Do’s and Don’ts

For Responding to Crises and Emergencies During the First Weeks

Larry Beutler, Ph.D.

¹ The following draws heavily from several sources, including the volume on crisis response by Gist and Lubin, the Cochrane report, informal consultation from other scholars, and many research reports. References have not been listed, but can be supplied and incorporated, if desired at a later point.

General guidelines for responding to victims and rescuers during crises:

    It is imperative that the ways that we help victims of crisis reflect the best scientific knowledge available.  However, the nature of science means that what we know and what we can recommend is always changing.  The way that scientific information accumulates means that we are likely to find out more quickly when something doesn’t work than when it does.  Thus, from scientific research, we have learned that many of the things that we initially believed should have been helpful, are ineffective and some are even harmful.  At the same time, we are finding that many of the common sense procedures and fundamental ways of providing assistance are proving to be surprisingly helpful to people in crisis.

Despite the extensive instruction that is frequently offered and the “treatments” that are accepted as if their use represents factual and scientifically derived knowledge, actual scientifically supported and generated knowledge about what best to do in the immediate wake of trauma is quite limited.  There are, however, some general guidelines that can be derived from what research studies have been reported and we have attempted below to digest these into a straightforward list of basic “dos” and “don’ts” for the clinician who is seeking to assist victims and rescuers in the first hours and days following a major community crisis.  These recommendations represent the best knowledge that is available at the present time.


    Things to Do:

1. Remember that effective, first response comes not from your role as a healer, but rather from your role as one who provides comfort, direct support, and useful information.  You are most effective as a source of accurate information, immediate guidance, and direct assistance with the needs and demands of the present.  It is far more effective in reducing the immediate stress of losing one’s home to provide shelter than it is to listen empathically to the feelings of helplessness that loss entails.  In the immediate face of loss and threat, it also is more effective in preventing later psychological difficulties to provide immediate calming and instrumental care than to encourage early ventilation and catharsis.
2. Get your hands “dirty”—get into the field—in order to make sure that physical and medical needs are addressed.  It is very helpful in later contacts to have met people first in these settings and to have first provided immediate and pragmatic forms of help before attempting to offer more personal levels of support.
3. Provide information and guidance at very practical levels.  Arm yourself with as much information as you can garner, and communicate it clearly and systematically to those you encounter.  Update your information clearly, using only fully authoritative sources (don’t be a vehicle for transmitting rumor and misinformation).  
4. Establish a working relationship with the client.  Make sure that your role is understood and that the client has given permission for you to assist.  Declare very clearly your identity, credentials, relationships to other organizations (Red Cross, employer of rescue personnel, or any other relevant entities), and establish the objectives for the encounter.  Do not proceed unless the individual is willing to accept your help.
5. Ensure that physical and safety needs (medical, shelter, food, etc.) are provided before addressing the emotional impacts of the trauma.  Keep the initial focus on meeting basic needs and preserving stamina. 
6. Provide a clearly defined objective and end point for the contact and relationship. Tell people what to expect.  Most of the time, you will need to provide one or more direct referrals for subsequent assistance.  Ensure that the options your provide reflect a wide range of possibilities. 
7. Emphasize the client’s strengths rather than weaknesses or deficits. Provide reassurance (“this will pass”; “you will get through this”) and maintain a sense of calm. If handouts or written information are used, these materials should be carefully structured to promote expectations of resilience and recovery, rather than providing “laundry lists” of pitfalls and “symptoms.”
8. Direct victims and rescuers to community resources for finding comfort and assistance. Connect victims with sources of aid that will provide direct and continuing assistance and support  (family, community, faith-based resources, etc.). 
9. Rescuers are most critically affected by the tendency to identify with victims and to the effects of exhaustion—help them to establish and maintain boundaries, pace their efforts and expectations, and control emotions during protracted encounters. 
10. Work with a companion whenever possible and let them help you maintain perspective and objectivity.
    

    Things to Avoid:

1. “Debriefing” in the immediate aftermath of trauma—by its many labels (PD, CISD, MSD)—has not been shown to be effective in preventing later difficulties and may even cause problems to become entrenched or more severe over time. “Debriefing” includes any approach that includes one or more of the following elements: (a) revisiting and reconstructing the details of the traumatic event; (b) encouragement to explore the emotional impact of the events; (c) “normalization” of reactions, especially elements of negative feelings; and (d) “education” regarding signs and symptoms of PTSD.  While doing these things often seem to be a “good idea”, the evidence is strong and accumulating that these are aspects of help-giving that should be avoided during the initial stages of trauma reaction. 
2. Some examples of other treatments that are frequently used but whose effects have not yet been demonstrated scientifically to be helpful, include: re-exposure therapy, Eye Movement Desensitization and Reprocessing (EMDR), Thought Field Therapy (TFT), acupuncture, and various patent remedies.  Cognitive therapy (CT) has been found to be effective in high risk populations and when problems persist beyond the initial reaction, but even this approach should be avoided during the immediate aftermath period.  Any continuing “treatment” should be used only if indicated by careful evaluation after the initial traumatic reaction. 
3. Avoid being the specific or primary focus for providing assistance and emotional or social support in the immediate aftermath.  Healthy resolution ultimately may depend on fostering a sense of self-efficacy and mastery of the threat and challenge. The greatest risk to “helper/clinicians” may be “overhelping” or what some have called “the tyranny of urgency”—the tendency to go “too far” out of your way to help people do what they need to do for themselves, or even doing for them what can best be done by their own families and reference groups. 
4. The vast majority of those who are exposed to even severe trauma, will not experience PTSD and will recover through their own resources and in their own time.  Thus, it is important to respect the natural recovery process and to avoid presuming that someone needs professional mental health assistance.  Be “invisibly supportive”.  People recover at different rates and through different processes.  Let each person set their own pace, talk about things that are important to them, and seek their own space. Some people need a period of withdrawal and beyond this, it is important that the victim feel empowered and to take some steps on their own to gain a sense of personal agency.   Don’t push them to discuss or do something that they are reluctant to do. 
5. Don’t be too formal. Don’t carry the badges of distance, such as a clipboard or a white coat, that might mark you as a “removed”, clinical observer.  Respect the client’s privacy and keep the relationship open.
   

Making the Transition for Longer Term Help
   
Most people are very resilient and do not need long term assistance.  It is very difficult to reliably distinguish those who will have prolonged difficulty of a serious or lasting nature and those who will not, during the first days and weeks following a crisis.  It is not recommended that a clinician attempt formal mental health assessments until two more weeks have passed. 

However, a brief, initial screening, as long as it does not interfere with providing immediate, physical and medical assistance along with support, encouragement, and comfort, might help identify those who should be re-contacted after a period of from two to six weeks.

    Initial Screening 
    Screening of risk factors can be accomplished with four basic, relatively unobtrusive queries:

1. Has the individual experienced other intense, traumatic exposures or instances of “trauma” (has anything like this happened before)?
2. Is there any history of prior mental health treatment or, of circumstances for which the  individual or others thought treatment should have been sought?
3. Does the individual have at least one other person with whom they can talk and share their problems? Has doing so seemed productive and helpful in the past?
4. Was the individual exposed (by his or her judgment) to particularly gruesome or disturbing aspects of this event?
   

    Follow-up Evaluation
    Persons experiencing lingering difficulties after the initial impact has passed (generally 2-6 weeks) should be evaluated for further mental health assistance within the context of an established professional relationship. These services are generally best provided by agencies and professional within the local community, where enduring therapeutic relationships can be developed. Pertinent elements in that assessment might include queries such as these (drawn from the STS Clinician Rating Form of Beutler & Williams):

Depression (Should not manifest more than three of these symptoms)
1.    Dysphoric (sad or blue) mood
2.     Absence of joy in activities (anhedonia)
3.     Weight increase or decrease
4.    Poor or disturbed sleep
5.    Change in activity level
6.    Excessive fatigue almost daily
7.    Feelings of worthlessness or guilt
8.    Decreased ability to concentrate

Suicidal Impulses (Should not have any of these symptoms)
1.     Currently actively suicidal
2.     Is or has been homicidal within the past few years
3.    Has been suicidal at some time in the past
4.    Has attempted suicide within the past 6 months
5.    Has a specific plan for committing suicide
6.    Owns a firearm
7.     Feels that the future is hopeless and things will not get any better
8.    Has many self-destructive injunctions

Phobias (Should not manifest any of these symptoms)
    Following and beginning with exposure to the traumatic event, has the individual experienced either of the following:

1. The patient has experienced extreme and debilitating anxiety about being in places or situations from which escape might be difficult or embarrassing or in which help may not be available.
2. The patient has experienced fears of objects or activities that are excessive or unreasonable, cued by the presence or anticipation of a specific object or situation (e.g., flying, height, animals, receiving an injection, seeing blood), and results in both avoidance and impaired ability to function.
   

PTSD (Should not manifest any of these symptoms)

1. Persistent, intrusive daytime memories and fears about the trauma that interfere with social, sexual, or work functioning. 
2. Disturbances of sleep and nightmares related to the trauma.
3. Avoidance of trauma-related thoughts and situations, including feelings of “reliving” the traumatic events. 
4. Excessive vigilence and irritibility that may be manifest, at moments, by the impression that things are not real—like a dream.
   

Where further treatment is indicated, empirically supported, conservative approaches such as CBT spread across four to five sessions should be among the primary considerations.  Therapists attempting longer term interventions should seek specific training and supervision in these approaches, and especially in their application to traumatic exposure.  Case management that includes social work and systems advocacy should also be considered as a critical adjunct to ensure that continuing or emergent instrumental needs continue to be supportively addressed.

Last updated May 17, 2008
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