1. Chapter 6 Crisis, Trauma and Fostering Resiliency and Recovery1. Purpose. Crisis and trauma within the Navy Expeditionary Forcecan happen at any time - in theater, during training, or at home.Crisis comes in many forms and every situation is unique—a new set oforders that requires a change in geographic station may be “businessas usual” to an experienced spouse, but to a newlywed or dependentchildren the orders may induce panic. The nature of the missionsundertaken by NECC forces requires commands to prepare Sailors andfamilies for the most challenging crises imaginable—natural disasters,injuries involving Sailors and/or family members or possibly death.Planning and preparation for these ‘worst-case scenarios’ will enableindividuals to deal with the smaller crises that populate every day.It is important to understand and remember three groups may beimpacted by crisis/trauma. The impacted sailor and family, The Commandand families (friends, team mates) and the CFRT members (to includeChaplain, CACO, Leadership and volunteers)In order to prepare, it is important to have a basic understanding ofhow individuals respond, what are the stressors of the event,individuals’ needs, and what resources are (or will be) available tosupport the CFRT, Sailors and their families. The intent is tominimize the impact of events that can be traumatizing for thecommand, Sailors, and families and to foster resilience, recovery andpersonal growth following a trauma. This chapter discusses theresponsibilities of the CFRT for planning, preparation and confrontinga crisis. It introduces the concept of a Casualty Response Team (CARETeam) built around certain CFRT billets. It also highlights the rolesof some key positions outside of the CFRT that may be involved incrisis response and the aftermath. Finally the chapter provides basicinformation on trauma and practical approaches to responding to it.2. CFRT Responsibilities in Crisis. The roles and responsibilitiesspecified in Chapters 2 and 3 are applicable in a crisis situation.This listing identifies duties and tasks which may not ordinarily becarried out, but are necessary to maintain overall readiness andaddress the needs of the command when confronting a crisis. a. Commanding Officer – Leader of the command. The CO mustbalance the needs of the Sailors and families directly impacted by anevent with the charge to maintain operational readiness of thecommand. b. Command Master Chief – Oversees communication concerning anevent within the command and externally through the FRO to commandfamilies. c. Leadership Spouses: Can be a member of the CARE Team
2. d. Family Readiness Officer (FRO). During CACO or other emergentresponse operations the FRO will be the understood “team leader”,coordinating response support with the Ombudsman (OMB) and FamilyReadiness Group Leader (FRGL) in support of the impacted family andcommand families. The FRO will collaborate with the Ombudsman and FRGLto conduct relief efforts and offers of support (donations, visiting,updates, meal teams) allowing command leadership to continue operatingin their critical mission role. e. Ombudsman (OMB) facilitates communications between the commandand command families. A member of the command care team (COMNECCtrained). f. Family Readiness Group Leader (FRGL) coordinate FRG volunteerteam response. A member of the command care team (COMNECC trained). g. CAsualty REsponse (CARE) Team. A group of 3-4 volunteers whoare trained to support the family of a deceased/wounded Sailorimmediately after a notification of a death or serious injury. Thesevolunteers also provide coordinated support for command families. CARETeams revolve around OMB and FRGL, but exist to alleviate the full"burden" of care for an impacted family from the OMB/FRGL so that theymay also focus on the larger issues of readiness during crisis(secondarily, the possibility of multiple casualties necessitates theCARE Team having individuals other than OMB and FRGL). Other membersare appointed by the CO and can include leadership spouses, pastexperienced ombudsman and FRGL’s. CFRT’s can also utilize commandapproved volunteers from other units. All must be NECC CARE Teamtrained. (1) What a command CARE team can do to support the impacted family and command families: • Communication support • Home care assistance • Childcare support • Meal support • Transportation • Assistance to visiting family • Other family support Policy and regulations may preclude certain members within theCommand CARE Team from performing specific missions (e.g. Ombudsmencannot physically provide childcare support.) Commands should beaware of these restrictions.Note: CARE Team support will only be utilized at the request of the impacted family.The CARE Team volunteers will provide meaningful and practical assistance thatcomplements the assistance provided by the CACO, Chaplain and TRIAD so that the familycan continue to function while dealing with a traumatic event. The actual support
3. provided depends on family needs and command guidance. It is important to stay withinthe guidelines provided Navy and COMNECC instructions. More information about the functions and practical actions of a CARE team is providedlater in this chapter. The information will also be helpful for CFRT members.3. How Should A Command Respond To A Traumatic Event? How a commandresponds to a traumatic event will have direct impact upon how Sailorsand families perceive the command and its leadership. It is vital toestablish proactive plans that address preparedness, response andrecovery phases. a. Preparation Phase: Due to the various mission types of NECCcommands it is important to understand that preparedness is notlimited to a scheduled deployment. (1) Ensure Care plans and CPFRP forms “Contact sheets” arecurrent and the location, usage and access of the forms are known andunderstood to the CFRT. (2) Ensure NFAAS, page 2’s etc. are current. (3) Review pertinent Navy and local SOP’s on Disasterpreparedness and response plans. To include; “Operation Prepare”http://www.cnic.navy.mil/CNIC_HQ_Site/WhatWeDo/FleetandFamilyReadiness/FamilyReadiness/FleetAndFamilySupportProgram/DIsasterPreparedness/index.htm (4) Ensure all CFRT members have a clear understandingand are included in the planning of the Disaster Preparedness andresponse plans. It’s important that CFRT members proactivelycommunicate with the families of known impending natural disasters,events (etc) with plans and resources available. If the command isdeployed communicate to both the Sailors and Families. (5) FRO’s and Ombudsman will be included in CommandDisaster Preparedness Exercises and understand their role in disasterpreparedness and response. (6) Review pertinent Navy policies on Casualty proceduresincluding; notification procedures, mass casualty response, and policyvariations if incident occurs in battle space of another servicebranch (Geographic Combat Commander Rules) (7) Ensure all CFRT members are included in the planningand have a clear understanding of casualty procedures, anunderstanding of the services a CACO provides assistance and thecommand response plan. To include care for the impacted, care for thecommand and families and care for the CFRT members.
4. (8) Have key points of contact (e.g. CACO, Chaplain,Installation CACO, Casualty Assistance Center, Safe Harbor, MemorialAffairs Operations Center, and Medical Treatment Facilities, TragedyAssistance Program for Survivors, and other resources that may beavailable to specific communities within NECC. (9) Ensure the volunteers have a clear understanding of proper communication methods to include what information to share and what information should not (10) Ensure Volunteers understand the utilization of Chain of command. (11) Ensure that the role of the FRO’s, Ombudsman andFRGLs is not to participate in notification process or to interfere inthe CACO’s administration of their duties. (12)If a Regional CACO is utilized the CommandingOfficer is highly encouraged to send a uniformed CommandRepresentative to further support and connect with the family, similarin spirit to the “Special Escort”. The use of a commandrepresentative has great benefits to a family who has just suffered aloss. The ability to talk to a friend of the deceased, attend thefuneral, assists the family in their grieving process. (13) Establish a strategic communication plan that allowsinformation from command (including deployed commander) to be quicklyand accurately disseminated to families. Meet with CFRT members andleadership to develop a communication strategy amongst the CFRTmembers and also to the command Sailors and families.b. Response phase (1) Provide a prompt response. Talk plainly and honestly tofamilies. (2) Meet basic needs. (3) Focus intervention on decreasing risk factors and strengthening protective factors. Do not assume individuals’ reactions are signs of mental health problems/disorders, especially in early phase. (4) Include families in the healing process. Conduct memorialservices that provide opportunity for tributes and shared mourning.Involve employers and schools in community memorials. (5) Provide information to help individuals understand normalreactions and recovery process. This is helpful in normalizing the
5. experience for individuals and helping individuals to have realisticexpectations for recovery. Keep in mind that most people will notneed counseling, but they will need education and resources. Providepsychological first aid for acutely distressed individuals throughreferrals and resources available. (6)The emotional response will be broad and many will feel the“realness” of the situation; sometimes great grief comes from thosewho are the least expected. Listen to the Sailors and families andrespond accordingly. Observe pattern changes, risky behaviors,anxiety, outbursts, and anger. It is important for CFRT to discusscommand climate, situations of concern. (7)Realize that discomfort and awkwardness occur for everyoneinvolved in the situation. People who want to help may feel guiltybecause they have not suffered their particular tragedy or they simplymay not know what to do or say. (8)Conduct crisis communications to control rumors, calm peopleand reduce people’s sense of risk. Be honest in communications. Byproviding open, clear and honest communications in times of heightenedanxiety will help mitigate rumors, misinformation and negativeperceptions. (9) Conduct Informational and family resiliency briefing forcommand and families within a few days’ hours of casualty or disaster(etc) (10)Ensure CFRT members and Care team members are aware ofresources and methods avoid burnout or compassion fatigue. (11) Tailor support or intervention efforts to particulargroups. Pay special attention to sailors or families close to theimpacted sailor/family. Such as detachment/company member, departmentco-worker, or close friend. In addition to the grief for the loss,families may have added concern for their Sailor especially if theyare deployed. Sailors if deployed may have concern for theirfamilies. Be aware of the impact of survivor’s guilt on both theservice member and spouse. c. Recovery phase (1) Facilitate community healing. Consider opportunities forfamilies to connect and lean on each other and even laugh. Doing sowill help reduce stress and remind families they are not alone.
6. (2) Continue to monitor needs, mental health issues andfunctioning. Get individuals with psychiatric diagnosis intotreatment rapidly. (3) Continue to conduct outreach to connect and provideinformation to build people’s resilience and coping skills. (4) If an incident occurred while on deployment; upon theexpected return of the remaining Sailors, discuss with the CFRTseparate post-crisis reintegration brief with the spouses. Considerhaving a counselor, Chaplain facilitating an opportunity for familiesto discuss concerns and understand what to possibly expect of theirreturning sailor, their own emotions, and any other topics that arise. (5)after assisting the family, an After Action Review (AAR) may be scheduled. This review provides a process for CFRT members and Care Team members to discuss the sailor and family readiness supportand make notes on what went well, what could’ve been changed, etc. Noresponse program runs smoothly or without incident. The AAR serves as a tool filled with best practices and lessons learned to change current response methods and for future command CFRT’s. The input is very valuable.4. A general understanding of Sailors and Families Emotions andReactions: a. Having an understanding of how and why Sailors and families react the way they do to traumatic events can be helpful to dealing with family’s emotions. Specific guidance on dealing with grief and trauma reactions is also provided in their section and at the beginning of their chapter. b. Understanding Reactions to Trauma Events. Individuals’ reactions to traumatic events vary so it cannot be assumed how a sailor and family will react. Reactions tend to be multi- faceted, meaning there are physical, emotional, cognitive, and behavioral reactions. Many factors can influence how any given individual reacts so it is not possible to predict how a Sailor or family will react to a traumatic event. The reactions a Sailor and family exhibits are a response to the stress, fear, vulnerability and loss the sailor and family has experienced or is feeling. c. When a traumatic event occurs, a family experiences: (1) An unexpected event (2) Injury or death of a loved one (3) Loss
7. (a) Personal loss such as loss of husband/parent (b) Symbolic loss such as loss of sense of security andloss of identity (c) Ambiguous loss (i.e., the uncertainty of family unitand relationships as in case of seriously wounded, POW and MIA) (4) A prolonged sense of crisis or lack of control feeling (afeeling that can arise from the sense “their whole world has justturned upside down” and the life change that has just occurred) (5) Additional stressors (family now faces decisions andmatters that have to be addressed, etc.).Note: It is common for a sailor and family to struggle to findmeaning in the event (i.e., “why did their happen?”). Thus,reactions initially following the trauma event may be intense, butnot always. Reactions do tend to change over time as the Sailor andfamily moves through the recovery process and transitions to the newsituation. During the recovery process, there will be good days andbad days for a sailor and family until they are able to thrive. Keepin mind that it will take time for a Sailor and family to recover.The length of time to recover will vary across families and acrossindividual family members.5. CFRT in Crisis Response mode: As mentioned above there are threegroups impacted by crisis and trauma, below provides some baselineinsight. The information is centered on the worst case scenario. Asthe CFRT develops an understanding of roles and exercises its abilityto communicate and collaborate so that each member is ready in theevent a Sailor is killed or wounded. A CFRT which is prepared toaddress a traumatic situation is an asset that enables the command tocontinue with the missionIt is important to keep in mind that there are three groups impactedwhen a traumatic event occurs: (1) Sailors and Families directly affected. (2) Families (i.e. remaining Sailors and Families in thecommand, including those temporarily assigned to the command). (3) Family Readiness Command Team and support staff. This caninclude leadership, FRO, CACO, Chaplain and Volunteers etc.Each trauma event and family (both their reactions and needs) isdifferent so CFRT members and Care Team members need to view eachsituation as unique. This means that CFRT will need to think on theirfeet and adjust to the situation. The key to providing valuablesupport is to take cues from the family; to be flexible and adaptableas the situation changes, and to never lose sight of the fact that
8. the family is the primary focus. The family is going to have gooddays and bad days. So please remember not to take things personally,and encourage others also to be tolerant and kind. The family isgoing through a difficult situation, and the CFRT role is to helpmake it a little easier, not add to it in any way. a. Understanding the Notification Process. Having a generalunderstanding of the Casualty notification process and casualtyassistance program is helpful in seeing how individual members fitinto the overall efforts to support families of casualties. Withtheir knowledge, the CFRT can support the command, Sailors andfamilies more effectively. b. How are families notified of a casualty? The casualtynotification process varies depending upon the type of casualty. If asailor is deceased (i.e. Death, Whereabouts Unknown or Missing inAction) the family will be notified in person. In the case of aninjured Sailor, notification depends upon the nature of the Sailorsinjury. Generally for very seriously injured (VSI), or seriouslyinjured (SI), the Command or CACO will notify the next of kin inperson or by telephone. When the sailor is not seriously injured(NSI), the PNOK is notified by telephone if the illness or injury is aresult of hostile action. In these cases, the Sailor generallynotifies their family.6. Who else assists the family? There are several individuals andagencies designated by the Navy to respond when a Sailor injury ordeath occurs. It is important to understand the role andresponsibilities of these individuals and not conduct tasks performedby these individuals. The best response and support provided to afamily is a coordinated effort and team approach. (1) Casualty Assistance Calls Officer (CACO) The CACO isresponsible for notifying the Primary Next of kin (PNOK) and SecondaryNext of kin (SNOK) and any other person listed on the Sailors page 2.The CACO provides support to the family and aids with personnelrelated matters such as provide survivor benefit information andassist with funeral arrangements. (2) Chaplain: The role of the chaplain is to accompany theCACO when notification is made in person. The Chaplain offers pastoralcounseling, comfort and solace to families. The Chaplain is also asource of information about religious observances and funeralservices.
9. (3) Public Affairs Officer (PAO) A Public Affairs Officer maycontact the family to offer information and guidance on dealing withthe media. (4) Personal affects: A member of the command is appointed tocollect, inventory, safeguard, and send the effects of the deceasedSailor to the place requested by the NOK.Take into consideration the type of incident when providing support: Wounding: When illness or injury strikes, the impact can be almost as devastating as a loss. Because of the varying degrees and seriousness of illnesses and injuries, those in support roles (including the family) may be confused about, or have questions concerning, the best way to give support and what’s resources and programs are available. Suicide: For surviving family members dealing with the aftermath of a suicide, the grieving process can be compounded by feelings of failure, shame and guilt. Being sensitive to the unique nature of their loss will better enable you to provide comfort and support. MIA/POW: Families of MIAs and POWs are forced to deal with the “not knowing.” This highly emotional and painful ordeal is exacerbated by the fact that the suffering might have to be endured for an indefinite period of time. Mass Casualty: Multiple injuries and/or deaths are certainly one of the most difficult situations a military command might face. Discussing the potential of this scenario with the CFRT prior to this occurring is paramount to handling this tragedy in a way that honors each Sailor and his/ her family d. Caring for “Others” Sailors and families in times of CACO or crisis response. e. f. How the “Trauma” is handled by the Command Triad, CACO, Ombudsman, FRG, FRO and Chaplain has long term affects on the grieving command families. The ‘Command Family’ may grow and strengthen as members see how we care for each other and respond to these situations. This can be an emotional time for the families of your Command, as it can highlight the harsh realities of the community in which the Sailor works. Follow the Command Crisis Response plan and follow up on any changes or new instructions regarding the specific incident. CFRT teamwork is essential.
10. (1) Coordinate and schedule informational and Resilience briefing: Determine the agenda. Families typically want to know the basics of what happened, who was involved, how the impacted family is handling the situation, how is the impacted sailor and/or family is being cared for and how can they provide support. During their meeting, families want to understand how to support their Sailor, their emotions and the Command, and what to expect in the near future. Its important center the meeting and speakers around the type of crisis/trauma event that occurred. Such as, if a families Sailor is still deployed anxiety will be heightened. If a suicide occurred the command and families may feel as sense of failure, shame and guilt. 2) Provide resources and options; A Chaplain, FFSC counselor, Mental health support failure with the nature and mission of the command and who can discuss and remind families to care for themselves and seek help if needed. Additionally, the emotions of the family can impact a child. The attendance of a counselor can pinpoint how children are affected by loss and grief. (2) It is necessary to have childcare available to families during a crisis briefing. (5) Provide comfort food and enlist support from otherCommands to assist with or standby to assist with crisis response. (6) Have sign-up sheets available for spouses/family membersto volunteer services for the grieving family, such as making meals,doing yard work, and helping with childcare. Provide to the impactedfamily a specific list of what services are willing to be provided andby whom. (7) Remember that there are former CFRT members across theNECC force that has firsthand experience in crisis response. They area critical asset for guidance in these situations.Note: Over the following weeks maintain open communication with yourCommand families regarding memorials, homecomings of wounded warriors,locations to send flowers/cards, and support services available tothem.h. Taking Care of Self.To support families effectively, it will be important for CFRT to takecare of them when assisting a sailor or family. This involves takingsteps to deal with own reactions, handle stress, and avoid compassionfatigue.
11. (1) Dealing With Own Reactions. Keep in mind that you may begrieving and/or dealing with your personal reactions to the traumaevent. This is especially true if the Soldier was a friend. Allowyourself to grieve. Helping a family can be rewarding and meaningful.However, it is important to be mindful of your reasons for assistingthe family. Have realistic expectations of how you can assist thefamily. This is vital to being able to maintain the empathy andprovide the support needed by the family. Additional guidance isprovided in the subsection entitled avoiding compassion fatigue. (2) Handling Stress. Helping a sailor and/or family indistress can take an emotional toll and be stressful. Emotionalreactions can be compounded by the leadership positions held. Beaware of the symptoms and signs of stress so that you can take actionwhen you feel stressed. Because individuals display stress indifferent ways, you may not show your stress in the same way asanother CFRT members. Care Team volunteer. Be attentive to what youare personally experiencing. Physical Symptoms Emotional Symptoms Behavioral Symptoms • Chest pain • Difficulty sleeping • Loss of appetite or • Pounding heart • Nightmares excessive appetite • Dryness of mouth and • Feeling powerless, • Inability to concentrate throat helpless or insecure • Impulsive behavior • Shortness of breath • Fear • Irritability; decreased • Muscle aches (e.g., pain • Anxiety anger control in neck or lower back) • Sadness • Increased alcohol, • Trembling, nervous tics, • Depression tobacco or drug use easily startled • Restlessness • Apathy; inactivity • Stuttering, other speech • Worrying • Withdrawal or isolation difficulties • Anger • Crying spells; crying for no reason; overpowering • High-pitched nervous • Mood swings urge to cry or run laughter • Confusion • Grinding teeth; clenched • Forgetfulness jaw • Fatigue Frequent need to urinate • Excessive sweating • Stomach problems (e.g., diarrhea, indigestion, queasiness, vomiting) • Headache • Muscle tension • High blood pressureIt is important to deal with stress right away and in effective ways.
12. I. TIPS FOR MANAGING STRESS. These tips are designed to increaseyour ability to cope with the situation and reduce your level ofstress. (1) Maintain health and well-being (a) Take good care of yourself. It is very important toexercise, eat properly, and get enough sleep. Maintaining your healthis very important, especially in highly stressful situations. (b) Avoid using alcohol and drugs. (2) Manage how you approach the situation and your time (a) Take one thing at a time. Determine priorities andpace yourself accordingly. (B) be realistic about what you and can’t do. Ask forhelp when you need it. (c) Know your limits. Say “no” when you need to do so. (d) Maintain a balance between assisting the family andown personal/family obligations. Maintain contact and spend time withyour family (e) Be flexible. Accept that you don’t have control oversome situations. j. Take action when “stressed out” (1) Do activities that help you relax? Exercise, meditate,listen to music, or whatever works for you to relax. (2) Do something fun and enjoyable. (3) Take a break. Taking a five minute break or brief walkcan be helpful to reenergize. Do not assist a family round theclock, work in shifts.Sources: National Mental Health Association; Mayo Clinic; AE PAM600-8-109-1, Family-Focused Deployment Guide; Family Readiness Guide:A Deployment Guide for 3rd COSCOM Soldiers, Civilians and FamiliesAvoiding burn out and compassion FatigueNote: CFRT/Care team members and other responders are at risk ofdeveloping burnout and compassion fatigue. Compassion fatigue (orvicarious dramatization) is when CFRT members/Care team members showsigns of posttraumatic stress. It occurs as a result of ongoingexposure to witnessing a Sailors or family’s suffering and hearingabout their experiences. Exhibiting some stress symptoms is normal.However, when the level of stress does not diminish, especially after
13. CFRT has ended its assistance, or normal functioning becomes impaired,then it is important to seek professional help. A constellation ofsymptoms listed in the table below may indicate a need forprofessional help.
14. SIGNS OF COMPASSION FATIGUEPhysical Cognitive Emotional Symptoms BehavioralSymptoms Symptoms Symptoms• Headaches • Difficulty • Nervous • Crying episodes• Upset stomach concentrating • Anxiety • Irritability(stomach aches, • Forgetful • Fear • Arguing nausea, • Slowness of • Worry • Aggression diarrhea) thinking and • Anger • Blaming or• Dizziness comprehension • Mood swings criticizing• Heart pounding • Inability to make • Flashbacks, others• Flu or cold-like decisions nightmares, • Restlessnesssymptoms • Limited attention distressing dreams • Hyper vigilant• Tremors span • Low self-esteem about safety• Sweating • Loss of • Feeling less • Social• Soreness in objectivity trusting (cynical withdrawal, muscles, lower and jaded) isolation back pain • Sadness • Change in• Exaggerated • Depression appetite startle • Grief • Change in sleep reaction; • Feeling habits jumpiness overwhelmed, • Loss of energy• Fatigue hopeless • Increased use of • Feeling heroic, alcohol, tobacco invulnerable, or drugs euphoric • Accident prone • Guilt or survivor • Inability to do guilt job • Identification with family/survivorCAsualty REsponse (CARE) Team.As touched on at the beginning of this chapter a CARE Team is group of3-4 volunteers who are trained to support the family of adeceased/wounded Sailor immediately after a notification of a death orserious injury. These volunteers also provide coordinated support forcommand families. All CARE team members must attend NECC CARE TeamTraining. (4)When Does A “Care Team”, The OMB and FRG Assist A Family? A Care Team(OMB/FRGL) is sent after the family is notified and ONLY if the familyrequests their assistance. In the case of fallen Sailors, the Care
15. Team will be sent immediately following notification. In the case ofwounded Sailors, the Care Team may be sent immediately followingnotification and prior to the family leaving to join the woundedSailor in the hospital/medical treatment facility or may be sentimmediately following family’s return. At the time the family returns,the wounded Sailor may or may not have been transferred to a hospitalor veteran’s rehabilitation program in the family’s geographical area. During CACO notification the Commanding Officer/CMC will ask if the FRO or Ombudsman may contact the family directly: (a) If the family says yes, the CACO will assesspossible family needs before the Ombudsman and FRO contacts thefamily. The FRO will also offer the type of support the Care team cancoordinate for the family. (b) If the family says no, the CO will follow up withthe CACO in 48 hours with the same question. It is normal within thefirst few hours or days for the impacted family to be overwhelmed andthus unsure of what type of support they may want or need. It’simportant to communicate what types of support can be provided. It isvery important to be ready but wait. (c) The CO will provide guidance to the CARE Teamrepresentatives (Ordinarily the OMB and FRGL) prior to the visit tothe family. While on site, the CARE representatives may determine,based on family’s requests and perceived needs, that additionalsupport is needed. However, additional suppor requested should bediscussed with the command.Note: All members of the CFRT and support organizations should seekclarification before providing any support not specifically cited orprohibited in this manual.Note: Other unit trauma situations in which a CARE Team may be sent toassist a family include: suicide of Sailor, MIA, POW, and death of aSailor’s spouse or dependent child or hospitalization(2) How Long Does a CARE Team Assist a Family? The intent is for theCARE Team to assist the family until extended family members arrive tosupport the family or when no extended family is available. Further,the CARE Team’s assistance is intended to be provided on a short-termbasis, anywhere from 72 hours to two weeks. The actual length of timedepends upon the family’s needs, Commander’s guidance and presence ofother family members/friends to support the family.g. Building Trust, Respecting privacy and Maintaining Confidentialityas CARE Team Members
16. (1) Privacy is of the utmost importance to Sailors andfamilies during times of trauma. It is expected that all CARE Teammembers in in this instance will keep personal matters disclosed tothem in the strictest confidence. A more detailed discussion withspecific examples of how to protect a family’s privacy is provided inthe tips box. THE BOTTOM LINE: Protect the person’s privacy as youwish yours protected. (2) TIPS ON MAINTAINING CONFIDENTIALITY (a) Do not disclose specific details to anyone other thanthe CFRT Members, the Chaplain, the Casualty Assistance Officer, andthe CARE Team members. (b) During the course of working with the sailor orfamily, you may learn many intimate details of the Sailor andfamily’s life. Keep their information to yourself. (c) Only give information with the permission of theSailor, spouse and/or family involved. (d) Protect the person’s privacy when reporting toothers. For instance, if you are informing the Chaplain of somethingthat happened with the family, do not use names or specific detailswhen others may be present. Move to a private area when possible. (e) When confidentiality does not apply. During the timeyou are assisting a Sailor or family, if there is any suggestion ofany of the following issues: suicide, neglect, or assault, inform theperson that you are obligated to report the situation. Depending onthe severity of the situation, call 911, CO/FRO, and/or Chaplain. Ifthere is a possibility of immediate danger to an individual, contactthe police right away. If you are asked to keep their this type ofinformation, which may be illegal or dangerous (to themselves orothers) in confidence, inform the person that confidentiality doesnot cover these areas. (f) Have a clear understanding of what situations the COexpects to be reported to them. This information should be discussedwith the CO before the FRO and CARE Team interacts with the Sailoror family. You should inform the person involved that they aretouching on areas which you must report. Informing the person ofyour obligation to report to others is being honest with the personand gives them the choice of whether or not to continue theconversation, knowing the consequences if they choose to do so. Ifyou are unsure about whether a specific situation falls outside theconfidentiality areas or must be reported to the command, excuseyourself and contact your command POC/FRO and/or the Chaplain foradvice.
17. A WORD OF CAUTION Let the family maintain control over what they can reasonably do for themselves. Let the family identify their needs rather than telling the family. Make suggestions or offer to help in a particular way, but you must seek feedback from the family on these suggestions/offers before taking action. It is important not to contribute to the family’s stress by being overbearing or “overly helpful”. (5). Call Support (a) Screen calls and visitors according to family’swishes.Verify with the family what information the family wants shared andwhat they do not what shared. Do not provide any information unlessyou are sure to whom you are talking and the family member hasauthorized the release of the information. Media inquiries should bedirected to the appropriate Public Affairs Officer. (b) Keep a phone log. Write down the name of allindividuals who call and associated telephone numbers. It may mean alot to the spouse later to see who called and can be used by thefamily for sending thank you notes. Also, you can use it to call backthose who wanted information on the funeral and memorial services. (c) Get a list of condolence phone calls received bythe command. CMC should coordinate with CARE representatives to insurecalls received by the command are delivered in a timely manner so theymay be added to the family’s phone log. (d) Ask if there is anyone the spouse/family wouldlike the CARE Team to contact.TIP: Making calls is the family’s responsibility. CARE volunteers, aChaplain or a supporter outside the command can support the spousethrough this process. (6) Home Care Assistance (a) Maintain a list of questions for the CACO. It isvery helpful to have a notebook to write down any and all questionsthat the spouse/family has. Remind the spouse of the questions whenthe CACO is there so the CACO can answer them. Remember, the CARE Teamshould not be answering questions that pertain to CACO or Leadershipresponsibilities (benefits, entitlements, funerals, etc.) (b) Maintain a list of questions for the CO . Writedown any and all questions that the spouse/family has for the CO.
18. (c) Record visitors and gifts. Keep a logbook offlowers and gifts received along with a brief description includingthe identity of who gives them. Keep all cards. Keep a record of whovisits the family, and if possible, who attends the memorial service. (d) Identify what household assistance is needed.Issues like laundry, housecleaning, lawn care, pet care/boarding,shopping, mail, or snow removal). Run errands as needed. Note: In theevent the family needs money, this matter should be addressed with theCACO and CO who can assist the family in getting emergency financialassistance. (e) Maintain good communications with the command.Notify the FRO of any needs the CARE Team cannot address. Forexample, notify the command if the family needs translation servicesor has difficulties accessing services. (7) Childcare Support: FRGL/OMB If the family haschildren, the CARE Team should assess needs and support required. (a) Assess children’s needs and obtain information toinclude: (1) Ages of the children (2) Immediate childcare arrangements and needswhile. (e.g., Does the family require someone to stay with anychildren at home so the adult(s) can meet with the CACO or attend topre-departure needs if traveling to medical facilities to visitwounded Sailor?) (3) Children’s medical issues (it may benecessary for caretakers/babysitters to be aware of particular medicalconditions/problems) (4) How death or injury was explained tochild(ren) (so caretakers, babysitters and others are aware of whatchildren have been told and have a sense of what can/cannot be said) (5) Whether children reside elsewhere (6) Children’s school and extracurricularactivities; and what adjustments will be made while family is dealingwith trauma situation, even if temporary (e.g does school requirefamily authorization for someone other than a parent to pick a childup from class, will children stay at home and not attend school untiltime of funeral?) (7) Children’s transportation needs.
19. (b) Identify friends of family or children who may be willing to offer support. (This can be very helpful for teens.) f. Meal Support (1) Go grocery shopping as needed. Be mindful of foodallergies, dietary restrictions and preferences. Funds to purchasegroceries are the responsibility of the family. This is to be fundedby the family, CARE Team volunteers do NOT pay for groceries. (2) Coordinate meals for the family. Ensure food is alsoavailable for visiting family and visitors when they are at family’sresidence. To make meal/food arrangements, will entail the followingsteps: - Identify special needs, food allergies, religious or dietaryrestrictions of family members. - Find out the types of dishes/foods family members (includingchildren) prefer. - Identify out-of-town family members and friends expected tovisit family. (3)Designate a Meal Coordinator. It is often helpful if thecoordinator is a friend of the family so they can be a liaison betweenthe family and those wanting to provide meals.The coordinator should: (a) Manage the delivery of food and meal assignments as necessary. Consider keeping a log of all who provided food so that they can be thanked later.TIP: It may be helpful and/or necessary to create a chart showingwhich volunteers or individuals can provide meals on which days. Thereare many online programs that can support this. (b) Ensure the family receives a variety of meals. Avoidproviding the same meals unless requested by the family. (c) Monitor the quantity of food provided. A family maynot want a meal delivered every night, but rather at specificintervals. Or a family may want food that they can put in the freezerand pull out as needed. (d) Provide guidance to those wanting to provide foodincluding: - Allergy and dietary restriction information
20. - Children’s preferences - Snack items desired - Times and locations for food drop off. - Format for meal preparation instructions (if dishwill not be eaten immediately) (e) Return dishes to owners as necessary. g. Family Support (1) Assist visiting family and friends. This may include: - Offer assistance with access to installation, lodging,and/or transportation as needed.(pass request to CACO or FRO, as thisis a command function) - Provide a welcome basket or information packet for out oftown family.TIP: Contact the local FFSC office in preparing an information packet.These offices often already have such packets. The Care Team wouldonly need to supplement the packet with unit information, directions,and other pertinent information related to the situation or visitingfamily/friends’ needs. h. Assist family with personal arrangements related to funeral.This support is not to interfere with the CACO or responsibilities ofthe Command. Working collaboratively with the CFRT and with theinvitation of the family support may include: (1) Help in getting necessary clothes for the funeral ormemorial service. (2) Help family prepare if funeral is not local. (3) Ensure a guest book to the funeral and memorial service. (4) Coordinate with Public Affairs Officer to called mediacoverage (articles, videotapes) for family including a videotape ofthe memorial service. (5) Help arrange someone to housesit during the funeral andmemorial service, if necessary. (6) Help family arrange location, food, preparation and cleanup for a gathering held after the service, if the family elects atfamily home or at designated location.(If Command Function/coordinate/discuss with command)
21. i. Assist family with arrangements related to visiting a woundedSailor. This support is NOT to interfere with the CACO orresponsibilities of the Command working collaboratively with the CFRTand with the invitation of the family support This may include: (1) Help in packing clothes (including clothes and itemsSoldiers may want or need while in hospital). (2) Help Ensure spouse/relative on Invitational Travel Ordershas the following documents assembled prior to traveling: - Copy of Invitational Travel Order (ITO) - Military ID card - Power of Attorney - Immunization records for traveling child(ren) (-) Name and phone number of the Sailor’s command (-) Valid passport if traveling overseas (If a familymember does not have a passport, one can be obtained quickly throughthe CACO. (3) If asked help coordinate with CFRT/CACO on travelarrangements. (e.g., transportation to and from airport, localtransportation information or car rental in location of woundedSailor.) (4) If asked help make necessary arrangements for familymembers that will remain in the home (e.g., children, elderly parents,individuals with special needs) (5) Discuss necessary house arrangements for extended periodof absence (e.g., pet boarding, house sitting, stopping mail andnewspaper service, lawn care, house plant care, snow removal, andemptying refrigerator) (6) Cancel and/or change personal appointments (7) Obtain notification or releases for children’s day careand schools. (8) Arrange or provide transportation. This may be helpful asthe intense emotions a family experiences can make an individual tootired or too distracted to drive. Discuss with CFRT/CACO and family. (9) Accompany family to local hospital. This can be a helpfulway to support families of wounded Sailors. Discuss with CFRT/CACO andfamily. Remember to respect the Sailor and families privacy.
22. (10) Offer family a stress relief break. Take Meet spouse and/or children out for a meal or an activity to have a break andenjoyable activity. This can be helpful to both families of fallen andwounded Sailors. f. Tips on Dealing with Individuals’ Grief and TraumaReactions (1) Do’s (a) Express your sorrow for the deceased and the family.Say you are sorry about the griever’s pain and the situation. Simplysay, “I’m sorry” or, “Words fail me.” (b) Remember to extend condolences to forgotten mourners:grandparents, siblings, stepchildren, aunts and uncles, and cousins.Be observant of the children. Children mourn too. (c) Be compassionate and sensitive. (d) Accept diversity in how individuals respond and cope.Accept grief and anger as normal reactions. (e) Let individuals know that their reactions are normal. (f) Be patient. Give the individual time to grieve andrecover. Avoid judgments about the family and the tragic situation. (g) Listen quietly and non-judgmentally. Allow the familyto talk and in the early stages of grieving, to take the lead inconversation. Allow family members to express as much grief as theyare feeling at any given moment and are willing to share. The familyneeds “permission to grieve.” Allow the family to talk about theendearing qualities of the person that has died. (h) Be comfortable with just being silent and nottalking. Also, if you do not know what to say, that is okay.Sometimes it is hard to find the words that convey what you arefeeling for the family and their loss. That is perfectly all right.Sometimes the best way to comfort is just by being with them. Yourpresence is all that is needed and is the one thing that is mostappreciated. (i) It is a good practice to mention the deceased byname. (j) Arrange or provide practical assistance and supportas appropriate. Also encourage individual to ask for help. Be awarethat it is often difficult for grieving people to reach out for help. (k) Let your genuine concern and caring be visible.Accept that it is not possible for you to make the grieving personfeel better. Be accessible, but not pushy.
23. (l) Sometimes the family just does not want to see anyonebecause they are tired or just want to be alone. Do not take this tpersonally, but give them the space needed. If you sense that“traffic control” is warranted, step in and be the gate keeper. (m) Encourage family to take care of themselves (i.e.,eat properly and get rest). (n) Ensure family does not become isolated. Encouragefamily to have contact with their support network and connect withothers.(2) Don’ts (a) Don’t be afraid of silence. Don’t be afraid of tears. (b) Don’t inhibit open communication. For example, don’tchange the subject when the griever mentions the deceased/wounded. (c) Don’t let your own sense of helplessness ordiscomfort; keep you from reaching out to the family. (d) Don’t answer questions about the injury or death. Itis common for families to have questions, but refer family to CACO orCommand Leadership/RBL. (e) Don’t impose your explanation on why their this hashappened. Don’t try to answer the question, “why?” (f) Don’t say “I know how you feel” or “Everything willbe all right”. (g) Don’t say anything that implies a judgment about thefamily’s feelings: “You ought to be feeling better now” or “You’ll befeeling better in a month or so” or “I know how you feel.” Don’tencourage the family to “get over it”. (h) Don’t make statements or ask questions that induceguilt or affix blame. (i) Don’t treat the family like invalids. Let thespouse/family be in control and do the things that they want to dofor themselves. There is a tendency for volunteers and those tryingto give assistance to overdo it. Although well intended, for thefamily, this can become very trying at times. Keep in mind that thefamily may be experiencing anger and a sense of loss of control solittle things can become big things. The bottom line is, if thefamily wants to get their own coffee, get their own sandwich, answertheir own phone, etc., let them.
24. (j) Don’t be too direct or give advice. (For example,don’t make suggestions regarding packing up clothes, photos, etc.) (k) Don’t try to find something positive in the death.Don’t make statements, such as “God knows best” or “It’s God’s will”. (l) Don’t impose your own religious beliefs or discountthose of the family. Respect family’s religious and cultural beliefs. (m) Don’t assume anything. For example: if the widow orspouse of wounded isn’t crying, don’t assume she’s not upset or ifshe’s screaming, don’t assume she can’t care for herself or herfamily.Source: This is a compilation of lessons learned, best practices andadaptation of information provided in Army War College’s A Leader’sGuide to Trauma in the Unit, Navy EOD Ombudsman Battle book, FortSill’s Care Team training and Phantom Thunder Care Team Guide, FortRiley’s CDR/1SGT Course, Deployment Health Clinical Center’s factsheet entitled A Normal Reaction to an Abnormal Situation, and US ArmyOperation READY Rear Detachment Commander’s training. Types of Trauma Events Individuals Exposed: Sailors and Families Community/Command Exposed (Mass Trauma)Intentional Unintentional Human Made Natural MadeTrauma Trauma
25. Examples: Examples: Examples: Example:• Sexual • Accident • Terrorism • Tsunami Assault • Injury • War • Hurricane• Physical • Transportation disasters • Tornado Assault (e.g., plane crash) • Flood• Robbery • Shootings/kidnapping/hostag • Earthquake• Rape e situation • Industrial AccidentIt is not uncommon for individuals to have experienced a traumaticevent. Individuals can be exposed to trauma in different ways:physical impact (i.e., injury), visual exposure (i.e., witness), knowsomeone hurt or exposed to trauma, and media (which results inrepeated exposure). With many trauma events, it is not just theindividual impacted, but an entire family or community. For example,when a Sailor is injured or killed in action the entire command,military community, and civilian community where the Sailor residedmay be impacted.4. Key facts to keep in mind about traumatic events a. Traumatic events may create extreme stress, intense fear,helplessness or horror. Individuals can feel isolated from others bythe experience. b. Traumatic events are different from normal stressful events.Traumatic events are unanticipated and may create a prolonged sense ofcrisis and lack of control feeling. c. Some traumas create additional stressors such as loss ofroutine, job loss, loss of financial income, relocations/displacementof family or children, and the need to navigate government andinsurance systems for assistance. d. Some traumatic events, as in the case of natural disasters forinstance, can cause disruption in community and social supports makingit difficult for individuals to get help. e. Traumatic events involve loss whether it is a death,destruction of property or community, or a symbolic loss (e.g., lossof sense of security, loss of ability to trust other people, loss ofpredictable future). Mass traumas often involve personal, communityand symbolic loss. f. With any trauma, individuals of all ages may struggle to findmeaning in the event.5. How do individuals respond to traumatic events? Individuals’(both children and adults) reactions to traumatic events reflect theirresponse to stress, intense fear, helplessness, vulnerability, and
26. loss. Their response involves physical (bodily), emotional (feelings)and cognitive (thoughts) reactions. Individuals’ reactions totraumatic events vary considerably and can have varying impacts. Forsome individuals, the reactions cause a mild disruption in anindividual’s life whereas others exhibit severe and debilitatingimpairment in functioning. Common Trauma Reactions • Grief/Traumatic grief (if sudden loss Anger/Irritability • Fear Confusion • Disbelief/shock Unexplained somatic symptoms • Numbing and withdrawal Depression • Helplessness Anxiety a. Normal Trauma Reactions. Individuals will have many reactions.The constellation of responses seen both in adults and children can bewide ranging. Some responses, such as grief, depression and anxiety,include a variety of additional and overlapping symptoms. For someindividuals, the cluster of reactions represents symptoms of acutestress disorder (ASD) or posttraumatic stress disorder (PTSD), but notnecessarily a diagnosis of ASD or PTSD. Symptoms of PTSD are notuncommon, and most will recover after a period of time. b. Reactions to Loss and Death. Traumatic events can involvesudden loss or death. A sudden loss of a Sailor, child or familymember is particularly difficult when death has occurred under any ofthe following circumstances: (1) Death occurred without warning and opportunity to saygoodbye (2) Death occurred as result of violence (3) Death in which body is never recovered (4) Multiple losses (e.g., mass casualty) (5) Death occurred as result of willful misconduct of others(e.g., accidents, war, and terrorism)In the case of war, Sailors can experience the sudden loss of asignificant and close attachment. Initially, reactions to theirtraumatic loss may involve a wide range of intense emotions. Overtime the frequency and intensity of these emotions are expected todiminish in a normal grieving process.
27. 6. Traumatic Grief. Traumatic deaths or sudden loss of significantand close attachment can lead to a grief process that is morecomplicated and difficult to resolve. Traumatic grief occurs when anindividual shows extreme distress over an extended period of time andthat grief dominates an individual’s life. It is not uncommon forthese individuals to experience intense reactions including agitation,suicidal ideation, and powerful rage (e.g., anger toward thoseperceived to be responsible) or revenge fantasies. These individualsmay also have frightening memories/thoughts about the traumatic eventby either agonizing about what their loved one experienced during thefinal moments of life or recalling the horror of the traumatic eventthey experienced. These frightening memories/thoughts along with theintense symptoms of distress are over and above the normal symptoms ofbereavement and disrupt the grieving process.7. Post-traumatic Stress Disorder (PTSD). Symptoms of PTSD can alsooccur. In the context of a traumatic death, PTSD symptoms may appearas follows: a. Re-experiencing the traumatic event by having painful,intrusive thoughts or nightmares about the death. b. Avoidance or emotional numbing (e.g., staying away from places,activities, or things related to the loved one’s death). c. Increased persistent anxiety and physiological arousal (e.g.,difficulty sleeping, irritability, difficulty concentrating, tendencyto be startled easily).While these symptoms are normal symptoms of grief, when all of thesesymptoms occur together and persist then the individual may beexperiencing PTSD and should be referred for professional help.8. Secondary Trauma and Trauma Reactions. Individuals can betraumatized indirectly. Secondary trauma can occur when learningabout someone’s (typically a loved one for families) trauma or throughfrequent interactions with a trauma victim and the victim’s traumasymptoms (as in the case of both Sailors, family members, and unitresponders such as CACO’s, Ombudsman, FRGL’s, FRO’s, Chaplains, andcommand leadership). The trauma reactions seen will be similar to thenormal trauma reactions described earlier. The only difference isthat in secondary trauma, the trauma reactions are associated with atrauma victim rather than the trauma event.9. Other Facts about Trauma Reactions. Key facts to keep in mindabout individuals’ responses to trauma a. Initially, individuals may have intense reactions. b. In many mass trauma situations, such as war and naturaldisasters, individuals’ use of media increases.
28. c. Individuals’ reactions will change with the phases of thetrauma event. (There are four phases to a trauma event: impact,immediate post trauma/rescue, early short term/recovery, and long-term/“return to life”). Early responses to a trauma event reflectsurvival and adapting to perceived harm to self or others. Inrecovery and later, responses reflect individuals’ efforts to copewith changed reality. d. Sailors and family’s reactions to trauma occur in parallel. e. Reactions and abilities to cope with trauma event depend onvarious factors that include: (1) Circumstances of trauma event (2) Perceptions of the event’s meaning (3) Ways individuals manage their emotions and cognitions (4) Recovery environment. f. Most people are resilient and do ok over time. g. Most people will not develop a psychiatric disorder. ThePTSD Alliance reports 20% will develop PTSD after a traumatic event.However, responses left untreated can lead to serious disorders. h. Trauma can lead to personal growth (e.g., greater selfreliance, stronger relationships, reevaluation of spiritual beliefs,and greater appreciation of life or rethink priorities).10. Why Do Individuals Respond The Way They Do To Traumatic Events?It is important to keep in mind that traumatic events create stress.Individuals’ reactions to trauma both in the immediate aftermath andthe months and years after the event reflect how individuals cope withstressful situations and change. It is difficult to predict how anygiven individual or family will respond. There are three sets offactors that determine how individual and families will respond. a. Circumstances of Traumatic events. Reactions to traumaticevent are dependent upon circumstances of the trauma such as: (1) Type or causality of traumatic event — Situations in whicha deliberate intentional effort to intimidate, control, or do harm toindividuals are very different forms of trauma than nature made oraccidents. Intentional and human made traumas tend to have a greaternumber of, more complex, and longer duration of psychological effects. (2) Whether single event, multiple events (e.g., 9/11), orongoing (e.g., war, abuse) — Multiple or ongoing trauma creates asense of fear, dread, and rage over expected repeated trauma. 7
29. (3) Amount and level of exposure — the greater proximity to orexposure to trauma event, the greater the impact. (4) Nature of losses — Losses, other than death, can result ingrief or depressed state reactions. (5) Ambiguous loss — According to Pauline Boss, 8 certainsituations create ambiguous loss. Ambiguous loss occurs: 1) whenindividuals are physically present, but psychologically not present(e.g., mental health disorder, war wounded, distressed parent, parentpreoccupied with work) and 2) when individuals are psychologicallypresent, but not physically present (e.g., military deployments,missing in action). These situations are stressful because theuncertainty is experienced on an ongoing basis with no closure. Thestress of the uncertainty can impact family coping and relationships.For example, for military families, the ambiguity of not knowingwhether the Sailor is dead or alive in a combat deployment can createa stress that is traumatizing and immobilizing (e.g., relationshipsand daily functioning are put on hold). b. Individual/Family Characteristics. How individuals (andfamilies) respond behaviorally and emotionally is determined by anumber of personal factors including: (1) Temperament – Individuals’ personality traits oftendetermine how individuals respond to extreme stress. (2) Resources – Individual and family resources shape copingbehavior. Individual resources are: (a) Financial well-being (b) Educational (problem-solving abilities, information) (c) Health (physical and emotional well-being), and (d) Psychological resources (self-esteem) (e) Family resources include family cohesion andadaptability (ability to change) (3) Culture – An individual’s cultural beliefs can impact howan individual perceives the event, expresses emotions, and seeks help. (4) Coping style – Individuals may use different copingstrategies in different phases of a trauma situation. Two differentcoping styles are generally seen, either avoidance (e.g., withdrawal)or approach (e.g., take action). (a) Family coping style. Family coping style has beendescribed as either a mastery (i.e., family perceives they haveresources or access to resources to exercise some control over the
30. situation) or fatalistic orientation (i.e., family believes they donot have resources to deal with the trauma). 11 When families takemastery orientation, they take a solution-oriented approach incontrast to fatalistic orientation which leads to passive behavior. (b) Effectiveness of coping strategies. Coping strategiescan be effective or ineffective. Further, ineffective copingstrategies can add to source of stress. Research has shown thatindividuals who use withdrawal and avoidance responses are more likelyto have greater posttraumatic distress, PTSD and failure to recoverthan those who use problem-solving or adaptive coping skills. (It isimportant to note that avoidance and hyper-vigilance are waysindividuals typically cope with repeated loss and death.) Other copingstrategies considered ineffective are drinking, denial, avoidingtalking about trauma, and regression (in children). According toPeebles-Kleiger, families may initiate controlling behaviors inresponse to the feelings of helplessness and these behaviors often donot “restore equilibrium and typically create additional harm”. (5) Past history of trauma and loss – Previous trauma can havea positive or negative effect. If an individual experienced mastery(or positive meaning) with previous trauma, then an individual maydisplay increased strength in their ability to cope with subsequenttrauma situation. However, individuals who have experienced priortraumas can be more vulnerable to development of PTSD. (6) Preexisting stressors – Stressors (such as marriage,divorce, serious health problems, job loss and family-relateddifficulties) preceding the trauma event can make an individual morevulnerable to traumatic stress reactions. (7) Spirituality and beliefs – Traumatic events often causepeople to question their beliefs about safety, trust, power/control,esteem and intimacy. For example, war (or combat deployments) oftenraises questions about moral and ethical beliefs. For example,terrorist attacks cause people to question their beliefs that theworld is safe, secure and predictable. Their questioning reflectsindividuals’ and families’ perceptions of their vulnerability, safetyand control in the world which shapes how they respond. For example,families often feel a need to focus on safety and thus can show hyper-vigilance and control behaviors. (8) Perception about meaning of events – How individuals andfamilies perceive events is a significant factor in the degree towhich an event distresses individuals and families. Theirinterpretation affects the nature of individuals’ coping andresponses. For example, Sailors may deal with war by finding meaningand gratification in helper role. 16 A child who blames him/herselfwhen a bad thing happens is likely to become distressed.
31. (9) Mental illness prior to event – Individuals who hadmental health problems or illness prior to event is likely to haveproblems following a traumatic event.These factors can serve as individuals’ strengths which enableindividuals/families to show resilience or areas of vulnerabilitywhich lead to mental health problems/disorder. Individuals (andfamilies) vary greatly in their strengths and vulnerabilities. Theinteraction of all these factors is complicated (see boxes below) andthus it is difficult to predict how any given individual (or family)will respond. A WORD ABOUT WHY DISTRESS AND MENTAL HEALTH PROBLEMS OCCUR An individual’s (families) responses to a stressor event and stress are shaped by the adequacy of individual (and family) resources along with their perceptions of the meaning of the event. If resources are overwhelmed and negative view is taken, then responses are likely to be maladaptive. In contrast, individuals who have sufficient resources and who reframe events or view event as opportunity for growth adapt better. The nature of individual/family responses determines the level of stress experienced. When mental health problems or impairment in A WORD ABOUT WHY RESILIENCE OCCURS Resilience is the ability to bounce back to a level of functioning equal to or greater than before the stressor event. To achieve this, an individual must be able to be flexible and stay healthy/thrive (i.e., maintain physical and emotional health and spirit for living) in times of undue stress. 19 Individuals can attain resilience in different ways. c. Support System and Recovery Environment. The focus is on thefactors in the informal and formal support network that impactsindividuals’ (and families) ability to get aid and regain normalfunctioning. (1) Family – Individuals often turn to family as a source ofsupport when they are stressed. Other family members’ reactions caninfluence an individual. For example, it has consistently been shownin the literature that children’s reactions are closely related toparents’ reactions to trauma. (2) Community – Community response and social support canmediate adverse effects of trauma events. For example, community-wideresponse (e.g., community mourning together) can aid group recovery,when mass trauma occurs. Community attitudes and perceptions can alsoinfluence community support efforts and individual reactions. Forexample, perceptions and attitudes about war have been known toinfluence the level of support Sailors and families receive.
32. A WORD ABOUT SOCIAL SUPPORT Social support is regarded as an important resource for families when dealing with stress21 and coping and adapting to a traumatic event. Social support refers to both information disseminated to facilitate problem-solving and development of new social contacts that provide help and assistance.10. Do Children Respond In The Same Way As Adults? What EffectsChildren’s Reactions to Trauma? Normal Children’s Reactions to Trauma and DeathYoung Children School-age Teens and Adolescents(0-5 years) (6-12 years) (13- 18 years) • Crying • Crying • Suppressed emotions or denial; • Fear of being separated from • Withdrawal Emotional numbing parent • Unable to pay attention • Re-experiencing • Clinging • Anger/disruptive behaviors (e.g., • Avoidance of feelings • Whimpering fighting, bullying, aggression) • Acting out (engaging in risky, • Change in sleep and eating • Nightmares sleep disturbances antisocial or illegal behavior) habits • Irritability • Resentment • Regression in behavior (e.g., • Fear • Guilt bedwetting, fear of darkness, • Self blame or guilt • Depression and/or suicidal thumb sucking) • Fluctuating moods thoughts • Repetitive play or talk • Physical complaints (e.g., stomach • Distancing, withdrawal (especially children less than aches, headaches) • Mood swings 3 years old) • School problems (e.g., academic • Anxiety, panic • Screaming, tantrums, irritable difficulty or decline, difficulty • Anger outbursts (especially 3-5 year concentrating, school refusal) • Fear olds) • Clinging (especially 6-9 year olds) • Appetite and sleep changes • Withdrawal (especially 3-5 • Regressive behaviors (especially • Nightmares year olds) 6-9 year olds) • Physical complaints (e.g., stomach • Resentment (especially 9-12year aches, headaches) olds) • Difficulty with peers • Suppressed emotions or denial • School problems (e.g., academic (9-12year olds) difficulty or decline, difficulty • Sadness, depression (especially concentrating, school refusal) 9-12year olds) • Increased dependence or independence • Anxiety (9-12year olds) • Repetitive talk with peers or thoughts (9-12year olds)School Age (6-12 yrs). Like adults, children will display a varietyof reactions and feelings in response to the stress, fear, and lossexperienced with a traumatic event (such as combat deployment orparent’s death). Not all children will exhibit all symptoms and theirreactions will change over time. Some symptoms will be short-livedwhereas other symptoms may persist. Some symptoms may not occur untilyears later. As with adults, mental health problems can subsequentlyappear. The problems most likely to be seen are posttraumatic stress
33. disorder, anxiety and depression. The nature of children’s reactionsto a traumatic event and their risk of developing a mental healthproblem depend on the same three factors as described for adults:circumstances of trauma event, individual and family characteristics,family and community support. Here is a closer look at the keyfactors as it relates to children. Individual Characteristics • Age – Children of different ages display emotions in different ways. For example, 3 to 5 year old children may display anger by fighting and throwing tantrums whereas 9 to 12year old children may exhibit aggressive and bullying behavior. • Cognitive level – Cognition influences children’s understanding of an event or death, which in turn influences children’s emotional and behavioral responses. Also keep in mind that fear (e.g., fear about parent’s death, fear about safety) is normal at certain developmental stages. A traumatic event can heighten a child’s normal fears. • Ability to cope – Children, especially young children, have less well developed coping strategies than adults. Thus they may have difficulty knowing how to handle their own feelings or can become overwhelmed by their feelings. • Child’s personality – A child’s personality and temperament influence how a child responds, although these traits can become exaggerated. For example, an anxious child may become more fearful. • Child’s relationship with deceased parent – The nature of this relationship may determine how children feel the loss and their emotional recovery. • Child’s prior experiences with trauma – Children are more likely to be severely impacted if they have already suffered from a trauma. • Child’s preexisting mental health problems – Children who have mental health problems illness prior to an event are more likely to have difficulties following the event. Family Characteristics and Support • Parent’s reactions – This is one of the most significant factors that determine how children react. 26 Children’s emotions can be in reaction to or mimic parent’s reactions. Also children may be affected if parent is preoccupied with event and thus not available physically or emotionally. • Family’s functioning style and relationships – The nature of a family’s communication and the way family members interact and support one another will determine the level of comfort and assurance children receive. A lack of family support makes children more vulnerable to having difficulties. • Changes in family life due to event – These changes can create additional stresses that can have a negative effect or influence children’s reactions.