PDF CRM Chapter 6 Draft FRS for the NECC Family Readiness Symposium.

1. Chapter 6
Crisis, Trauma and Fostering Resiliency and Recovery
1. Purpose. Crisis and trauma within the Navy Expeditionary Force
can happen at any time - in theater, during training, or at home.
Crisis comes in many forms and every situation is unique—a new set of
orders that requires a change in geographic station may be “business
as usual” to an experienced spouse, but to a newlywed or dependent
children the orders may induce panic. The nature of the missions
undertaken by NECC forces requires commands to prepare Sailors and
families 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 enable
individuals to deal with the smaller crises that populate every day.
It is important to understand and remember three groups may be
impacted by crisis/trauma. The impacted sailor and family, The Command
and families (friends, team mates) and the CFRT members (to include
Chaplain, CACO, Leadership and volunteers)
In order to prepare, it is important to have a basic understanding of
how individuals respond, what are the stressors of the event,
individuals’ needs, and what resources are (or will be) available to
support the CFRT, Sailors and their families. The intent is to
minimize the impact of events that can be traumatizing for the
command, Sailors, and families and to foster resilience, recovery and
personal growth following a trauma. This chapter discusses the
responsibilities of the CFRT for planning, preparation and confronting
a crisis. It introduces the concept of a Casualty Response Team (CARE
Team) built around certain CFRT billets. It also highlights the roles
of some key positions outside of the CFRT that may be involved in
crisis response and the aftermath. Finally the chapter provides basic
information on trauma and practical approaches to responding to it.
2. CFRT Responsibilities in Crisis. The roles and responsibilities
specified in Chapters 2 and 3 are applicable in a crisis situation.
This listing identifies duties and tasks which may not ordinarily be
carried out, but are necessary to maintain overall readiness and
address the needs of the command when confronting a crisis.
a. Commanding Officer – Leader of the command. The CO must
balance the needs of the Sailors and families directly impacted by an
event with the charge to maintain operational readiness of the
command.
b. Command Master Chief – Oversees communication concerning an
event within the command and externally through the FRO to command
families.
c. Leadership Spouses: Can be a member of the CARE Team

2. d. Family Readiness Officer (FRO). During CACO or other emergent
response operations the FRO will be the understood “team leader”,
coordinating response support with the Ombudsman (OMB) and Family
Readiness Group Leader (FRGL) in support of the impacted family and
command families. The FRO will collaborate with the Ombudsman and FRGL
to conduct relief efforts and offers of support (donations, visiting,
updates, meal teams) allowing command leadership to continue operating
in their critical mission role.
e. Ombudsman (OMB) facilitates communications between the command
and command families. A member of the command care team (COMNECC
trained).
f. Family Readiness Group Leader (FRGL) coordinate FRG volunteer
team response. A member of the command care team (COMNECC trained).
g. CAsualty REsponse (CARE) Team. A group of 3-4 volunteers who
are trained to support the family of a deceased/wounded Sailor
immediately after a notification of a death or serious injury. These
volunteers also provide coordinated support for command families. CARE
Teams revolve around OMB and FRGL, but exist to alleviate the full
"burden" of care for an impacted family from the OMB/FRGL so that they
may also focus on the larger issues of readiness during crisis
(secondarily, the possibility of multiple casualties necessitates the
CARE Team having individuals other than OMB and FRGL). Other members
are appointed by the CO and can include leadership spouses, past
experienced ombudsman and FRGL’s. CFRT’s can also utilize command
approved volunteers from other units. All must be NECC CARE Team
trained.
(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 the
Command CARE Team from performing specific missions (e.g. Ombudsmen
cannot physically provide childcare support.) Commands should be
aware 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 that
complements the assistance provided by the CACO, Chaplain and TRIAD so that the family
can 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 within
the guidelines provided Navy and COMNECC instructions.
More information about the functions and practical actions of a CARE team is provided
later in this chapter. The information will also be helpful for CFRT members.
3. How Should A Command Respond To A Traumatic Event? How a command
responds to a traumatic event will have direct impact upon how Sailors
and families perceive the command and its leadership. It is vital to
establish proactive plans that address preparedness, response and
recovery phases.
a. Preparation Phase: Due to the various mission types of NECC
commands it is important to understand that preparedness is not
limited to a scheduled deployment.
(1) Ensure Care plans and CPFRP forms “Contact sheets” are
current and the location, usage and access of the forms are known and
understood to the CFRT.
(2) Ensure NFAAS, page 2’s etc. are current.
(3) Review pertinent Navy and local SOP’s on Disaster
preparedness and response plans. To include; “Operation Prepare”
http://www.cnic.navy.mil/CNIC_HQ_Site/WhatWeDo/FleetandFamilyReadiness
/FamilyReadiness/FleetAndFamilySupportProgram/DIsasterPreparedness/ind
ex.htm
(4) Ensure all CFRT members have a clear understanding
and are included in the planning of the Disaster Preparedness and
response plans. It’s important that CFRT members proactively
communicate with the families of known impending natural disasters,
events (etc) with plans and resources available. If the command is
deployed communicate to both the Sailors and Families.
(5) FRO’s and Ombudsman will be included in Command
Disaster Preparedness Exercises and understand their role in disaster
preparedness and response.
(6) Review pertinent Navy policies on Casualty procedures
including; notification procedures, mass casualty response, and policy
variations if incident occurs in battle space of another service
branch (Geographic Combat Commander Rules)
(7) Ensure all CFRT members are included in the planning
and have a clear understanding of casualty procedures, an
understanding of the services a CACO provides assistance and the
command response plan. To include care for the impacted, care for the
command 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, Memorial
Affairs Operations Center, and Medical Treatment Facilities, Tragedy
Assistance Program for Survivors, and other resources that may be
available 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 and
FRGLs is not to participate in notification process or to interfere in
the CACO’s administration of their duties.
(12)If a Regional CACO is utilized the Commanding
Officer is highly encouraged to send a uniformed Command
Representative to further support and connect with the family, similar
in spirit to the “Special Escort”. The use of a command
representative has great benefits to a family who has just suffered a
loss. The ability to talk to a friend of the deceased, attend the
funeral, assists the family in their grieving process.
(13) Establish a strategic communication plan that allows
information from command (including deployed commander) to be quickly
and accurately disseminated to families. Meet with CFRT members and
leadership to develop a communication strategy amongst the CFRT
members and also to the command Sailors and families.
b. Response phase
(1) Provide a prompt response. Talk plainly and honestly to
families.
(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 memorial
services that provide opportunity for tributes and shared mourning.
Involve employers and schools in community memorials.
(5) Provide information to help individuals understand normal
reactions and recovery process. This is helpful in normalizing the
experience for individuals and helping individuals to have realistic

5. expectations for recovery. Keep in mind that most people will not
need counseling, but they will need education and resources. Provide
psychological first aid for acutely distressed individuals through
referrals and resources available.
(6)The emotional response will be broad and many will feel the
“realness” of the situation; sometimes great grief comes from those
who are the least expected. Listen to the Sailors and families and
respond accordingly. Observe pattern changes, risky behaviors,
anxiety, outbursts, and anger. It is important for CFRT to discuss
command climate, situations of concern.
(7)Realize that discomfort and awkwardness occur for everyone
involved in the situation. People who want to help may feel guilty
because they have not suffered their particular tragedy or they simply
may not know what to do or say.
(8)Conduct crisis communications to control rumors, calm people
and reduce people’s sense of risk. Be honest in communications. By
providing open, clear and honest communications in times of heightened
anxiety will help mitigate rumors, misinformation and negative
perceptions.
(9) Conduct Informational and family resiliency briefing for
command and families within a few days’ hours of casualty or disaster
(etc)
(10)Ensure CFRT members and Care team members are aware of
resources and methods avoid burnout or compassion fatigue.
(11) Tailor support or intervention efforts to particular
groups. Pay special attention to sailors or families close to the
impacted sailor/family. Such as detachment/company member, department
co-worker, or close friend. In addition to the grief for the loss,
families may have added concern for their Sailor especially if they
are deployed. Sailors if deployed may have concern for their
families. Be aware of the impact of survivor’s guilt on both the
service member and spouse.
c. Recovery phase
(1) Facilitate community healing. Consider opportunities for
families to connect and lean on each other and even laugh. Doing so
will help reduce stress and remind families they are not alone.
(2) Continue to monitor needs, mental health issues and
functioning. Get individuals with psychiatric diagnosis into
treatment rapidly.

6. (3) Continue to conduct outreach to connect and provide
information to build people’s resilience and coping skills.
(4) If an incident occurred while on deployment; upon the
expected return of the remaining Sailors, discuss with the CFRT
separate post-crisis reintegration brief with the spouses. Consider
having a counselor, Chaplain facilitating an opportunity for families
to discuss concerns and understand what to possibly expect of their
returning 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 support
and make notes on what went well, what could’ve been changed, etc. No
response 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 and
Reactions:
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
(a) Personal loss such as loss of husband/parent
(b) Symbolic loss such as loss of sense of security and
loss of identity

7. (c) Ambiguous loss (i.e., the uncertainty of family unit
and relationships as in case of seriously wounded, POW and MIA)
(4) A prolonged sense of crisis or lack of control feeling (a
feeling that can arise from the sense “their whole world has just
turned upside down” and the life change that has just occurred)
(5) Additional stressors (family now faces decisions and
matters that have to be addressed, etc.).
Note: It is common for a sailor and family to struggle to find
meaning in the event (i.e., “why did their happen?”). Thus,
reactions initially following the trauma event may be intense, but
not always. Reactions do tend to change over time as the Sailor and
family moves through the recovery process and transitions to the new
situation. During the recovery process, there will be good days and
bad days for a sailor and family until they are able to thrive. Keep
in mind that it will take time for a Sailor and family to recover.
The length of time to recover will vary across families and across
individual family members.
5. CFRT in Crisis Response mode: As mentioned above there are three
groups impacted by crisis and trauma, below provides some baseline
insight. The information is centered on the worst case scenario. As
the CFRT develops an understanding of roles and exercises its ability
to communicate and collaborate so that each member is ready in the
event a Sailor is killed or wounded. A CFRT which is prepared to
address a traumatic situation is an asset that enables the command to
continue with the mission
It is important to keep in mind that there are three groups impacted
when a traumatic event occurs:
(1) Sailors and Families directly affected.
(2) Families (i.e. remaining Sailors and Families in the
command, including those temporarily assigned to the command).
(3) Family Readiness Command Team and support staff. This can
include leadership, FRO, CACO, Chaplain and Volunteers etc.
Each trauma event and family (both their reactions and needs) is
different so CFRT members and Care Team members need to view each
situation as unique. This means that CFRT will need to think on their
feet and adjust to the situation. The key to providing valuable
support is to take cues from the family; to be flexible and adaptable
as the situation changes, and to never lose sight of the fact that
the family is the primary focus. The family is going to have good
days and bad days. So please remember not to take things personally,
and encourage others also to be tolerant and kind. The family is
going through a difficult situation, and the CFRT role is to help
make it a little easier, not add to it in any way.

8. a. Understanding the Notification Process. Having a general
understanding of the Casualty notification process and casualty
assistance program is helpful in seeing how individual members fit
into the overall efforts to support families of casualties. With
their knowledge, the CFRT can support the command, Sailors and
families more effectively.
b. How are families notified of a casualty? The casualty
notification process varies depending upon the type of casualty. If a
sailor is deceased (i.e. Death, Whereabouts Unknown or Missing in
Action) the family will be notified in person. In the case of an
injured Sailor, notification depends upon the nature of the Sailors
injury. Generally for very seriously injured (VSI), or seriously
injured (SI), the Command or CACO will notify the next of kin in
person or by telephone. When the sailor is not seriously injured
(NSI), the PNOK is notified by telephone if the illness or injury is a
result of hostile action. In these cases, the Sailor generally
notifies their family.
6. Who else assists the family? There are several individuals and
agencies designated by the Navy to respond when a Sailor injury or
death occurs. It is important to understand the role and
responsibilities of these individuals and not conduct tasks performed
by these individuals. The best response and support provided to a
family is a coordinated effort and team approach.
(1) Casualty Assistance Calls Officer (CACO) The CACO is
responsible for notifying the Primary Next of kin (PNOK) and Secondary
Next of kin (SNOK) and any other person listed on the Sailors page 2.
The CACO provides support to the family and aids with personnel
related matters such as provide survivor benefit information and
assist with funeral arrangements.
(2) Chaplain: The role of the chaplain is to accompany the
CACO when notification is made in person. The Chaplain offers pastoral
counseling, comfort and solace to families. The Chaplain is also a
source of information about religious observances and funeral
services.
(3) Public Affairs Officer (PAO) A Public Affairs Officer may
contact the family to offer information and guidance on dealing with
the media.
(4) Personal affects: A member of the command is appointed to
collect, inventory, safeguard, and send the effects of the deceased
Sailor to the place requested by the NOK.

9. 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.
(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

10. 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 other
Commands to assist with or standby to assist with crisis response.
(6) Have sign-up sheets available for spouses/family members
to volunteer services for the grieving family, such as making meals,
doing yard work, and helping with childcare. Provide to the impacted
family a specific list of what services are willing to be provided and
by whom.
(7) Remember that there are former CFRT members across the
NECC force that has firsthand experience in crisis response. They are
a critical asset for guidance in these situations.
Note: Over the following weeks maintain open communication with your
Command families regarding memorials, homecomings of wounded warriors,
locations to send flowers/cards, and support services available to
them.
h. Taking Care of Self.
To support families effectively, it will be important for CFRT to take
care of them when assisting a sailor or family. This involves taking
steps to deal with own reactions, handle stress, and avoid compassion
fatigue.
(1) Dealing With Own Reactions. Keep in mind that you may be
grieving and/or dealing with your personal reactions to the trauma
event. This is especially true if the Soldier was a friend. Allow
yourself to grieve. Helping a family can be rewarding and meaningful.
However, it is important to be mindful of your reasons for assisting
the family. Have realistic expectations of how you can assist the
family. This is vital to being able to maintain the empathy and

11. provide the support needed by the family. Additional guidance is
provided in the subsection entitled avoiding compassion fatigue.
(2) Handling Stress. Helping a sailor and/or family in
distress can take an emotional toll and be stressful. Emotional
reactions can be compounded by the leadership positions held. Be
aware of the symptoms and signs of stress so that you can take action
when you feel stressed. Because individuals display stress in
different ways, you may not show your stress in the same way as
another CFRT members. Care Team volunteer. Be attentive to what you
are 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 pressure
It is important to deal with stress right away and in effective ways.
I. TIPS FOR MANAGING STRESS. These tips are designed to increase
your ability to cope with the situation and reduce your level of
stress.
(1) Maintain health and well-being
(a) Take good care of yourself. It is very important to
exercise, eat properly, and get enough sleep. Maintaining your health
is very important, especially in highly stressful situations.

12. (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 and
pace yourself accordingly.
(B) be realistic about what you and can’t do. Ask for
help when you need it.
(c) Know your limits. Say “no” when you need to do so.
(d) Maintain a balance between assisting the family and
own personal/family obligations. Maintain contact and spend time with
your family
(e) Be flexible. Accept that you don’t have control over
some 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 walk
can be helpful to reenergize. Do not assist a family round the
clock, work in shifts.
Sources: National Mental Health Association; Mayo Clinic; AE PAM 600-
8-109-1, Family-Focused Deployment Guide; Family Readiness Guide: A
Deployment Guide for 3rd COSCOM Soldiers, Civilians and Families
Avoiding burn out and compassion Fatigue
Note: CFRT/Care team members and other responders are at risk of
developing burnout and compassion fatigue. Compassion fatigue (or
vicarious dramatization) is when CFRT members/Care team members show
signs of posttraumatic stress. It occurs as a result of ongoing
exposure to witnessing a Sailors or family’s suffering and hearing
about their experiences. Exhibiting some stress symptoms is normal.
However, when the level of stress does not diminish, especially after
CFRT has ended its assistance, or normal functioning becomes impaired,
then it is important to seek professional help. A constellation of
symptoms listed in the table below may indicate a need for
professional help.

13. SIGNS OF COMPASSION FATIGUE
Physical Cognitive Emotional Symptoms Behavioral
Symptoms 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, • Restlessness
symptoms • 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/survivor
CAsualty REsponse (CARE) Team.
As touched on at the beginning of this chapter a CARE Team is group of
3-4 volunteers who are trained to support the family of a
deceased/wounded Sailor immediately after a notification of a death or
serious injury. These volunteers also provide coordinated support for
command families. All CARE team members must attend NECC CARE Team
Training.
(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 family
requests their assistance. In the case of fallen Sailors, the Care

14. Team will be sent immediately following notification. In the case of
wounded Sailors, the Care Team may be sent immediately following
notification and prior to the family leaving to join the wounded
Sailor in the hospital/medical treatment facility or may be sent
immediately following family’s return. At the time the family returns,
the wounded Sailor may or may not have been transferred to a hospital
or 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 assess
possible family needs before the Ombudsman and FRO contacts the
family. The FRO will also offer the type of support the Care team can
coordinate for the family.
(b) If the family says no, the CO will follow up with
the CACO in 48 hours with the same question. It is normal within the
first few hours or days for the impacted family to be overwhelmed and
thus unsure of what type of support they may want or need. It’s
important to communicate what types of support can be provided. It is
very important to be ready but wait.
(c) The CO will provide guidance to the CARE Team
representatives (Ordinarily the OMB and FRGL) prior to the visit to
the family. While on site, the CARE representatives may determine,
based on family’s requests and perceived needs, that additional
support is needed. However, additional suppor requested should be
discussed with the command.
Note: All members of the CFRT and support organizations should seek
clarification before providing any support not specifically cited or
prohibited in this manual.
Note: Other unit trauma situations in which a CARE Team may be sent to
assist a family include: suicide of Sailor, MIA, POW, and death of a
Sailor’s spouse or dependent child or hospitalization
(2) How Long Does a CARE Team Assist a Family? The intent is for the
CARE Team to assist the family until extended family members arrive to
support the family or when no extended family is available. Further,
the CARE Team’s assistance is intended to be provided on a short-term
basis, anywhere from 72 hours to two weeks. The actual length of time
depends upon the family’s needs, Commander’s guidance and presence of
other family members/friends to support the family.
g. Building Trust, Respecting privacy and Maintaining Confidentiality
as CARE Team Members

15. (1) Privacy is of the utmost importance to Sailors and
families during times of trauma. It is expected that all CARE Team
members in in this instance will keep personal matters disclosed to
them in the strictest confidence. A more detailed discussion with
specific examples of how to protect a family’s privacy is provided in
the tips box. THE BOTTOM LINE: Protect the person’s privacy as you
wish yours protected.
(2) TIPS ON MAINTAINING CONFIDENTIALITY
(a) Do not disclose specific details to anyone other than
the CFRT Members, the Chaplain, the Casualty Assistance Officer, and
the CARE Team members.
(b) During the course of working with the sailor or
family, you may learn many intimate details of the Sailor and
family’s life. Keep their information to yourself.
(c) Only give information with the permission of the
Sailor, spouse and/or family involved.
(d) Protect the person’s privacy when reporting to
others. For instance, if you are informing the Chaplain of something
that happened with the family, do not use names or specific details
when others may be present. Move to a private area when possible.
(e) When confidentiality does not apply. During the time
you are assisting a Sailor or family, if there is any suggestion of
any of the following issues: suicide, neglect, or assault, inform the
person that you are obligated to report the situation. Depending on
the severity of the situation, call 911, CO/FRO, and/or Chaplain. If
there is a possibility of immediate danger to an individual, contact
the police right away. If you are asked to keep their this type of
information, which may be illegal or dangerous (to themselves or
others) in confidence, inform the person that confidentiality does
not cover these areas.
(f) Have a clear understanding of what situations the CO
expects to be reported to them. This information should be discussed
with the CO before the FRO and CARE Team interacts with the Sailor
or family. You should inform the person involved that they are
touching on areas which you must report. Informing the person of
your obligation to report to others is being honest with the person
and gives them the choice of whether or not to continue the
conversation, knowing the consequences if they choose to do so. If
you are unsure about whether a specific situation falls outside the
confidentiality areas or must be reported to the command, excuse
yourself and contact your command POC/FRO and/or the Chaplain for
advice.

16. 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’s
wishes.
Verify with the family what information the family wants shared and
what they do not what shared. Do not provide any information unless
you are sure to whom you are talking and the family member has
authorized the release of the information. Media inquiries should be
directed to the appropriate Public Affairs Officer.
(b) Keep a phone log. Write down the name of all
individuals who call and associated telephone numbers. It may mean a
lot to the spouse later to see who called and can be used by the
family for sending thank you notes. Also, you can use it to call back
those who wanted information on the funeral and memorial services.
(c) Get a list of condolence phone calls received by
the command. CMC should coordinate with CARE representatives to insure
calls received by the command are delivered in a timely manner so they
may be added to the family’s phone log.
(d) Ask if there is anyone the spouse/family would
like the CARE Team to contact.
TIP: Making calls is the family’s responsibility. CARE volunteers, a
Chaplain or a supporter outside the command can support the spouse
through this process.
(6) Home Care Assistance
(a) Maintain a list of questions for the CACO. It is
very helpful to have a notebook to write down any and all questions
that the spouse/family has. Remind the spouse of the questions when
the CACO is there so the CACO can answer them. Remember, the CARE Team
should not be answering questions that pertain to CACO or Leadership
responsibilities (benefits, entitlements, funerals, etc.)
(b) Maintain a list of questions for the CO . Write
down any and all questions that the spouse/family has for the CO.
(c) Record visitors and gifts. Keep a logbook of
flowers and gifts received along with a brief description including

17. the identity of who gives them. Keep all cards. Keep a record of who
visits 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 the
event the family needs money, this matter should be addressed with the
CACO and CO who can assist the family in getting emergency financial
assistance.
(e) Maintain good communications with the command.
Notify the FRO of any needs the CARE Team cannot address. For
example, notify the command if the family needs translation services
or has difficulties accessing services.
(7) Childcare Support: FRGL/OMB If the family has
children, the CARE Team should assess needs and support required.
(a) Assess children’s needs and obtain information to
include:
(1) Ages of the children
(2) Immediate childcare arrangements and needs
while. (e.g., Does the family require someone to stay with any
children at home so the adult(s) can meet with the CACO or attend to
pre-departure needs if traveling to medical facilities to visit
wounded Sailor?)
(3) Children’s medical issues (it may be
necessary for caretakers/babysitters to be aware of particular medical
conditions/problems)
(4) How death or injury was explained to
child(ren) (so caretakers, babysitters and others are aware of what
children have been told and have a sense of what can/cannot be said)
(5) Whether children reside elsewhere
(6) Children’s school and extracurricular
activities; and what adjustments will be made while family is dealing
with trauma situation, even if temporary (e.g does school require
family authorization for someone other than a parent to pick a child
up from class, will children stay at home and not attend school until
time of funeral?)
(7) Children’s transportation needs.
(b) Identify friends of family or children who may be
willing to offer support. (This can be very helpful for
teens.)

18. f. Meal Support
(1) Go grocery shopping as needed. Be mindful of food
allergies, dietary restrictions and preferences. Funds to purchase
groceries are the responsibility of the family. This is to be funded
by the family, CARE Team volunteers do NOT pay for groceries.
(2) Coordinate meals for the family. Ensure food is also
available for visiting family and visitors when they are at family’s
residence. To make meal/food arrangements, will entail the following
steps:
- Identify special needs, food allergies, religious or dietary
restrictions of family members.
- Find out the types of dishes/foods family members (including
children) prefer.
- Identify out-of-town family members and friends expected to
visit family.
(3)Designate a Meal Coordinator. It is often helpful if the
coordinator is a friend of the family so they can be a liaison between
the 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 showing
which volunteers or individuals can provide meals on which days. There
are many online programs that can support this.
(b) Ensure the family receives a variety of meals. Avoid
providing the same meals unless requested by the family.
(c) Monitor the quantity of food provided. A family may
not want a meal delivered every night, but rather at specific
intervals. Or a family may want food that they can put in the freezer
and pull out as needed.
(d) Provide guidance to those wanting to provide food
including:
- Allergy and dietary restriction information
- Children’s preferences
- Snack items desired

19. - Times and locations for food drop off.
- Format for meal preparation instructions (if dish
will 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 this
is a command function)
- Provide a welcome basket or information packet for out of
town family.
TIP: Contact the local FFSC office in preparing an information packet.
These offices often already have such packets. The Care Team would
only need to supplement the packet with unit information, directions,
and other pertinent information related to the situation or visiting
family/friends’ needs.
h. Assist family with personal arrangements related to funeral.
This support is not to interfere with the CACO or responsibilities of
the Command. Working collaboratively with the CFRT and with the
invitation of the family support may include:
(1) Help in getting necessary clothes for the funeral or
memorial 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 media
coverage (articles, videotapes) for family including a videotape of
the memorial service.
(5) Help arrange someone to housesit during the funeral and
memorial service, if necessary.
(6) Help family arrange location, food, preparation and clean
up for a gathering held after the service, if the family elects at
family home or at designated location.(If Command
Function/coordinate/discuss with command)
i. Assist family with arrangements related to visiting a wounded
Sailor. This support is NOT to interfere with the CACO or
responsibilities of the Command working collaboratively with the CFRT
and with the invitation of the family support This may include:

20. (1) Help in packing clothes (including clothes and items
Soldiers may want or need while in hospital).
(2) Help Ensure spouse/relative on Invitational Travel Orders
has 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 family
member does not have a passport, one can be obtained quickly through
the CACO.
(3) If asked help coordinate with CFRT/CACO on travel
arrangements. (e.g., transportation to and from airport, local
transportation information or car rental in location of wounded
Sailor.)
(4) If asked help make necessary arrangements for family
members that will remain in the home (e.g., children, elderly parents,
individuals with special needs)
(5) Discuss necessary house arrangements for extended period
of absence (e.g., pet boarding, house sitting, stopping mail and
newspaper service, lawn care, house plant care, snow removal, and
emptying refrigerator)
(6) Cancel and/or change personal appointments
(7) Obtain notification or releases for children’s day care
and schools.
(8) Arrange or provide transportation. This may be helpful as
the intense emotions a family experiences can make an individual too
tired or too distracted to drive. Discuss with CFRT/CACO and family.
(9) Accompany family to local hospital. This can be a helpful
way to support families of wounded Sailors. Discuss with CFRT/CACO and
family. Remember to respect the Sailor and families privacy.
(10) Offer family a stress relief break. Take Meet spouse
and/or children out for a meal or an activity to have a break and
enjoyable activity. This can be helpful to both families of fallen and
wounded Sailors.

21. f. Tips on Dealing with Individuals’ Grief and Trauma
Reactions
(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. Simply
say, “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 and
recover. Avoid judgments about the family and the tragic situation.
(g) Listen quietly and non-judgmentally. Allow the family
to talk and in the early stages of grieving, to take the lead in
conversation. Allow family members to express as much grief as they
are feeling at any given moment and are willing to share. The family
needs “permission to grieve.” Allow the family to talk about the
endearing qualities of the person that has died.
(h) Be comfortable with just being silent and not
talking. Also, if you do not know what to say, that is okay.
Sometimes it is hard to find the words that convey what you are
feeling for the family and their loss. That is perfectly all right.
Sometimes the best way to comfort is just by being with them. Your
presence is all that is needed and is the one thing that is most
appreciated.
(i) It is a good practice to mention the deceased by
name.
(j) Arrange or provide practical assistance and support
as appropriate. Also encourage individual to ask for help. Be aware
that 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 person
feel better. Be accessible, but not pushy.
(l) Sometimes the family just does not want to see anyone
because they are tired or just want to be alone. Do not take this t

22. personally, 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. Encourage
family to have contact with their support network and connect with
others.
(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’t
change the subject when the griever mentions the deceased/wounded.
(c) Don’t let your own sense of helplessness or
discomfort; keep you from reaching out to the family.
(d) Don’t answer questions about the injury or death. It
is common for families to have questions, but refer family to CACO or
Command Leadership/RBL.
(e) Don’t impose your explanation on why their this has
happened. Don’t try to answer the question, “why?”
(f) Don’t say “I know how you feel” or “Everything will
be all right”.
(g) Don’t say anything that implies a judgment about the
family’s feelings: “You ought to be feeling better now” or “You’ll be
feeling better in a month or so” or “I know how you feel.” Don’t
encourage the family to “get over it”.
(h) Don’t make statements or ask questions that induce
guilt or affix blame.
(i) Don’t treat the family like invalids. Let the
spouse/family be in control and do the things that they want to do
for themselves. There is a tendency for volunteers and those trying
to give assistance to overdo it. Although well intended, for the
family, this can become very trying at times. Keep in mind that the
family may be experiencing anger and a sense of loss of control so
little things can become big things. The bottom line is, if the
family wants to get their own coffee, get their own sandwich, answer
their own phone, etc., let them.
(j) Don’t be too direct or give advice. (For example,
don’t make suggestions regarding packing up clothes, photos, etc.)

23. (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 discount
those of the family. Respect family’s religious and cultural beliefs.
(m) Don’t assume anything. For example: if the widow or
spouse of wounded isn’t crying, don’t assume she’s not upset or if
she’s screaming, don’t assume she can’t care for herself or her
family.
Source: This is a compilation of lessons learned, best practices and
adaptation of information provided in Army War College’s A Leader’s
Guide to Trauma in the Unit, Navy EOD Ombudsman Battle book, Fort
Sill’s Care Team training and Phantom Thunder Care Team Guide, Fort
Riley’s CDR/1SGT Course, Deployment Health Clinical Center’s fact
sheet entitled A Normal Reaction to an Abnormal Situation, and US Army
Operation 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 Made
Trauma Trauma
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 Accident

24. It is not uncommon for individuals to have experienced a traumatic
event. Individuals can be exposed to trauma in different ways:
physical impact (i.e., injury), visual exposure (i.e., witness), know
someone hurt or exposed to trauma, and media (which results in
repeated exposure). With many trauma events, it is not just the
individual 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 resided
may 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 by
the experience.
b. Traumatic events are different from normal stressful events.
Traumatic events are unanticipated and may create a prolonged sense of
crisis and lack of control feeling.
c. Some traumas create additional stressors such as loss of
routine, job loss, loss of financial income, relocations/displacement
of family or children, and the need to navigate government and
insurance systems for assistance.
d. Some traumatic events, as in the case of natural disasters for
instance, can cause disruption in community and social supports making
it 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., loss
of sense of security, loss of ability to trust other people, loss of
predictable future). Mass traumas often involve personal, community
and symbolic loss.
f. With any trauma, individuals of all ages may struggle to find
meaning in the event.
5. How do individuals respond to traumatic events? Individuals’
(both children and adults) reactions to traumatic events reflect their
response to stress, intense fear, helplessness, vulnerability, and
loss. Their response involves physical (bodily), emotional (feelings)
and cognitive (thoughts) reactions. Individuals’ reactions to
traumatic events vary considerably and can have varying impacts. For
some individuals, the reactions cause a mild disruption in an
individual’s life whereas others exhibit severe and debilitating
impairment in functioning.

25. Common Trauma Reactions
 Grief/Traumatic grief (if sudden loss Anger/Irritability
 Fear Confusion
 Disbelief/shock Unexplained somatic symptoms
 Numbing and withdrawal Depression
 Helplessness Anxiety
 Feeling Jumpy Easily startled Nightmares/flashbacks
 Sleep disturbances Distrust
a. Normal Trauma Reactions. Individuals will have many reactions.
The constellation of responses seen both in adults and children can be
wide ranging. Some responses, such as grief, depression and anxiety,
include a variety of additional and overlapping symptoms. For some
individuals, the cluster of reactions represents symptoms of acute
stress disorder (ASD) or posttraumatic stress disorder (PTSD), but not
necessarily a diagnosis of ASD or PTSD. Symptoms of PTSD are not
uncommon, and most will recover after a period of time.
b. Reactions to Loss and Death. Traumatic events can involve
sudden loss or death. A sudden loss of a Sailor, child or family
member is particularly difficult when death has occurred under any of
the following circumstances:
(1) Death occurred without warning and opportunity to say
goodbye
(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 a
significant and close attachment. Initially, reactions to their
traumatic loss may involve a wide range of intense emotions. Over
time the frequency and intensity of these emotions are expected to
diminish in a normal grieving process.
6. Traumatic Grief. Traumatic deaths or sudden loss of significant
and close attachment can lead to a grief process that is more
complicated and difficult to resolve. Traumatic grief occurs when an
individual shows extreme distress over an extended period of time and
that grief dominates an individual’s life. It is not uncommon for
these individuals to experience intense reactions including agitation,
suicidal ideation, and powerful rage (e.g., anger toward those
perceived to be responsible) or revenge fantasies. These individuals

26. may also have frightening memories/thoughts about the traumatic event
by either agonizing about what their loved one experienced during the
final moments of life or recalling the horror of the traumatic event
they experienced. These frightening memories/thoughts along with the
intense symptoms of distress are over and above the normal symptoms of
bereavement and disrupt the grieving process.
7. Post-traumatic Stress Disorder (PTSD). Symptoms of PTSD can also
occur. In the context of a traumatic death, PTSD symptoms may appear
as 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, tendency
to be startled easily).
While these symptoms are normal symptoms of grief, when all of these
symptoms occur together and persist then the individual may be
experiencing PTSD and should be referred for professional help.
8. Secondary Trauma and Trauma Reactions. Individuals can be
traumatized indirectly. Secondary trauma can occur when learning
about someone’s (typically a loved one for families) trauma or through
frequent interactions with a trauma victim and the victim’s trauma
symptoms (as in the case of both Sailors, family members, and unit
responders such as CACO’s, Ombudsman, FRGL’s, FRO’s, Chaplains, and
command leadership). The trauma reactions seen will be similar to the
normal trauma reactions described earlier. The only difference is
that in secondary trauma, the trauma reactions are associated with a
trauma victim rather than the trauma event.
9. Other Facts about Trauma Reactions. Key facts to keep in mind
about individuals’ responses to trauma
a. Initially, individuals may have intense reactions.
b. In many mass trauma situations, such as war and natural
disasters, individuals’ use of media increases.
c. Individuals’ reactions will change with the phases of the
trauma 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 reflect
survival and adapting to perceived harm to self or others. In
recovery and later, responses reflect individuals’ efforts to cope
with changed reality.
d. Sailors and family’s reactions to trauma occur in parallel.

27. e. Reactions and abilities to cope with trauma event depend on
various 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. The
PTSD 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 self
reliance, 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 and
the months and years after the event reflect how individuals cope with
stressful situations and change. It is difficult to predict how any
given individual or family will respond. There are three sets of
factors that determine how individual and families will respond.
a. Circumstances of Traumatic events. Reactions to traumatic
event are dependent upon circumstances of the trauma such as:
(1) Type or causality of traumatic event — Situations in which
a deliberate intentional effort to intimidate, control, or do harm to
individuals are very different forms of trauma than nature made or
accidents. Intentional and human made traumas tend to have a greater
number of, more complex, and longer duration of psychological effects.
(2) Whether single event, multiple events (e.g., 9/11), or
ongoing (e.g., war, abuse) — Multiple or ongoing trauma creates a
sense of fear, dread, and rage over expected repeated trauma. 7
(3) Amount and level of exposure — the greater proximity to or
exposure to trauma event, the greater the impact.
(4) Nature of losses — Losses, other than death, can result in
grief or depressed state reactions.
(5) Ambiguous loss — According to Pauline Boss, 8 certain
situations create ambiguous loss. Ambiguous loss occurs: 1) when

28. individuals are physically present, but psychologically not present
(e.g., mental health disorder, war wounded, distressed parent, parent
preoccupied with work) and 2) when individuals are psychologically
present, but not physically present (e.g., military deployments,
missing in action). These situations are stressful because the
uncertainty is experienced on an ongoing basis with no closure. The
stress of the uncertainty can impact family coping and relationships.
For example, for military families, the ambiguity of not knowing
whether the Sailor is dead or alive in a combat deployment can create
a stress that is traumatizing and immobilizing (e.g., relationships
and daily functioning are put on hold).
b. Individual/Family Characteristics. How individuals (and
families) respond behaviorally and emotionally is determined by a
number of personal factors including:
(1) Temperament – Individuals’ personality traits often
determine how individuals respond to extreme stress.
(2) Resources – Individual and family resources shape coping
behavior. 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 and
adaptability (ability to change)
(3) Culture – An individual’s cultural beliefs can impact how
an individual perceives the event, expresses emotions, and seeks help.
(4) Coping style – Individuals may use different coping
strategies in different phases of a trauma situation. Two different
coping styles are generally seen, either avoidance (e.g., withdrawal)
or approach (e.g., take action).
(a) Family coping style. Family coping style has been
described as either a mastery (i.e., family perceives they have
resources or access to resources to exercise some control over the
situation) or fatalistic orientation (i.e., family believes they do
not have resources to deal with the trauma). 11 When families take
mastery orientation, they take a solution-oriented approach in
contrast to fatalistic orientation which leads to passive behavior.
(b) Effectiveness of coping strategies. Coping strategies
can be effective or ineffective. Further, ineffective coping
strategies can add to source of stress. Research has shown that

29. individuals who use withdrawal and avoidance responses are more likely
to have greater posttraumatic distress, PTSD and failure to recover
than those who use problem-solving or adaptive coping skills. (It is
important to note that avoidance and hyper-vigilance are ways
individuals typically cope with repeated loss and death.) Other coping
strategies considered ineffective are drinking, denial, avoiding
talking about trauma, and regression (in children). According to
Peebles-Kleiger, families may initiate controlling behaviors in
response to the feelings of helplessness and these behaviors often do
not “restore equilibrium and typically create additional harm”.
(5) Past history of trauma and loss – Previous trauma can have
a positive or negative effect. If an individual experienced mastery
(or positive meaning) with previous trauma, then an individual may
display increased strength in their ability to cope with subsequent
trauma situation. However, individuals who have experienced prior
traumas can be more vulnerable to development of PTSD.
(6) Preexisting stressors – Stressors (such as marriage,
divorce, serious health problems, job loss and family-related
difficulties) preceding the trauma event can make an individual more
vulnerable to traumatic stress reactions.
(7) Spirituality and beliefs – Traumatic events often cause
people to question their beliefs about safety, trust, power/control,
esteem and intimacy. For example, war (or combat deployments) often
raises questions about moral and ethical beliefs. For example,
terrorist attacks cause people to question their beliefs that the
world is safe, secure and predictable. Their questioning reflects
individuals’ and families’ perceptions of their vulnerability, safety
and 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 and
families perceive events is a significant factor in the degree to
which an event distresses individuals and families. Their
interpretation affects the nature of individuals’ coping and
responses. For example, Sailors may deal with war by finding meaning
and gratification in helper role. 16 A child who blames him/herself
when a bad thing happens is likely to become distressed.
(9) Mental illness prior to event – Individuals who had
mental health problems or illness prior to event is likely to have
problems following a traumatic event.
These factors can serve as individuals’ strengths which enable
individuals/families to show resilience or areas of vulnerability
which lead to mental health problems/disorder. Individuals (and
families) vary greatly in their strengths and vulnerabilities. The
interaction of all these factors is complicated (see boxes below) and

30. thus 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 the
factors in the informal and formal support network that impacts
individuals’ (and families) ability to get aid and regain normal
functioning.
(1) Family – Individuals often turn to family as a source of
support when they are stressed. Other family members’ reactions can
influence an individual. For example, it has consistently been shown
in the literature that children’s reactions are closely related to
parents’ reactions to trauma.
(2) Community – Community response and social support can
mediate adverse effects of trauma events. For example, community-wide
response (e.g., community mourning together) can aid group recovery,
when mass trauma occurs. Community attitudes and perceptions can also
influence community support efforts and individual reactions. For
example, perceptions and attitudes about war have been known to
influence the level of support Sailors and families receive.
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.

31. 10. Do Children Respond In The Same Way As Adults? What Effects
Children’s Reactions to Trauma?
Normal Children’s Reactions to Trauma and Death
Young Children School­age Teens and Adolescents
(0‐5 years) (6­12 years) (13‐ 18 years)
• Crying • Crying • Suppressed emotions or denial;
• Fear of being separated from Emotional numbing
• Withdrawal
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 6‐ • Nightmares
year olds) • Physical complaints (e.g., stomach
9 year olds)
• Resentment (especially 9‐12year aches, headaches)
olds) • Difficulty with peers
• Suppressed emotions or denial (9‐ • School problems (e.g., academic
12year olds) difficulty or decline, difficulty
• Sadness, depression (especially 9‐ concentrating, school refusal)
• Increased dependence or
12year olds)
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 variety
of reactions and feelings in response to the stress, fear, and loss
experienced with a traumatic event (such as combat deployment or
parent’s death). Not all children will exhibit all symptoms and their
reactions will change over time. Some symptoms will be short-lived
whereas other symptoms may persist. Some symptoms may not occur until
years later. As with adults, mental health problems can subsequently
appear. The problems most likely to be seen are posttraumatic stress
disorder, anxiety and depression. The nature of children’s reactions
to a traumatic event and their risk of developing a mental health
problem 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 key
factors as it relates to children.

32. 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.