (2006). Psychosocial consequences of disaster. In F. H. Norris (Ed.), Methods for disaster
mental health research (pp. 20–42). New York, NY: Guilford Press.

Ogle, C. M., Rubin, D. C., Berntsen, D., & Siegler, I. C. (2013). The frequency and impact of exposure to
potentially traumatic events over the life course. Clinical psychological science, 1(4), 426-434. https://doi.
org/10.1177/2167702613485076

Parker, G., Lie, D., Siskind, D. J., Martin-Khan, M., Raphael, B., Crompton, D., & Kisely, S. (2016). Mental health
implications for older adults after natural disasters—a systematic review and metaanalysis. International
Psychogeriatrics, 28, 11–20. http://dx.doi.org/10.1017/S1041610215001210

Parliament of India. “Disaster Management Act, 2005 [23rd December, 2005.] No. 53 OF 2005” [Internet]. [cited 2024
January 11]. Ministry of Home Affairs. Available from https://web.archive.org/web/20160129071454/ https://ndma.gov.
in/sites/default/files/PDF/DM_act2005.pdf

Peek, L. (2008). Children and disasters: Understanding vulnerability, developing capacities, and promoting
resilience-an introduction. Children, Youth, and Environments, 18, 1–29

Pietrzak, R. H., Goldstein, R. B., Southwick, S. M., & Grant, B. F. (2012). Physical health conditions associated with
posttraumatic stress disorder in U.S. older adults: Results from wave 2 of the National Epidemiologic Survey on
Alcohol and Related Conditions. Journal of the American Geriatrics Society, 60, 296–303. http://dx.doi.org/10.1111/j.1532-
5415.2011.03788.x

Ronan, K. R., Crellin, K., Johnston, D. M., Finnis, K., Paton, D., & Becker, J. (2008). Promoting child and family resilience
to disasters: Effects, interventions and prevention effectiveness. Children, Youth, and Environments, 18, 332–353

Somasundaram D. Addressing collective trauma: Conceptualisations and interventions. Intervention: Journal of

Mental Health and Psychosocial Support in Conflict Affected Areas. 2014 Dec.

Substance Abuse and Mental Health Services Administration. (2014). SAMHSA’s concept of trauma and guidance
for a trauma-informed approach. HHSpublicationno. (SMA) 14–4884. Rockville: Substance Abuse and Mental Health
Services Administration https://store.samhsa.gov/shin/content/SMA144884.pdf.

UNISDR (United Nations International Strategy for Disaster Reduction). 2009. Terminology. Geneva: UNISDR.
Viswanath, B., Maroky, A. S., Math, S. B., John, J. P., Cherian, A. V., Girimaji, S. C., . . . Chaturvedi, S. K. (2013). Gender
differences in the psychological impact of tsunami. International Journal of Social Psychiatry, 59, 130–136. http://
dx.doi.org/10.1177/0020764011423469

Watson, P., & Hamblen, J. (2017). Assisting individuals and communities after natural disasters and community
traumas. In S. N. Gold (Ed.), APA handbook of trauma psychology: Foundations in knowledge (pp. 87–97). American
Psychological Association. https://doi.org/10.1037/0000019-005

West, J. C., Benedek, D. M., Hamaoka, D. A., & Ursano, R. J. (2015). Managing psychological consequences in disaster
populations. In A. Tasman, J. Kay, J. A. Lieberman, M. B. First, & M. B. Riba (Eds.), Psychiatry (4th ed., pp. 2521–2532).
http://dx.doi.org/10.1002/9781118753378.ch127

32
2
CHAPTER 2

Trauma
responses in
disasters
 The manner in which disaster affects a person is
1 mediated by their prior experiences and coping
strategies. It is also influenced by the help and support
REACTIONS TO that is offered to them in the aftermath of the disaster
DISASTERS and the response of the larger community towards them.
People who have survived disasters may react to the
traumatic experience with exhaustion and confusion
or feeling sad, anxious, agitated, numb, spaced out, or
constantly on alert. These responses can be considered
normal, socially acceptable and even helpful for them.
They may resolve on their own without any long-term
repercussions. More severe indicators include prolonged
and unremitting distress without any intervening period
of calm, feeling as if they are not present in the moment,
and intense and intrusive recollections of the disaster
situation despite being safe. This may necessitate the
intervention of mental health professionals. Sometimes,
people show more severe but delayed responses to the
disaster. They may persistently be fatigued, experience
sleep related difficulties, nightmares, fear that the
disaster may reoccur, low mood and avoidance of
trauma-related emotions, sensations or associations. A
trauma-focused intervention is needed in this situation.

These reactions are summarized in

the picture below:

THE CONTINUUM OF STRESS AND TRAUMA

EUSTRESS
CULTURAL
NORMS
PHISIOLOGY DISTRESS
TEMPERAMENT

THE
ACUTE
LIFE TRAUMATIC
Something EXPERIENCE
IS FILTERED
CIRCUMSTANCE RESPONSE RESPONSE
Happens THROUGH:
RESILIENCY &
VULNERABILITY DELAYED
FACTORS
TRAUMATIC
SOCIETAL RESPONSE
RESPONSE

PRIOR LIFE CHRONIC

EXPERIENCES TRAUMATIC
RESPONSE

CHAPTER 2: TRAUMA RESPONSES IN DISASTERS 34

 It is important to note that even though some traumas
are experienced collectively by a community, people may
have their own unique responses to disasters. Traumatic
experiences typically feel surreal for the people who
experience them and can bring about significant
disorientation and disconnection from activities of daily
life. Those who survive trauma struggle to feel like a part
of their worlds and worry that others might not fully
understand their unique experiences. This can bring on
a sense of shame towards their own feelings, thoughts,
and reactions (SAMHSA, 2014).

2
There are certain common responses that occur
REACTIONS TO following single, multiple or enduring traumatic events.
DISASTERS These reactions are considered to be normal but
distressing to the person experiencing them. These are
not considered indicative of mental health conditions or
a disorder. They can be categorised under the following
domains:

Emotional Physical Cognitive

Behavioral Social Developmental

CHAPTER 2: TRAUMA RESPONSES IN DISASTERS 35

 2.1 EMOTIONAL

Traumatic experiences elicit a wide variety of emotional

reactions within an individual. The post trauma
emotional reactions In a disaster situation, may include
feelings of shock, disbelief, anxiety, fear, grief, anger,
resentment, guilt, shame, helplessness, hopelessness,
betrayal, depression, emotional numbness (difficulty
having feelings, including those of love and intimacy, or
taking interest and pleasure in day-to-day activities). In
the case of emotional numbing, the person’s emotions
get detached from thoughts, behaviors, and memories.
Emotional numbing may manifest as experiencing a
limited range of emotions, not showing any emotional
response to an emotion evoking situation or even
distancing themselves from expressing any emotions
when recounting emotionally charged memories.

The skill to identify, label and manage emotions is called

emotion regulation. This skill may get compromised in
a disaster situation. Clients may not have the vocabulary
to talk about emotions or they may be afraid that talking
about them makes them worse or more dangerous.
They may also be experiencing a lack of emotions as
they may feel a sense of numbness. Traumatic events
may lead to two extreme emotional reactions, that is,
feeling too much (overwhelmed) or feeling too little
(numb) emotion. In these states, it is difficult to manage
emotions. The degree to which the skill of emotion
regulation is compromised depends on the severity and
the duration of the event as well as the age at which
a person experiences it. They may experience and
express these emotions more intensely. For example,
research shows that when the traumatic event occurs in
childhood, it is more difficult to regulate emotions such
as anger, anxiety, sadness, and shame as compared to
when the event happens later in life (van der Kolk, et al,
1993). This may lead to heightened emotional distress for
the individual.

CHAPTER 2: TRAUMA RESPONSES IN DISASTERS 36

 Reflective Exercise

Mr. A and Mr. R were both at home when the fire broke out in their building.
They got out of the burning building along with their families in time with
limited injuries. After two weeks, they received a call from the reverse helpline
assessing their mental health.

Mr. A. reported that he has seen that he gets agitated very quickly. He is
constantly plagued with the memories of the fire and feels as if he is on the
edge. At that time, if someone says anything to him which he disagrees with, he
starts shouting uncontrollably. His family remarks that it has become impossible
to speak to him. He sounds very agitated as he narrates this and says loudly, “Do
you think I am overreacting?”

Mr. R reported that he is doing fine and has seen no change in himself. When
asked how he felt about the entire incident, he replied in a monotonous tone,
“what is there to feel? It is done now. I don’t feel anything about it.” When asked
about if he wanted to speak further about how he was feeling now, he replied
that there was no use feeling about things.

If you were the counsellor on the reverse helpline, how would you respond to Mr.
A? What about Mr. R? Is there any difference in the way you respond to them? If
yes, what do you think could be the reason?

2.2 PHYSICAL

Many clients may experience physical and physiological

responses to traumatic events. Examples of these
responses include somatic complaints; sleep
disturbances; gastrointestinal, cardiovascular,
neurological, musculoskeletal, respiratory, and
dermatological disorders; urological problems; and
substance use disorders. Many of them may not even
consider these as responses to trauma and may not
discuss these with their mental health professionals. It
may then fall on us as counsellors to enquire about these
concerns.

In case of a disaster, the physical (bodily) reactions

commonly associated are tension, fatigue, edginess,
being startled easily, racing heartbeat, nausea, aches and

CHAPTER 2: TRAUMA RESPONSES IN DISASTERS 37

 pains, worsening health conditions, change in appetite
and change in sex drive. These changes often result in a
state of hyperarousal (or hypervigilance). Hyperarousal
may lead to perceiving and reacting to safe situations as
if they were threatening. A consequence of hyperarousal
is sleep disturbances characterised as early awakening,
restless sleep, difficulty falling asleep, and nightmares.

Some people may express their emotional distress

through bodily symptoms or dysfunctions. However
they may not be aware of this connection between
the physical and emotional distress. This is especially
common in cultures in which emotional expression of
distress is not encouraged. People in these cultures
may focus on bodily complaints as a means of avoiding
emotional experiences. Somatization may present as
medically unexplained aches and pains, nausea, fatigue,
blurred visions, shortness of breath and palpitations
(APA, 2015).

Reflective Exercise

In the Indian context, it is seen that often there is no dichotomy between mind
and body. Hence people are able to express their somatic concerns without
prompting whereas psychological distress is expressed only after the doctor
prompts (Raguram et al, 2001). How do you think this affects the way clients
who have gone through disasters express their psychological concerns? What
could be the possible somatic concerns that we may be on the lookout for when
looking for signs of trauma?

2.3 COGNITIVE

Cognitions are affected and altered by traumatic

experiences. Trauma challenges the core assumptions
which many of us use to navigate daily life (Janoff-
Bulman, 1992). Our belief that our efforts and intentions
are enough to protect us from bad things helps us
traverse life. For example, a person who feels confident
while swimming may enjoy the experience. But if
during one of the swims, the person gets close to a
CHAPTER 2: TRAUMA RESPONSES IN DISASTERS 38
 site of a flood, they may feel unsafe in any situation
where they have to be near a water body. Hence, an
enjoyable experience becomes an experience where
they have to constantly be vigilant (state of hyperarousal
is a physical state described previously). Cognitive
reactions which are common during disasters include
confusion, disorientation (not knowing the time or date),
indecisiveness (inability to decide or follow-through
with decisions), worry, shortened attention span,
difficulty concentrating, memory loss, unwanted
memories (of the disaster), repeated imagery (of the
disaster situation) and self-blame (feeling that the person
could have done something to prevent the disaster or
coped better with it).

Trauma may alter three main cognitive patterns:

thoughts about self, the world (others/environment),
and the future (Ehlers & Clark, 2000). After an individual
experiences a traumatic event such as a disaster, they
may start viewing themselves as incompetent or
damaged, viewing others and the world as unsafe and
unpredictable, and seeing the future as hopeless, that is,
they or the situation will never get better. Subsequently,
these cognitions drive the clients’ sense of efficacy
in their ability to use internal resources and external
support.

2.4 BEHAVIORAL

People may start engaging in uncharacteristic

behaviors in order to manage the aftereffects of disaster
People may reduce their stress through avoiding,
self-medicating (e.g., alcohol abuse), compulsive (e.g.,
overeating), impulsive (e.g.,high-risk behaviors), and/
or self-injurious behaviors. One of the most common
behavioural responses is avoidance against anxiety.
Individuals begin to avoid people, places, or situations
to alleviate unpleasant emotions, memories, or
circumstances related to the disaster. For example, the
person may avoid driving to a part of the town where
they were housed following the fire. Initially, it may work
to decrease anxiety, but over time, anxiety increases
and this leads to more avoidance. It reinforces perceived
danger in such a way that the person hesitates to
test the danger’s validity and may in fact extend this

CHAPTER 2: TRAUMA RESPONSES IN DISASTERS 39

 perception of danger to other aspects of life as well.
Children may try to gain control over their experiences
by being aggressive or reenacting aspects of the event.
For example, a child who was rescued from the rubble
after an earthquake may reenact the situation in play by
running and hiding under the table and trembling till an
adult comes to them. This may be an attempt to create a
sense of mastery for the child.

2.5 SOCIAL/INTERPERSONAL

Common interpersonal responses to disaster include

feeling like the person needs to depend on others and
cannot do anything by themselves, not being able
to trust others, irritability in interactions with others,
increased conflict, withdrawal and isolation from loved
ones, feeling rejected or abandoned by them, being
distant, judgmental, or over-controlling in friendships,
marriages, family, or other relationships. Significant
others may get affected by a loved ones’ traumatic
experience either through secondary traumatization or
by directly experiencing the survivor’s stress reactions.
In natural disasters, social and community support get
severely disrupted. Social support and relationships
can be protective factors against traumatic stress as
survivors may rely on them. However, when people who
go through disasters avoid social support, it can have
detrimental effects . Survivors may avoid social support
because of many reasons such a belief that people are no
longer understanding or trustworthy or they may think
that they have become a burden to others or that they
may feel ashamed of their stress reactions.

2.6 DEVELOPMENTAL

Each age group is vulnerable in unique ways to the

stresses of a traumatic event, with children and the
elderly at greatest risk. Young children may show
symptoms such as generalized fear, nightmares,
heightened arousal and confusion, and physical
symptoms, (e.g., stomach aches, headaches). Older,
school-going children may display symptoms such as
aggressive behavior and anger, regression to behavior

CHAPTER 2: TRAUMA RESPONSES IN DISASTERS 40

 seen at younger ages, repetition of traumatic events in
play, reduced ability to concentrate, and deteriorating
school performance. Adolescents may display more
depressive features and social withdrawal, rebellion,
increased risky activities, and sleep and eating
disturbances (Hamblen, 2001). Adults may display sleep
problems, increased agitation, hypervigilance, isolation
or withdrawal, and increased use of substances. Older
adults may exhibit increased withdrawal and isolation,
reluctance to leave home, worsening of chronic illnesses,
confusion, depression, and fear (DeWolfe & Nordboe,
2000).

2.6.1 TRAUMA IN CHILDREN

The experience of traumatic events and expression

of distress depends on the child’s age and level of
development. For example when preschool-age children
are exposed to disasters, they may have feelings of
helplessness, uncertainty about the future and a general
sense of being afraid. They may have difficulty verbally
describing their fears and emotions but present with
a loss of previously acquired developmental skills such
as sleeping independently, speech and toilet training.
Children may also engage in traumatic play, that is,
representing the traumatic event in play, by repeating
it in an attempt to change its negative outcome. When
school-age children are exposed to disasters, they may
experience persistent fears of their own and others’
safety. They may experience guilt or shame about their
actions during the event and may feel overwhelmed by
fear or sadness. They may also experience sleep-related
difficulties such as fear of sleeping alone, or frequent
nightmares. This may affect their concentration and
learning and consequently their academic performance.
There may be some somatic concerns such as headaches
and stomach aches and behavioural concerns such
as increased aggression. Adolescents who have been
exposed to a traumatic event may feel concerned about
their emotional responses such as fear, vulnerability and
may label these as “abnormal”. They may also compare
their responses to their peers and may withdraw from
their family and friends. They may also experience
feelings of shame and guilt and express fantasies about
revenge and retribution. This may foster a radical shift in
their perception of the world and themselves. Increased
aggression towards self and others may be a common
response of adolescents. Some common experiences of

CHAPTER 2: TRAUMA RESPONSES IN DISASTERS 41

 children are shown in the table below (Recognizing and
Treating Child Traumatic Stress, 2023).

Age of the child Possible responses

Preschool Children • Fearing separation from parents or caregivers

• Crying and/or screaming a lot
• Eating poorly and losing weight
• Having nightmares

Elementary School • Becoming anxious or fearful

Children • Feeling guilt or shame
• Having a hard time concentrating
• Having difficulty sleeping

Middle and High School • Feeling depressed or alone

Children • Developing eating disorders and self-harming
behaviors
• Beginning to abuse alcohol or drugs
• Becoming sexually active

Practice Exercise

For each of the domains mentioned above, some sample questions are given
below. We can role play and adapt these to our own native tongue and consider
using them to elicit reactions to trauma. We can also think of other questions to
ask.

Emotions: Ever since the disaster occurred, do you feel that your emotions are
all over the place? Do you feel that it is difficult for you to control them? Do they
feel more intense? Do you feel that you are not able to feel emotions fully? Do
you feel like you do not experience any emotions?

Physical: Have you been experiencing aches and pains in your body? Shortness
of breath? Have they started after the traumatic event? Have you shown it to
the doctor? What did they say? [as the absence of a physical cause of pain is an
important consideration for understanding the reaction as somatization]. How is
your sleep? Are you able to sleep at the same time as you used to earlier? Is your
sleep interrupted? How do you feel after waking up? Do you feel like you are
constantly on alert? Are you finding it difficult to relax?

CHAPTER 2: TRAUMA RESPONSES IN DISASTERS 42

 Cognitive: Has the traumatic event led to a change in the way you see yourself?
In the way you see the world? What are your views about the future?

Behavioural: Have you noticed any changes in your behaviours? Any change
in consumption of substances? Any change in your eating patterns? Any
behaviour which you would usually not do? Is there any risk for harm? Have you
been avoiding any person? Any place? Any situation?

Social/Interpersonal: How have your friendships been impacted after the

traumatic events? How is your relationship with your family members?

3
SUB-THRESHOLD Even when clients are doing well and showing minimal
distress, they may show subclinical symptoms or
TRAUMA-RELATED symptoms that do not meet the diagnostic criteria for
SYMPTOMS a disorder (SAMHSA, 2014). These symptoms tend to
limit their ability to function normally such as regulating
emotions, maintaining and engaging in social and family
relationships, working steadily, taking care of the needs
of their bodies to name a few. It is possible that these
symptoms may be transient and come into play only
when triggered. Such sub-threshold symptoms may
appear intermittently for a few weeks or months and
recede on their own.

4
TRAUMA-RELATED As mentioned previously, some people may experience
more severe and long-lasting and disabling effects.
PSYCHOLOGICAL Care must be taken that we consider diagnosing a
DISORDERS mental health concern only after the criteria for these
have been met. Normal reactions to disasters should
not be pathologised (APA, 2008). Post-traumatic
Stress Disorder and Acute Stress Disorder are the most
common diagnoses associated with trauma. Some other
commonly associated mental health concerns include
substance use disorders, mood disorders, various anxiety
disorders, and personality disorders. For individuals with
a predisposition for mental health concerns, a traumatic
event may precipitate onset or exacerbate symptoms of
pre-existing disorders.

CHAPTER 2: TRAUMA RESPONSES IN DISASTERS 43

 4.1 ACUTE STRESS DISORDER (ASD)

ASD represents symptoms of stress which develop within

4 weeks of the occurrence of a traumatic event. However,
it is not a precursor for PTSD as many individuals with
ASD do not go on to develop further impairment. It is
more commonly associated with the experience of one
specific traumatic experience rather than long-term
exposure to chronic traumatic stress. An individual with
Acute Stress Disorder appears overwhelmed by the
traumatic experience; there is a preoccupation with the
experience and a need to talk about the event over and
over again They may insist on describing in repetitive
details about what happened, and may seem like they
are constantly trying to make sense of the traumatic
experience. They may also not be able to remember the
details of the traumatic events and hence repeatedly ask
questions to fill in the gaps in their memory. Persons
experiencing ASD may seek assurance from others that
they could not have prevented the event. Hypervigilance
is increased and the person may constantly try to avoid
reminders of the event. For instance, a person who was in
a train accident may feel anxious if they hear the sound
of a train. Symptoms associated with ASD tend to be
less severe and transient and resolve about a month
after the event. If the symptoms persist after 4 weeks,
the diagnosis is changed to PTSD. If early intervention is
carried out for ASD, it is possible that the individuals may
not develop PTSD or other mental health concerns later.

There are very few well-established and empirically-

validated measures to assess ASD (Byrant et al, 2016).
The Acute Stress Disorder Structured Interview (Byrant
et al, 2016 for review on updating as per DSM-5) and the
Acute Stress Disorder Scale (Byrant et al, 2016 for review
on updating as per DSM-5) are available for assessment
but these require training. One of the freely available
measures for ASD is National Stressful Events Survey
Acute Stress Disorder Short Scale (NSESASDSS). It is
available on the following link: https://www.psychiatry.
org/File%20Library/Psychiatrists/Practice/DSM/APA_
DSM5_Severity-of-Acute-Stress-Symptoms-Adult.pdf.
The Child Stress Reaction Checklist (CSRC), can be used
for children 2 to 18 years old (Saxe et al., 2003).

4.2 POSTTRAUMATIC STRESS DISORDER

The most commonly diagnosed and researched trauma-

related disorder is PTSD. PTSD symptoms are seen in
CHAPTER 2: TRAUMA RESPONSES IN DISASTERS 44
 a number of other mental health concerns , including
major depressive disorder (MDD), anxiety disorders, and
psychotic disorders (Foa et al., 2006).

According to DSM-5 (APA, 2013), there are four symptom

clusters for PTSD: presence of intrusion symptoms,
persistent avoidance of stimuli, negative alterations
in cognitions and mood, and marked alterations in
arousal and reactivity. These reactions occur in response
to exposure to actual or threatened death, serious
injury, or sexual violence, produce significant distress
and persist for more than 4 weeks. These symptoms
usually appear within 3 months of a traumatic event,
though they may remain dormant for months or years
after the event. It is possible that these symptoms
appear suddenly especially when triggered by external
events. For example, a child who was sexually abused
may get triggered years later when they see a movie
about the same theme. Similarly, anniversaries of the
traumatic event may trigger these responses. Personal
characteristics, social support, and the environment’s
response to aftermath of traumatic events influence the
presence of PTSD (Brewin, et al, 2000).These symptoms
are similar to the ones listed under Acute Stress Disorder
and similar questions can be asked to elicit these.

Experiences of multiple traumas, prolonged and

repeated trauma during childhood, or repetitive trauma
in the context of significant interpersonal relationships
can lead to a unique constellation of reactions, called
complex traumatic stress (Herman, 1992). Often, these
reactions tend to be more severe than the symptoms of
PTSD but may not match the criteria for it. Culture also
plays an important role in this context. While PTSD is
observed across different cultures (Osterman & de Jong,
2007), it may manifest differently . Culture may affect the
presence of somatic and psychological symptoms and
beliefs people hold about the cause of traumatic events.
Certain religious and spiritual beliefs can also affect the
way in which distress is experienced and reported. For
example, in societies where disasters are considered acts
of God, it is difficult to be angry about the situation.

Interview instruments used to assess PTSD include the

Clinician Administered PTSD Scale for DSM-5 (CAPS-5;
Weathers et al., 2013a), PTSD Symptom Scale - Interview
for DSM-5 (PSS-I-5; Foa, et al., 2016a), Structured Interview
for PTSD (SI-PTSD; Davidson et al., 1990) for adults. Some

CHAPTER 2: TRAUMA RESPONSES IN DISASTERS 45

 self-report measures include PTSD Checklist for DSM-
5 (Weathers et al., 2013b), Posttraumatic Diagnostic
Scale (PDS-5; Foa, et al., 2016b) for adults. For children,
Clinician-Administered PTSD Scale for DSM-5 - Child/
Adolescent Version (CAPS-CA-5; Pynoos et al., 2015) can
be used.

5
OTHER CO- There is a considerable overlap between symptoms of
PTSD and other mental health concerns such as mood
OCCURRING and anxiety disorders, substance use, and personality
DISORDERS disorders. Some of these are listed below.

5.1 MOOD AND ANXIETY RELATED DISORDERS

Major Depressive Disorder is the most common co-

occurring disorder in people with histories of trauma
(SAMHSA, 2014). Research has indicated a causal
relationship between stressful events and depression,
such that prior history of MDD predicts the occurrence
of PTSD after trauma exposure (Foa et al., 2006). This
may lead to greater impairment, more severe symptoms
and less likelihood of remission of symptoms. PTSD and
anxiety disorders share a bidirectional relationship such
that PTSD may exacerbate symptoms of anxiety disorder
and the pre-existing anxiety symptoms may increase
vulnerability to PTSD. Pre-existing anxiety may lead to an
increased likelihood of experiencing hyperarousal-related
symptoms.*

5.2 PEOPLE WITH SUBSTANCE USE DISORDERS

Research has indicated a correlation between trauma

and substance use as well as the presence of PTSD and
substance use disorders (SAMHSA, 2014). Substances
are often used to manage traumatic stress and specific
PTSD symptoms. Sleep disturbances are a common
symptom in PTSD and substances are used to manage
this symptom. The relationship between PTSD and
substance use disorders is thought to be bidirectional
and cyclical: substance use increases the risk for trauma,
and exposure to trauma initiates or escalates substance

* Questions to elicit anxiety and low mood have been mentioned in Section
3; chapters 3 and 4 respectively.

CHAPTER 2: TRAUMA RESPONSES IN DISASTERS 46

 use to manage trauma-related symptoms. Managing
PTSD symptoms thus is an important goal in substance
use treatment.

In order to elicit substance use we may ask questions

regarding the kind of alcohol or drugs that people are
consuming, number of times in a day they consume the
substance and how they are affected by its consumption.
A common questionnaire for asking about substances
is the CAGE questionnaire (Ewing, 1984). The CAGE
acronym represents keywords present in each question.
It stands for: Cut, Annoyed, Guilty and Eye.

The questions represented by the CAGE acronym are:‌

• Have you ever felt you should “cut” down on your

substance use?
• Have people “annoyed” you by criticizing your
substance use?
• Have you felt bad or “guilty” about your substance
use?
• Have you ever used a substance first thing in the
morning to steady your nerves or start the day (an
“eye” opener)?

If the answer is yes to 2 or more questions, the likelihood

of substance abuse is high.

6
POST-TRAUMATIC People who have undergone stressful or traumatic
events also report experiencing the events as ‘catalysts’
GROWTH for positive psychological change (Tedeschi & Calhoun,
2004). This phenomenon is known as Post-Traumatic
Growth (PTG; Tedeschi & Calhoun, 2004) and is
known to be associated with enhanced interpersonal
relationships, newer possibilities for a fulfilling life,
increased appreciation for life and personal strength
and opportunities for spiritual development. It is
important to note that PTG is not a linear journey where
the pain of the traumatic event is forgotten. Rather, it
can be understood as an experience of growth where
the capacity to hold what is lost, co-exists with an
appreciation of what is gained, bringing forth a deeper
connection with life. (Tedechi et al, 2014).

The process of PTG involves engaging with the traumatic

events by making attempts to understand why this

CHAPTER 2: TRAUMA RESPONSES IN DISASTERS 47

 event happened and what it means for the person. This
engagement is termed as cognitive processing and is
associated with higher levels of PTG (Tedeschi et al, 2014).
This cognitive processing takes place through a process
of slow and intentional inquiry about the traumatic
event. It is fostered by sharing or disclosing the internal
experience in a safe and supportive environment
(Tedeschi et al, 2014). Thus, sharing negative emotions
in presence of safe social support promotes PTG
(Saltzman, et al, 2018). Positive coping strategies foster
positive appraisal of the traumatic event by promoting
belief in our ability to adapt to the situation and help
find meaning (Henson et al, 2020). Another important
mediator for growth is spirituality (Tsai & Pietrzak, 2017).
Spirituality promotes meaning-making and increased
sense of belongingness (Prati & Pietrantoni, 2009).
Reappraising the negative event by construing it in a
positive way generates positive changes (Henson et al,
2020). Reappraising the event as a challenge and finding
gratitude in being able to survive it may also foster PTG
(Tsai & Pietrzak, 2017). Research evidence shows that
personality traits such as Agreeableness, altruism (Tsai
et al., 2016), Extraversion, Openness (Mattson et al., 2018)
and Conscientiousness (Owens, 2016) have been found
to be positively correlated to growth. Having hope (Yuen
et al, 2014) and a sense of purpose (Reker, 2000) also
predicts PTG.

The most commonly used measure for assessing

PTG is the Post-Traumatic Growth Inventory (PTGI;
Tedeschi & Calhoun, 1996). It is a self-report inventory
to retrospectively assess the growth that a person
perceives. It consists of 21 items which assess domains of
New Possibilities, Relating to Others, Personal Strength,
Spiritual Change, and Appreciation of Life (Tedeschi &
Calhoun, 1996). However, it is not a freely available tool.

7
SALUTOGENESIS Salutogenesis refers to focusing on human health
and well-being and not just on the disease model
(Antonovsky 1979). In difficult circumstances such
as disasters, salutogenesis is especially important
in understanding and promoting well-being of
the community. Sense of coherence, an important
component of salutogenesis, is associated with helping
individuals and communities navigate the challenges
of disasters (Antonovsy, 1980). Sense of coherence is
CHAPTER 2: TRAUMA RESPONSES IN DISASTERS 48
 the ability of a person to see life as comprehensible,
manageable and meaningful. Comprehensibility refers
to the ability to understand the challenges that disaster
brought to their life e.g. what caused the disaster and
how it affects the daily life of those who have gone
through the disaster. Manageability refers to the belief
that a person has the resources to deal with the disaster.
This includes having access to resources such as food,
shelter, social support and personal coping skills.
Meaningfulness is the belief that there is purpose to life
and that it is important to overcome the challenges that
disaster has brought in the lives of people impacted by it.
Disasters may be seen as precursors for personal growth
and community solidarity and also promote future
preparedness (Eriksson & Lindström, 2006).
For example, when the earthquake hit Nepal, a
salutogenic approach yielded a community focused
approach to managing the disaster (Omer & Fajardo,
2017; Taludhar et al., 2015). In order to promote
comprehensibility, various educational programs helped
people understand the causes of the earthquake,
the expected aftershocks, and how to stay safe which
reduced fear and confusion. To help community
members increase a sense of manageability, relief efforts
focused on providing resources like temporary housing,
food supplies, and access to medical care. Community-
based initiatives empowered locals to participate in
rebuilding efforts, which increased their sense of control.
And lastly, to promote meaningfulness, community
rituals and ceremonies were organized to honor lost
lives and celebrate the survivors. This helped people find
meaning and collective purpose in the recovery process.
Thus, salutogenesis helped foster resilience and a sense
of solidarity among the community members.

Reflective Exercise

Post-traumatic growth is an important construct in understanding the

experience of trauma holistically. As a mental health professional, it is imperative
for us to understand our conceptions of PTG. We can wonder

• How can we identify PTG in our clients?

• What are the factors associated with PTG in our clients’ narratives?
• What can be the consequences of enhancing PTG among our clients?

CHAPTER 2: TRAUMA RESPONSES IN DISASTERS 49

 Let’s avoid...

Pathologising the normal responses of people after encountering trauma.

It is important to remember that responses to trauma may be normal, socially
acceptable and even helpful to the survivors.

Using a one-fit all approach in understanding the trauma responses. An

individual’s response to trauma is varied and needs to be contextualised in the
experiences, coping strategies and the support offered to them by the external
environment. It is also influenced by the developmental stage of the client.

Believing that trauma responses manifest as only emotional dysregulation.

Trauma responses manifest in various ways including emotional dysregulation
but also manifests as numbing, different cognitions, behaviours, and social and
interpersonal relationships.

Being unaware of the various trauma-related disorders. Trauma responses

may manifest as acute stress disorder, post-traumatic stress disorder, mood
and anxiety disorders, substance use disorders to name a few. Identifying
and eliciting trauma history may help us make distinctions amongst these
categories.

Ignoring narratives of post-traumatic growth in our clients. Post-trauma

phenomenology is replete with stories of distress and growth. It is imperative for
us as mental health professionals to see our clients as people with these varied
experiences and not box them into categories of distress. We need to identify,
acknowledge, nurture and honour narratives of growth.

Forcing narratives of post-traumatic growth onto our clients. At the same

time, we have to be careful that we do not force these narratives onto clients
who may not be ready or willing to engage in this context as this forceful way
may be perceived as invalidation of the clients’ experiences as well as their
agency. Let the clients discover their own meanings of their experiences.

CHAPTER 2: TRAUMA RESPONSES IN DISASTERS 50

 Self-care Exercise

It is imperative to conduct an assessment about ourselves to identify our own

concerns. Some questions that we may ask ourselves help us in doing trauma-
informed work include (Meichenbaum, 2007):

• Self-check-ins: These include questions about how we are doing, what we

need and what would we like to change. We can also ask how we take care of
ourselves, who our social support networks are and how we respond to their
support.

• Check-in about work: Questions such as what is the hardest thing about
work or what worries us about it, what are our specific goals for the clients
and how successful are we in accomplishing them can help us in checking in
with our work.

• Check-in about self at work: Questions such as how have we changed since
we began working, do we like these changes and if not what can we do
about it can help understand us in context of work. We can even ask what is
our sense of accomplishment at work, how we can ensure that my sense of
satisfaction in work persists and how we communicate about our concerns,
feelings and rewards of our work to others.

Tips for Supervisors

This chapter helps us in identifying the concerns of the clients. One important
consideration that we can look out for is identifying concerns of the supervisees.
It is possible that in supervision, a parallel process may be unfolding. Parallel
process refers to the process in which the dynamic of the supervisee and
supervisor reflects the dynamic between the counsellor (that is the supervisee
in this context) and the client (Searles, 1955).

Some signs and indicators that may help us in identifying parallel process
includes:

• Mirroring Interactions: Noticing if the supervisee’s behaviors, emotions, or

attitudes towards the supervisor reflect their client’s behaviors, emotions, or
attitudes towards them.

CHAPTER 2: TRAUMA RESPONSES IN DISASTERS 51

 • Emotional Resonance: Paying attention to the emotional climate in the
supervision session. Similar emotional patterns might emerge in both the
supervision and MHPSS sessions.

• Similar Themes or Conflicts: Identifying recurring themes or conflicts that

appear both in the sessions and the supervision.

• Observation: Analyzing the communication styles and patterns. If there is

a noticeable similarity in how the supervisee and their client communicate
compared to how the supervisee communicates with the supervisor, this
might indicate a parallel process.

We can use techniques such as reflective listening, exploration of feelings,

creating a visual or conceptual map of the dynamics between the client and the
supervisee and then compare it to the dynamics between the supervisee and
the supervisor and role-playing to help identify parallel processes.

This chapter describes the trauma-related concerns that occur in the disaster context.
The next chapter will focus on basic concepts that are required to understand trauma-
informed therapy.

CHAPTER 2: TRAUMA RESPONSES IN DISASTERS 52

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed.). Arlington,
VA: American Psychiatric Association.

American Psychological Association. (2015). APA Dictionary of Psychology (2nd ed.)

Antonovsky, A. (1979). Health, stress, and coping. San Francisco, CA: Jossey-Bass.

Brewin, C. R., Andrews, B., & Valentine, J. D. (2000). Meta-analysis of risk factors for post traumatic stress disorder in
trauma-exposed adults. Journal of Consulting and Clinical Psychology, 68, 748–766.

Bryant, R. A. (2016). Acute stress disorder: What it is and how to treat it. New York, NY: The Guilford Press.

Davidson, J. R. T., Kudler, H. S., & Smith, R. D. (1990). Assessment and pharmacotherapy of posttraumatic stress
disorder. In J. E.L. Giller (Ed.), Biological assessment and treatment of posttraumatic stress disorder (pp. 205-221).
Washington, DC: American Psychiatric Press.

DeWolfe, D. J. (2000). Training manual: For mental health and human service workers in major disasters (Rep. No.
ADM 90-538). Rockville, MD: Substance Abuse and Mental HealthServices Administration.

Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy,
38(4), 319-345. https://doi.org/10.1016/S0005-7967(99)00123-0

Eriksson, M., & Lindström, B. (2006). Antonovsky’s sense of coherence scale and the relation with health: A systematic
review. Journal of Epidemiology and Community Health, 60(5), 376-381. https://doi.org/10.1136/jech.2005.041616

Ewing, J. A. (1984). Detecting alcoholism: the CAGE questionnaire. Jama, 252(14), 1905-1907.

Falender, C. A., & Shafranske, E. P. (2008). Best practices of supervision. In C. A. Falender & E. P. Shafranske (Eds.),
Casebook for clinical supervision: A competency-based approach (pp. 3–15). American Psychological Association.
https://doi.org/10.1037/11792-001

Foa, E. B., McLean, C. P., Zang, Y., Zhong, J., Powers, M. B., Kauffman, B. Y., ... Knowles, K. (2016b). Psychometric
properties of the Posttraumatic Diagnostic Scale for DSM-5 (PDS-5). Psychological Assessment, 28, 1166-1171.
doi:10.1037/pas0000258

Foa, E. B., McLean, C. P., Zang, Y., Zong, J., Rauch, S., Porter, K., ...& Kauffman, B. (2016a). Psychometric properties of
the Posttraumatic Stress Disorder Symptoms Scale Interview for DSM-5 (PSSI-5). Psychological Assessment, 28, 1159-
1165. doi:10.1037/pas0000259

Foa, E. B., Stein, D. J., & McFarlane, A. C. (2006). Symptomatology and psychopathology ofmental health problems
after disaster. Journal of Clinical Psychiatry, 67 Supplement 2, 15–25.

Hamblen, J. (2001). PTSD in children and adolescents, a National Center for PTSD fact sheet. Washington, DC:
National Center for PTSD.

Herman, J. L. (1992). Trauma and recovery. New York: Basic Books

Janoff-Bulman, R. (1992). Shattered assumptions: Towards a new psychology of trauma. New York: Free Press.

Khantzian, E. J. (1985). The self-medication hypothesis of addictive disorders: focus on heroinand cocaine
dependence. American Journal of Psychiatry, 142, 1259–1264.

Malta, L. S., Levitt, J. T., Martin, A., Davis, L., & Cloitre, M. (2009). Correlates of functionalimpairment in treatment-
seeking survivors of mass terrorism. Behavior Therapy, 40, 39–49.

Meichenbaum, D. (2007, May). Self-care for trauma psychotherapists and caregivers: Individual, social and
organizational interventions. In 11th Annual Conference of the Melissa Institute for Violence Prevention and
Treatment of Victims of Violence, Miami, FL. Retrieved from http://www.melissainstitute.org/documents/
Meichenbaum_SelfCare_11thconf.pdf.

Osterman, J. E. & de Jong, J. T. V. M. (2007). Cultural issues and trauma. In M. J. Friedman, T. M.Keane, & P. A. Resick
(Eds.), Handbook of PTSD: Science and practice (pp. 425–446). Guilford Press: New York

53
Pynoos, R. S., Weathers, F. W., Steinberg, A. M., Marx, B. P., Layne, C. M., Kaloupek, D. G., Schnurr, P. P., Keane, T. M.,
Blake, D. D., Newman, E., Nader, K. O., & Kriegler, J. A. (2015). Clinician-Administered PTSD Scale for DSM-5 - Child/
Adolescent Version. [Assessment] Available from the National Center for PTSD at www.ptsd.va.gov.

Recognizing and Treating Child Traumatic Stress. (2023, October 3). SAMHSA. https://www.samhsa.gov/child-trauma/
recognizing-and-treating-child-traumatic-stress#signs

Saxe G, Chawla N, Stoddard F, Kassam-Adams N, Courtney D, Cunningham K, Lopez C, Hall E, Sheridan R, King D,
King L. Child Stress Disorders Checklist: a measure of ASD and PTSD in children. J Am Acad Child Adolesc Psychiatry.
2003 Aug;42(8):972-8.

Searles, H. F. (1955). The informational value of the supervisor’s emotional experience. Psychiatry, 18(2), 135-146.

Substance Abuse and Mental Health Services Administration. Trauma-Informed Care in Behavioral Health Services.
Treatment Improvement Protocol (TIP) Series 57. HHS PublicationNo. (SMA) 13-4801. Rockville, MD: Substance Abuse
and Mental Health Services Administration, 2014.

Tuladhar, G., Yatabe, R., Dahal, R. K., & Bhandary, N. P. (2015). Disaster risk reduction knowledge of local people in
Nepal. Geoenvironmental Disasters, 2(5). https://doi.org/10.1186/s40677-014-0011-4

van der Kolk, B., Roth, S., Pelcovitz, D., & Mandel, F. (1993). Complex PTSD: Results of the PTSD field trials for DSM-IV.
Washington, DC: American Psychiatric Association.

Weathers, F.W., Blake, D.D., Schnurr, P.P., Kaloupek, D.G., Marx, B.P., & Keane, T.M. (2013b). The Clinician-Administered
PTSD Scale for DSM-5 (CAPS-5). [Assessment] Available from www.ptsd.va.gov.

Weathers, F.W., Litz, B.T., Keane, T.M., Palmieri, P.A., Marx, B.P., & Schnurr, P.P. (2013a). The PTSD Checklist for DSM-5
(PCL-5). [Assessment] Available from www.ptsd.va.gov.

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3
CHAPTER 3

Trauma-informed
Mental health
and Psychosocial
support (MHPSS)
in disasters
 The brain is one of the most complex organs in the
1 human body. In order to understand the various
functions it performs, it is important to be able to
AN visualise the major parts of the brain. The triune model
INTRODUCTION TO by Dr. Paul McLean (1998) is a simplified example. In this
model, the brain is conceptualised to be divided into
NEUROBIOLOGY three parts:

1. REPTILIAN BRAIN: Consisting of brainstem and

cerebellum, it is responsible for functions of our body
such as regulating the heartbeat, breathing, and other
autonomic processes to ensure survival and smooth
functioning of the body. It regulates the autonomic
nervous system.

2. MAMMALIAN BRAIN: The subcortical region and

limbic system for this brain which is responsible for
emotion and memory formation allowing us to learn.

3. PRIMATE/HUMAN BRAIN: Consisting of the neocortex,

it is responsible for executive and higher cognitive
function such as regulating attention and focus,
experiencing empathy, and enabling complex
reasoning and abstract thought.

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https://www.nicabm.
com/brain-a-quick-
and-simple-way-
to-think-about-the-
brain/

CHAPTER 3: TRAUMA-INFORMED MENTAL HEALTH AND PSYCHOSOCIAL SUPPORT (MHPSS) IN DISASTERS 57

 This model can be represented as the ‘hand model of
the brain’ (Siegel, 2012) and offers us a simple way to
represent the brain in the form of a fist. The fist is formed
by tucking the thumb inside it. The wrist represents the
spinal cord, the thumb represents the limbic system and
the fingers that cover the thumb are representing the
cortices (frontal cortex particularly).
When there is no threat, these parts of the brain perform
their functions seamlessly, that is, the brainstem
regulates our heartbeat and breathing, our limbic system
is responsible for making us curious about the world
and learn about it and our prefrontal cortex allows us to
process the information around us and make sense of it.
The prefrontal cortex regulates the limbic system.
However, it is different when the brain perceives a threat.

Reflective Exercise

Neurobiology is often complicated and difficult to understand. However, a good

understanding of how the brain works can help in understanding trauma and
sharing this understanding with clients.

• We may want to see how we can make this process interesting and easy
to comprehend for ourselves. For example, we can use some memory
techniques to remember this information. This will help us in explaining
these concepts to our clients as well.

• We may also want to translate these constructs and concepts in our local
languages.

2
Trauma is a psychobiological experience; its presence in
NEUROBIOLOGY IN childhood may lead to detrimental effects even later in
TRAUMA adulthood (Cassiers et al. 2018).

When we first encounter trauma, a helpful emergency

response system built by nature to help us survive a
major threat. It is deployed immediately and does not
require thinking (it is automatic) and is carried out by
the autonomic nervous system (ANS). This part of the
nervous system controls rapid, unconscious responses
such as reflexes. This includes carrying out a series of

CHAPTER 3: TRAUMA-INFORMED MENTAL HEALTH AND PSYCHOSOCIAL SUPPORT (MHPSS) IN DISASTERS 58

 involuntary responses and physiological changes that
allow the person to handle this situation and manage the
danger. The ANS can send messages that tell the body to
prepare for danger in different ways such as:

1. TO THE BRAINSTEM: increasing breathing and heart

rate to send more oxygenated blood to the muscles
and brain, redirect blood to key areas, and keeping
them away from others such as face or salivary
glands, tensing muscles which may cause shaking
or trembling, constricted feeling in the throat, and
dilated pupils to allow more light into the eyes, which
allows someone to see better and observe their
surroundings.

2. TO THE LIMBIC SYSTEM: In efforts to ensure safety

for the future, the amygdala encodes all the sensory
information associated with the threatening event
to form implicit memory. Implicit memory includes
all the d non-verbal experiences of the memory
such as the most significant part (worst image),
conclusions/meanings made about self, others, and
world, emotions experienced in the event and body
sensations, when the event happened. The amygdala
will encode the implicit memory and anything
moving forward which seems the same or similar
(anything that brings up the worst part, cognitions,
emotions, and/or body sensations) to the original
event will trigger the same responses.

3. TO THE PREFRONTAL CORTEX: This part of the brain

supports the other parts but does not receive or
interpret new information.

This can be represented in the hand-model described

above. In this scenario, the prefrontal cortex is no longer
regulating the limbic system. Thus, the activity of the
limbic system overrules the prefrontal cortex. Or we
simply say, the lid is off.

When we are exposed to extreme threats, these short

term, adaptive responses become chronic and long
term such that even when we transition into a safe
environment, the primitive brain does not turn off. We
are stuck in the survival brain, very little information can
get passed up to the higher parts of their brain. Whilst
we are stuck here, we find it difficult to feel safe, form
secure attachments; manage emotions or behaviour,

CHAPTER 3: TRAUMA-INFORMED MENTAL HEALTH AND PSYCHOSOCIAL SUPPORT (MHPSS) IN DISASTERS 59

 think, learn or reflect because we are simply trying to
stay alive in a world that we feel is highly dangerous.
In this scenario, certain changes occur in the brain.

Predominant among these are:

1. INCREASE IN AMYGDALA ACTIVITY: The amygdala

which acts as an alarm signal for stressful events and
helps protect us from danger, becomes overactive
due to extreme exposure to trauma. This can lead to
feelings of anxiety or being in danger.

2. REDUCTION IN HIPPOCAMPAL VOLUME: The

hippocampus which assists with learning and
memory storage, also stores cues for remembering
safety and danger. When it detects safety, it helps
calm the amygdala. However, exposure to trauma can
cause the hippocampus to shrink thereby weakening
the cues to calm the amygdala which may lead to
flashbacks or confusion around the trauma memory.

3. SHRINKING OF THE PREFRONTAL CORTEX: The

prefrontal cortex which is responsible for managing
thoughts, behavior, and regulating our emotional
response to events, t helps us decide that a situation is
okay. Trauma can lead to weakening of these signals
which may lead to negative emotions from the
trauma memory taking over the prefrontal cortex’s
reasoning ability.

3
TRAUMA The autonomic nervous system (ANS) regulates the
stress response (Sapolsky, 1998). It is divided into two
RESPONSES IN THE categories, the sympathetic and the parasympathetic
BODY nervous systems. The sympathetic nervous system
activation is characterised by increased heart rate, and
sweat production. Parasympathetic nervous system
activation, on the other hand, is linked to slowing of the
heart, reduced stimulation of salivary glands, and other
relaxation responses (Thayer et al, 2012).

In order to understand the responses to trauma, we have

to understand the concept of defense cascade (Lang et
al, 1997) – a term used to describe progressive defense/
fear responses in humans (Kozlowska, et al. 2015).
These responses are evolutionary patterns of motor-

CHAPTER 3: TRAUMA-INFORMED MENTAL HEALTH AND PSYCHOSOCIAL SUPPORT (MHPSS) IN DISASTERS 60

 autonomic-sensory responses which get automatically
activated in the presence of danger. These responses are
suddenly activated and perceived to be out of conscious
control. Five defensive strategies emerge in the context
of danger: freeze-alert, fight, flight, freeze-fright and
collapse; each having distinct effects on the body
(Bracha, 2004). First, we will explore the body state when
a person is safe and then the manner in which these
states differ from these states will be described (Baldwin,
2013).

3.1 SAFETY

This is characterized by parasympathetic ventral

vagal dominance. This means that the person will be
able to carry out their activities of daily living, engage
socially and acts opposite to the sympathetic activation
described above. This is reflected in a relaxed state, face
and eyes are animated, eye contact is maintained and
heart rate is robust. Capacity for speech, laughter, play
and tears is present. They are able to self-soothe and seek
social support (Porges & Furman, 2011).

3.2 FREEZE-ALERT (STILLNESS)

The shift to freeze-alert state almost starts when the

threat is first detected. It is assumed to be outside of our
coping. The body starts to relinquish parasympathetic
control which is manifested as wariness, quickening of
heart rate, almost as if in preparation of defense. This
is manifested as a still body, fixed eyes, stiff and tense
muscles, tightening of throat, and difficulty in breathing.
The person seems to be assessing the threat of the
seemingly dangerous situation, is alert, watchful and
waiting.

3.3 FLIGHT AND FIGHT

In both these states, the sympathetic nervous system

gets activated. The flight response is characterized by
increased blood flow to legs, respiration, heart rate and
sweating and decrease in digestion. The person feels
panicked, afraid, having cold hands and an impulse to
run or warn others. In fight response, shoulders, arm,
hand and jaw get tensed and clenched. Respiration,
sweating and blood flow are increased. Hands are warm,
impulses of hitting, kicking or screaming may also be
present.

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 3.4 FREEZE-FRIGHT RESPONSE

Freeze-fright response occurs when the body is unsure

or undecided about the use of other defense responses
even though the situation has been appraised as being
dire. Because of this indecision, there is simultaneous
activation of the sympathetic and parasympathetic
dorsal activity resulting in this state (Zhang et al.,
2004). In this state, the person appears to be immobile,
tense and ready to move but this movement is
inhibited, making them feel ‘frozen’. The stomach
gets clenched,the heart is pounding and breathing
becomes fast and shallow. This response strengthens
heart contractions, increasing blood flow while slightly
decreasing heart rate relative to flight or fight. The
person feels paralyzed and scared stiff.

3.5 COLLAPSE

Finally, when it seems to the body that all states have not
yielded any results, the body enters a state of collapse. In
this situation of extreme threat (i.e., inescapable or life-
threatening), the sympathetic activity recedes and the
parasympathetic dorsal vagal starts dominating the body
responses. This result in sharply decreased heart rate and
a flaccid immobility (“playing dead”) almost as a sense of
giving up. Breath is shallow, feeling hopeless, detached
and numb.

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 Reflective Exercise

Listening to traumatic experiences may also elicit some of these responses in us.
It is important for us to recognise our responses to trauma stimuli as well. We
can identify our own bodily responses to trauma narratives.

4
WINDOW OF Window of tolerance is a model of autonomic arousal
(Seigel, 1999) that helps to understand the fluctuations
TOLERANCE in various trauma responses described above. This
model suggests that there are two extreme reactions
in trauma- the (sympathetic) hyperarousal and the
(parasympathetic) hypoarousal. Between these two
states rests a window or a zone where emotions are
tolerated, experienced, regulated and integrated
(Corrigan et al, 2011). This zone thus, allows the person
to have an internal sense of safety and a willingness to
engage socially and learn (Boon et al, 2011). With flexibility
in this zone, the person is able to experience various
intensities of arousal (both emotional and physical)
without the entire system becoming disrupted (Seigel,
1999). This model describes all the responses in the
defense cascade.

The hyperarousal state is dominated by the activation of

the sympathetic nervous system. This is associated with
increased reactivity, impulsivity, hypervigilance, intrusive
images, flashbacks, nightmares, racing thoughts and
engaging in high-risk behaviours (Ogden, et al 2006;
Seigel, 1999).

In the hypoarousal state, activation of the

parasympathetic nervous system dominates the
experience of the individual. In this state, the affect is flat,
numbness, emptiness and feelings of collapse dominate.
The person feels helpless, hopeless and unable to think
(Ogden, et al, 2006; Seigel, 1999).

The window of tolerance is unique for all individuals

and is determined by our temperament, physiological
reactivity and experiences (Boon et al, 2011). The ‘width’
of this window will influence the ability to process

CHAPTER 3: TRAUMA-INFORMED MENTAL HEALTH AND PSYCHOSOCIAL SUPPORT (MHPSS) IN DISASTERS 64

 information (Ogden et al., 2006). People who have
wider windows of tolerance will be able to manage a
wide range of arousal and process complex information
efficiently and simultaneously whereas if the window
is narrow, any change in arousal will be experienced as
overwhelming and push us into hypo or hyperarousal.

Coming back into the window of tolerance is done by

regulating with self and others. Interactive regulation
refers to regulating and soothing the self with others
(Schore, 2001). Examples of interactive regulation is
calling friends when we are upset or even using the
therapeutic space to gain different perspectives about
our situation. Autoregulation refers to self-soothing
practices to regulate oneself (Schore, 2001). It involves
reassuring ourselves, pausing and reflecting on ourselves,
doing activities that help us feel differently.

https://www.nicabm.com/
trauma-how-to-help-your-
clients-understand-their-
window-of-tolerance/

CHAPTER 3: TRAUMA-INFORMED MENTAL HEALTH AND PSYCHOSOCIAL SUPPORT (MHPSS) IN DISASTERS 65

 Let’s avoid...

Not knowing the neurobiological underpinnings of trauma. Trauma

experiences are inherently psychobiological in nature and have a profound
impact on the body and mind. Ignoring the impact of one in favour of the other
will not lead to holistic recovery.

Not knowing and identifying trauma responses. Individuals behave in

characteristic ways when triggered by reminders of their traumatic stimuli.
Mental health professionals who do not recognise these triggers or responses
for what they are, will be at a risk for misdiagnosing and misinterpreting these
responses. This will increase their risk for retraumatization and will be an ethical
violation for us as well.

Paying attention to the clients’ narratives without engaging in reflection

about our own window of tolerance. Being in our own window of tolerance
serves two functions: It helps the clients regulate interactively with us as well as
not trigger the clients further. Clients with histories of trauma often are sensitive
to the arousal levels of others. If the client experiences us as being outside of our
window of tolerance, they may be at risk for getting triggered even further.

Self-care Exercise

Being in our own window of tolerance when working with clients with histories
of trauma is very important as we can use our own sense of calm for interactive
regulation. In order to do this, we can think of taking the following steps to
understand our window of tolerance:

• How do we identify the states of hyperarousal, hypoarousal and window of

tolerance?

• What are our potential triggers that push us outside of our window of
tolerance?

• What strategies help us to return to our window of tolerance?

• What strategies may help us to expand our window of tolerance?

CHAPTER 3: TRAUMA-INFORMED MENTAL HEALTH AND PSYCHOSOCIAL SUPPORT (MHPSS) IN DISASTERS 66

 Self-reflection and observing ourselves can aid our own
regulation. A key exercise that we can also practise for
ourselves is a mindfulness-based exercise.

Practice Exercise

Becoming an Observer and Learning To Tolerate Discomfort: The Leaf and

Stream Metaphor

The following exercise, “leaves floating on a stream,” is adapted from the

SAMHSA’s Trauma-Informed Care in Behavioral Health Services. It inculcates the
ability to stand back and observe thoughts rather than get caught up in them.

We can do this for ourselves. Let us say, “Thoughts are just thoughts; they
come and go like water flowing down a stream. We don’t need to react to
the thoughts. Instead, we can just notice them. We can do this by imagining
ourselves sitting next to a stream. Begin to sit quietly, bringing your attention to
your breath. If you feel comfortable, close your eyes. As you focus on breathing
in and out, imagine that you are sitting next to a stream. In your imagination,
you may clearly see and hear the stream, or you may have difficulty visualizing
the stream. Now begin to notice the thoughts that come into your mind.
Some thoughts rush by, while others linger. Just allow yourself to notice your
thoughts. As you begin to notice each thought, imagine putting those words
onto a leaf as it floats by on the stream. Just let the thoughts come, watching
them drift by on the leaves. If your thoughts briefly stop, continue to watch the
water flow down the stream. Eventually, your thoughts will come again. Just let
them come, and as they do, place them onto a leaf. Your attention may wander.
Painful feelings may arise. You may feel uncomfortable or start to think that
the exercise is “stupid.” You may hook onto a thought—rehashing it repeatedly.
That’s okay; it’s what our minds do. As soon as you notice your mind wandering
or getting stuck, just gently bring your focus back to your thoughts, and place
them onto the leaves. Now, bring your attention back to your breath for a
moment, then open your eyes and become more aware of your environment.

We can use the following questions to facilitate this process:

• What was it like for you to observe your thoughts?

• Did you get distracted? Stuck?
• Were you able to bring yourself back to the exercise after getting distracted?
• In what ways was the exercise uncomfortable?
• In what ways was the exercise comforting?

CHAPTER 3: TRAUMA-INFORMED MENTAL HEALTH AND PSYCHOSOCIAL SUPPORT (MHPSS) IN DISASTERS 67

 Tips for Supervisors

It is important to recognise signs of a triggered nervous system in a supervisee.

We may want to look out for the following key signs:

• Anger or Irritability – Key to identify: disproportionate reactions

• Mood – Key to identify: unexplained changes in mood
• Dissociation – Key to identify: the mind’s distance from the body

Fogginess, confusion, losing track of conversation, memory gaps, looking into

nothing, hunched posture, rapid changes in breathing, discussing event as if
they were “there”-flashback

Anxiety – Key to identify: evaluation and control

Hyperarousal, repeating same worries, rushed speech, intellectualization,

jumpiness

Once there is a presence of such triggers, we can:

• Remain calm ourselves –nervous system to nervous system regulation
• Help the supervisee come back to the present- grounding and stabilization
(discussed in the next chapters)
• Empathy can also be a trigger is some instances- maintain a clear, even tone
• Check in with the supervisee once it seems that they are somewhat stable-
how are they doing? –preferably do not reinitiate a discussion about feelings
about the incident or event
• Check if they would like to step away for a bit
• Debrief- We can say, “I noticed….” Then educate them on trauma triggers (if
supervisee is in a place to discuss then)

CHAPTER 3: TRAUMA-INFORMED MENTAL HEALTH AND PSYCHOSOCIAL SUPPORT (MHPSS) IN DISASTERS 68

References

Acheson, D. T., Gresack, J. E., & Risbrough, V. B. (2012). Hippocampal dysfunction effects on context memory: possible
etiology for posttraumatic stress disorder. Neuropharmacology, 62(2), 674-685.

Admon, R., Leykin, D., Lubin, G., Engert, V., Andrews, J., Pruessner, J., & Hendler, T. (2013). Stress‐induced reduction in
hippocampal volume and connectivity with the ventromedial prefrontal cortex are related to maladaptive responses
to stressful military service. Human brain mapping, 34(11), 2808-2816.

Arnold, D., Calhoun, L. G., Tedeschi, R., & Cann, A. (2005). Vicarious posttraumatic growth in psychotherapy. Journal of
Humanistic Psychology, 45(2), 239-263.

Baldwin, D. V. (2013). Primitive mechanisms of trauma response: An evolutionary perspective on trauma-related

disorders. Neuroscience & Biobehavioral Reviews, 37(8), 1549-1566.

Bolsinger, J., Seifritz, E., Kleim, B., & Manoliu, A. (2018). Neuroimaging correlates of resilience to traumatic events—a
comprehensive review. Frontiers in psychiatry, 9, 693.

Boon, S., Steele, K., & Van Der Hart, O. (2011). Coping with trauma-related dissociation: Skills training for patients and
therapists. WW Norton & Company.

Calem M, Bromis K, McGuire P, Morgan C, Kempton MJ. Meta-analysis of associations between childhood adversity
and hippocampus and amygdala volume in non-clinical and general population samples. NeuroImage Clin. (2017)
14:471–9. doi: 10.1016/j.nicl.2017.02.016

Cassiers, L. L., Sabbe, B. G., Schmaal, L., Veltman, D. J., Penninx, B. W., & Van Den Eede, F. (2018). Structural and
functional brain abnormalities associated with exposure to different childhood trauma subtypes: A systematic
review of neuroimaging findings. Frontiers in psychiatry, 9, 370528.

Conway, M. A., & Pleydell-Pearce, C.W. (2000). The construction of autobiographical memories in the self-memory
system. Psychological Review, 107, 261–288.

Corrigan, F. M., Fisher, J. J., & Nutt, D. J. (2011). Autonomic dysregulation and the window of tolerance model of the
effects of complex emotional trauma. Journal of psychopharmacology, 25(1), 17-25.

Foa, E.B., & Kozak, M.J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological
Bulletin, 99, 20–35

Gasquoine, P. G. (2013). Localization of function in anterior cingulate cortex: from psychosurgery to functional
neuroimaging. Neuroscience & Biobehavioral Reviews, 37(3), 340-348.

Goodkind MS, Gyurak A, Etkin A. Functional Neurocircuitry and Neuroimaging Studies of Anxiety Disorders. In:
Charney DS, Buxbaum JD, Sklar P, Nestler EJ, editors. Neurobiology of Mental Illness. New York, NY: Oxford University
Press. (2013) p. 606–20

Gurvits, T. V., Metzger, L. J., Lasko, N. B., Cannistraro, P. A., Tarhan, A. S., Gilbertson, M. W., ... & Pitman, R. K. (2006).
Subtle neurologic compromise as a vulnerability factor for combat-related posttraumatic stress disorder: results of a
twin study. Archives of General Psychiatry, 63(5), 571-576.

Hein, T. C., & Monk, C. S. (2017). Research Review: Neural response to threat in children, adolescents, and adults after
child maltreatment–a quantitative meta‐analysis. Journal of child psychology and psychiatry, 58(3), 222-230.

Henson, C., Truchot, D., & Canevello, A. (2021). What promotes post traumatic growth? A systematic review. European
Journal of Trauma & Dissociation, 5(4), 100-195.

Jackowski, A. P., De Araújo, C. M., De Lacerda, A. L. T., de Jesus Mari, J., & Kaufman, J. (2009). Neurostructural imaging
findings in children with post‐traumatic stress disorder: Brief review. Psychiatry and clinical neurosciences, 63(1), 1-8.
Kozlowska, K., Walker, P., McLean, L., & Carrive, P. (2015). Fear and the defense cascade: clinical implications and
management. Harvard review of psychiatry, 23(4), 263-287.
Lang, P.J. (1979). Bio-informational theory of emotional imagery. Psychophysiology, 16, 495–512.
Lang, P.J., Bradley, M., & Cuthbert, B., (1997). Motivated attention: affect, activation, and action. In P.J. Lang, R. Simons,
& M. Balaban (Eds.), Attention and Orienting: Sensory and Motivational Processes (pp. 97–135). Mahway, NJ: Lawrence
Erlbaum

69
Malta, L. S., Levitt, J. T., Martin, A., Davis, L., & Cloitre, M. (2009). Correlates of functionalimpairment in treatment-
seeking survivors of mass terrorism. Behavior Therapy, 40, 39–49.

Mattson, E., James, L., Engdahl, B. (2018). Personality Factors and Their Impact on PTSD and Post-traumatic Growth
is Mediated by Coping Style Among OIF/OEF Veterans. Military Medicine, 00, 0/0:1.

McCrory, E. J., Gerin, M. I., & Viding, E. (2017). Annual research review: childhood maltreatment, latent vulnerability
and the shift to preventative psychiatry–the contribution of functional brain imaging. Journal of child psychology
and psychiatry, 58(4), 338-357.

McLaughlin, K. A., Peverill, M., Gold, A. L., Alves, S., & Sheridan, M. A. (2015). Child maltreatment and neural systems
underlying emotion regulation. Journal of the American Academy of Child & Adolescent Psychiatry, 54(9), 753-762.
Metcalfe J. & Jacobs W. (1996). A hot-system/cool-system view of memory under stress. PTSD Research Quarterly, 7,
1-3.

Ogden P., Minton K., Pain C. (2006). Trauma and the body: a sensorimotor approach to psychotherapy. New York:
Norton

Owens, G. P. (2016). Predictors of Posttraumatic Growth and Posttraumatic Stress Symptom Severity in
Undergraduates Reporting Potentially Traumatic Events. Journal of Clinical Psychology, 72(10), 1064–1076.

Paquola, C., Bennett, M. R., & Lagopoulos, J. (2016). Understanding heterogeneity in grey matter research of adults
with childhood maltreatment—A meta-analysis and review. Neuroscience & Biobehavioral Reviews, 69, 299-312.

Picó-Pérez, M., Alonso, P., Contreras-Rodríguez, O., Martínez-Zalacaín, I., López-Solà, C., Jiménez-Murcia, S., ... &
Soriano-Mas, C. (2018). Dispositional use of emotion regulation strategies and resting-state cortico-limbic functional
connectivity. Brain Imaging and Behavior, 12(4), 1022-1031.

Pitman, R. K., Rasmusson, A. M., Koenen, K. C., Shin, L. M., Orr, S. P., Gilbertson, M. W., ... & Liberzon, I. (2012). Biological
studies of post-traumatic stress disorder. nature Reviews neuroscience, 13(11), 769-787.

Porges, S. W., & Furman, S. A. (2011). The early development of the autonomic nervous system provides a neural
platform for social behaviour: A polyvagal perspective. Infant and child development, 20(1), 106-118.

Prati, G. and Pietrantoni, L. (2009). Optimisim, Social Support, and Coping Strategies as Factors Contributing to
Posttraumatic Growth: A Meta-Analysis. Journal of Loss and Trauma, 14, 364–388.

Reker, G. T. (2000). Theoretical perspective, dimensions, and measurement of existential meaning. In G. T. Reker & K.
Chamberlain (Eds.), Exploring existential meaning: Optimizing human development across the life span (pp. 39–55).
Thousand Oaks, CA: Sage Publications

Saltzman, L. Y., Pat-Horenczyk, R., Lombe, M., Weltman, A., Ziv, Y., McNamara, T., Takeuchi, D., Brom, D. (2018). Post-
combat adaptation: improving social support and reaching constructive growth. Anxiety, Stress & Coping, 31(4),
418–430.

Sapolsky, R. M. (1998). Why zebras don’t get ulcers: The acclaimed guide to stress, stress-related diseases, and coping.
Holt paperbacks.

Schore, A. (2001). The effects of a secure attachment relationship on right brain development, affect regulation, and
infant mental health. Infant Mental Health Journal, 22, 7–66.

Siegel D.J. (1999). The Developing Mind. New York: Guilford

Squire, L.R. (1994). Declarative and nondeclarative memory: Multiple brain systems supporting learning and
memory. In D.L. Schacter & E. Tulving (Eds.), Memory Systems (pp. 207-228). Cambridge, MA: MIT Press

Tedeschi RG, & Calhoun LG (2004). Posttraumatic growth: Conceptual foundations and empirical evidence.
Psychological inquiry, 15(1), 1–18.
Tedeschi, R. G., & Calhoun, L. G. (1996). The Posttraumatic Growth Inventory: Measuring the positive legacy of trauma.
Journal of traumatic stress, 9, 455-471.
Tedeschi, R. G., Calhoun, L. G., Groleau J.M. (2014). Clinical applications of posttraumatic growth. Chapter 30, 503–514
.
Tedeschi, R. G., Park, C. L., Calhoun, L. G. (1998). Posttraumatic growth: Positive change in the aftermath of crisis.
Mahwah, NJ: Erlbaum.

70
Thayer, J. F., Åhs, F., Fredrikson, M., Sollers III, J. J., & Wager, T. D. (2012). A meta-analysis of heart rate variability
and neuroimaging studies: implications for heart rate variability as a marker of stress and health. Neuroscience &
Biobehavioral Reviews, 36(2), 747-756.

Tsai, J., Pietrzak, R. H. (2017). Trajectories of posttraumatic growth among US military veterans: a 4-year nationally
representative, prospective cohort study. Acta Psychiatrica Scandinavica, 136(5), 483–492

Tsai, J., Sippel, L. M., Mota, N., Southwick, S. M., Pietrzak, R. H. (2016). Longitudinal course of posttraumatic growth
among U.S. military veterans: Results from the National Health and Resilience in Veterans study. Depression &
Anxiety, 33(1), 9–18.

van der Knaap, L. J., & van der Ham, I. J. (2011). How does the corpus callosum mediate interhemispheric transfer? A
review. Behavioural brain research, 223(1), 211-221.

Woon, F. L., Sood, S., & Hedges, D. W. (2010). Hippocampal volume deficits associated with exposure to psychological
trauma and posttraumatic stress disorder in adults: a meta-analysis. Progress in Neuro-Psychopharmacology and
Biological Psychiatry, 34(7), 1181-1188.

Yuen, A. N. Y., Ho, S. M. Y., Chan, C. K. Y. (2014). The mediating roles of cancer-related rumination in the relationship
between dispositional hope and psychological outcomes among childhood cancer survivors. Psycho-Oncology,
23(4), 412–419.

Zhang, W. N., Murphy, C. A., & Feldon, J. (2004). Behavioural and cardiovascular responses during latent inhibition of
conditioned fear: measurement by telemetry and conditioned freezing. Behavioural brain research, 154(1), 199-209.

71
4
CHAPTER 4

Role of
Mental health
professionals in
delivering trauma-
informed MHPSS
during disasters
 Trauma-informed care is an umbrella term referring
1 to a service delivery approach where the focus is on
understanding and responding to the impact that a
AN INTRODUCTION traumatic event has on the individual. It is aimed at
TO TRAUMA improving outcomes of care by focusing on ensuring
physical, psychological, and emotional safety. This is
INFORMED CARE achieved by empowering people to understand and
work towards defining their needs and goals and
exercising choices about the kind of care and services
they receive. Trauma-informed approach focuses on
increasing awareness about trauma and encouraging
service providers to work actively to discourage processes
and practices that have the potential to re-traumatize
survivors.

“Trauma-focused services” and “trauma-informed care”

are occasionally thought to be the same as they are
therapies oriented towards providing care for those
with histories of traumatic stress. However, these are
different. Trauma-specific services refer to the clinical
interventions which may be directed towards individual
and group therapies intended to prevent or intervene for
trauma-related symptoms, PTSD and other co-occurring
disorders. Trauma-informed care on the other hand, is
aimed at creating a universal framework for helping
counsellors develop awareness, knowledge, and skills to
provide a supportive environment for survivors of trauma
(Hopper et al., 2010). Thus, trauma-informed care includes
trauma-specific assessment, treatment and building
support systems for recovery.

2
KEY ASSUMPTIONS The concept of a trauma-informed approach is grounded
in a set of four assumptions and six key principles to
AND PRINCIPLES guide the context of care.
OF TRAUMA
INFORMED
APPROACH

CHAPTER 4: ROLE OF MENTAL HEALTH PROFESSIONALS IN DELIVERING TRAUMA-INFORMED MHPSS DURING DISASTERS 73
 2.1 KEY ASSUMPTIONS

The key principles in this approach are captured by 4Rs.

These are:

Realisation Realisation that trauma is wide-

spread and that traumatic events
impact individuals, families, groups,
organizations, as well as communities.
These experiences, behaviours and
coping strategies are contextualised
in the framework of adversity and
overwhelming circumstances that
people may have faced in the past or
are currently facing either directly or
indirectly.

Recognition Recognition of signs and symptoms

of trauma while keeping in mind the
intersectionality of gender, age or
settings of the individual.

Responding Responding to the presence of

trauma by using the key principles
of a trauma-informed approach in
all areas of functioning. It involves
incorporating the understanding
that traumatic experiences impact all
people involved directly or indirectly.
Policies of the organization, budget,
and leadership endorse a culture
based on resilience, recovery, and
healing from trauma.

Resisting Lastly, it involves taking precautions

against replicating the traumatic
Retraumat- experiences in the life of survivors,
ization that is, by resisting retraumatization
(SAMHSA, 2014). These principles
are considered to be essential to the
context of care (Brave Heart et al, 2011;
Ford et al, 2009).

CHAPTER 4: ROLE OF MENTAL HEALTH PROFESSIONALS IN DELIVERING TRAUMA-INFORMED MHPSS DURING DISASTERS 74
 2.2 PRINCIPLES OF A TRAUMA-INFORMED APPROACH
A trauma-informed approach is guided by six key
principles. These principles can be generalized across
different settings and adapted to become setting or
sector-specific. These key principles are crucial in linking
and promoting resilience and recovery of individuals or
families affected by trauma (Elliot et al., 2005; Harris &
Fallot, 2001).

Trustworthiness Peer
Safety and transparency support

Collaboration Empowerment, Cultural, Historical

and Mutuality Voice and Choice and Gender Issues

2.2.1 SAFETY

It is imperative that anyone associated with trauma-

informed care, including the counsellor and client feel
safe. This can be reflected in a physically safe setting.
It is also reflected in interactions which promote
psychological safety in the relationship. This safety is
defined and understood from the client’s perspective.
Establishing safe spaces in disaster settings where
individuals can feel secure and supported is important in
its aftermath (National Child Traumatic Stress Network
& National Center for PTSD, [NCTS], 2006). This may
start with physical safety (for example, settling in relief
camps, away from the site of disaster) and then extend to
psychological safety (providing interventions to bring the
people back to the present following a disaster).

2.2.2 TRUSTWORTHINESS & TRANSPARENCY

The aim is to build a relationship based on trust and

transparency. This involves creating a system of honesty,
honouring the commitments made by people providing

CHAPTER 4: ROLE OF MENTAL HEALTH PROFESSIONALS IN DELIVERING TRAUMA-INFORMED MHPSS DURING DISASTERS 75
 trauma-informed care and maintaining an atmosphere
of trust between the client and counsellor. We can try
to establish trustworthiness by actively listening to
and amplifying community voices. This can be done
by engaging people from the community to facilitate
communication and deliver messages to other members
of the community. This may also help convey respect
for the community. Lastly, candidly acknowledging
limitations of the counsellors in the disaster situation
may help people connect to us better (Rosenberg et al,
2022)

2.2.3 PEER SUPPORT

It is important to provide and receive support from

peers in trauma work to gain valuable insights and
knowledge in the context of trauma. It is not possible
that one individual will have complete knowledge and
understanding of the various ways in which trauma
manifests. Peers help in providing understanding and
newer perceptions that may get missed otherwise.
They also help in building hope, creating safety and
promoting healing. In the disaster context, people may
be able to connect better to a person who is a part of
their community. Thus, community engagement can
be actively encouraged by promoting local resources by
partnering with local practitioners on projects, and with
mental health providers and public health practitioners
(Rosenberg et al, 2022).

2.2.4 COLLABORATION & MUTUALITY

Collaboration with the client is a key component of

trauma-informed care. There is an active effort to
recognise power differences and reduce them between
the client and the counsellor. It helps demonstrate
that healing in trauma is possible when power and
decision-making are shared, thereby increasing agency
and control that clients have in their paths of recovery.
For those who are recovering from disasters, having
local leaders from the community actively encouraged
to take ownership and control may promote a sense
of empowerment and choice. These local leaders
may help to increase participation and direction by
providing meaningful alternatives in accessible language
(Rosenberg et al, 2022).

CHAPTER 4: ROLE OF MENTAL HEALTH PROFESSIONALS IN DELIVERING TRAUMA-INFORMED MHPSS DURING DISASTERS 76
 2.2.5 EMPOWERMENT, VOICE & CHOICE

This principle highlights the importance of recognising

and celebrating the strengths of clients and keeping them
central in all our endeavours. This translates into believing
in the resilience of clients and trusting in their ability to
heal. It also involves sharing decision-making processes
with them, finding out and bringing client choices in the
foreground and keeping their goals as the priority of the
work. The aim is to nurture within us the importance of
the primacy of the clients, their resilience and their ability
to set goals for their healing journey. This promotes self-
advocacy and agency of the clients. For communities
affected by disaster, helping them understand the
vision for short-term and long-term recovery by sharing
these in local, simple and accessible language may
help in implementing them better. Communities may
have specific recommendations based on their local
knowledge and expertise and honoring these may help
in tailor-making the intervention plans (Rosenberg, et al,
2022). Fostering a sense of control and autonomy among
survivors by offering choices and respecting individual
preferences and boundaries also helps in empowerment
(Kaniasty & Norris, 2008). This may include asking for
permission to speak to those affected by disasters,
checking about the comfortable time for them to speak
and ensuring that any intervention that is carried out is
only after taking consent from them.

2.2.6 CULTURAL, HISTORICAL & GENDER ISSUES

It is important to acknowledge the unique socio-cultural,
historical and gender backgrounds of the clients and
respond to these through the cultural and intersectional
lens. It involves understanding and honouring these
aspects of the client and offering culturally competent
responses. At the same time it is imperative that we keep
away our own stereotypes and biases. In the context of
disaster this may translate as identifying community
history with traumatic events; creating space for other
cultural/historic issues (e.g., caste or class tensions, land
use, immigration, etc.); finding out the potential points
of conflict with government/authority; and, fostering
community strength and pride. We can also promote
outreach for historically vulnerable or marginalized
populations, creating processes to ensure that they
receive the requisite access and are able to participate in
decision-making processes (Rosenberg et al, 2022).

CHAPTER 4: ROLE OF MENTAL HEALTH PROFESSIONALS IN DELIVERING TRAUMA-INFORMED MHPSS DURING DISASTERS 77
 Reflective Exercise

• Which key assumption is the most difficult to follow in your understanding?

•
• What should we do if we unknowingly do not follow the key assumptions?
•
• Which principle is the most important according to you?

3
TRAUMA INFORMED Counsellors are said to be ‘trauma-informed’ when they
can demonstrate certain skills in their work. This group of
COUNSELLOR skills or ‘competencies’ are specific to trauma and can
COMPETENCIES be acquired through training and supervision (Hoge et al,
2007). They include:

1. planning using a person-centered approach

2. displaying culturally competent care
3. focusing on developing a therapeutic alliance
4. ensuring decision-making is a shared responsibility,
5. displaying collaboration while developing recovery
plans
6. practicing evidence-based interventions
7. providing care oriented towards recovery and
resilience
8. recognising the importance of providing
interdisciplinary care, willingness to work in
multidisciplinary teams and promoting client
advocacy.

In addition to these competencies, counselors also need

to focus on the following processes while working with
clients with histories of trauma:

1. Effectively screening and assessing for a history of

trauma and the mental health concerns which may
accompany it, such as mood and anxiety disorders.
It also involves understanding the bidirectional
relationship between trauma and mental health
difficulties.
2. Acknowledging the differences between trauma-
informed and trauma-specific services

CHAPTER 4: ROLE OF MENTAL HEALTH PROFESSIONALS IN DELIVERING TRAUMA-INFORMED MHPSS DURING DISASTERS 78
 3. Keeping the tenets of person-centered approach in
mind while carrying out the counselling process
4. Advanced training in trauma-informed and trauma-
specific interventions, particularly those which are
evidence-based, to focus on symptom reduction and
client well-being
5. Being committed towards self-care practices that
prevent burnout and help to reduce the impact of
secondary traumatization on counsellors.

The ‘Task Force on International Trauma Training’

published consensus-based recommendations for
trauma training (The International Society for Traumatic
Stress Studies (ISTSS), 2002) which include:

1. Training for competence in listening to the client

2. Training in appropriate methods of assessment which
identify psychosocial problems that accompany
experiences of trauma
3. Training for evidence-based interventions specific to
their client population
4. Promoting knowledge about the local context of the
client which includes their help-seeking expectations,
expected duration and cost-effectiveness of
interventions, and community and family attitudes
toward intervention
5. Training in specific strategies for problem-solving at
individual, family, and community levels
6. Training in and awareness of interventions for
medically unexplained somatic pain
7. Training in collaborating with and building capacities
for local resources (e.g., traditional healers, informal
leaders etc.).
8. Self-care components for counsellors (Weine et al.,
2002).

This is especially useful in the context of disaster where

disaster-specific assessments and interventions are
needed (Hobfoll, et al, 2007). A thorough understanding
of the effect of disaster on mental health, especially
common responses is beneficial in providing tailor-
made interventions (Norris et al, 2002). Given the
diverse populations affected by disasters, counsellors
must be culturally sensitive and aware of how cultural
factors influence coping mechanisms, help-seeking
behaviors, and healing practices (Schwartz & Sendor,
1999). counsellors working in disaster settings need to
be flexible and adaptable to changing circumstances,

CHAPTER 4: ROLE OF MENTAL HEALTH PROFESSIONALS IN DELIVERING TRAUMA-INFORMED MHPSS DURING DISASTERS 79
 such as limited resources, logistical challenges, and the
evolving needs of survivors (Ursano et al, 2003) as well as
being engaged in community-related work. Given the
demanding and potentially stressful nature of disaster
response work, counsellors must prioritize their own self-
care and resilience to prevent burnout and secondary
traumatic stress (Brymer et al, 2006).

Reflective Exercise

• Make a list of all the competencies mentioned in the above paragraphs. It

may be useful to explore which competencies we have already and which
ones we would like to enhance further.

• We can also explore additional checklists which are already available on the
internet to understand our level of competence in trauma-informed care.

4
SPECIAL ETHICAL All ethical practices that are followed in MHPSS,
(e.g. beneficence and non-malificence, fidelity and
CONSIDERATIONS responsibility, integrity, justice and respect for people’s
WHILE WORKING rights and dignity) must be incorporated when working
with trauma. In addition to these, there are certain
WITH TRAUMA ethical considerations that are particularly important to
keep in mind.

Green Cross Academy of Traumatology Ethical Guidelines for the Treatment of

Clients Who Have Been Traumatized

RESPECT FOR THE DIGNITY OF CLIENTS

Recognize and value the personal, social, spiritual, and cultural diversity present
in society, without judgment. As a primary ethical commitment, make every
effort to provide interventions with respect for the dignity of those served.

CHAPTER 4: ROLE OF MENTAL HEALTH PROFESSIONALS IN DELIVERING TRAUMA-INFORMED MHPSS DURING DISASTERS 80
 RESPONSIBLE CARING

• Take the utmost care to ensure that interventions do no harm.

• Ensure a commitment to the care of those served until the need for care
ends or the responsibility for care is accepted by another qualified service
provider.
• Support colleagues in their work and respond promptly to their requests for
help.
• Recognize that service to survivors of trauma can be extremely stressful on
providers. Maintain vigilance for signs in self and colleagues of such stress
effects, and accept that dedication to the service of others imposes an
obligation to sufficient self-care to prevent impaired functioning.
• Engage in continuing education in the appropriate areas of trauma response.
Remain current in the field and ensure that interventions meet current
standards of care.

INTEGRITY IN RELATIONSHIPS

• Clearly and accurately represent your training, competence, and credentials.

Limit your practice to methods and problems for which you are appropriately
trained and qualified. Readily refer to or consult with colleagues who have
appropriate expertise; support requests for such referrals or consultations
from clients.
• Maintain a commitment to confidentiality, ensuring that the rights of
confidentiality and privacy are maintained for all clients.
• Do not provide professional services to people with whom you already have
either emotional ties or extraneous relationships of responsibility. The one
exception is in the event of an emergency in which no other qualified person
is available.
• Refrain from entering other relationships with present or former clients,
especially sexual relationships or relationships that normally entail
accountability.
• Within agencies, ensure that confidentiality is consistent with organizational
policies; explicitly inform individuals of the legal limits of confidentiality.

RESPONSIBILITY TO SOCIETY

• Be committed to responding to the needs generated by traumatic events,

not only at the individual level, but also at the level of community and
community organizations in ways that are consistent with your qualifications,
training, and competence.
• Recognize that professions exist by virtue of societal charters in expectation
of their functioning as socially valuable resources. Seek to educate
government agencies and consumer groups about y our expertise, services,
and standards; support efforts by these agencies and groups to ensure social
benefit and consumer protection.

CHAPTER 4: ROLE OF MENTAL HEALTH PROFESSIONALS IN DELIVERING TRAUMA-INFORMED MHPSS DURING DISASTERS 81
 • If you become aware of activities of colleagues that may indicate ethical
violations or impairment of functioning, seek first to resolve the matter
through direct expression of concern and offers of help to those colleagues.
Failing a satisfactory resolution in this manner, bring the matter to the
attention of the officers of professional societies and of governments with
jurisdiction over professional misconduct.

CLIENTS’ UNIVERSAL RIGHTS

All clients have the right to:

• Not be judged for any behaviors they used to cope, either at the time of the
trauma or after the trauma.
• Be treated at all times with respect, dignity, and concern for their well-
being.
• Refuse treatment, unless failure to receive treatment places them at risk of
harm to self or others.
• Be regarded as collaborators in their own treatment plans.
• Provide their informed consent before receiving any treatment.
• Not be discriminated against based on race, culture, sex, religion, sexual
orientation, socioeconomic status, disability, or age.
• Have promises kept, particularly regarding issues related to the treatment
contract, role of counselor, and program rules and expectations.

PROCEDURES FOR INTRODUCING CLIENTS TO TREATMENT

• Obtain informed consent, providing clients with information on what they

can expect while receiving professional services. In addition to general
information provided to all new clients, clients presenting for treatment
who have histories of trauma should also receive information on:
• The possible short-term and long-term effects of trauma treatment on the
client and the client’s relationships with others.
• The amount of distress typically experienced with any particular trauma
treatment.
• Possible negative effects of a particular trauma treatment.
• The possibility of lapses and relapses when doing trauma work, and the fact
that these are a normal and expected part of healing.

REACHING COUNSELING GOALS THROUGH CONSENSUS

• Collaborate with clients in the design of a clearly defined contract that

articulates a specific goal in a specific time period or a contract that allows
for a more open-ended process with periodic evaluations of progress and
goals.

CHAPTER 4: ROLE OF MENTAL HEALTH PROFESSIONALS IN DELIVERING TRAUMA-INFORMED MHPSS DURING DISASTERS 82
 • Informing clients about the healing process
• Clearly explain to clients the nature of the healing process, making sure
clients understand.
• Encourage clients to ask questions about any and all aspects of treatment
and the therapeutic relationship. Provide clients with answers in a manner
they can understand.
• Encourage clients to inform you if the material discussed becomes
overwhelming or intolerable.
• Inform clients of the necessity of contacting you or emergency services if
they feel suicidal or homicidal, are at risk of self-injury, or have a sense of
being out of touch with reality.
• Give clients written contact information about available crisis or emergency
services.
• Inform clients about what constitutes growth and recovery and about the
fact that some trauma symptoms may not be fully treatable.
• Address unrealistic expectations clients may have about counseling and/or
the recovery process.

LEVEL OF FUNCTIONING

1. Inform clients that they may not be able to function at the highest level
of their ability––or even at their usual level––when working with traumatic
material.
2. Prepare clients to experience trauma-related symptoms, such as intrusive
memories, dissociative reactions, reexperiencing, avoidance behaviors,
hypervigilance, or unusual emotional reactivity.

Source: SAMHSA (2014).

In disaster-like situations, it is possible that the guidelines

or codes of ethics may not be followed strictly or to the
letter. Ethical codes are often open to interpretation and
bound by the context in which they operate. Certain
boundary crossings may happen. For example, we as
counsellors may be operating in the same context as
the clients during a disaster and may share contacts
of associations that have helped us. We may not do so
in other contexts though. Similarly, we may decide to
contribute monetarily to a cause that our client may be
involved with because it is helpful to our community.
However, it is important to distinguish it from boundary
violations which will still not be acceptable. Boundary
crossing can be referred to as deviating from the usual
CHAPTER 4: ROLE OF MENTAL HEALTH PROFESSIONALS IN DELIVERING TRAUMA-INFORMED MHPSS DURING DISASTERS 83
 psychological, physical, or social norms in the counselling
context in a way that is harmless, is not exploitative,
and may actually help in advancing therapy (Gutheil
& Brodsky, 2008). An example can be self-disclosure of
a counsellor’s recovery from trauma to offer hope to
the client. But this is not done to express unprocessed
trauma memory, rather, it should be done judiciously
without going into details of the trauma story and
with the express purpose of building hope. Boundary
violation, on the other hand, is unsolicited, harmful
and exploitative (Gutheil & Brodsky, 2008). These are
distinguished from boundary crossing in their intent
and or the effect that they have has on the client. Intent
is when the violation is done for the extra therapeutic
gratification of the counsellor and not for the client’s
well-being. The detrimental effect is when the action
brings about harm rather than help to the client. One of
the key areas where counsellors working with trauma
commonly encounter ethical dilemmas is boundaries
in therapeutic relationships. It is possible that clients
with histories of trauma may require additional support
in understanding the roles and responsibilities of
counsellors and clients. For example, since they may
not be trusting of many individuals around them, they
may not understand or appreciate why their counsellors
cannot share their personal numbers with them and
may perceive it as a rejection or the counsellor not
caring for them. Clients with histories of trauma may also
not realise boundary violations by the counsellors. For
example, they may be more tolerant of counsellors who
may show inconsistencies such as forgetting sessions,
not ending on time or even self-disclosure which is not
therapeutic. Supervision can be an important area where
such boundary violations may be discussed.

Practice Exercise

Consider the following example. We can reflect if this is a boundary crossing or a

boundary violation.

Mrs T is a counsellor with 12 years of experience at an in-patient hospital set-

up. Two years ago, she and her daughter had met with an accident. She had
escaped with a few scrapes but her daughter had suffered a major arm injury

CHAPTER 4: ROLE OF MENTAL HEALTH PROFESSIONALS IN DELIVERING TRAUMA-INFORMED MHPSS DURING DISASTERS 84
 and had to undergo an extensive rehabilitation to preserve the use of her arm.
She made full recovery but it took a toll on Mrs. T. She was very supportive of her
daughter but felt very guilty about the entire process as she had survived with
very little impact. Her daughter tried to reassure her but she was not convinced.

Four months ago, she started working with Ms. B who had undergone a
traumatic brain injury after a train accident. While working with her, Mrs T
started extending her sessions feeling that Ms. B should not feel pressured
to speak fast (Ms. B had slurred speech). She also started meeting her more
frequently, finding herself checking with Ms B before her day started and
after her last session. During these times, she would often help Ms. B convey
her wants to the staff because they had some difficulty in understanding her.
Recently, they have started exploring how Ms. B is making meaning of her
experience. Mrs. T found herself asking Ms. B about attribution of blame. She
questioned her if she blamed her parents for sending her on the train or not. In
the last session, she gave Ms. B a hypothetical situation, asking, “if this was a
car instead of train, would you blame the person driving the car? What if it was
your mother?”

Ms. B felt very uncomfortable answering this question. This discomfort was
noticed by her nurse who asked her about it. Ms. B felt compelled to protect
Mrs. T after all the kindness she had shown to her. So she answered that she
had no problem with Mrs. T. Mrs. T continued to work with Ms. B but sometimes
she asked her this question again and again.

• What were the instances of boundary crossings in this vignette?

• What were the instances of boundary violations?

• How did you make the distinction between boundary violation and boundary
crossing? (The key is to consider the context, intent and effect of the actions
of the counsellor)

• How do you think Ms. B feels in this situation?

• How do you think we can help Ms B in this context?

• If you were in the position of Mrs T and a supervisor helped you understand
the difference between boundary violation and crossing, what steps could
you take to redress this situation?

CHAPTER 4: ROLE OF MENTAL HEALTH PROFESSIONALS IN DELIVERING TRAUMA-INFORMED MHPSS DURING DISASTERS 85
 5
ROLE AS Mental health professionals (MHPs) play a crucial role
in managing trauma responses to disasters. We bring
MENTAL HEALTH our unique competencies such as managing stress and
PROFESSIONALS developing coping strategies to the disaster situation
(APA, 2021). The NDMA (2023) has prepared guidelines to
IN PROVIDING help understand our role as counsellors in the disaster
TRAUMA- context.
INFORMED MENTAL 1. For example, prior to the occurrence of the disaster,
HEALTH AND that is in the preparedness phase, our role can be:
PSYCHOSOCIAL 2. Carrying out assessment of vulnerabilities such
as understanding the pre-existing psychosocial
SUPPORT DURING problems of the individuals and communities in the
DISASTERS disaster-prone area as well as the resources available
to them including trained personnel keeping the key
principles of trauma-informed care at the forefront.
This assessment can inform the actions taken during
the disaster phase.
3. Building the capacities of stakeholders such as
citizens, disaster responders, community level
workers, local, state and central government
personnels, health and allied health professionals,
NGO personnels and media. These training can be
on topics such as psychosocial considerations in
the context of disasters, trauma-informed MHPSS<
community awareness, and psychosocial care and
support during disasters.
4. Building technological support such as a centralized
portal to identify, consolidate, and provide access
to disaster mental health and psychosocial support
resources available containing IEC (Information,
Education and Communication), self-help guides,
information for help-seeking, to name a few.
5. Providing support through research endeavors by
participating in trauma-informed disaster mental
health research on topics such as intervention, ethics,
to name a few.

The next phases are the early phases of disasters which

last from one week till 8 weeks post disaster. counsellors
are engaged in planning and preventive roles during
these early phases of disasters such as:

1. Participating in a multi-disciplinary relief team

CHAPTER 4: ROLE OF MENTAL HEALTH PROFESSIONALS IN DELIVERING TRAUMA-INFORMED MHPSS DURING DISASTERS 86
 2. Carrying out rapid assessment which focuses on:

. Nature of the hazard

. Social determinants of mental health
. Mental health and psychosocial context including
prevalence of trauma responses, psychosocial
responses of those affected by the disaster
. Social and community based resources
. Formal resources available for the community
such as number of trained personnels,
technological resources, healthcare institutions to
name a few
. Socio-cultural beliefs and attitudes towards mental
health

3. Providing capacity building services to understand

disaster and its responses for the community
members through IEC material and self-help
strategies and carrying out community awareness
programs promoting help-seeking behaviours

4. Providing psychosocial support such as psychological

first-aid, and other specialised mental health services
addressing trauma responses, emotions distress, and
other responses.

The next phase of disasters is the disillusionment phase

starting after the end of the earlier phases (from two
months) and can last for the next three years. counsellors
are engaged in more curative roles including:

• Interventions for those with significant mental health

concerns
• Attending to the referrals for specialised care
• Spreading the scope of capacity building activities
• Training and hand holding community members
such as private physicians/doctors, primary health care
staff, paramedical staffs, school teachers, anganwadi
workers, alternative complementary medicine
personnel, religious leaders, spiritual leaders and faith
healers for better outreach of services
• Participating in community outreach camps
• Assessing the efficacy of interventions and developing
a feedback mechanism

Lastly, the phase of restoration starts where counsellors

are involved in the preparedness phase once again. This
cycle shows the crucial role that counsellors have in every
phase of disaster management.
CHAPTER 4: ROLE OF MENTAL HEALTH PROFESSIONALS IN DELIVERING TRAUMA-INFORMED MHPSS DURING DISASTERS 87
 The scope of this work is covered more in detail in the
NDMA guidelines (2023). The World Health Organization
(WHO) is one of the many organisations that advocates
for integrating trauma-informed care into general
mental healthcare systems (Van Ommeren, & Wessells,
2007). This chapter will focus on introducing the idea
of trauma-informed care, discussing its principles and
lastly, unique ethical considerations that may form a part
of trauma-informed care.

Reflective Exercise
The above paragraph describes different roles that counsellors play.

• Which one of these roles do you find most meaningful?

• Which one of these roles may be most challenging for you?

• Which one of these roles do you think will be most impacted if you were also
a part of the community that was affected by the disaster?

Let’s avoid...

Not knowing the limits of our role as mental health professionals in the
context of disaster. Disaster situations may make us feel compelled to rescue
clients to avoid feeling helpless in the situation. It is important to understand
our role in this context and work in multidisciplinary teams so as not to get
overwhelmed by the situation.
Not differentiating between trauma-informed practice and trauma-specific
services. Trauma-informed practices are an overarching framework whereas
trauma-specific services are evidence-based clinical interventions used to
assess and treat PTSD and other trauma-related symptoms.
Believing that key assumptions and principles of trauma-informed care is
only applicable within the therapy session. Trauma-informed care is a set of
universal frameworks that is applicable in all our interactions with clients.
Engaging in boundary violations. Trauma histories of clients may make us
want to go the extra mile for them. However, it is important that we engage in
self-reflection about the reasons for our actions. We can keep the context of our
practice, our intent is crossing boundaries and the possible effect on the client
in mind while making such a decision.

CHAPTER 4: ROLE OF MENTAL HEALTH PROFESSIONALS IN DELIVERING TRAUMA-INFORMED MHPSS DURING DISASTERS 88
 Self-care Exercise

Drawing a comprehensive self-care plan involves assessing ourselves on our

current available coping skills and strategies and planning for a holistic and all-
inclusive routine that addresses these four domains (SAMHSA, 2014):

• Physical self-care (having a healthy and relaxed body)

• Psychological self-care (includes cognitive/mental aspects for building bigger
perspectives, working towards them, countering negative self-talk and
beliefs and becoming more self-reflective)
• Emotional self-care (includes relational aspects, feelings of connectedness
and groundedness)
• Spiritual self-care (involves meaning, hope and working towards something
greater)

Tips for Supervisors

This chapter discusses the key concepts of trauma-informed practice.

Supervision can also draw parallels with these principles. A trauma-informed
supervision incorporates exercising safety, trustworthiness, choice, collaboration,
and empowerment in the supervision space (Berger & Quiros, 2014). We can
reflect in the following directions for supervision:

• How can we make supervision trauma-informed?

• As a supervisor, what are our expectations from our supervisees?
• If we are a part of a peer supervisor group, how can we keep it trauma-
informed?

This chapter helps us in understanding our role as mental health professionals in the
context of disasters. It also helps us in understanding the basics of trauma-informed
care. The next chapter focuses on discussing ways of carrying out the process of
trauma-informed mental health and psychosocial support.

CHAPTER 4: ROLE OF MENTAL HEALTH PROFESSIONALS IN DELIVERING TRAUMA-INFORMED MHPSS DURING DISASTERS 89
References

American Psychological Association. Relief [internet]. [cited 2024 Jan 23]. Available from https://www.apa.org/topics/
disasters-response/relief

Arkowitz, H., Miller, W. R., Westra, H. A., & Rollnick, S. (2008). Motivational interviewing in the treatment of
psychological problems: Conclusions and future directions. In Motivational interviewing in the treatment of
psychological problems (pp. 324–342). New York: Guilford Press.

Brymer, M., Jacobs, A., Layne, C., Pynoos, R., Ruzek, J., Steinberg, A., & Watson, P. (2006). Psychological first aid field
operations guide (2nd ed.). National Child Traumatic Stress Network and National Center for PTSD.

Berger, R., & Quiros, L. (2014). Supervision for trauma-informed practice. Traumatology, 20(4), 296-301.

Brave Heart, M.Y.H., Chase, J., Elkings, J., and Altschul, D.B. (2011). Historical trauma among indigenous peoples of the
Americas: Concepts, research, and clinical considerations. Journal of Psychoactive Drugs, 43 (4), 282-290.

Connors, G. J., Donovan, D. M., & DiClemente, C. C. (2001). Substance abuse treatment and the stages of change
selecting and planning interventions. New York: Guilford Press.

Elliot, D.E., Bjelajac, P., Fallot, R.D., Markoff, L.S., and Reed, B.G. (2005). Trauma-informed or trauma-denied: Principles
and implementation of trauma-informed services for women. Journal of Community Psychology, 33(4), 461-477.

Ford, J.D., Fallot, R., and Harris, M. (2009). Group Therapy. In C.A. Courtois and J.D. Ford (Eds.), Treating complex
traumatic stress disorders: An evidence-based guide (pp.415-440). New York, NY, US: Guilford Press.

Gutheil, T. G. & Brodsky, A. (2008). Preventing boundary violations in clinical practice. New York: Guilford Press.

Harris, M. and Fallot, R. (2001). Using trauma theory to design service systems. New Directions for Mental Health
Services, 89. Jossey Bass.

Hobfoll, S. E., Watson, P., Bell, C. C., Bryant, R. A., Brymer, M. J., Friedman, M. J., ... & Ursano, R. J. (2007). Five essential
elements of immediate and mid–term mass trauma intervention: Empirical evidence. Psychiatry, 70(4), 283-315.

Hoge, M. A., Morris, J. A., Daniels, A. S., Stuart, G. W., Huey, L. Y., & Adams, N. (2007). An action plan for behavioral
health workforce development: A framework for discussion. Rockville, MD: Substance Abuse and Mental Health
Services Administration.

Hopper, E. K., Bassuk, E. L., & Olivet, J. (2010). Shelter from the storm: Trauma-informed care in homeless service
settings. The Open Health Services and Policy Journal, 3, 80–100.

Kaniasty, K., & Norris, F. H. (2008). Longitudinal linkages between perceived social support and posttraumatic stress
symptoms: Sequential roles of social causation and social selection. Journal of Traumatic Stress: Official Publication
of The International Society for Traumatic Stress Studies, 21(3), 274-281.

Kress, V. E. & Hoffman, R. M. (2008). Non-suicidal self-injury and motivational interviewing: Enhancing readiness for
change. Journal of Mental Health Counseling, 30, 311–329.

Math SB, Naveen Kumar C, Maria C Nirmala. Disaster Mental Health & Public health: An integrative approach to
recovery., In., Post-traumatic Stress Disorder. Eds Dan J. Stein, Matthew Friedman, Carlos Blanco., Vol. 26. John Wiley
& Sons, 2011 pp266-272. . 2011.

Math, S. B., Nirmala, M. C., Moirangthem, S., & Kumar, N. C. (2015). Disaster Management: Mental Health Perspective.
Indian journal of psychological medicine, 37(3), 261–271. https://doi.org/10.4103/0253-7176.162915

Najavits, L. M. (2002). Seeking safety: A treatment manual for PTSD and substance abuse. New York: Guilford Press.

National Child Traumatic Stress Network & National Center for PTSD (2006). Psychological first aid: Field operations
guide (2nd ed.). National Child Traumatic Stress Network & National Center for PTSD.

Norris, F. H., Friedman, M. J., & Watson, P. J. (2002). 60,000 disaster victims speak: Part I. An empirical review of the
empirical literature, 1981–2001. Psychiatry, 65(3), 207-239.

Schwartz, R., & Sendor, R. M. (1999). Helping in disasters: A community approach to psychological first aid.
Professional Psychology: Research and Practice, 30(5), 487.

90
Substance Abuse and Mental Health Services Administration (SAMHSA). (2014). Trauma informed care in behavioral
health services: A treatment protocol (TIP) SERIES 57. HHS Publication No. (SMA) 14-4816. Rockville, MD

Ursano, R. J., Fullerton, C. S., & Norwood, A. E. (2003). Psychiatric dimensions of disaster: Patient care, community
consultation, and preventive medicine. Psychiatric Clinics, 26(3), 639-655.

US Department of Health and Human Services. SAMHSA’s concept of trauma and guidance for a trauma-informed
approach.

Van Ommeren, M., & Wessells, M. (2007). Inter-agency agreement on mental health and psychosocial support in
emergency settings. Bulletin of the World Health Organization, 85, 822-822.

Weine, S., Danieli, Y., Silove, D., Ommeren, M. V., Fairbank, J. A., & Saul, J. (2002). Guidelines for international training
in mental health and psychosocial interventions for trauma exposed populations in clinical and community settings.
Psychiatry, 65, 156–164.

91
5
CHAPTER 5

Providing
Trauma-
informed MHPSS
during disasters
 Interventions aimed at working with traumatic events
1 such as disasters focus on promoting healing and
recovery by addressing the psychological, emotional,
PLANNING AND and social consequences of disaster. We help individuals
DELIVERING and communities to focus on experiencing safety and
stability, and integrate the traumatic experience in our
INTERVENTIONS lives. Acknowledging and validating the experience of
the individual and the community is an integral part of
this process. It is important to recognize that recovery
from trauma is not a linear process, and there might
be setbacks, challenges, and fluctuations in progress.
Experiences of disaster are not to be simply forgotten or
moved on; not necessarily returning to the way things
were before the disaster, but rather about finding new
ways of living and thriving in spite of this experience.

We need to be in our own window of tolerance for

facilitating trauma-informed work. It is important for
us to use the strategies discussed in the chapter with
ourselves first. We can then use the strategies with our
clients as well.

2
STAGES OF
RECOVERY

Recovery unfolds in three stages (Herman, 1998).

The central task of The central task of the The central task of
the first stage is the second stage is the third stage is
establishment of safety. remembrance and reconnection with
mourning. ordinary life.

CHAPTER 5: PROVIDING TRAUMA-INFORMED MHPSS DURING DISASTERS 93

 We must make sure that the strategies we suggest
for the clients are timed appropriately to their stage of
recovery. It is important to note that these stages are
not linear. The clients may move back and forth on these
stages. For example, a client who might have started
reconnecting with their ordinary life, may once again
feel anxious and panicked. In this case, it is important to
understand what could have triggered the clients and
what can we do to restore safety and stablise them. We
have to be attuned to the client’s reactions and keep
track of their processes.

It is important to understand the triggers that clients

may face. A trigger is a stimulus or a sensory reminder
such as noise, smell, temperature, physical sensation
or visual scene that sets off a memory of a trauma or
a specific portion of a traumatic experience (SAMHSA,
2014). For example, a person who was at a hill station
during a flood may get triggered by the sound of running
water, or the feel of wet clothes and may experience
increased heartbeat or an urge to escape or run. While
some triggers may be easy to identify and anticipate,
others may be more subtle and inconspicuous. For
example, being triggered by the time of the day at which
the disaster occurred. These triggers may catch the client
off-guard. Triggers can generalize to any characteristic
that resembles or represents a previous trauma. These
triggers elicit a strong emotional reaction and need to be
managed by using coping strategies. Triggers may lead
to flashbacks, intrusive thoughts or nightmares. Triggers
are important because they are the doorway into post
traumatic flashbacks etc and people go to extreme
lengths to restrict their lives to avoid being triggered.

2.1 ESTABLISHING SAFETY AND STABILIZATION

Disasters can shake the sense of safety that one

experiences in an environment. People may get
displaced from their homes, not be able to access the
support that they may have and even have to experience
loss of homes, people and their livelihood. As we have
seen previously in chapter 3, the body also starts
showing responses which the client may not completely
understand. Thus, the first task of recovery is to establish
the client’s safety. No further work can be done without
securing safety for the client. This stage may last for a
short duration such as a few sessions or may last for a
much longer duration based on the severity, duration,

CHAPTER 5: PROVIDING TRAUMA-INFORMED MHPSS DURING DISASTERS 94

 and early onset of the trauma experienced by the client.
This stage can be addressed in relief camps, for both
individually and in groups.

2.1.1 SAFETY

An important step in establishing safety is to focus on

helping our clients regain control of the body as well
as establishing some control of the environment.
Regaining control of the environment involves
restoration of basic needs. This involves helping clients
and communities have access to safe living spaces, food
and water.* We can explore the strategies for helping
clients with basic needs in the Section 3 chapter 1
(addressing basic needs). Feeling unsafe in the body
is expressed as a permanent sense of looming danger
and feeling out of control with respect to emotions and
thoughts. It may also be expressed as difficulty paying
attention to the basic needs such as sleep, food, and
exercise. Helping clients re-establish their relationship
with their emotions, thoughts and attending to their
basic needs will help in establishing control over their
lives. Establishing control over the environment
includes having a safe living situation, financial security,
mobility, and a plan for self-protection against any threat.
It requires building awareness of their own resources for
practical and emotional support to build self-regulation
and provide a sense of competence and resilience.

Clients also need to feel safe in their body. For

establishing safety within the body we need to
help clients understand what happens in the body
during traumatic events, and then proceed to discuss
specific tools for restoring safety. This process is called
stabilization.

2.1.2 STABILIZATION
Stabilization is the process of restoring safety and
increasing a sense of control over trauma responses
(Curtois & Ford, 2009). In case we feel the client is getting
triggered, stabilizing the client becomes important.
Some important strategies that we may use are (a
detailed discussion of these techniques is done in the
next chapter):
Grounding Techniques: Grounding techniques help
clients feel more present and connected to the present
moment, rather than being overwhelmed by distressing
memories or emotions.
CHAPTER 5: PROVIDING TRAUMA-INFORMED MHPSS DURING DISASTERS 95
 Coping Skills: Teaching certain techniques such as
relaxation techniques, self-soothing activities, and
grounding exercises can help the clients.

Somatic Techniques: Somatic approaches such as body

awareness, gentle movement, or grounding exercises
that focus on bodily sensations can help regulate the
nervous system and reduce the intensity of trauma-
related symptoms.

Psychoeducation: Providing information about trauma

reactions and the physiological response to triggers
can help normalize the client’s experience and reduce
feelings of shame. Educating clients about the fight-
flight-freeze response and how triggers can affect the
body and mind can help them feel more in control.
Some scripts for psychoeducation that we may use to
enhance a sense of safety include:

1. About disaster. We can start by asking the client how

they felt during the disaster. They may reply with
emotions of fear and uncertainty. We can use that as
a window to start psychodeducating the clients about
the impact of disasters,

“Disasters tend to affect us profoundly because they

make us feel as if our lives are unpredictable and
that we are not in control of our own lives. Once we
have such an experience, we may find it difficult to
feel safe or to trust others. We might also lose trust in
ourselves and our judgments. We may feel scared, on
edge and uncertain about things.”

We can pause then ask, if they felt this way as well. We

can then ask them if they would like to understand
what happens to the brain during this time.

2. About how the brain deals with disasters. We can

explain the neurobiology of trauma by saying,
“In everyday life, our reasoning center called the
prefrontal cortex or PFC is active and our emotional
centre or the amygdala is quietly observing the
situation. Thus, we tend to respond to situations
rationally, rather than emotionally. During events
that threaten our safety such as a disaster, the
amygdala gets activated. We can think of the
amygdala as an alert watchman looking out for our
safety. As soon as the amygdala feels that there is

CHAPTER 5: PROVIDING TRAUMA-INFORMED MHPSS DURING DISASTERS 96

 a threat to us, it starts sending signals to activate
emotions such as fear and anger. At the same time,
the PFC becomes quiet. We can imagine the PFC
to be like the reasoning head of the family. Just
like in case of a robbery, the members of the house
stay quiet and let the watchman take charge of
the situation, when the amygdala is active, the
PFC becomes quiet. This means that our reasoning
centers are less active and emotions take charge of
the responses. PFC and amygdala work like a see-
saw; when one part is active, the other is quiet. In
order for things to go back to usual, the PFC has to
become active and amygdala has to be quiet. If the
situation is too frightening, it is possible that the PFC
becomes too quiet, and thus, the message to the
amygdala to stop becomes slower and becoming
calm takes more time.”

Another way of explaining this is when we use the

hand model described in chapter 3. We can
say,

“The brain is one of the most complex organs

in the human body. We can think of the major
parts of the brain as being divided into three parts:

1. Lower part of the brain which is responsible for

functions of our body such as regulating the
heartbeat, breathing, etc.

2. Emotional Brain which is responsible for

emotion and forming memories, thereby helping
us learn.

3. Rational Brain which is responsible for thinking

and reasoning.

We can imagine the brain to be like a fist formed

by tucking the thumb inside it. The wrist represents
the lower part of the brain, the thumb represents
the emotional brain and the fingers that cover the
thumb are representing the rational brain. This
means that the rational brain takes charge of the
other parts. When there is no threat, all functions are
performed seamlessly. However, it is different when
the brain perceives a threat. In case of threat, the
fingers no longer cover the thumb. The thumb takes
over. The rational brain is no longer regulating the
emotional brain. Thus, the activity of the emotional
CHAPTER 5: PROVIDING TRAUMA-INFORMED MHPSS DURING DISASTERS 97
 brain overrules the rational brain. Often these are
short-term changes. When the threat is removed the
rational brain once again takes over the emotional
brain.

When we are exposed to extreme threats this short

term, adaptive response becomes chronic and long
term such that even when we transition into a safe
environment, the emotional brain does not turn off.
We are stuck in the survival system. Thus, very little
information gets passed up to the higher, rational
parts of their brain. Whilst we are stuck here, we
find it difficult to feel safe, form secure attachments;
manage emotions or behaviour, think, learn or reflect
because we are simply trying to stay alive in a world
that we feel is highly dangerous.”

3. About trauma responses. We can focus on helping

clients understand various ways that people
respond after trauma. It is important that we do not
overwhelm the client with the information as this
conversation is heavy.

First, we can start by validating the clients’ experience.

We may say,

“if someone went through what you did, they are also
likely to experience similar responses. Our brain and
body are designed for survival; we tend to store any
threatening information. The body, thus, starts to be
in a state of vigilance, looking out for and predicting
danger. But this strategy that helps us survive when
the danger is active, becomes painful and exhausting
once the threat has passed”.

The next step will be to describe the fight-flight-freeze

response. We begin by helping clients understand the
physiological alarm state. We can say,

“When the body starts feeling threatened, it starts

some changes in the body and brain. These changes
are very rapid and affect the entire body. During this
time, our heart rate increases, muscles become tense,
and our breathing becomes shallow. Alongside, our
emotions are also activated. In case we start feeling
angry, the body prepares itself to fight. If we feel
afraid, our body may start preparing to run away or
flee. If the fear becomes too much and the body feels
neither fight or flight will help, it goes into a freeze
CHAPTER 5: PROVIDING TRAUMA-INFORMED MHPSS DURING DISASTERS 98
 mode. This freeze response may be one of two types.
One, we may freeze if we want to orient ourselves
to the situation to understand the threat, take stock
of what is happening and decide what to do. In the
other type, we feel immobilized and dissociated (that
is, feeling lost and not present in the here and now).”

Once we have explained the fight-flight-freeze

response, we can take a pause and ask the clients
if they felt any of these responses. It is important to
once again validate and normalise their response. We
can say,

“In life-threatening situations, becoming highly

aroused (no sleep, constant state of anxiety) or
danger-focused (not concentrating on other things)
or numb (feeling no pain) are all adaptive to survive.
It is only when these states continue in the absence
of the threatening situation, these feelings of anger,
anxiety or arousal or being numb may seem to be
coming out of the blue. It is our mind’s way of making
sense of what has happened”.

We can then explain the concept of trigger. We may

say,

“Even though these responses seem to come out

of the blue, most of these are actually reactive. We
have to identify triggers. Triggers are reminders of
the traumatic event. It is often tied to our senses
– something you may have seen, heard, touched,
smelled or tasted while the disaster occurred. For
example, many people like you who had experienced
floods, become triggered by the sound of water
dripping. People who have survived fire may get
triggered by the sensation of heat and people
coughing”.

4. About the window of tolerance. The concept

of window of tolerance (Seigel, 1999) proposes
that between the extremes of hyperarousal and
hypoarousal is a ‘window’ or range of optimal arousal
states where emotions are felt as tolerable and our
experiences can be integrated. We can explain this to
our clients by saying,
“Window of tolerance is the zone where we are able
to process intense emotional arousal in a healthy
way, allowing us to function and react to stress or
CHAPTER 5: PROVIDING TRAUMA-INFORMED MHPSS DURING DISASTERS 99
 anxiety effectively. We feel like we can deal with the
situations in our lives. Even if we feel stressed we
are not bothered. However, when we feel anxious,
angry, overwhelmed and out of control, we may
feel like fighting or running away. This is the state
of hyperarousal. On the other hand, when we
feel spaced out, zoned out, numb or frozen, we
may feel like shutting down. This is the state of
hypoarousal. Traumatic situations shrink our window
of tolerance such that we spend more time in hyper
or hypoarousal; rather than window of tolerance.”
Working with trauma in the first stage of recovery
means working with expanding the clients’ window
of tolerance; helping them to manage states of
hyperarousal and hypoarousal.

We can also notice signs of hyperarousal in the session

(e.g., tension, shallow breath, rapid speech). In this
situation, we must interrupt the client’s narrative gently.
We can ask the client to move away from their narrative
and focus towards their body. The signs of arousal
can be identified and managed using strategies such
as diaphragmatic breathing, progressive relaxation,
mindfulness based exercise to name a few. These have
been discussed in the next chapter. Conversely, when
the client seems hypoaroused (e.g. when it feels like they
are not listening, lost, inattentive in our conversation),
we may redirect their attention to the environment
especially towards objects in the present environment.
This may help the client to pause thinking about the
past and come back to the present. Some important
strategies that can be used are grounding, movement
such as asking the clients to push down on the ground
with their feet, pushing the back against the wall,
orienting clients to the present by reminding them
of the date and their safety, etc. These strategies are
described in more detail in the next chapter.

By utilizing these techniques, counsellors can help

clients regain a sense of safety, stability, and control
after experiencing triggers, thus facilitating a more
secure foundation for further therapeutic work. Working
on safety and stabilization is a continuous process in
trauma-informed care to ensure that the client should
not get overwhelmed. Keeping a balance of using
techniques and checking in with the client is very
important.

CHAPTER 5: PROVIDING TRAUMA-INFORMED MHPSS DURING DISASTERS 100

 To prevent overwhelming the client and reducing
the possibility of retraumatization, we have to pace
our sessions. This technique is called titration (Levine,
1997). In order to understand titration, we can think of
working with trauma as drinking a very strong drink.
Instead of drinking it all at once and overwhelming our
sensation, we need to drink it slowly to get used to its
taste. Similarly, any work with trauma stimuli has to
be done slowly, step-by-step. We need to start with a
trauma response by working with the least amount of
discomfort. Allow the client to feel discomfort but not
so much that it overwhelms them. We can then ask
them to come back to the window of tolerance. Once
the discomfort disappears, we can move on to the next
stimuli. Another important construct to be kept in mind
is pendulation (Levine, 1997). It means swinging between
discomfort associated with trauma memories and
feelings of safety. Before we begin with any technique,
we have to review the concept of safety with the client.
Once this feeling is identified in the body, we can ask
the client to swing between this feeling and then move
on to feeling the distress. Just like when a child starts
swinging, they start slowly and come back to keep their
feet on the ground, and then start gaining momentum
later, the process of working with trauma will also be
undertaken with the same precaution.

Tool Box for Safety and Stabilization

GROUNDING helps in managing reminders of trauma memories. These techniques

using senses to bring the mind back to the present, focusing on breath and using
imagery to make the mind and body feel safe.

• Common grounding techniques such as smelling essential oils, drinking

fragrant tea, mindfully eating crunchy food, doing yoga and stretching and
other such techniques described above may be helpful.

• Another technique is the 54321. We ask clients to look around and see 5 objects
they can see, 4 things they are touching, 3 sounds they can hear, 2 things we
can smell and 1 thing they can taste.

• Another helpful grounding technique is playing a favourite song, paying

attention to its melody and music and singing it aloud.

CHAPTER 5: PROVIDING TRAUMA-INFORMED MHPSS DURING DISASTERS 101

 We can also grounding statements such as

“It seems like you are overwhelmed by the repeating experience of past
memories or emotions. Let us try to bring you back to the present. Take a deep
breath, relax your body; let the tension seep out of your body towards your feet
which touch the ground. Imagine walking out of the past and into the present.
Look around you and tell me what you can see presently?”

SAFE OBJECT TECHNIQUE may also help clients feel a sense of safety and regulate
their emotions. We can ask clients to find a physical object that can anchor them.
This object is something that has personal significance to them like a toy or a piece
of cloth or jewellery or a photograph that can be carried around. We can ask them
to imagine feeling safe with the comfort that this object may bring. We can also
ask them to carry it around so that they can use it whenever they want.

Some SOMATIC TECHNIQUES may also help in bringing the person back to the
present. Drop three (Lynch et al, 2015) is one such technique. It includes asking the
client to drop first the jaw, shoulders and stomach. We can say

“First drop your jaw by making your tongue fall to the bottom of your mouth.
Then drop your shoulders, release them and let them fall. And lastly, drop your
stomach. Just let it go without holding it tightly. Notice how you feel.”

We can also clients to include the SELF-STATEMENTS FOR SAFETY such as:

• What is it that I would like to do?

• What can I do in this situation? What is in my control?
• I am in control of my reactions.
• I am not in danger. I am safe now.
• I am triggered right now but I will be okay. This flashback will pass. I am safe
now. I have survived this. I am trying to be healthy and happy now

SAFE SPACE VISUALIZATION with the client especially after they feel
overwhelmed. A script adapted from Lynch et al (2015) reads

“Sit comfortably, relaxed and at ease, by keeping your hands empty and your
feet on the ground. Start by taking three breaths, long, slow and deep breaths.
Focus on it, the way it changes as you become aware of it. Let it stay calm
and relaxed and move on to your heart beat. Let it stay rhythmic, warm and
relaxed. Let go of the tension with each breath and the beat of your heart.
Now, think of a place where you feel safe and secure. It can be a real place
or a place in your imagination. Let it come to you. Whatever it is, a beach, a
lake, a mountain, anywhere; just picture it in your mind. Imagine now you
have entered this safe space. You are inside this safe place. Look at the objects
around you in this safe place… Notice what they are, their colors, their shapes.
Look around… And now, listen to the sounds in your safe place, anything
you can hear, maybe birds, animals, sound of nature, wind, etc. As you look

CHAPTER 5: PROVIDING TRAUMA-INFORMED MHPSS DURING DISASTERS 102

 around and listen to your surroundings allow yourself to feel safe, warm and
comfortable. Now, pay attention to the smells in your safe place. What are the
smells that you are noticing? They could smell of nature, maybe your favourite
food, any flower? Enjoy the smells as you breathe in deeply… Allow yourself to
feel safe in this space surrounded by the smells, Now, walk around this space
in your mind. Notice the objects and pick them up. Touch these objects and
observe their textures. Are they soft or rough? Warm or cold? Soft or hard?
Continue to walk around and keep on touching these objects. Spend some
time in your safe place, while relaxing and enjoying it… (pause one minute).
And when you are ready, come back into the present, knowing that your safe
space is within you and you can return there at any time. It will always be
there for you.”
CREATING COPING CARDS may also help. Coping cards refer to a card or a piece
of paper that has all the strategies that a client has learnt so far. In times of crisis,
it is possible that they may not remember these strategies. It might be helpful to
simply have written reminders for them. They can supplement this list by writing
down the situations and scenarios where the specific coping strategies on the
card can be used.

Reflective Exercise

• What could be the reason for establishing safety and stabilization as the first
step of recovery according to you?

• Some of these constructs may be easy for us to understand and

psychoeducate about in English. How can we ease this process in our local
languages?

2.2 REMEMBRANCE AND MOURNING

Once the client feels safe and can trust us, we can
gently proceed to the second stage of recovery. This
involves reconstruction of the traumatic memory
to integrate it into the client’s life (Mollica, 1988). It is
based on the principle of empowerment (Herman,
1992). The role of the counsellor is to be a witness to the
story and be an ally in recovery. This allows the client
to reconstruct the fragmented story of the traumatic
events in an organized, detailed, and verbal account,
which is centered in the client’s timeline and context,
incorporating their emotional responses.
CHAPTER 5: PROVIDING TRAUMA-INFORMED MHPSS DURING DISASTERS 103
 Throughout this process, the strategies learnt in the
first phase of recovery must be actively used to access
safety internally, so that traumatic memories can be
worked with without clients feeling ‘flooded’. . This helps
to maintain the balance between avoidance of the
traumatic memories and the feeling of overwhelm they
may bring. The other consideration is the pacing and
timing of the reconstruction of the trauma narrative.
It also includes the acceptance that the memories are
reconstructed and change as they are filtered by new
experience, which means that we may not be able to
uncover a ‘complete’ picture of the client’s story. This
tolerance to uncertainty and ambiguity must be learnt.
It also involves examining moral questions of guilt,
responsibility and the belief in justness of the world.
Engaging in this process along with the client may make
us question our beliefs as well. Our stance cannot be
neutral; rather it is to express our solidarity with their
process (Agger & Jensen, 1990).

A major task for this stage is grief and mourning about

what has been lost from the clients. It is different for
different experiences of trauma. Once the client is able
to navigate this grief they may start realising that trauma
is a part of their life, not their entire life. At this time, they
may feel hope and a desire to engage with life.

One of the ways of helping clients at this stage is to help

them write their narratives. We can ask them to think
about one of their traumatic experiences. For the first
time, we ask them to select an event that is not very
triggering. Once we understand how to proceed, we can
take on more distressing events. The format that can be
used is :

DEAR SELF (Reutter, 2019). The acronym stands for

Describe, Express and empathize, Assert, appreciate
and apologise and reinforce.

It can be described as:

D-Describe. In the first part of the letter, we ask the

client to describe a traumatic event that happened to
them. We ask them to retell the specific order of events
including details of the information gathered from our
senses such as what they saw, what they heard, what
they smelled, what they tasted and what they felt.

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 E-Express and Empathize. We can ask them to express all
the emotions they felt as the traumatic event unfolded.
We also ask them to express their emotions after the
experience ends. It can also be useful to have clients
identify emotions that became frozen, numb, or stuck
after the traumatic event. We will ask them to show
empathy towards themselves that they never received.

A-Assert, Appreciate, Apologize. The next step is to assert to

their traumatized self that what happened to them was
wrong and was not their fault, no matter what people
say to them. Try to balance their thinking when any
cognitive distortions arise (see section 3; chapter 5). We
will then help the clients verbalize their appreciation to
their traumatized self for how strong and brave they have
been to have survived this trauma. We will remind them
to elaborate on all of their positive qualities that helped
them survive the trauma. Lastly, we will ask them to write
the apology that they never received or that they wish
they could have received. It is important to reiterate that
they are not apologizing for their own trauma. Rather,
the apology is for the fact that the trauma happened to
them in the first place.

R-Reinforce. We will help the clients reinforce their belief

to strengthen their relationship to themselves as well as
increase their dedication to the healing process. Many R
words can be used: remind, reassure, recall, recommit,
reflect, redeem, repurpose, redefine, and reenvision their
lives. We can remind them that the trauma is now over;
they can reassure themselves that they are safe. They can
practise and recall all the skills they have learned along
the way and recommit to practicing these. We will help
the clients to reflect on what they have learned from the
trauma, and even find ways to redeem or repurpose their
suffering. We can help them by asking questions such
as: How can their trauma be used to help others? What
insights have they learned from this trauma that they
could not have learned otherwise? How can they use this
trauma to help transform themselves, others, and the
world? We can also help them redefine their goals, plans,
and dreams moving forward. What future can they re-
envision that is no longer defined by their trauma? What
is their plan to live, love, and laugh as they have not done
before?.

CHAPTER 5: PROVIDING TRAUMA-INFORMED MHPSS DURING DISASTERS 105

 Another technique is COMPASSIONATE LETTER
WRITING (Lee & James, 2013). It includes the following
steps like identifying their motivation for writing this
letter, getting into the right mindset, experiencing
safety, and checking if they are ready to start writing as
the compassionate ‘self’ which understands, validates,
empathizes with, and supports the client unconditionally.
The next step is to help clients recognise their wisdom,
courage, strength, and resilience, adding empathy and
understanding to their experience and the unintended
consequences of the ways they coped, accepting that
it is not their fault, but it is their responsibility to work
through the trauma, describing what they need to help
them cope with their memories and release their final
statement of courage and commitment to a future
without suffering.

As disasters affect communities, we can integrate

community strengths and resilience in this stage. We
can ask communities to regularly get-together in a safe
environment where we can facilitate the group. We can
use these groups to disseminate information about
disasters and recovery, create rituals and ceremonies
to honour the lives and livelihoods that were lost, share
stories, memories and feelings about the disaster,
exploring themes of loss and meaning and build on
stories of resilience (Dembert & Simmer, 2000).

Example of community exercise

Hosting events where community members can share stories and memories
of those who have been lost can foster a collective remembrance.

We can organize

• Story Circles: Organize small groups where individuals can share personal
stories and memories in a supportive and respectful setting.

• Digital Memory Archives: Create online platforms where community

members can contribute stories, photos, and videos to preserve the
memories of loved ones.

In the aftermath of the Grenfell Tower fire in London, community events were
organized where survivors and relatives shared their memories of the victims,
helping to keep their stories alive and fostering community solidarity (BBC
News, 2018).

CHAPTER 5: PROVIDING TRAUMA-INFORMED MHPSS DURING DISASTERS 106

 2.3 RECONNECTION

The last stage is accompanied with a state of trust,

feeling in charge of our own self and staying connected
with others. It helps them maintain and respect the
boundaries of others (Herman, 1992). This allows clients to
deepen their relationship with others by drawing upon
their own initiative, energy, and resourcefulness. Many
clients may also want to transcend their relationships
and engage in social action. While most clients at this
stage may not require our help, we can still consider the
following strategy to help them transverse this stage.

The TREE OF LIFE METAPHOR (Ncube, 2006) includes

the following parts:

The Fruits. These represent the

gifts that the client has been
given, including material gifts
as well as acts of kindness, love,
care etc.
The Leaves. These are the
significant people in the
client’s life.

The Branches. These are

representative of the hopes, dreams The Trunk. This represents the
and wishes of the client. special and precious memories of
the client.

The Ground. This represents where

the client is at present and how
their daily life goes. The Roots. This prompt helps in
understanding where the client comes
from, their family, their origins etc.

For communities and groups, we can focus on exploring

new collective identity and strengths by helping
members identify shared values, cultural traditions,
and some resilience stories which serve as sources of
support and solidarity (Kaniasty & Norris, 2008). We can
also foster a sense of empowerment and agency by
encouraging them to take on advocacy roles to address
systemic issues and promote positive change. For
example, communities can be mobilized to advocate for
better disaster preparedness in their area.

CHAPTER 5: PROVIDING TRAUMA-INFORMED MHPSS DURING DISASTERS 107

 Reflective Exercise
• What are the unique challenges for stages 2 and 3 that we can envision?

• What could be our markers or indicators for understanding when the client
may need to review strategies for the first stage?

• How do you think the stages 1, 2 and 3 of recovery may be experienced by the
counsellor?

• What unique skills and requirements may be asked of the counsellors in

each of these stages?

3
POST-TRAUMATIC Evidence for personal growth during suffering or
following adversity have been found in philosophical,
GROWTH (PTG) existential and psychological literature. Post-traumatic
growth (PTG) is one such positive transformational
change that some individuals experience after a major
life crisis or traumatic event. PTG has been defined as
“positive psychological changes experienced as a result
of the struggle with traumatic or highly challenging life
circumstances” (Tedeschi & Calhoun, 2004). It may occur
in a variety of areas such as finding new opportunities
and possibilities for personal development and relational
capacities that were not present before the crisis. For
example, people may feel that they have become closer
to people they care about or have an increased sense
of connection to others who have gone through deep
suffering. They may also feel a renewed sense of their
own strength and appreciation for life in general. Some
individuals may also find growth in their religious or
spiritual beliefs.

We as mental health professionals may facilitate this

process by asking strengths-based questions (discussed
in Section -3; chapter 11). We may also ask clients to
engage with their values. Values are freely-chosen ideas
that can give us purpose and direction in life; they act as
a compass for guiding our actions and decisions (Plumb
et al., 2009). We may want to check with the clients, the

CHAPTER 5: PROVIDING TRAUMA-INFORMED MHPSS DURING DISASTERS 108

 values they live by. A question that may help can be,
“Which value do you identify with the most? How can
you remember this at all times?” Helping clients live a life
aligned with their values help in promoting a sense of
purpose and meaning in their life.

Reflective Exercise
• What are some of the values that we espouse in our personal and
professional identities?

• How can we facilitate the process of vicarious post-traumatic growth for us

as counsellors?

Let’s avoid...

Working with clients in a triggered state ourselves. It is important to

remember that trauma work is guided by regulation of the counsellor
themselves. If we are in a triggered state we cannot be present for our clients
and may risk re-traumatizing them.

Hurrying through the stage of safety and stabilization. The first stage of
trauma work, that is, safety and stabilization remains the most crucial stage
and sets up the work for further intervention. Missing out on this stage or not
rooting it firmly in the intervention plan places the client at risk for worsening of
their condition.

Considering stages as being separate instead of continuous. The presentation

of the client’s difficulties requires us to astute in our observations as well as
flexible in our approach to work with them. It may require us to go back to
reviewing strategies in the first stage even when the work has started for grief
and mourning.

Not nurturing the growth narratives of the clients. Identifying pathways

of resilience and growth are important considerations for us as counsellors.
We must be vigilant to these narratives and expand on them. However, care
must be taken that we do not consider post-traumatic growth as an expected
outcome for the clients and force its presence in client narratives.

CHAPTER 5: PROVIDING TRAUMA-INFORMED MHPSS DURING DISASTERS 109

 Self-care Exercise
The counsellor who commits to trauma work also commits to an ongoing
contention with self. They must be able to access interpersonal and intrapersonal
resources. Sublimation, altruism, and humor can be used to be more present in
trauma work to engage an enriched life by appreciating life more fully, taking it
more seriously, having a greater scope of understanding of others and themselves,
forming new friendships and deeper intimate relationships, and feeling inspired by
the daily examples of their clients’ courage, determination, and hope. We can use a
compassion tool-box which may consist of:

• Compassionate scent, for example, a bottle of perfume or a scent soaked cloth

• Compassionate objects such as stones or shells
• Drawing of a perfect nurturer
• Something in their favorite color
• Copy of new compassionate version of themselves exercise
• Pictures of loved ones smiling
• Important letters
• Copy of compassionate story of their lives
• Compassionate letter to themselves

Tips for Supervisors

Working with trauma means that we have to be careful with understanding our
own style of supervision. It may be helpful to keep the following considerations in
mind:
• Establishing trustworthiness: Transparent decision making and supervisee
inclusion in process by having regular, open and honest communication.
• Encouraging collaboration and mutuality: Reducing power differences
between clients and staff and between staff members/employees by
collaboratively discussing the plan of action instead of didactically telling them
what to do.
• Fostering empowerment: Acknowledging survivors voice and strength in
determining choices by listening to supervisee feedback and encouraging and
supporting supervisees

This chapter provides an overview of the process of intervention in trauma-informed

care. The various modalities of trauma-focused interventions and stages of recovery
as well as the strategies were discussed. The next chapter will focus on the specific
strategies that will help alleviate trauma-related symptoms.

CHAPTER 5: PROVIDING TRAUMA-INFORMED MHPSS DURING DISASTERS 110

References

Agger I & Jensen SB. Testimony as ritual and evidence in psychotherapy for political refugees. J. Traumatic
Stress1990; 3: 115 130.

American Psychological Association. (2017). Addressing discrimination: A call to action for psychologists. Retrieved
from https://www.apa.org/advocacy/civil-rights/discrimination

Cloitre, M., Koenen, K. C., Cohen, L. R., & Han, H. (2002). Skills training in affective an dinterpersonal regulation
followed by exposure: A phase-based treatment for PTSD related to childhood abuse. Journal of Consulting and
Clinical Psychology, 70, 1067–1074.

Dembert, M. L., & Simmer, E. D. (2000). When trauma affects a community: Group interventions and support after a
disaster. Group psychotherapy for psychological trauma, 239-264.

Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD:Emotional processing of
traumatic experiences: Therapist guide. New York: Oxford University Press.

Herman, J. L. (1998). Recovery from psychological trauma. Psychiatry and Clinical Neurosciences, 52(S1), S98-S103.
Kaniasty, K., & Norris, F. H. (2008). Longitudinal linkages between perceived social support and posttraumatic stress
symptoms: Sequential roles of social causation and social selection. Journal of Traumatic Stress: Official Publication
of The International Society for Traumatic Stress Studies, 21(3), 274–281. https://doi.org/10.1002/jts.20332

Lee, D. A., & James, S. (2013). The compassionate-mind guide to recovering from trauma and PTSD: Using
compassion-focused therapy to overcome flashbacks, shame, guilt, and fear. New Harbinger Publications.

Linehan, M. M. (1993). Dialectical behavior therapy for treatment of borderline personality disorder: Implications for
the treatment of substance abuse. In L. S. Onken, J. D. Blaine, & J. J.Boren (Eds.), Behavioral treatments for drug
abuse and dependence (pp. 201–216). Rockville, MD: National Institute on Drug Abuse

Mollica R. The trauma story: The psychiatric care of refugee survivors of violence and torture. In: Ochberg F (ed.), Post
Traumatic Therapy and Victims of Violence. Brunner/Mazel, New York, 1988; 295–314.

Neuner, F., Schauer, M., Roth,W.T., & Elbert,T. (2002). A narrative exposure treatment as intervention in a refugee
camp: A case report. Behavioural and Cognitive Psychotherapy, 30, 205–210.

Plumb, J. C., Stewart, I., Dahl, J. A., & Lundgren, T. (2009). In search of meaning: Values in modern clinical behavior
analysis. Behavior Analyst, 32(1), 85–103. https://doi.org/10.1007/BF03392177

Resick, P. A. & Schnicke, M. K. (1993). Cognitive processing therapy for rape victims: A treatment manual. Newbury
Park, CA: Sage Publications.

Reutter, K. (2019). The Dialectical Behavior Therapy Skills Workbook for PTSD: Practical Exercises for Overcoming
Trauma and Post-Traumatic Stress Disorder. New Harbinger Publications.

Shapiro, F. (2001). Eye movement desensitization and reprocessing (EMDR): Basic principles, protocols, and
procedures. (2nd ed.). New York: Guilford Press.

Siegel DJ (1999) The Developing Mind. New York: Guilford.

Substance Abuse and Mental Health Services Administration. Trauma-Informed Care in Behavioral Health Services.
Treatment Improvement Protocol (TIP) Series 57. HHS PublicationNo. (SMA) 13-4801. Rockville, MD: Substance Abuse
and Mental Health Services Administration, 2014.

Tedeschi, R. G., & Calhoun, L. G. (2004). Posttraumatic growth: Conceptual foundations and empirical evidence.
Psychological Inquiry, 15(1), 1-18. https://doi.org/10.1207/s15327965pli1501_01

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6
CHAPTER 6

Mental Health
and Psychosocial
Interventions for
specific trauma
responses
during disasters.
 In the previous chapter, the phases of working with
trauma were discussed. In this chapter the focus is
on interventions that can be carried out with specific
responses that individuals with histories of trauma may
present with. It is important to note that while there
are a lot of interventions listed here, we need to use our
own discretion in using them. As we have explained to
clients, the reasoning part of the brain, the PFC goes
offline when threat is present (real or perceived), and the
emotional brain takes over (see the detailed explanation
in chapters 3 and 5), the first focus will be on helping
clients feel safe and getting them back in their window
of tolerance. Thus, we will use the techniques to regulate
arousal first before using other techniques which require
us to work with our rational mind.

The list of these responses is not exhaustive and it is

possible that counsellors may come across certain
responses that are not discussed in this chapter.
Supervision and further training may be helpful in
understanding working with these responses.

1
REMINDERS OF Memories, images, smells, sounds, and feelings
associated with the traumatic event may come back
TRAUMA MEMORIES to the individuals and makes it difficult for them to
stay in the present. These may present as unwanted,
frequent, distressing visuals, memories or nightmares
of the traumatic event. People may feel as though the
events were happening again (flashbacks) and become
highly distressed. It is possible that physical signs such
as sweating, heart racing, and muscle tension may be
present. This may lead to other emotions such as grief,
guilt, fear or anger.

In order to assess the presence of reminders of trauma

memories, we may ask, “Do you remember …. (using
the language of the client for the traumatic event)
repeatedly?”; further we can ask, “Do you have dreams
about the event?”. In order to understand flashbacks
better, we may want to say, ““Do you feel that event
comes back to you as if you are re-experiencing it? or as if
it plays as a movie in front of you?”. This can be followed
up by another question like, “Do you feel that when the
event is mentioned, you feel very distressed and it is
difficult for you to come back from it?”

CHAPTER 6: MENTAL HEALTH AND PSYCHOSOCIAL INTERVENTIONS FOR SPECIFIC TRAUMA RESPONSES DURING DISASTERS 113
 In order to help clients regain a sense of control or
mastery, we can use the following interventions:

1. Psychoeducation helps clients understand concepts

such as flashbacks. We may say, “Intrusive thoughts
or feelings may appear to us as flashbacks, dreams,
or memories of the trauma. They may come to us
when we do not want them and upset us. The reason
these memories make appearances is to allow
the mind to process the traumatic event by going
over them again and again. This is the mind’s way
of understanding and resolving these important
experiences. Even though this may seem strange
to us, it is quite useful in helping us learn about our
experiences and to sort through them.”

2. Having nightmares may disturb sleep. For sleeping

well, we can develop a “sleep kit” (Boon et al, 2011)
with the client. It is a real or imagined box which we
can ask the client to fill with those items that help
them to relax and calm down and bring them back
to the bed. It can be used before going to sleep or
during the night if the client gets up feeling anxious
or triggered. It can consist of relaxing and soothing
music or sounds (stored in a playlist), anchoring items
such as a special pillow or blanket, favorite pieces of
clothing, a toy stuffed animal, a book that the client
enjoys, photographs of people who are important to
them, or of safe places which may relax them and
a list of people they can call if needed during an
emergency. It can also contain a guide with prompts
that include:
• Describing what helps them unwind and prepare for
bed.
• Listing activities that need to be avoided before
bedtime.
• Bed-time routine to be followed.
• Checking in with oneself about what is needed before
going to sleep.
• Obstacles and the ways to manage them.

CHAPTER 6: MENTAL HEALTH AND PSYCHOSOCIAL INTERVENTIONS FOR SPECIFIC TRAUMA RESPONSES DURING DISASTERS 114
 Practice Exercise

Mrs R comes to us at relief centre for people who went through the earthquake.
She says that she gets nightmares of that night. She reports that she is not
able to sleep once she has the nightmare, which happens at least two to three
times in a week. Due to these, she is starting to feel scared to fall asleep. She
has not been able to sleep properly.

• What do you think is the reason for Mrs. R’s nightmares? How would you
explain it to her?

• Which strategy would you like to use with Mrs. R?

• How would you introduce the strategy to her?

2
ANY AVOIDANCE Memories and reminders of traumatic events can be
very distressing and unpleasant and thus, people with
BEHAVIOUR histories of trauma often avoid situations, people, or
events that serve as reminders. They try not to think
about, or talk about, what happened, and even avoid
their feelings about the traumatic event. This may result
in withdrawal from their families, friends and society as
well. They may not be willing to take part in activities
they used to enjoy earlier for the fear of being confronted
with triggers. They may feel even more isolated. They
may also start feeling unmotivated to do things and
feel hopeless about the future for this fear. This fear also
maintains avoidance as the more the fear, the more is
the avoidance. Overcoming this fear will be important for
helping clients re-experience their life fully.

In order to assess avoidance, we may want to

ask questions such as, “Do you feel that you are
constantly avoiding some experiences? For example
; thoughts, memories, feelings or even people or
places that remind you of the traumatic event?”

CHAPTER 6: MENTAL HEALTH AND PSYCHOSOCIAL INTERVENTIONS FOR SPECIFIC TRAUMA RESPONSES DURING DISASTERS 115
Once the client begins to recognize avoidance, we can
offer them the following interventions:

1. Psychoeducating about avoidance. In order to help

clients understand what is avoidance and why it
occurs with respect to trauma memories, we may say,

“A common experience is avoidance of all thoughts

and reminders of the traumatic event. We often want
to put those things aside which are distressing to
us. We may feel momentarily better because we are
distracting ourselves from this distress. However such
avoidance actually prevents us from getting over the
experience.”

We can highlight how avoidance ultimately leads to

increased distress. We may say,

“When people go through difficult times, they tend to

avoid thinking about them. It may help them feel less
distressed. It is understandable why they would avoid
thinking about this. But, it is not very helpful in the
long run. Avoiding traumatic memories or reminders
prevents us from understanding and processing
these memories. Avoidant information tends to come
back to us in distressing ways, such as nightmares
or flashback memories. Let us do an experiment to
verify this. Please sit back, and close your eyes. Try to
imagine a pink elephant. Can you see it in your mind?
Now please try to stop this image. Do not think of the
pink elephant. Do not let it enter your mind. What
happened? Were you able to suppress it? This is what
happens to traumatic memories as well. Hence we
will focus on these memories.”

Here we can ask about some instances from their

lives where exposure has helped them in their daily
lives. We can say,

“Have you ever confronted something you feared?

What happened then?” We can continue our
psychoeducation then and say, “We are going to
tackle them head on. We will have to do this again
and again so that our mind gets used to this?
Have you put your hand in warm water? When you
first put it inside, it feels very hot. But if you keep
it in the water, our hand gets used to it and feels
comfortable. Similarly, by focusing attention on our
memories, we will get used to them and they will
116
 not be so distressing. It is possible that this may still
sound scary. It is like exercising, we will not be able
to understand the experience till we do not do it. To
use another example, imagine when you first wake
up from sleep to a room full of light. At first the light
is very bright and we are not able to see anything.
But after a few moments, we are able to see well. It’s
the same with memories. When we first think about
them, they will be distressing, but after we stay with
them for a while, we get used to them and feel less
overwhelmed.”

2. Traumatic stimuli may be avoided even before the

fear that they may generate is registered in the
body. An important step will be helping the clients in
identifying the bodily sensations associated with fear
so that they can plan for further interventions. Many
body scan meditations are freely available online.
This script is adapted from the one available on the
website va.gov. We may say:
The body scan practice helps you become more
aware of how all parts of your body are feeling. When
you first start this practice, it may be helpful to go to
a quiet location. Find a comfortable position, lying on
your back with your eyes closed. Take five breaths,
feeling your stomach expand as you breathe in and
relax as you breathe out. Now notice how your body
feels as a whole, try to understand what information
is your body giving you? Is there any area of tension
overall? Now begin to focus on each part of your
body in order. We can start with the toes of your left
foot. What do you feel? Cool air? A bed sheet? Your
socks or shoes? It is possible that we may not feel
anything; it is OK. Take a deep breath and end your
focus on your toes. Next step is to move to the sole of
your left foot. Again, what do you feel? When you are
ready, take a deep breath, and now shift your focus
from your foot to the next part of your body. We will
then go to the left ankle. Repeat the process. Focus
and allow yourself to hear your body. Take a deep
breath and move to the left shin; then to the left calf;
left knee; left thigh; left hip; pelvis; repeating all the
steps. Now shift your attention to your right foot and
leg (as you did the left) and then once again return
to your pelvis. Next we move to the belly and then the
back--lower, middle, and upper; moving to your chest
and then to our hands. Notice your left fingers, your
left hand, wrist, forearm, upper arm, shoulder. Move
CHAPTER 6: MENTAL HEALTH AND PSYCHOSOCIAL INTERVENTIONS FOR SPECIFIC TRAUMA RESPONSES DURING DISASTERS 117
 to the right hand and arm (as you did the left). We
will then move to your neck, face, scalp and top of the
head. During this process, when your mind wanders,
be gentle with yourself, knowing that this is what
minds do. Take a breath and refocus where you left
off. End the practice by returning to your breath. Take
five breaths, noting the rise and fall of your belly.

3. We can also focus on identifying emotions related

to avoidance (Cucu-Ciuhan, 2015). Identifying and
labelling emotions may help us in addressing them.
Common examples of emotions which lead to
avoidance include anxiety, anger, guilt, and shame.
For anxiety, we may want to label anxiety and validate
their fears. We may also help them understand that
anxiety is external to them; the anxiety is the problem,
the person is not. Additionally, acknowledging the
contextual factors that might be responsible for
maintaining anxiety is important. Similarly, for anger,
understanding and validating the anger is important.
We can also try to identify secondary emotions, that
is, emotions which may be accompanying the angry
response such as guilt.

4. Identifying and labeling guilt and shame can help

clients understand their emotions. Considering
trauma tends to make clients feel out of control, one
of the ways of taking control is self-blame and shame.
Shame and self-blame are natural human tendencies
especially when confronted with relationships where
we both fear and are dependent on the person
(Lee & James, 2013). It helps in seeing the world as
meaningful and finding some reason for bad things
to happen in life. Validating and psychoeducating
about the function of guilt can help clients contain
it.* For psychoeducating about the role of shame and
guilt, we may say,

“We may try to understand why the disaster

happened to us and our community, and how to
prevent it from happening in the future. This may
evoke feelings of self-blame, guilt or shame which is
different from the emotions such as fear, anger, or
sadness which come naturally in disasters. Shame
and guilt help us in trying to find some reason for

*Some strategies for containing anxiety (chapter 4), regulating anger (chapter 6) and assuaging guilt
(chapter 7) are found in the manual at xxx.

CHAPTER 6: MENTAL HEALTH AND PSYCHOSOCIAL INTERVENTIONS FOR SPECIFIC TRAUMA RESPONSES DURING DISASTERS 118
 this disaster. However, this process does not provide
us complete information as inherently disasters are
outside of our control”.

5. For shame, using a compassion-focused approach

may be helpful. An example of using compassion-
focused intervention can be helping the client
understand that avoidance, shaming and blaming
self actually aids our suffering rather than alleviating
it (Lee & James, 2013). We can ask the client what they
think is the function of the shame. We may ask,

“If I could take away this emotion, what do you think

will happen?”

This may elicit the function of the emotion (Gilbert

& Procter, 2006). Once this function has been
established, we may then ask the client to take an
imagery exercise. One way of doing this is to create a
perfect nurturer. We can create a perfect nurturer by
asking our clients certain questions like:

• How does your perfect nurturer look? Describing the

physical attributes of the perfect nurturer.

• How would they sound? If the client cannot come

up with a response, we may suggest some prompts:
calm, soothing, strong

• How do they smell? Does this smell feel familiar to

you? Can you identify it in your surroundings?

• How can your perfect nurturer comfort you?

Some prompts can be: by offering unconditional
acceptance? Non-judgmentality? Warmth, care,
kindness? Strength and wisdom? Hope?

• What does the perfect nurturer want for you?

CHAPTER 6: MENTAL HEALTH AND PSYCHOSOCIAL INTERVENTIONS FOR SPECIFIC TRAUMA RESPONSES DURING DISASTERS 119
 Practice Exercise

As a result, Mrs R has been avoiding sleeping. She tries to keep herself busy
throughout the day and tires herself so much that she should directly fall asleep.
She avoids her bedroom and prefers to sleep on the floor in the kitchen. She has
also been avoiding seeing her children at the time of sleeping so that it does
not start reminding her of how desperate she was while searching for them. Her
children miss her and often cry. In order to avoid hearing their cries, she puts on
her earphones something she feels very guilty about.

• What do you think is the reason for Mrs. R’s avoidance? How would you
explain it to her?

• Which strategy would you like to use with Mrs. R?

• How would you introduce the strategy to her?

3
HYPOAROUSAL It is possible that clients may feel a sense of hypoarousal,
that is when they feel like they are not able to listen, feel
lost, unable to pay attention to conversations. We may
assess different ways in which hypoarousal by asking
questions related to

1. Decreased interest in activities that were once

enjoyable to the client. We may ask,

“What do you enjoy these days? [if the client says

nothing, we may further ask] What did you enjoy
before the event occurred? Do you still enjoy it?”

2. Feelings of alienation, estrangement, or detachment

from others. It may be helpful to start with an open-
ended question such as

“how would you describe your relationships with your

loved ones currently?” on further probing, we may
ask, “do you feel connected to them?”

CHAPTER 6: MENTAL HEALTH AND PSYCHOSOCIAL INTERVENTIONS FOR SPECIFIC TRAUMA RESPONSES DURING DISASTERS 120
 3. Persistent inability to experience a positive emotion
such as happiness, satisfaction, or love. We can assess
this by asking,

“are you able to feel happy? Do you feel a sense of

achievement when you succeed at something? Are
you able to feel love?”

We can help clients who seem hypoaroused by:

1. Identifying and labelling emotions is the most

important part of the intervention. Along with
managing the emotions described above, it is
important for us to address the need to create
opportunities for generating positive emotions. It is
important for us to provide warmth and kindness
to inner experience. In this context, we can use the
loving kindness meditation (Shapiro & Carlson, 2009).
It is freely available online. One such example that can
be shared with the clients is given below:

“Begin by getting yourself comfortable and

connecting with your body and bring your attention
to your breathing. Follow your breath as it comes in,
and then out of your body, without trying to change
it. Simply be aware of it, and any feelings associated
with it. Give full attention to each in breath and
then to each out breath. Being total here in each
moment with each breath. If distracting thoughts
arise, acknowledge them without becoming involved
and return to the practice. Take a moment now to
consciously set an intention for this practice, some
examples are: “to cultivate loving-kindness”, Bring
to mind a person whom you are happy to see and
have deep feelings of love for. Imagine this person
sitting in front of you and notice the feelings you
have for them arise in your body. It may be a smile
that spreads across your face, it may be a warmth in
your body. Whatever it is, allow it to be felt. Let go of
this person and continue to keep in awareness the
feelings that have arisen. Bring to mind now, and see
if you can offer loving kindness to yourself, by letting
these words become your words: May I be safe, May
I be happy, May I be healthy, May I live in peace, no
matter what I am given, May my heart be filled with
love and kindness. Notice the feelings and sensations
that arise and let them be”.

CHAPTER 6: MENTAL HEALTH AND PSYCHOSOCIAL INTERVENTIONS FOR SPECIFIC TRAUMA RESPONSES DURING DISASTERS 121
 2. An important intervention for working with
dissociation is understanding the dissociative part,
derived from the Internal Family Systems model (IFS;
Schwartz, 1995). In this system, we understand that
we are all comprised of different ‘parts’, wherein each
part has its own feelings, experiences and a role to
perform, just like a team or family. We can think of
the Self as a wise, compassionate and calm presence
which has the ability to understand all other parts
just like a leader or a captain. We can help clients
in identifying these parts and strengthen their
connection to the Self. When dissociation happens,
it is because some part has shut down in the face
of pain. We can help clients identify these parts,
approach them with a sense of curiosity about their
roles, rather than fear or judgment. We can try to
understand why these parts are behaving in this way.
Once we learn their role, we may be able to show
some compassion to them. We can for example,
thank the dissociative part for protecting the client
from the pain and assure the part that we now have
the resources to deal with the pain. Hence the part
can stop protecting us from the pain. Questions
that can be asked after psychoeducating about the
protective role of dissociation (Lynch et al., 2015).

• What emotions do you numb or not feel?

• What makes it easier not to feel these emotions?
• What do you think would happen if you had to
feel these emotions? (can be anger, sadness and even
joy)
• How do you think this affects your relationships?
What emotions would you like to feel again?

3. Maintain an emotion expression diary may also help

clients identify emotions. This means that we use
prompts for sadness, happiness, anger and fear and
ask the client to fill the diary with instances when they
felt these emotions over the course of the week.

4. Healthy mind platter (Rock et al, 2012) is a metaphor

to imagine the needs of a healthy mind. It includes
the following components:

• Sleep: Sleep and rest help to consolidate learning

and recover from the experiences of the day. It helps
in improving concentration, emotional wellbeing,
learning and behaviour.

CHAPTER 6: MENTAL HEALTH AND PSYCHOSOCIAL INTERVENTIONS FOR SPECIFIC TRAUMA RESPONSES DURING DISASTERS 122
 • Physical time: Movement strengthens the brain in
many ways. Exercising improves mood, reduces stress
and anxiety and increases focus.

• Focus time: Focusing on interesting tasks such as

solving problems, journaling, reading and taking on
challenges help in making deep connections in the
brain.

• Play time: This involves engagement in spontaneous

and creative experiences such as joking, being silly
and having fun also helps us in promoting positive
emotions.

• Connecting time: This includes connecting with other

people, or taking the time to appreciate connection to
the world around by expressing gratitude and a sense
of contributing to the world.

• Down time: This involves engaging in activities

without any focus or specific goal, and letting the
mind wander or simply relax

• Time in: This involves internal reflection that is,

focusing on inner sensations, images, feelings and
thoughts, through mindfulness and self-awareness
activities.

Reflective Exercise
As her guilt and avoidance increases, Mrs. R finds herself feeling low and
agitated with herself. She feels very ashamed about the way in which she has
been behaving in the aftermath of the earthquake but finds herself unable to
change anything. She feels more and more hopeless and believes that this is
how she will be for the rest of her life now.

• What do you think is the reason for Mrs. R is feeling the way she is? How
would you explain it to her?

• Which strategy would you like to use with Mrs. R?

• How would you introduce the strategy to her?

CHAPTER 6: MENTAL HEALTH AND PSYCHOSOCIAL INTERVENTIONS FOR SPECIFIC TRAUMA RESPONSES DURING DISASTERS 123
 Clients may also show hyperarousal responses such as
4 persistent physical sensations of tension: tenseness,
agitation, restlessness, impatience, and feeling
HYPERAROUSAL constantly on the alert. It also includes jumpiness, easily
startled, and hypersensitivity to what is going on around
you, irritability, outbursts of anger or rage, emotional
outbursts, serious difficulty falling asleep or frequent
waking and concentration and attention problems.
Any perception of threat by our bodies and minds
results in some changes in the body. We increase some
body responses and decrease the others. For example,
digestion is slowed down while heart rate and breathing
increase. We are shifting from a “normal, everyday”
state where our tasks are to love, learn, work, and
play, to another state of high alertness where we are
hypervigilant and looking out for threats and preparing
for the fight, flight, and/or freeze response. These lead to
a state of hyperarousal.
In order to assess these changes in reactivity, we can
questions such as:

“Are you experiencing any difficulty in sleeping?

Are you able to sleep on time? Do you find yourself
waking up while sleeping? Do you feel fresh after
waking up?”

“Do you feel like you have been getting angry more
often? Does it feel like you get angry for no reason?”

“Do you feel like you are constantly alert? Do you find
it difficult to relax?”

“Do you find it difficult to concentrate? Do you get

distracted easily?”

“Are you getting startled easily? Do you feel that you

are on edge all the time?”

We can help reduce hyperarousal through the following

means:

1. Psychoeducating about hyperarousal. We may say,

“Many people may report sleep, and concentration

related difficulties, feeling restless and irritable,
or being very preoccupied with the future. These
problems reflect the body’s state of heightened

CHAPTER 6: MENTAL HEALTH AND PSYCHOSOCIAL INTERVENTIONS FOR SPECIFIC TRAUMA RESPONSES DURING DISASTERS 124
 arousal where the body is constantly trying to be
aware of threat. This interferes with daily functioning
as the body still thinks it is under threat.”

2. We can another strategy called the opposite action

(MacKay, et al, 2007). This means that we ask the client
to do the opposite of what they would like to do. We
explain the wave metaphor of emotions. We can say,

“Emotions are like waves in that they rise in intensity,

peak and eventually crash. They ebb and flow in their
intensity. If we do not act on them or do anything to
aggravate them further, they subside in time”.

We can then ask the client to do the opposite action

to these emotions, so that they can subside in the
meantime. For example if the client says that they
are so angry, they would like to shout at someone,
we explain the wave metaphor and ask them to do
an action opposite to that, such as asking them to sit
quietly and focus on their breath. It is important not to
invalidate the client’s emotions at that time.

3. Another strategy is a mindfulness exercise called the

RAIN Dance (Reutter, 2019). RAIN is an acronym for
Recognize, Allow, Investigate, and Nurture. The first
task is to recognise the emotion. It can be recognised
by physiological reactions for example, anger may be
experienced in the body as clenched fists. The next
step is to allow the emotion. This means that instead
of judging or fighting the emotion, we allow it to
come. Emotions can be imagined as waves; just like
waves they come and go. The next is to investigate the
context of the emotion. Showing curiosity towards,
what made us angry? What could have triggered us?
Am I more upset than usual? And lastly, we can use
some of the coping strategies discussed in chapters 4
and 6 to work with anxiety and anger.

CHAPTER 6: MENTAL HEALTH AND PSYCHOSOCIAL INTERVENTIONS FOR SPECIFIC TRAUMA RESPONSES DURING DISASTERS 125
 Reflective Exercise
Due to the lack of sleep and the constant need to avoid her guilt by avoiding her
children, she feels on the edge. She feels like she has no energy to do anything
but when her children call for her and ask her to do things with them, she gets
very angry with them. it is as if they cannot see how tired she is and how she
does not have the strength to help them. At the same time, she also feels very
anxious when she feels that her children will be distant from her. She does not
know what to do further.

• What do you think is the reason for Mrs. R’s anger? How would you explain it
to her?

• Which strategy would you like to use with Mrs. R?

• How would you introduce the strategy to her?

It is important to note that we may have to provide

referrals to clients who continue to show significant
distress and impairment after some time has elapsed post
disaster. We can use the checklists provided in Chapter 2
to assess if the client has symptoms of a diagnosable
disorder. We can then refer them to therapists who are
trained in trauma-focused therapy for further assessment
and interventions.

Let’s avoid...

Considering ourselves the expert of the client’s life circumstances. It is

important to remember that trauma manifests in different ways and we cannot
predict how the client is expected to react.

Trying to offer strategies for the experiences of the client without asking
them about it. It is important to first hear the client, assess the symptoms and
then link it to the intervention.

CHAPTER 6: MENTAL HEALTH AND PSYCHOSOCIAL INTERVENTIONS FOR SPECIFIC TRAUMA RESPONSES DURING DISASTERS 126
 Underestimating the influence of the client’s unique strengths for managing
their experiences. Clients may have tried a number of strategies to cope and
it is important for us to check in with them about the strategies that they may
have tried before we suggest other strategies to them.

Negating our internal experience. Working with trauma is difficult. It is

important for us to be aware of our internal experience and cater to our needs
before we help others. If we are experiencing hypervigilance, we cannot co-
regulate with the client. If we are dissociated, we cannot be present with the
client.

Self-care Exercise
We can use any of these strategies mentioned in the chapter to take care of
ourselves. Another way of taking care of ourselves is to develop a compassionate
version of ourselves (Lee & James, 2013). We can ask ourselves the following
questions:

• If I were compassionate to myself…

• How would I think about myself?
• How would I think about others?
• How would I behave towards myself if I was struggling?
• How would I behave in my life in general?
• What would I have in life?
• What would I want for my future?

Tips for Supervisors

This chapter discusses the key interventions for working with specific aftermaths
of trauma experience. Sometimes, it is important to reignite meaning in the work.
We may want to help the supervisee to reflect on the following:

• Why did I choose this work?

• What have I gained and/or learned from my clients?
• What has changed in my life since becoming a counselor?
• What are my strengths as a counselor?
• How have I changed as a result of my work with clients?

CHAPTER 6: MENTAL HEALTH AND PSYCHOSOCIAL INTERVENTIONS FOR SPECIFIC TRAUMA RESPONSES DURING DISASTERS 127
 Specializing in trauma-focused therapy

The APA has suggested the following trainings with strong and conditional
evidence for treating PTSD when there is a need to work with clients with
histories of trauma long-term therapy:

Cognitive–behavioral therapies (CBT)

Cognitive processing therapy (CPT)

Exposure therapy

Eye movement desensitization and reprocessing (EMDR)

Narrative therapy

Skills training in affective and interpersonal regulation (STAIR)

Dialectic Behavioural Therapy (DBT)

CHAPTER 6: MENTAL HEALTH AND PSYCHOSOCIAL INTERVENTIONS FOR SPECIFIC TRAUMA RESPONSES DURING DISASTERS 128
References

American Psychiatric Association. (2013). Diagnostic and statistic manual of mental disorders (5th ed.). Washington,
DC: American Psychiatric Association.

Boon, S., Steele, K., & Van Der Hart, O. (2011). Coping with trauma-related dissociation: Skills training for patients and
therapists. WW Norton & Company.

Cucu-Ciuhan, G. (2015). Emotion focused therapy in posttraumatic stress disorder: a clinical case. Procedia-Social and
Behavioral Sciences, 205, 13-17. 1-s2.0-S1877042815050235-main

Gilbert, P., & Procter, S. (2006). Compassionate mind training for people with high shame and self‐criticism: Overview
and pilot study of a group therapy approach. Clinical Psychology & Psychotherapy: An International Journal of
Theory & Practice, 13(6), 353-379. https://doi.org/10.1002/cpp.507

Gill, P., Fraser, E., Tran, T.T.D. et al. Psychosocial treatments for nightmares in adults and children: a systematic review.
BMC Psychiatry 23, 283 (2023). https://doi.org/10.1186/s12888-023-04703-1

Jon Kabat-Zinn ( n.d), Mindfulness meditation, CD series 3, retrieved from http://mindfulnesshamilton.ca/meditation-

scripts

Krakow, B., Kellner, R., Neidhardt, J., Pathak, D.,& Lambert, L.(1993). Imagery rehearsal treatment of chronic
nightmares: With a thirty month follow-up. Journal of Behavior Therapy & Experimental Psychiatry, 24, 325–330.
https://doi.org/10.1016/0005-7916(93)90057-4

Lee, D. A., & James, S. (2013). The compassionate-mind guide to recovering from trauma and PTSD: Using
compassion-focused therapy to overcome flashbacks, shame, guilt, and fear. New Harbinger Publications.

Levine, P. A. (1997). Waking the tiger: Healing trauma. Berkeley, CA: North Atlantic Books

Lynch, J.R.; Mack, L.J.; Benesek, J.; Marshall, C.; Clevinger, L.; McHenry, S.; Reynolds, S.; Mutchler, B.; Meyer, B.;
Panissidi, D.; et al. PTSD Recovery Program: Treatment Manual, 3rd ed. 2015. Available online: https://www.mirecc.
va.gov/visn6/Docs/PTSD_Recovery_Group_Participant_Manual_11_1_updated_04_2017_1_.pdf (accessed on 29
February 2024)

McKay, M., Wood, J. C., & Brantley, J. (2007). The Dialectical Behaviour Therapy Skills Workbook: Practical DBT
Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation & Distress Tolerance. Oakland,
CA: New Harbinger Publications.

Reutter, K. (2019). The Dialectical Behavior Therapy Skills Workbook for PTSD: Practical Exercises for Overcoming
Trauma and Post-Traumatic Stress Disorder. New Harbinger Publications.

Rock, D., Siegel, D. J., Poelmans, S. A. Y., & Payne, J. (2012) The healthy mind platter. NeuroLeadership Journal,
Volume 4, pages 1-23. Retrieved on 03/03/2022 from https://davidrock.net/files/02_The_Healthy_Mind_Platter_US.pdf

Schwartz, R. C. (1995). Internal family systems therapy. New York, NY: Guilford Press.

Sharpio, S., & Carlson, L. (2009). Mindfulness and Self-Care for Clinicians The Art and Science of Mindfulness:
Integrating Mindfulness into Psychology and the Helping Professions: American Psychological

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Thank you!