Mental Health

Objective: Manage fear and panic to maintain mental clarity and survival effectiveness.

Steps:
1. Realistic and challenging training builds self-confidence and confidence for a unit’s leadership.
2. The feeling of fear and panic will be present. The survivor must control these feelings.

Objective: Understand the types of stressors in survival situations and develop coping strategies.

Steps:
1. Identify common stressors such as injury, illness, or death; uncertainty and lack of control; environmental challenges (weather, terrain, creatures); hunger and thirst; fatigue; and isolation.
2. Develop strategies to cope with these stressors by anticipating them and managing the body’s “fight or flee” response.
3. Prioritize tasks that ensure survival, such as securing food and water, preserving energy, and maintaining mental focus.

Procedure:
1. Discuss the natural reaction to stress that is related to 'die of shame' (such as panic or emotional breakdown).
2. Highlight how understanding these reactions can help manage stress during survival scenarios.
3. Emphasize the importance of mental resilience and coping strategies in high-stress environments.

Objective: Identify signs of stress and manage them effectively to maintain mental health.

### Steps:
1. Recognize common signs of distress such as:
- Difficulty making decisions (not related to hypothermia)
- Angry outbursts
- Forgetfulness
- Low energy levels
- Constant worrying
- Propensity for mistakes
- Thoughts about death or suicide
- Trouble getting along with others
- Withdrawing from others
- Hiding from responsibilities
- Carelessness
2. Monitor yourself and others closely for these signs.
3. Use coping strategies to manage stress, such as practicing mindfulness, taking breaks, or engaging in physical activity.

Loss of Adaptability from Stress:

• Panic and confusion may occur when a service member is overwhelmed by danger.
- This can impair mental ability, making it difficult to think clearly or follow simple commands.
- Judgment may be faulty, leading to actions such as standing up in a fighting position during an attack.

• Symptoms resembling head injuries:
- Dazed appearance or aimless wandering.
- Confusion and disorientation.
- Partial or complete loss of memory.

What to Do:
1. If symptoms resemble those of a head injury, rapidly medically evacuate the service member for evaluation.
2. Do not allow the service member to expose themselves to further personal danger until the cause of the problem is determined.
3. Provide immediate support and ensure they are removed from stressful environments if necessary.

Purpose: Help Soldiers manage stress and fear to maintain operational effectiveness during combat or dangerous situations.

Steps:
1. Recognize that fear and physical signs of stress are normal reactions before and during high-stress events such as combat or field training.
2. Do not let fear or stress prevent you from performing your duties.
3. Discuss the situation with fellow Soldiers, especially during after-action debriefings.
4. Learn and practice techniques to relax quickly under pressure.
5. Integrate new unit members into the group and build camaraderie rapidly.
6. If joining a new unit, be proactive in forming friendships and establishing trust.

Notes:
• Stress management is critical for maintaining focus and effectiveness during high-stress scenarios.

Procedure:

To take measures to resist stress, follow these steps:

1. Practice regular physical exercise to reduce stress and improve mental well-being.
2. Ensure adequate rest and sleep to maintain cognitive function and emotional stability.
3. Engage in relaxation techniques such as deep breathing, meditation, or mindfulness practices.
4. Maintain strong social connections with fellow personnel and family members for emotional support.
5. Seek professional help if stress becomes unmanageable or begins to affect performance.
6. Educate personnel on the importance of mental health and provide resources for managing stress.

Warnings:
• Chronic stress can lead to physical and psychological health issues.
• Always prioritize rest and recovery.

Sleep Disturbance and Repetition of Dreams:

• Common effects of stress on sleep:
- Difficulty sleeping.
- Nightmares related to the stressful event.
- These are considered normal in the short term after intense stress.

• Repetitive reexperiencing of events:
- Some service members may repeatedly think about or act out parts of the stressful experience while awake.
- This is a natural part of recovery and should not be discouraged.

What to Do:
1. Encourage the service member to ventilate by talking extensively, even repetitively, about their experience.
2. Provide a safe environment for them to express emotions without judgment.
3. Monitor for signs of disruption in daily life due to these reactions and offer additional support if needed.

Emotional Reactions to Stress:

• Inefficient performance may include:
- Slow thinking or reaction time.
- Difficulty recognizing priorities or seeing what needs to be done.
- Indecisiveness and trouble focusing attention.
- Tendency to perform only familiar tasks and become preoccupied with details.
- Passive behavior, such as sitting or wandering aimlessly without purpose.

• Uncontrolled emotional outbursts may include:
- Crying, screaming, or laughing uncontrollably.
- Withdrawal and isolation from others.

What to Do:
1. Encourage service members who are withdrawn to remain with their unit for support.
2. If a person is experiencing uncontrolled emotional outbursts (e.g., crying one moment and laughing the next), provide reassurance and avoid confrontation.
3. Monitor for signs of restlessness or inappropriate aggression, such as indiscriminately striking others.
4. Ensure the individual is not exposed to further danger until their condition is assessed.

Objective: Assist and support employees during the pandemic by managing emotional stress and fostering cohesion and morale.

Steps to Implement:
1. Establish stress control/resilience teams that:
- Monitor employee health and well-being in collaboration with occupational health clinics, if possible.
- Staff rest and recuperation sites (see below).
- Distribute informational materials on pandemic response and self-care strategies (see S11-III.B for details).
2. Ensure infection control precautions are followed by stress control teams operating in hospitals.

To help manage emotional reactions caused by physical exhaustion:

1. Establish a unit sleep plan and ensure it is implemented.
2. Provide service members with a safe and relatively comfortable area for sleeping, such as:
- An area away from heavy traffic, noise, and congestion.
- A place that is clean, dry, and protected from environmental conditions.
3. Encourage uninterrupted sleep, as it improves the ability to function in the tactical environment.

When a service member is emotionally distressed due to physical exhaustion, ensure they get adequate rest:

1. Establish and implement a unit sleep plan.
2. Provide a safe and relatively comfortable area for sleeping:
- Away from heavy traffic, noise, and congestion.
- In a clean, dry location protected from environmental conditions.
3. Ensure the service member gets as much uninterrupted sleep as possible to improve their ability to function in the tactical environment.

Procedure: Reduce Uncertainty

Steps:
1. Provide clear and consistent communication to all personnel.
2. Ensure that soldiers understand their roles, missions, and expectations.
3. Address any concerns or questions promptly and transparently.
4. Maintain a stable environment through effective leadership and planning.

Details:
• Uncertainty can lead to stress, anxiety, and decreased performance.
• Leaders must be proactive in communicating information and managing expectations.
• Reducing uncertainty is essential for maintaining unit cohesion and effectiveness.

Purpose: Minimize the impact of stress on blood sugar levels during emergencies.

Steps:
1. Recognize that stress can raise blood sugar levels, so take steps to manage it.
2. Practice deep breathing, meditation, or other relaxation techniques when possible.
3. Maintain a regular routine as much as possible, including meal times and rest periods.
4. Avoid overworking yourself in disaster recovery efforts without taking breaks for snacks or meals.
5. Stay connected with family members or support networks to reduce feelings of isolation and stress.

Procedure:

1. Recognize that severe weather can negatively impact morale and increase survival challenges for personnel.
2. Train soldiers to be self-sufficient in mountain environments so they can adapt to harsh conditions.
3. Ensure proper training and equipment are provided to help soldiers use the weather as an advantage during combat operations.

- Allocate time for relaxation in order to “recharge your batteries.”

• Talk with someone you feel at ease with about your doubts, fears, frustrations, nightmares, etc.

• Maintain a healthy lifestyle and personal hygiene.

• Make sure you are comfortable enough and have adequate privacy.

• Do things you enjoy (in moderation).

You should know yourself, recognize your limits and communicate freely with others.

- Ask your team leader to halt or change your assignment, or accept a change when offered.

• Ask for psychological support if needed.

In armed conflicts and other situations of violence, you will face ordinary everyday settings and health problems as well as new ones relating specifically to the situation.

You will be able to handle these problems properly only if care is provided in an organized way and resources managed correctly, in response to needs and according to the context.

To evaluate your present state of stress:

• Answer the 10 questions by placing a tick in the appropriate box and adding up the results.

Scoring Guidelines:
• Under 15: Your state of stress is normal, considering your working conditions.
• From 16 to 25: You are suffering from stress, and should take it easy.
• From 26 to 30: You are under severe stress and should ask for help from someone close to you or seek medical advice.

Note: By using easily erasable pencil marks to tick the boxes, you can use the questionnaire over and over again.

### Questions:
| Question | Never (1) | Sometimes (2) | Often (3) |
|---|---|---|---|
| I have difficulty in sleeping – I do not take any exercise ||||
| I feel tense, irritable and nervous – I have cramps, headaches or stomach ache ||||
| The smallest noise makes me jump ||||
| I feel frightened/threatened all the time ||||
| I feel distant from my colleagues and avoid them ||||
| My work no longer interests me and I feel I have no future ||||
| I am very tired, physically and mentally – I injure myself from time to time when working ||||
| I have attacks of giddiness and sweating, a tight throat, and heart palpitations, particularly when something reminds me of a traumatic event ||||
| I never stop working – I feel overexcited, I act impulsively, and I take uncalculated risks ||||
| I relive traumatic events in my thoughts, in my dreams, or in nightmares ||||

If you feel overstressed, the best thing you can do is to **stop working and look for support."

Procedure:

• Recreation and Relaxation: Provide regular recreation opportunities for troops to maintain mental well-being.
• Personal Solitude and Group Relaxation: Allow periods of personal solitude and group relaxation as necessary for psychological health.
• Mental Distress Monitoring: All personnel must be alert to signs of mental distress, especially withdrawal from social interaction or duties.
• Health Promotion Responsibility: Commanders at all levels are responsible for promoting the physical and mental health of their troops.

- Be in good physical and mental condition.

• Adopt a healthy lifestyle (healthy eating, drinking and sleeping habits, etc.) and proper hygiene.

• Manage your work time; give yourself regular breaks from work and time for relaxation.

• Learn to give yourself a “psychological” break and to pause prior to any engagement (a crucial breathing space).

• Build a strong psychological capacity to face difficult situations (major human violence and suffering; political and physical threats; lack of respect for the distinctive emblems; criticism against the International Red Cross and the Red Crescent Movement; tensions within the National Society; etc.).

• Be prepared to ask for, or to accept, changes in your work assignment.

- Recognize and accept the situation: “It is normal and OK to feel like this.”

• Think of all your experience and how well prepared you are: “I am well prepared. I can manage this.”

Tell yourself again and again: “I am calm, I can handle the situation.”

• Imagine how the situation is likely to be: several casualties, hazardous environment, screaming and shouting, etc.: “I will stay calm and start by observing the scene, assessing security and collecting information.”

- If you feel overstressed, the best thing you can do is to stop working and ask for help and guidance.

Stress is a natural reaction to a challenge. Cumulative stress is discernible mainly through changes in behaviour that can be observed by you or members of your team, such as:

• Doing something pointless;
• Acting out of character;
• Behaving in an unusual fashion.

There is a great deal you can do to help yourself to cope with stress.

- Show yourself to be calm and confident.

• Overcome your impulses (e.g., to run to casualties in the field prior to any situation assessment) and strange feelings (fatalism, premonition of death, euphoria, invulnerability, etc.).

• Keep open communication lines with your team leader so as to be able to express your feelings at any time (including your concerns about other members of the team).

Take care of yourself, even if you must do so at the expense of your emergency tasks. You are important, and you should realize that a tired First Aider is inefficient, even dangerous.

Objective: Provide stress control measures to manage excessive stress in combat and operational environments.

Procedure:
1. Identify Stressors: Identify command and leadership responsibilities for managing stress within the unit.
2. Training and Education: Implement training and education programs on stress management techniques.
3. Consultation Services: Provide consultation services to soldiers experiencing excessive stress or mental health issues.
4. Leadership Actions: Encourage sound leadership actions that help keep stressors within tolerable limits.

Details:
• Combat and operational stress control is essential for maintaining unit cohesion and soldier well-being.
• Early identification of stressors can prevent long-term psychological effects.

Procedure:

1. Identify target audiences, including hospital administrators, emergency department staff, safety and security professionals, behavioral health providers, social workers, psychologists, chaplains, and others.
2. Develop educational materials that address psychosocial issues related to pandemic influenza.
3. Ensure the materials are comprehensive and include topics such as coping strategies, communication techniques, and recognizing signs of mental health distress.
4. Provide these materials to all relevant stakeholders for use during interpandemic periods so they are available when needed during a pandemic.
5. Continuously update the content based on new research or lessons learned from past public health emergencies.

Details:
• Materials may include brochures, online modules, training sessions, and informational videos.
• Training should be mandatory for all employees who may be involved in pandemic response efforts.

Objective: Offer psychological and emotional support to deployed personnel.

Procedure:
1. Provide behavioral health services, such as counseling or therapy, upon request by deployed staff.
2. Ensure that these services are accessible on-site or through telehealth options if available.
3. Train mental health professionals in pandemic response scenarios to better support responders.

Objective: Support the mental and physical health of central operations personnel during a pandemic.

Procedure:
1. Enlist stress control or resilience teams to monitor the occupational safety, health, and psychological well-being of employees.
2. Use these teams to identify early signs of burnout or stress-related issues.
3. Provide immediate support through counseling, rest periods, or other interventions.

Objective: Recognize and address psychosocial challenges faced by response workers.

Procedure:
1. Identify common psychosocial issues, such as:
- Illness or death of colleagues/family members
- Fear of contagion or transmitting disease
- Emotional distress, exhaustion, frustration, or powerlessness
- Difficulty maintaining self-care (e.g., rest)
- Prolonged separation from family
- Stress from working with sick individuals or under quarantine restrictions
2. Monitor for signs of these issues and provide appropriate support.
3. Address exacerbating factors, such as lack of information, rumors, or perceived inequities in resource distribution.

Objective: Ensure the safety and mental health of deployed personnel during a pandemic.

Procedure:
1. Frequently monitor the occupational safety, health, and psychological well-being of all deployed staff.
2. Use tools such as check-ins, surveys, or direct observation to assess stress levels and overall condition.
3. Provide immediate support if signs of burnout, anxiety, or depression are detected.

Objective: Support the families of responders during a pandemic.

Procedure:
1. Provide all services listed under “Services for Families” in S11-III.A, including instrumental and psychosocial support.
2. Enlist employee assistance programs to help family members obtain food, medicine, and other essential resources.
3. Offer family support groups, bereavement counseling, and courses on resilience, coping skills, and stress management.

Objective: Ensure continued mental health support after deployment.

Procedure:
1. Provide ongoing access to post-emergency psychosocial support services, either on-site or through partner organizations.
2. Offer counseling, group therapy, and other resources as needed for both responders and their families.
3. Ensure that these services are available for an extended period after the pandemic response has concluded.

Procedure:

• Provide psychological and social support services to employees and their families during an influenza pandemic.
• Address stigmatization issues that may arise from participation in such services, ensuring a supportive environment for all individuals involved.

Objective: Ensure that central operations personnel have access to rest and recovery during high-stress periods.

Procedure:
1. Establish rest and recuperation sites, as outlined in S11-IVA, for central operations staff.
2. Encourage the use of these sites by providing transportation or scheduling flexibility.
3. Ensure that these sites are equipped with basic amenities such as sleeping areas, food, and medical support.

Objective: Gather feedback from responders and their families after deployment.

Procedure:
1. Interview responders and family members, including children, to assess lessons learned that can improve future emergency response efforts.
2. Use the insights gained to refine training programs, support systems, and policies.
3. Ensure that all participants are comfortable sharing feedback in a safe environment.

Objective: Support responders in the field by maintaining team cohesion and psychological well-being.

Procedure:
1. Deploy several persons as a team to ensure mutual support during high-stress situations.
2. Assign buddies who maintain frequent contact with each other to provide emotional and practical assistance.
3. Ensure that all deployed personnel are aware of the buddy system and its purpose in reducing stress and enhancing resilience.

Objective: Assess the long-term impact of pandemic response efforts on employees.

Procedure:
1. Conduct an ongoing evaluation of the after-effects of the pandemic on employees’ health, morale, and productivity.
2. Use surveys, interviews, or performance metrics to gather data.
3. Adjust policies and support systems based on findings from these evaluations.

Objective: Allow families of responders to provide feedback and express concerns.

Procedure:
1. Provide a suggestion box for input via e-mail, anonymous voice-mail, or a toll-free number.
2. Ensure that all family members are aware of these channels and how to use them.
3. Regularly review and act on the feedback received from families.

Objective: Reduce stress and improve the well-being of deployed personnel.

Procedure:
1. Provide access to rest, hot showers, nutritious snacks, and light exercise as part of daily routines.
2. Ensure that these activities are available at regular intervals, especially during long deployments.
3. Encourage staff to take advantage of these services to maintain physical and mental health.

To support the emotional well-being of emergency responders during and after an emergency, access the following resources:

Organizations Providing Information on Psychological First Aid:
1. American Psychiatric Association: [www.psych.org/disasterpsych/links/weblinks.cfm](http://www.psych.org/disasterpsych/links/weblinks.cfm)
2. American Psychological Association (APA) Help Center: [www.apahelpcenter.org](http://www.apahelpcenter.org)
3. Disaster Epidemiology Emergency Preparedness (DEEP) Center, University of Miami Miller School of Medicine: [www.deep.med.miami.edu](http://www.deep.med.miami.edu)
4. National Center for PTSD, Department of Veterans’ Affairs: [www.ncptsd.va.gov/](http://www.ncptsd.va.gov/)
5. National Child Traumatic Stress Network: [www.nctsnet.org](http://www.nctsnet.org)
6. Project Liberty: [www.projectliberty.state.ny.us/](http://www.projectliberty.state.ny.us/)

Resources from HHS Agencies:
1. CDC/American Red Cross: [Maintaining a healthy state of mind](http://www.redcross.org/preparedness/cdc_english/health.asp)
2. National Institute of Mental Health (NIMH/NIH/HHS): *Mental Health and Mass Violence: Evidence-Based Early Psychological Intervention for Victims/Survivors of Mass Violence: A Workshop to Reach Consensus on Best Practices* (NIH Publication No. 02-5138, Washington, D.C., U.S. Government Printing Office, 2002)
3. Substance Abuse and Mental Health Services Administration (SAMSHA/HHS): [Disaster Readiness and Response](http://www.samhsa.gov/Matrix/matrix_disaster.aspx)
4. Disaster Technical Assistance Center: [Research listings and fact sheets on self-care](http://mentalhealth.samhsa.gov/dtac/Selfcare.asp)
5. Center for Mental Health Services: *Mental Health Response to Mass Violence and Terrorism: A Training Manual* (HHS Pub. No. SMA 3959, Rockville (MD), 2004)
6. Guide to Managing Stress in Crisis Response Professions (under development)

Procedure:

1. Identify situations where psychological first aid is needed, such as:
- When a service member or individual cannot perform their mission due to emotional distress.
- In combat, hostage and terrorist situations, or civilian disasters like floods, hurricanes, or industrial accidents.
2. Assess the severity of stress symptoms:
- Temporary reactions (e.g., minutes to days) may be managed with encouragement and support.
- If symptoms are seriously disabling (e.g., prolonged anxiety, depression, substance abuse), professional intervention is required.
3. Be aware that emotional distress can be contagious, potentially affecting the entire unit or group if not addressed early.
4. Provide psychological first aid to all participants in a disaster, even those who appear to function well, as they may develop long-term issues like PTSD later on.

Notes:
• Psychological first aid is crucial for maintaining mission readiness and preventing long-term mental health consequences.
• Early detection and support can significantly reduce the risk of future psychological complications.

Procedure:

1. Remain Calm: Ensure that you stay calm at all times. Feeling that others are afraid of him can cause the emotionally disturbed service member to become even more fearful.

2. Avoid Excitement or Abruptness: Do not get excited, angry, or abrupt with the individual. This may worsen their condition.

3. Use Familiar Things: Introduce familiar elements such as:
- A cup of coffee
- Using his name
- Attending to a minor wound
- Assigning him a simple job
- Showing him familiar people or activities

4. Encourage Expression: Let the service member talk about what happened in his own words. Encourage him to describe the event and any contributing factors (e.g., home front problems or worries).

5. Be a Good Listener: Listen patiently without interrupting. This shows that you are interested in him and helps him work through his fear.

6. Provide Breaks if Needed: If he becomes overwhelmed during the conversation, suggest taking a break (e.g., having a cup of coffee) and assure him that you will listen again when he is ready.

7. Help Reestablish Realistic Perspective: Assist him in putting his perception of what happened into a more realistic context. However, do not argue about it.

8. Encourage Activity: Once the service member has calmed down, encourage him to engage in useful activity such as:
- Loading trucks
- Cleaning up debris
- Digging fighting positions
- Returning to his usual duty

9. Focus on Strengths: Identify and utilize his strong points to help rebuild self-confidence.

10. Provide Clear Instructions: If necessary, give him clear and simple instructions about what to do and where to do it. Repeat the instructions as needed.

11. Avoid Argument: Do not argue with the service member if he is resistant or panicking. Instead, focus on immediate, obtainable needs and channel his energy into constructive tasks.

Procedure:

1. Recognize signs of emotional distress, such as overexcitement, severe fear, excessive worry, deep depression, misdirected irritability, or anger.
2. Approach the individual calmly and with empathy:
- Use a supportive tone and avoid judgmental language.
- Let the person know you are there to help and listen without interrupting.
3. Offer reassurance and support, emphasizing that their feelings are normal and temporary in most cases.
4. Encourage the individual to talk about their emotions:
- Ask open-ended questions (e.g., "What’s on your mind?") to facilitate communication.
5. Avoid dismissive or overly cheerful responses such as joking, indifference, or fearful-tearful attention.
6. Provide practical assistance, if possible, such as helping them find a safe place, contacting a friend or family member, or arranging for professional help.
7. Monitor the individual’s condition and seek further assistance from mental health professionals if symptoms persist or worsen.

Notes:
• Psychological first aid is essential in situations like combat, hostage scenarios, terrorist attacks, natural disasters, and industrial accidents.
• Early intervention can prevent long-term psychological issues such as post-traumatic stress disorder (PTSD).
• Psychological first aid should be administered alongside physical first aid when necessary.

Procedure:

1. Assess the casualty for both physical and psychological injuries simultaneously.
2. Provide immediate first aid for any visible physical injuries (e.g., burns, fractures, hemorrhage) using standard procedures.
3. While addressing physical injuries, be attentive to signs of emotional distress such as fear, anxiety, or confusion.
4. Offer reassurance and support to the casualty during the treatment process:
- Use a calm tone and avoid joking or showing indifference.
- Acknowledge their feelings (e.g., “I know this is scary”).
5. Ensure that the casualty feels safe and supported throughout the care process.
6. Monitor for any changes in the casualty’s condition, both physically and emotionally, and adjust care as needed.
7. If psychological distress persists or worsens, provide continued emotional support and consider referring them to a mental health professional if possible.

Notes:
• Psychological and physical injuries often occur together and should be treated with equal attention.
• Emotional support can significantly impact the casualty’s recovery and overall well-being.

Objective: Apply psychological first aid to individuals experiencing stress reactions.

Procedure:
1. Understand that the application of psychological first aid involves providing immediate support and comfort to individuals in distress.
2. Recognize that it is important to create a safe and stable environment for the individual.
3. Know that psychological first aid should be tailored to the individual's specific needs and circumstances.
4. Ensure that all personnel are trained to provide psychological first aid effectively.
5. Provide access to professional mental health services for individuals who require long-term care.

Notes:
• Psychological first aid should be delivered in a non-judgmental manner.
• It is important to avoid overwhelming the individual with too much information or support at once.

Objective: Address combat and other operational stress reactions.

Procedure:
1. Understand that individuals involved in combat or other high-stress operations may experience a range of psychological and emotional responses.
2. Recognize that these reactions can include anxiety, depression, post-traumatic stress disorder (PTSD), or other mental health issues.
3. Know that it is important to provide immediate support and care for individuals experiencing these reactions.
4. Ensure that all personnel are trained to recognize the signs of combat-related stress and respond appropriately.
5. Provide access to professional mental health services for individuals who require long-term care.

Notes:
• Psychological first aid should be provided as soon as possible after exposure to traumatic events.
• It is important to create a supportive environment that encourages open communication and trust.

Objective: Address the impact of emotional and physical disability on psychological first aid.

Procedure:
1. Understand that individuals with emotional or physical disabilities may require additional support during psychological first aid.
2. Recognize that these individuals may experience heightened stress, anxiety, or trauma due to their condition.
3. Know that it is important to provide care that is tailored to the individual's specific needs and limitations.
4. Ensure that all personnel are trained to respond appropriately to individuals with disabilities.
5. Provide a safe and accessible environment for individuals receiving psychological first aid.

Notes:
• Psychological first aid should be adapted to accommodate the individual's physical and emotional needs.
• It is important to avoid assumptions about the individual's capabilities or limitations.

Objective: Provide general information on psychological first aid.

Procedure:
1. Understand that psychological first aid is essential in managing stress and trauma reactions.
2. Recognize the importance of addressing both emotional and physical needs simultaneously.
3. Be aware that psychological first aid can prevent long-term mental health issues.
4. Know that it involves providing support, comfort, and practical assistance to individuals affected by traumatic events.
5. Ensure that psychological first aid is delivered with respect for the individual's feelings and cultural background.

Notes:
• Psychological first aid should be provided in a safe environment.
• It is not a substitute for professional mental health care.

Objective: Define the goals of psychological first aid.

Procedure:
1. Understand that the primary goal is to provide immediate support and comfort to individuals in distress.
2. Recognize that it aims to reduce suffering, prevent further harm, and promote recovery.
3. Know that it helps restore a sense of safety, stability, and hope.
4. Ensure that psychological first aid is provided in a respectful and culturally sensitive manner.
5. Emphasize the importance of connecting individuals with appropriate resources for long-term care.

Notes:
• Psychological first aid should be delivered by trained personnel.
• It should not replace professional mental health treatment.

Objective: Address the various reactions to stress that may occur during psychological first aid.

Procedure:
1. Understand that individuals may experience a wide range of reactions to stress, including anxiety, depression, anger, or confusion.
2. Recognize that these reactions can vary in intensity and duration depending on the individual's circumstances.
3. Know that it is important to provide support and care tailored to the individual's specific needs.
4. Ensure that all personnel are trained to recognize and respond to different types of stress-related reactions.
5. Provide a safe and supportive environment for individuals receiving psychological first aid.

Notes:
• Psychological first aid should be delivered in a non-judgmental manner.
• It is important to avoid making assumptions about the individual's experience or emotions.

Objective: Emphasize the importance of respecting others' feelings during psychological first aid.

Procedure:
1. Understand that respect for others' feelings is a fundamental principle of psychological first aid.
2. Recognize that individuals may be experiencing a wide range of emotions, including fear, anger, sadness, or confusion.
3. Know that it is important to listen actively and validate the individual's experience without judgment.
4. Ensure that all interactions are conducted with empathy, compassion, and cultural sensitivity.
5. Avoid making assumptions about the individual's feelings or experiences.

Notes:
• Psychological first aid should be delivered in a non-intrusive manner.
• It is important to create a safe and supportive environment for the individual.

Objective: Identify situations where psychological first aid is necessary.

Procedure:
1. Recognize that psychological first aid is needed in situations involving trauma, stress, or emotional distress.
2. Understand that it is essential for individuals who have experienced combat, natural disasters, accidents, or other traumatic events.
3. Know that psychological first aid should be provided to anyone showing signs of emotional distress, anxiety, or depression.
4. Be aware that it may also be necessary in situations involving loss, grief, or social isolation.
5. Ensure that psychological first aid is available for all personnel involved in emergency response operations.

Notes:
• Psychological first aid should be provided as soon as possible after the traumatic event.
• It should be tailored to the individual's specific needs and circumstances.

Procedure for Recognizing and Addressing Suicide Risk in Marines:

1. Understand the Warrior Ethos: Embrace the warrior ethos and live by core values daily to build mental toughness and resilience.
2. Acknowledge Personal Challenges: Accept that personal problems and tragedies may occur, but prepare mentally to deal with them effectively.
3. Recognize Mental Limits: Even strong individuals have limits; recognize this in yourself and others to avoid reaching a breaking point.
4. Promote Help-Seeking Behavior: Encourage Marines to ask for help when needed. There is no shame in seeking assistance, and it reflects strength, judgment, and maturity.
5. Utilize Chain of Command Support: Understand that every member of the chain of command is prepared to provide assistance through support agencies and trained personnel.
6. Leadership Responsibility: Leaders are responsible for fellow Marines; rapid intervention is crucial in suicide prevention.
7. Educate on Suicide Prevention: Learn about suicide prevention resources, be aware of available help, and stay vigilant for potential risks.
8. Use the AID LIFE Acronym:
- A: Ask: “Are you thinking about hurting yourself?”
- I: Intervene immediately.
- D: Do not keep a secret concerning a person at risk.
- L: Locate help (NCO, chaplain, corpsman, doctor, nurse, friend, family, crisis line, hospital emergency room).
- I: Inform your chain of command of the situation.
- F: Find someone to stay with the person. Do not leave them alone.
- E: Expedite! Get help immediately. A suicidal person needs immediate attention from helpers.
9. Teamwork and Cohesion: Develop teamwork, build cohesion, and remember that the strength of the Corps is the Marine, and the strength of the Marine is the Corps.

Purpose: To understand key strategies for preventing suicide.

Technique:
1. Foster strong social connections and encourage individuals to seek help from friends, family, or mental health professionals.
2. Promote open communication about emotional struggles and reduce stigma around seeking help.
3. Provide access to crisis intervention services and support hotlines.
4. Encourage the development of coping skills and resilience through training and education.
5. Ensure that individuals at risk are monitored and supported by trained personnel or mental health professionals.

Purpose: To identify individuals who may be at risk of suicide.

Technique:
1. Look for signs of emotional distress, such as changes in behavior, mood swings, or withdrawal from social interactions.
2. Identify individuals who express feelings of hopelessness, worthlessness, or a lack of purpose.
3. Be aware of any history of mental health issues or previous suicide attempts.
4. Pay attention to individuals who may be experiencing significant life stressors, such as loss, financial difficulties, or relationship problems.

Purpose: To recognize signs that may indicate a person is at risk of suicide.

Technique:
1. Look for verbal cues such as expressions of hopelessness, worthlessness, or statements about wanting to die.
2. Observe behavioral changes like increased isolation, loss of interest in activities, or sudden mood swings.
3. Be alert to physical signs such as sleep disturbances, changes in appetite, or unexplained weight loss.
4. Note any increase in risky behavior, substance abuse, or self-harm.
5. Pay attention to any mention of a plan or method for committing suicide.

Objective: Identify signs that may indicate a person is at risk for an emotional fall (suicide).

Procedure:
1. Be aware of the following signs in yourself or others:
- Believes the situation is hopeless.
- Appears depressed, sad, tearful, with changes in sleep and/or appetite patterns.
- Talks about or threatens suicide, or discusses death and dying in an unusual manner.
- Shows changes in behavior, appearance, or mood.
- Increases or starts using drugs or alcohol.
- Engages in self-injury or risky behavior.
- Abandons planning for the future.
- Withdraws from family and close friends.
- Gives away possessions.
- Appears apathetic, unmotivated, indifferent.

Note: These signs may indicate a person is struggling with emotional or mental stress that could lead to an emotional fall (suicide).

Many women worry when they are pregnant, especially about the baby’s health and about giving birth.

### Steps to Manage Worry and Fear:
1. Recognize that these worries are normal and do not mean something bad will happen.
2. Provide emotional support, like someone to listen to their worries and encourage them to feel hopeful.
3. Help solve the problems they are having in their lives, such as issues with partners, money, drugs or alcohol, or other concerns.

Pregnancy can make women very emotional. Some women laugh or cry for no clear reason. Some feel depressed, angry, or irritable.

### Steps to Manage Emotional Changes:
1. Recognize that these feelings are normal and usually pass quickly.
2. Do not ignore a woman’s feelings simply because she is pregnant.
3. Provide emotional support, like someone to listen to their worries and encourage them to feel hopeful.
4. Help solve the problems they are having in their lives, such as issues with partners, money, drugs or alcohol, or other concerns.

Some women forget things when they are pregnant. For most women, this is not a big problem.

### Steps to Manage Forgetfulness:
1. Recognize that forgetfulness during pregnancy is normal and common.
2. No one knows why it happens, but it is a known side effect of pregnancy.
3. If a woman feels concerned about her forgetfulness, she should know that this is not unusual.

Pregnant women may have strong, vivid dreams. They can be beautiful, strange, or frightening.

### Steps to Manage Strange Dreams:
1. Recognize that these dreams are normal and usually do not predict future events.
2. The events in the dream may reflect fears, desires, or stories made up by the mind during sleep.
3. Women who have frightening dreams may need someone to talk to about their hopes, fears, and feelings.

### Identify Combat Operational Stress Reaction (COSR) Risk Factors

Objective: Recognize factors that increase the risk of COSR in Soldiers.

#### Common COSR Risk Factors:

1. Domestic worries
2. Newly assigned to unit
3. First time in combat, horrors
4. Casualties
5. Lack of mobility
6. Surprise attacks
7. Inability to strike back (e.g., indirect fire, IEDs)
8. Information vacuum
9. Chemical, biological, radiological, and nuclear (CBRN) weapons threat
10. Sleep loss
11. Physical exhaustion
12. Dehydration, hunger

Note: Leaders must be aware of these risk factors to proactively manage stress and prevent COSR from developing.

Combat stress can significantly impact performance and mental health during NBC warfare. To manage combat stress effectively, follow these steps:

1. Implement short rest breaks: Allow soldiers to remove MOPP gear periodically for brief rest periods to reduce physical and psychological strain.
2. Ensure adequate sleep: Provide at least 6 hours of uninterrupted sleep per 24-hour period; if this is not possible, ensure a minimum of 4 hours of sleep for a few days of sustained operations.
3. Maintain proper nutrition and hydration: Ensure soldiers have access to food and drink to sustain energy levels and prevent dehydration.
4. Schedule activities during optimal times: Be aware that between 0100 and 0700, the body experiences reduced mental concentration, confusion, nervousness, and lack of clear thinking. Plan non-critical tasks during this period.
5. Reduce boredom and fatigue: Engage soldiers in activities to alleviate monotony, fatigue, inattention, and discomfort, which can lead to ineffective performance.
6. Promote unit cohesion: Train units together frequently under demanding conditions to build trust and unity among soldiers.
7. Leaders must show genuine concern for soldier welfare: Build confidence through leadership that supports soldiers during high-stress situations.
8. Keep soldiers informed of the tactical situation: Minimize uncertainty by providing clear communication about the battlefield environment.
9. Provide rest and support to stressed soldiers: Soldiers who become ineffective due to combat stress should be given a period of rest as close to the front as possible, along with reassurance and support from their unit.

### Recognize Stress-Related Behaviors in Soldiers

Objective: Identify stress-related behaviors to manage combat operational stress reaction (COSR) risk factors.

#### Types of Stress-Related Behaviors:

1. Positive Combat Stress Behaviors:
• Heightened alertness
• Increased strength and endurance
• Greater tolerance to discomfort
• These are typically part of the fight or flight response and can be beneficial in short-term combat scenarios.

2. Misconduct Stress Behaviors:
• Minor breaches of unit orders or regulations
• Serious violations of the Uniform Code of Military Justice (UCMJ)
• Violations of the Law of Land Warfare

3. Combat Operational Stress Reaction (COSR):
• May accompany excellent combat performance and be found in heroes.
• More serious behaviors are warning signs that require immediate attention from a leader, medic, or buddy to prevent harm to the Soldier, others, or the mission.

4. Post-Traumatic Stress Disorder (PTSD):
• A psychiatric disorder following exposure to life-threatening events such as military combat, natural disasters, or terrorist incidents.
• Symptoms include:
- Reliving the experience through nightmares and flashbacks
- Difficulty sleeping
- Feelings of detachment or estrangement
- These symptoms can significantly impair daily life if not addressed.

Note: Leaders must be vigilant in identifying these behaviors to ensure proper support is provided.

### Take Leader Actions to Control Combat Operational Stress Reaction (COSR)

Objective: Implement leader actions that help control and reduce the risk of COSR in Soldiers.

#### Effective Leader Actions:

1. Build unit cohesion and pride
- Foster a strong sense of unity and teamwork among Soldiers.
- Encourage mutual support and trust within the unit.

2. Help Soldiers stabilize the home front
- Assist Soldiers in resolving personal issues that may contribute to stress (e.g., family problems, financial concerns).
- Provide resources or referrals for Soldiers who need additional help at home.

3. Keep Soldiers physically fit
- Ensure Soldiers maintain a high level of physical fitness through regular training and exercise.
- Encourage healthy habits such as proper nutrition and adequate rest.

4. Conduct tough, realistic training
- Prepare Soldiers for the rigors of combat by simulating real-world scenarios.
- Build resilience and confidence in Soldiers' abilities to handle stress.

5. Cross train in key areas
- Provide Soldiers with opportunities to develop skills outside their primary duties.
- Increase flexibility and adaptability within the unit.

Note: These actions help reduce the risk of COSR by promoting mental and physical well-being, building resilience, and strengthening unit cohesion.

Steps to Provide Emotional Reassurance to Children After an Emergency:

1. Assure children they are safe: Explain that the emergency was a natural event and not their fault.
2. Address fears openly: Acknowledge that it is normal for children to feel afraid or anxious after an emergency.
3. Offer physical reassurance: Spend time with the child, provide affection, and let them know you will take care of them.
4. Encourage expression of feelings: Allow children to talk about their fears and emotions. Listen carefully and show understanding.
5. Normalize the situation: Reassure children that the emergency is not permanent and things will return to normal.
6. Prepare in advance: Use drills, books, and activities to help children understand what may happen during an emergency before it occurs.

Additional Tips:
• Include children in simple clean-up tasks after a disaster to give them a sense of control and purpose.
• Encourage creative expression through drawing, molding clay, or other art forms to help children process their emotions.
• Be aware that symptoms of anxiety may not appear immediately and can affect people of any age.
• If anxiety disrupts daily life for any family member or staff, seek professional assistance from a school counselor, community religious organization, physician, or licensed professional.

Objective: Understand how school-age children react to trauma and provide appropriate care.

Steps:
1. Be aware of preoccupation with the event: They may want to talk about the disaster repeatedly, which can interfere with schoolwork and academic performance.
2. Listen actively: Allow them to express their thoughts and feelings without judgment or interruption.
3. Correct misinformation: If they hear inaccurate information from peers, provide clear and factual explanations in an age-appropriate manner.
4. Watch for emotional responses: They may display sadness, fear of the event recurring, guilt over actions during the disaster, anger at not being able to prevent it, or fantasies about rescuing others.
5. Encourage open communication: Create a safe environment where they feel comfortable discussing their emotions and experiences.

Notes: School-age children are more capable of understanding the permanence of loss but may still need reassurance and support.

Objective: Reassure children and help them regain a sense of normalcy after a disaster.

Steps:
1. Provide Physical Comfort: Offer hugs and touch to provide reassurance.
2. Share Factual Information: Calmly explain the situation, current safety plans, and recovery efforts in an age-appropriate way.
3. Encourage Emotional Expression: Allow children to talk about their feelings without judgment.
4. Spend Extra Time Together: Increase time with your child, especially during routine moments like bedtime.
5. Restore Daily Routines: Re-establish regular schedules for work, school, meals, and rest as soon as possible.
6. Involve Children in Recovery: Assign them simple chores or tasks to help restore family and community life, giving them a sense of purpose.
7. Praise Positive Behavior: Recognize and reinforce responsible actions that contribute to recovery.
8. Acknowledge Diverse Reactions: Understand that children may react differently to the disaster and be patient with their responses.
9. Involve Children in Planning: Encourage them to help update or create a family disaster plan.
10. Seek Professional Help if Needed: If stress persists, worsens over time, or interferes with daily life, consult a child’s primary care physician, mental health professional, or clergy.

Children of various ages express worry in different ways. Be present and pay attention to signs of stress or concern.

Steps to take:
1. Explain the situation to the child.
2. Listen and invite to a conversation.
3. Only talk about verified information. Avoid unnecessary details.
4. If you don’t have all the answers, be honest and admit it.
5. Plan activities with the child to help shift their focus.

Procedure:

Support the mother emotionally after childbirth.

Steps:
1. Recognize and honor the mother’s efforts during labor through customs, rituals, or celebrations.
2. Encourage open communication about her feelings.
3. Reassure her that it is normal to experience a range of emotions postpartum.
4. Offer practical help with caring for herself and her baby if she feels overwhelmed.
5. Ensure someone stays with the mother if she shows signs of severe depression or risk of self-harm.

Details:
• Emotional support helps in recovery and bonding with the baby.
• Traditional rituals can be used alongside modern approaches.

Procedure:

1. Observe the mother for signs of emotional distress, such as sadness, anxiety, or withdrawal.
2. Encourage open communication and provide a safe space for her to express feelings.
3. Offer emotional support through listening, reassurance, and counseling if needed.
4. If the mother exhibits symptoms of postpartum depression (e.g., persistent sadness, loss of interest in the baby), notify a healthcare provider immediately.
5. Provide resources for mental health care and community support.

Notes:
• Emotional well-being is crucial for both the mother and the baby’s development.
• Early intervention can prevent long-term complications.

Procedure:

Step 1: If the mother and baby are healthy, allow them time alone together.

Step 2: Ensure they have privacy to bond, talk, laugh, cry, or celebrate as needed.

Note: This helps new parents adjust emotionally and physically after childbirth.

Procedure for Developing Emotional Resilience Through Core Values and Teamwork:

1. Adopt Core Values: Live by the core values of the Marine Corps daily to build character, mental toughness, and resilience.
2. Practice Mental Toughness: Train mentally to handle challenges and setbacks effectively, just as physical training builds strength.
3. Emphasize Teamwork: Recognize that Marines fight as units, not individuals. Support fellow Marines in times of need to prevent emotional breakdowns.
4. Train the Mind and Body: Develop both a strong body and character through consistent training, which helps absorb life's challenges and return to your feet mentally and physically.
5. Build Cohesion: Strengthen team bonds so that Marines can trust and rely on each other in all situations, whether on the battlefield or in daily life.

There are natural reactions to stress that need to be recognised, expected and for which strategic interventions need to be implemented. These include:

• Fear
• Anxiety
• Anger
• Frustration
• Depression

Do not over-react and remember that too much stress leads to ‘distress’ resulting in anti-social behaviour, angry outbursts, difficulty making decisions, unwillingness to accept responsibility, an inability to get on with others and eventual withdrawal from the group.

Procedure:

1. Always act with cheerfulness in all situations, no matter how difficult or challenging they may be.
2. Laugh and encourage others to laugh, as laughter helps prevent sadness and promotes a positive environment.
3. If you cannot laugh, at least grin and maintain an upbeat demeanor.
4. Remember Benjamin Franklin's advice: Money does not bring happiness; personal usefulness is more important than personal enjoyment.
5. Focus on helping others rather than solely on your own happiness. Those who are truly happy have their minds fixed on something greater than themselves.
6. Strive to make others happier even if it means sacrificing your own comfort or convenience.
7. Practice kindness daily, as doing a good deed for someone else can bring personal fulfillment and contribute to overall happiness.
8. Remain cheerful under both fortune and misfortune, bearing challenges with a smile and maintaining a positive attitude.

Procedure:

1. Understand the Ethical Implications of Substance Abuse:
- Recognize that substance abuse is contrary to the ethos of a Marine Warrior.
- Acknowledge that using illegal drugs or abusing alcohol undermines the physical, mental, and spiritual integrity of a warrior.

2. Avoid Actions That Compromise Integrity:
- Refrain from engaging in behaviors such as drunk and disorderly conduct, driving under the influence, or using illegal drugs.
- Adhere to laws and regulations concerning substance use.

3. Recognize Impaired Judgment:
- Understand that alcohol and drug use impair judgment and may lead to decisions that result in trouble or regret.

4. Avoid Moral and Ethical Compromise:
- When impaired, avoid making moral or ethical decisions that could dishonor oneself.

5. Maintain Physical Readiness:
- Recognize that substance abuse can render a warrior physically helpless, even after rigorous training.
- Avoid situations where one might be unable to defend themselves due to intoxication.

6. Practice Self-Control:
- If drinking, know your limits and enjoy yourself without letting your guard down completely.
- Always remain in control of oneself and never compromise personal values or standards.

To address alcohol misuse and its negative effects on health and community well-being:

1. Recognize the problem:
- Identify individuals who may be struggling with excessive drinking.
- Understand that alcohol abuse can lead to serious health issues, such as liver disease and mental health problems.

2. Encourage self-awareness and honesty:
- Help individuals acknowledge their drinking habits and the impact on themselves and others.
- Encourage them to be honest with themselves and seek support from family and friends.

3. Provide support for quitting alcohol:
- Offer emotional and practical support to those who want to stop drinking.
- Connect individuals with local resources such as Alcoholics Anonymous (AA) groups, where recovering alcoholics can provide guidance and encouragement.

4. Promote community action:
- Organize meetings in the village to discuss the issue of alcohol misuse and its effects on health and well-being.
- Develop strategies for reducing alcohol consumption, such as education campaigns or policy changes.

5. Encourage healthy alternatives:
- Promote activities that can replace drinking, such as sports, community events, or spiritual practices.
- Support families in finding ways to improve their living conditions rather than spending money on alcohol.

Note: Addressing alcohol misuse requires a collective effort from individuals, families, and the entire community.

Objective: Ensure staff are supported emotionally during and after emergencies.

Steps:
1. Develop a plan to support staff emotional well-being during and after emergency events (e.g., debriefings, access to counseling services).
2. Encourage open discussions about stress or trauma experienced by staff.
3. Provide resources for mental health support both internally and through external organizations.

During and after an emergency incident, it is common for people—including response workers and health care staff—in the affected region to experience distress and anxiety about safety, health, and recovery, as well as grief and loss. Most people are to some degree personally prepared for an emergency and have access to pre-existing support systems that contribute to their own and their community’s resiliency, and thus they are likely to recover from disaster without behavioral health intervention. However, in an extended disaster, health care staff may be subjected to far greater stress both personally and professionally and become secondary victims, as they work long, hard hours under poor conditions. Some will become burned out and be unable to perform their duties. In some cases, physical dangers might exist in their travel to visit patients, adding to their levels of stress. Supervisors, administrative organization and regulation often change with little warning, adding confusion and additional stressors as workers try to satisfy the needs of the patients and of the agency. Organizational response as a whole will depend, to some extent, on the extent to which staff feels that management is attempting to ensure their safety, minimize their stress and offer overall support.

Steps to Support Staff Emotional Well-Being After an Emergency:

1. Recognize the emotional impact on staff: Understand that staff members may also experience anxiety, stress, or trauma after a disaster.
2. Provide access to counseling resources: Offer professional assistance through school counselors, community religious organizations, physicians, or licensed professionals.
3. Encourage open communication: Allow staff to express their feelings and concerns in a safe environment.
4. Monitor for signs of distress: Be aware of any changes in behavior, mood, or performance that may indicate emotional strain.
5. Promote self-care: Encourage staff to take time for rest, relaxation, and activities that help them manage stress.

Additional Tips:
• Create a supportive environment where staff feel comfortable seeking help.
• Provide information on available mental health resources in the community.
• Consider organizing group sessions or workshops focused on coping strategies after traumatic events.

Procedure:

1. Observe if the mother shows disinterest in her baby.

2. Consider possible reasons: fatigue, illness, bleeding, lack of desire for a child, or depression.

3. Check for signs of blood loss or infection (see page 236 and 271).

4. If the mother is depressed or has a history of postpartum depression:
- Encourage family to provide extra support and attention in the following weeks.
- Note that depression may take time to resolve, sometimes several weeks or months.

5. Ensure someone in the family takes care of the new baby if needed.

Procedure:

Identify signs of postpartum depression and provide appropriate support.

Steps:
1. Monitor the mother for persistent sadness, anxiety, or feelings of worthlessness that last beyond a few days.
2. Encourage her to express her emotions and listen without judgment.
3. Explain that these feelings are common but require attention if they become severe.
4. If the woman is unable to care for herself or baby, provide practical help with household tasks and childcare.
5. Ensure someone stays with her if she shows signs of self-harm or harm to the baby.
6. Consider traditional remedies or modern medicines only in extreme cases, as modern medications can be expensive and have side effects.

Details:
• Women who experienced depression after a previous birth are at higher risk for it again.
• Support is essential to prevent long-term mental health issues.

Checklist for Managing Yourself After an Intervention:

1. Evaluate your performance: Think about your achievements and feelings.
2. Evaluate your condition: Think about whether you require support from someone else.
3. Decide: To recuperate i.e., to “recharge your batteries”.
4. Act: Debrief with your team and team leader and draw conclusions from lessons learned.
5. Act: Relax properly and prepare yourself for the next mission.

After working in an armed conflict or another situation of violence, you should think about yourself. The humanitarian task of helping people to help themselves continues after the “spotlights are switched off”. After your break, you may be called upon to step in again.

To help emotionally distressed service members reestablish a sense of belonging and security:

1. Reintegrate the service member into team or squad activities.
2. Encourage participation in group tasks that align with shared goals, interests, and mission objectives.
3. Group activity helps service members:
- Work better under pressure
- Face danger more effectively
- Handle serious problems with greater resilience
4. This fosters esprit de corps, which is a powerful tool for psychological first aid.

Group activities are essential for maintaining a service member’s morale and functionality:

1. Encourage participation in team-based or squad activities.
2. Reinforce the importance of esprit de corps through shared goals, interests, and mission focus.
3. Group involvement helps a service member:
- Feel a sense of belonging and security.
- Reestablish confidence and productivity.
4. This is particularly effective in psychological first aid, helping the service member return to duty as a useful unit member.

Objective: Provide mental health support during and after a pandemic.

• Step 1: Identify or develop an existing mental health hotline that can be accessed by community members during emergencies.
• Step 2: Ensure the hotline is staffed with trained professionals who can provide:
- Emotional support
- Crisis intervention
- Referrals to local mental health services
• Step 3: Promote awareness of this resource through community outreach and public service announcements.

Procedure:

1. Psychological Services: Immediate and ongoing psychological support services should be provided to quarantined persons to minimize psychological distress.

2. Communication Access: Ensure that quarantined persons can maintain regular communication with their loved ones and healthcare providers.

Procedure:

1. Identify key stakeholders, including state and local health departments, first-responder organizations, and employers of essential service workers.
2. Develop a plan to create workforce resilience programs that enhance performance and personal resilience during public health emergencies.
3. Use behavioral health expertise to guide the development of these programs.
4. Include strategies for stress management, communication training, and team-building activities in the program design.
5. Ensure that these programs are implemented before a pandemic occurs so they can be activated quickly when needed.

Details:
• Workforce resilience programs should be tailored to the specific needs of different occupational groups.
• Programs may include mental health screenings, peer support systems, and access to professional counseling.

Procedure:

1. Identify key stakeholders, including hospital administrators, emergency department staff, safety and security professionals, behavioral health providers, social workers, psychologists, chaplains, and others.
2. Develop guidance documents that outline self-care strategies for employees during public health emergencies.
3. Include recommendations such as stress management techniques, time management skills, and healthy lifestyle choices in the guidance.
4. Provide training on these self-care strategies to ensure they are implemented effectively.
5. Ensure that workforce resilience programs are integrated into organizational policies and emergency response plans.

Details:
• Self-care strategies should be tailored to the specific needs of different occupational groups.
• Workforce resilience programs may include mental health screenings, peer support systems, and access to professional counseling.

Objective: Prepare for the psychosocial and behavioral health impacts following a nuclear detonation.

Procedure:
1. Coordinate with behavioral healthcare providers to identify necessary resources, including mental health professionals, counseling services, and psychiatric care.
2. Develop distribution plans for these resources to ensure they reach affected populations promptly.
3. Train responders in administering behavioral health first aid, focusing on addressing both responder distress and interactions with distressed individuals.
4. Establish partnerships with behavioral health community partners (BHCPs) to mitigate the development or exacerbation of mental health conditions during resource-stress environments.
5. Plan for long-term support, as psychosocial impacts may persist for years following a nuclear detonation.

Notes:
• Psychosocial issues may affect not only direct victims but also observers and those indirectly impacted (e.g., family members of victims).
• Evacuation or relocation can worsen mental health outcomes and must be considered in planning.

Procedure:

1. **Recognize Psychosocial Challenges:
- Acknowledge the emotional and psychological stress that responders may experience during disaster relief efforts, including trauma from witnessing death or suffering.

2. **Provide Mental Health Support:
- Offer access to mental health professionals for individual counseling and group therapy sessions.
- Encourage peer support programs where responders can share experiences with colleagues, teammates, and family members.

3. **Promote Self-Help Activities:
- Facilitate activities that help responders manage stress, such as physical exercise, mindfulness practices, or creative outlets like art or music.

4. **Ensure Timely Communication:
- Share accurate and transparent information with responders to reduce uncertainty and improve decision-making during the response.

5. **Support Family and Friends:
- Provide resources for responders to maintain contact with family members and address concerns about their safety and well-being.

6. **Address Cultural and Organizational Differences:
- Train responders on cultural sensitivity to better understand and support victims from diverse backgrounds.
- Promote collaboration between different responder groups to ensure efficient and effective emergency services.

Procedure:

1. Use the Code of Conduct as a guiding principle for behavior and decision-making.
2. Recite the Pledge of Allegiance to reinforce patriotism and purpose.
3. Maintain faith in your country and its values.
4. Sing patriotic songs to boost morale and unity.
5. Keep thoughts focused on returning to family and friends as motivation to survive.

Procedure:

1. Recognize your personal capabilities and limitations.
2. Keep a positive mindset to enhance resilience.
3. Develop a realistic survival plan based on the situation.
4. Anticipate potential fears such as injury, death, fatigue, illness, environmental challenges, hunger, and isolation.
5. Combat psychological stress by:
- Recognizing and anticipating existing stressors (injury, death, fatigue, etc.).
- Attributing normal reactions to these stressors (fear, anxiety, guilt, boredom, depression, anger).
- Identifying signals of distress such as indecision, withdrawal, forgetfulness, carelessness, or a tendency to make mistakes.
6. Use the Code of Conduct, Pledge of Allegiance, faith in America, patriotic songs, and thoughts of returning to family and friends to strengthen your will to survive.

Procedure:

1. Collect your thoughts and emotions to maintain mental clarity.
2. Identify your personal beliefs and values that can guide you during survival situations.
3. Use self-control to manage emotional responses to stress.
4. Meditate regularly to center yourself and reduce anxiety.
5. Recall past inner sources of strength or inspiration to help overcome adversity.
6. Pray for God’s help, strength, wisdom, and rescue by:
- Talking directly to your God.
- Giving thanks that God is with you.
- Asking for divine assistance in survival challenges.
- Praying for protection and a positive outcome.
7. Remember scripture, verses, or hymns; repeat them to yourself and to others.
8. Worship without the aid of written scripture, clergy, or others if necessary.
9. Forgive:
- Yourself for any wrongdoings you may have committed.
- Others who have failed you or caused harm.
10. Praise God and give thanks because:
- God is greater than your circumstances.
- God will see you through no matter what happens.
- Hope comes from a belief in heaven or an afterlife.
11. Trust in your faith, love for family, and self to maintain strength and hope.
12. Never lose hope or give up on survival.
13. With other survivors:
- Identify or appoint a religious lay leader if needed.
- Discuss what is important to you and others in the group.
- Share scriptures and songs with your fellow survivors.
- Pray for each other regularly.
- Try to hold worship services when possible.
14. Write down any scriptures or songs you remember for future reference.
15. Encourage each other while waiting for rescue by remembering:
- Your God loves you.
- Praise your God continuously.

Procedure:

1. Identify or appoint a religious lay leader to guide spiritual practices.
2. Discuss what is important to you and others regarding faith and beliefs.
3. Share scriptures, songs, and hymns with other survivors for encouragement.
4. Pray for each other to build unity and support.
5. Try to hold worship services if possible.
6. Write down scriptures and songs that you remember for future reference.
7. Encourage each other while waiting for rescue by:
- Remembering that your God loves you.
- Praising your God regularly.

Procedure: Manage Combat Stress Reaction (COSR) - Rest COSR

Steps:
1. Identify symptoms that indicate the Soldier is too much of a risk or burden to stay with their unit.
2. Ensure that the Section cannot provide a safe, stable environment for recovery.
3. Place the Soldier in a parent or support unit for rest and recovery.
4. Monitor the Soldier's condition during their time in the support unit.

Details:
• Rest COSR refers to symptoms that require temporary removal from the unit for recovery.
• Leaders must ensure that the Soldier is placed in an environment where they can receive proper care and support.
• The Soldier should not be disruptive or dangerous, but may need time away from their current unit.

Objective: Ensure that all mental health and combat stress control matters are addressed within the unit.

Steps:
1. Identify Soldiers who may be experiencing signs of stress, anxiety, or other mental health concerns.
2. Coordinate with the unit's mental health professionals or combat stress control teams for support.
3. Provide education to all Soldiers on recognizing and reporting mental health issues.
4. Ensure that Soldiers have access to confidential counseling services when needed.
5. Monitor the overall morale of the unit and take corrective actions if necessary.

Taking proactive steps to ease disaster-related stress can help with recovery and well-being.

Follow these strategies:

1. Talk with someone about your feelings—anger, sorrow, and other emotions—even though it may be difficult.
2. Seek help from professional counselors who deal with post-disaster stress.
3. Do not hold yourself responsible for the disastrous event or be frustrated because you feel you cannot help directly in the rescue work.
4. Take steps to promote your own physical and emotional healing by healthy eating, rest, exercise, relaxation, and meditation.
5. Maintain a normal family and daily routine, limiting demanding responsibilities on yourself and your family.
6. Spend time with family and friends.
7. Participate in memorials.

Recognizing signs of disaster-related stress is crucial for timely intervention.

The following are common signs that adults may need crisis counseling or stress management assistance:

1. Difficulty communicating thoughts.
2. Difficulty sleeping.
3. Difficulty maintaining balance in their lives.
4. Low threshold of frustration.
5. Increased use of drugs/alcohol.
6. Limited attention span.
7. Poor work performance.
8. Headaches/stomach problems.
9. Tunnel vision/muffled hearing.
10. Colds or flu-like symptoms.
11. Disorientation or confusion.
12. Difficulty concentrating.
13. Reluctance to leave home.
14. Depression, sadness.
15. Feelings of hopelessness.
16. Mood-swings and easy bouts of crying.
17. Overwhelming guilt and self-doubt.
18. Fear of crowds, strangers, or being alone.

Objective: Direct individuals to appropriate resources for managing trauma after an emergency.

Steps:
1. Refer affected individuals to GOV.UK/Prepare, which provides links to relevant NHS pages and other support services.
2. Ensure that the information provided is up-to-date and accessible to those in need.
3. Encourage use of professional help if informal support does not suffice.

Details:
• These resources are designed to assist individuals with long-term recovery from trauma following serious incidents.

Address Anxiety and Panic in Survival Situations

To manage anxiety or panic attacks during survival scenarios:

1. Provide reassurance: Offer one-on-one counseling and emotional support to individuals experiencing intense anxiety.
2. Use time as a tool: In most cases, the passage of time will help reduce feelings of panic and anxiety.
3. Consider medication for severe cases: If someone is unmanageable due to extreme anxiety or panic, consider using psychotropic medications such as Haloperidol or Midazolam for chemical relaxation.
4. Implement physical restraint if necessary: In extreme cases where the individual poses a risk to themselves or others, physical restraint may be required.
5. Consider expulsion in worst-case scenarios: If all other options fail and the person is unmanageable, difficult decisions such as expulsion from the group may need to be made.

Uncertain times can make people feel worried and anxious. Here are some tips on how to manage your anxiety:

• Talk to family, friends, neighbours or a mental health organisation about your feelings. It can help you feel less alone.
• Get involved – for example, by helping others improve their emergency preparedness. This can give you a sense of purpose.
• Take care of your personal health. Good food, sleep and physical exercise relieve stress and improve wellbeing.
• Restrict your news intake. Find a level that works for you and spend more time doing things that make you feel good.
• Seek professional help if you have severe anxiety.

Helpers must manage their own emotional reactions to effectively assist emotionally distressed service members:

1. Be aware that you may experience emotional reactions (conscious or unconscious) toward the service member.
2. Avoid becoming overly sympathetic, as this can be harmful and make the service member feel inadequate.
3. Do not become impatient, resentful, or overly negative if the service member is slow to recover or shows signs of distress.
4. Display calmness, confidence, and competence in your behavior and attitude.
5. Expect the service member to recover and return to duty, reinforcing this expectation through actions and words.

Emotional care is essential whenever someone is ill or injured. It can be as simple as offering comfort through words, or as involved as providing deliberate emotional support to someone who has suffered a significant injury and may be experiencing depression.

• Be aware that people in pain or with disabilities may become short-tempered or irritable. This is often an unconscious response and typically improves with recovery or increased comfort.
• The caregiver should remain understanding, recognizing that this behavior is temporary and not reflective of the person’s true personality.
• Provide simple comfort measures such as observing modesty, offering an ear to listen, and allowing the patient to express their concerns or frustrations.
• Reducing feelings of vulnerability or helplessness in the patient will make the situation more tolerable for both the caregiver and the patient.

Procedure:

1. Engage in regular physical activity to maintain health and prevent illness.
2. Ensure adequate rest by getting enough sleep each night.
3. Avoid overexertion, especially during pregnancy or when recovering from illness.
4. Encourage a balanced lifestyle that includes both exercise and sufficient rest.

Benefits:
• Physical activity helps maintain overall health.
• Adequate rest supports recovery and well-being.
• A balanced lifestyle reduces the risk of illness.

Procedure:

1. Inquire about postpartum depression history:
- Determine if the mother experienced depression after a previous birth.
2. Evaluate risk for recurrence in current pregnancy:
- Note that this increases her likelihood of experiencing postpartum depression again.
3. Prepare support systems and interventions:
- Be ready to provide emotional and psychological support if needed during or after the current birth.
4. Reference page:
- See page 274 for further information on managing postpartum depression.

Procedure:

• Encourage open communication and support from family, friends, or community groups.
• Offer counseling services or connect individuals with peer support programs.
• Educate others about HIV to reduce stigma and promote understanding.

Details:
• Emotional well-being is essential for managing the challenges of living with HIV.
• Support systems can improve adherence to treatment and quality of life.
• Reducing stigma helps individuals feel more comfortable seeking care and support.

Title: Manage the Emotional Impact of Death on Others

Procedure to Follow:
1. Watch for signs of shock: Be alert for symptoms such as rapid heartbeat, sweating, pale skin, or confusion in witnesses.
2. Provide emotional support: Offer comfort and reassurance to those affected by the death to prevent further stress and shock.
3. Address depression and distress: Encourage group members to express their feelings and provide a supportive environment for them to cope with the loss.
4. Maintain group cohesion: Ensure that the group remains united and does not become fragmented due to emotional trauma.
5. Seek professional help if needed: If signs of severe stress or shock persist, seek assistance from a qualified medical professional or mental health expert.

Procedure:

1. Be aware of symptoms of diminishing personal resistance:
- Recognize signs that may indicate a breakdown in your own or a colleague’s mental resilience.
- These can include confusion, emotional instability, or an inability to make decisions under pressure.

2. Take proactive steps to maintain mental stability:
- Stay grounded by recalling the rewarding aspects of your work, such as seeing people recover and regain hope.
- Use positive reinforcement from past experiences to build resilience.

3. Support colleagues in maintaining their resistance:
- Identify signs of stress or disorientation in others and offer support.
- Encourage open communication about feelings and challenges faced during high-stress situations.

4. Practice self-care and mental preparation:
- Engage in regular training to build psychological resilience.
- Reflect on your own capabilities and limitations, especially when dealing with traumatic or stressful events.

Title: Relax After a Mission

Procedure:
1. Take time to relax after completing your mission.
2. Avoid feeling under-appreciated or rejected if your team leader encourages you to take time off.
3. Do not feel ashamed of taking time off for yourself, even if it is far away from the place where you have been working.
4. Use self-awareness to determine what actions will help you recover and recharge.

Notes:
• Relaxation is crucial for mental and physical well-being after a mission.
• It is normal to need time off, and it should not be seen as a negative action.

Procedure:

1. Establish and maintain a normal daily routine, including regular bedtimes, wake-up times, meal times, and personal hygiene.
2. Avoid letting routines slip as this can lead to negative psychological effects such as depression, anxiety, or anger.
3. Maintain standards of behavior, dress, and conduct at home to provide a sense of stability and reassurance.
4. Follow familiar patterns of interaction and expectations, which help reduce uncertainty and stress during challenging times.

Notes:
• This is particularly important for families dealing with the psychological impact of illness or pandemics.
• Consistency in behavior helps reinforce positive mental states and emotional resilience.

Procedure:

1. Identify responders (healthcare workers, emergency personnel) and affected communities in need of psychosocial support.
2. Deploy mental health professionals or trained personnel to provide counseling services.
3. Develop and implement workforce resiliency programs for responders.
4. Offer community-based support initiatives to help individuals cope with the stress and trauma associated with a pandemic.

Important: Psychosocial support is crucial in maintaining the well-being of both responders and affected populations.

Objective: Support pandemic response activities of state, local, and tribal mental health and substance abuse agencies.

Procedure:
1. Communicate with mental health and substance abuse agencies to ensure they are prepared for increased demand during a pandemic.
2. Provide technical assistance and resources to support the delivery of behavioral health services.
3. Share information on how to address stress, anxiety, and other mental health impacts caused by pandemics.
4. Coordinate with public health officials to integrate mental health care into overall pandemic response plans.

Keywords: mental health, substance abuse, pandemic response

Objective: Provide psychosocial support to healthcare workers during an influenza pandemic.

Steps:
1. Institutionalize psychosocial support services to help manage emotional stress and resolve personal, professional, and family issues.
2. Develop informational materials for employees and their families about the psychological impact of pandemics.
3. Create workforce resilience programs that include:
- Counseling services
- Peer support networks
- Mental health resources
4. Ensure these programs are accessible to all healthcare workers, including those deployed in non-hospital settings.

Procedure:

1. Identify Needs of Emergency Field Workers:
- Assess the psychological and social needs of emergency field workers, including healthcare personnel, law enforcement, and other responders.

2. Develop Support Programs:
- Create programs that provide access to mental health services, counseling, and peer support for emergency responders during a pandemic.

3. Coordinate with Mental Health Professionals:
- Collaborate with local and state mental health professionals to ensure adequate resources are available for responders.

4. Ensure Accessibility of Support Services:
- Ensure that psychological and social support services are easily accessible and available to all emergency personnel, including those in remote or underserved areas.

Psychosocial health services

• Identify mental health and faith-based resources for counseling of healthcare personnel during a pandemic. Counseling should include measures to maximize professional performance and personal resilience by addressing management of grief, exhaustion, anger, and fear; physical and mental health care for oneself and one’s loved ones; and resolution of ethical dilemmas.

• Determine a strategy for supporting healthcare workers’ needs for rest and recuperation.

• Develop a strategy for housing and feeding healthcare personnel who might be needed on-site for prolonged periods.

• Develop a strategy for accommodating and supporting staff who have child- or elder-care responsibilities.

Procedure:

• During the pandemic period, deliver psychosocial support services to response workers including:
- Healthcare providers.
- Emergency field workers and public health personnel.
- First-responder and nongovernmental organization employees assisting affected groups (e.g., those in quarantine or isolation).
- Essential service workers maintaining community functions.
• Ensure that these services also extend to the families of all these groups.

Objective: Ensure psychosocial support services are integrated into occupational health and emergency preparedness planning for an influenza pandemic.

Steps:
1. Healthcare institutions and state/local health agencies should incorporate psychosocial support services into their emergency preparedness plans.
2. Consider the needs of first responders and essential service workers, including those employed by companies and local governments (see Box 2).
3. Contact community-based organizations and nongovernmental organizations to identify available psychological and social support services and training courses in the jurisdiction.

Additional Considerations:
• Coordinate with emergency planners in schools, law enforcement agencies, and local businesses for information sharing.

Objective: Equip healthcare and public health staff with behavioral techniques to support employees during a pandemic.

Steps:
1. Train hospital and occupational health clinic staff (e.g., social workers, psychiatrists, nurses, psychologists, counselors) in techniques for managing grief, stress, exhaustion, anger, and fear during an emergency.
2. Provide training in psychological support services to non-behavioral health professionals such as primary-care clinicians, emergency department staff, medical/surgical staff, safety and security personnel, chaplains, community leaders, and staff of cultural/faith-based organizations.

Additional Considerations:
• Ensure that administrators, managers, and supervisors are familiar with tools and techniques for supporting staff and their families during times of crisis (see S11-IV.A and Appendix 3).
• Identify additional resources available to employees and their families during and after a pandemic.
• Develop strategies to assist staff with child-care or elder-care responsibilities or other special needs that may affect their ability to work.

Objective: Offer emotional support and expert advice to pandemic workers and their families.

Steps to Implement:
1. Establish confidential telephone support lines staffed by behavioral health professionals.
2. Ensure these lines are available 24/7 during the pandemic response period.
3. Provide information on how to access these services through websites, hotlines, or informational materials.

Objective: Use community- and faith-based organizations to provide relaxation and comfort during the pandemic.

Steps to Implement:
1. Collaborate with local religious institutions, charities, or community groups that can offer emotional support and resources.
2. Encourage these organizations to host activities such as group meetings, prayer sessions, or social gatherings that promote mental well-being.
3. Provide information on how to access these services, especially for individuals who may not have other sources of support.

Procedure:

Healthcare workers and emergency responders should be provided with information on how to address stigmatization or discrimination they or their family members may experience due to their role in the pandemic response. This includes:

1. Training and Resources
- Provide guidance on handling stigmatization.
2. Public Affairs Support
- Hospital public affairs offices should be prepared to address these issues promptly and effectively.
3. Communication Strategies
- Develop clear communication plans for responding to discrimination or stigma-related incidents.

Procedure:

Before deployment or assignment during a pandemic, the following training should be conducted:

1. Behavioral Health and Stress Management Training
- Provide education on coping skills, resilience strategies, and behavioral health issues.
2. Supervisor Training
- Train supervisors in maintaining supportive work environments.
3. Preparation for Psychological Challenges
- Equip workers with tools to manage stress, anxiety, and trauma related to pandemic response activities.

Procedure:

1. Promote Respect and Equality: Treat all individuals with respect, including those living with HIV or AIDS.
2. Support People Living with HIV: Encourage community leaders, health workers, and religious figures to support people living with HIV by helping them access healthcare, housing, and employment opportunities.
3. Combat Stigma and Discrimination: Refrain from stigmatizing individuals who are infected with HIV or suspected of being infected. Avoid making assumptions about the character or behavior of those affected.
4. Advocate for Human Rights: Support the human rights of people living with HIV by opposing discrimination and ensuring they receive care and respect in their communities.

Additional Notes:
• Stigma and fear can prevent individuals from seeking testing or treatment, which increases transmission risks.
• Encouraging open dialogue and education about HIV helps reduce prejudice and fosters a more inclusive society.

To improve the overall health of individuals and communities:

1. Promote nutritious eating:
- Encourage consumption of a balanced diet rich in fruits, vegetables, whole grains, and lean proteins.
- Avoid excessive intake of processed foods, sugar, and unhealthy fats.

2. Support physical activity:
- Encourage regular exercise such as walking, cycling, or other forms of movement that are accessible to all community members.
- Create safe spaces for physical activity, such as parks or open areas.

3. Foster mental health awareness:
- Educate the community about the importance of mental well-being and how it affects overall health.
- Provide support for individuals dealing with stress, anxiety, or depression through counseling or peer groups.

4. Strengthen social connections:
- Encourage participation in community events, religious gatherings, or cultural activities that promote a sense of belonging and purpose.
- Support family units by providing resources for parenting education and child care.

5. Address harmful behaviors collectively:
- Work with the community to identify and address harmful habits such as smoking, excessive drinking, or drug use.
- Encourage open discussions about these issues and provide support for those who want to change their behavior.

Note: Healthy habits contribute significantly to long-term well-being and can prevent many chronic diseases.

Procedure:

1. Explore adoption or fostering as a way to care for children who need homes.

2. Encourage community involvement, such as becoming a health worker or supporting others in the village.

3. Promote social support groups to help individuals and couples deal with societal stigma related to infertility, especially in communities where women are judged for not having children.

4. Provide emotional support through counseling or peer groups to help individuals lead fulfilling lives despite infertility.

5. Educate the community on the value of non-parental contributions to society and challenge harmful stereotypes.

Ways to help children learn and become involved in community health care:

• Encourage learning through observation and experience at home, in the forest, or fields. Children learn more from watching others than from being told.
• Teach by example: Values such as kindness, responsibility, and sharing are best learned when adults model them.
• Allow children to explore and make mistakes as part of learning. Provide them with responsibility and respect for their judgment, even if it differs from yours.
• Encourage helping others: Children who help others gain a deeper sense of pleasure and purpose. Welcome their contributions and let them know how much they are valued.
• Answer questions honestly: Encourage curiosity by answering children's questions clearly and truthfully, even when you don't have the answer.

Resources for further learning:
• The Child-to-Child program is a valuable resource for helping children learn about health care. It is described in *Helping Health Workers Learn*, Chapter 24.
• For more information, contact:
- The Child-to-Child Trust Institute of Education, 20 Bedford Way, London WC1H 0AL, England
- Tel: +44 (0) 207-612-6649
- Fax: +44 (0) 207-612-6645
- E-mail: ccenquiries@ioe.ac.uk
- Website: [www.child-to-child.org](http://www.child-to-child.org)

Historical context on biliousness:

• In many cultures, people who are easily angered or irritable were once believed to be ‘bilious’ due to excess bile.
• However, most short-tempered individuals do not have gallbladder disease, and the connection between bile and anger is largely a myth.
• People with gallbladder disease may become anxious or worried about their health, which can lead to irritability or short temper.
• The term ‘hypochondria’ (excessive worry about one’s health) comes from the Greek words for ‘under rib’, referring to the location of the gallbladder.

Insomnia is a condition in which a person is unable to sleep despite wanting or needing it.

Causes may include:
• Stress or anxiety.
• Poor sleeping habits.
• Medical conditions.

Management includes:
• Maintaining a regular sleep schedule.
• Avoiding caffeine and electronic devices before bedtime.
• Creating a comfortable sleeping environment.
• Seeking medical help if insomnia persists.

Procedure:

• Leadership Importance: Above-average leadership at all levels is essential to maintain morale during northern operations.
• Physical Fitness Impact: The physical condition of soldiers directly affects their confidence and ability to meet the rigours of cold weather operations. Emphasize fitness training as a key factor in maintaining morale.
• Discipline Requirements: Ensure unceasing supervision at all levels, especially during winter months, to maintain discipline and effective operations.
• Commander Responsibilities: Subordinate commanders must take on added duties due to limited personal contact with higher command from weather and terrain conditions.

Fear of the environment has a degrading effect on efficiency, and must be addressed.

Key considerations:
• Knowledge, positive attitude, physical fitness, and strong leadership can overcome this fear.
• Training should focus on building confidence rather than emphasizing dangers unnecessarily.
• Encourage natural leaders to emerge within tent groups and utilize them effectively within the chain of command.
• Provide psychological support and ensure that personnel are mentally prepared for northern operations.

Procedure:

1. Understand the Psychological Impact of MOPP:
- Recognize that NBC warfare increases stress due to fears, isolation from the environment, and sensory limitations caused by MOPP4.
- Acknowledge that wearing bulky protective gear may cause frustration, claustrophobia, or panic in soldiers.

2. Implement Realistic Training for Psychological Resilience:
- Conduct tough, realistic training using MOPP4 to build experience and confidence among soldiers.
- Use METL-driven (Mission Essential Task List) training scenarios that simulate the stressful conditions of MOPP operations.

3. Minimize Adverse Psychological Effects During Operations:
- Ensure that soldiers are trained in communication techniques while wearing protective gear to reduce feelings of isolation and confusion.
- Encourage team cohesion and support systems during prolonged periods of reduced mobility and sensory awareness.
- Provide psychological support as needed to counteract alienation or emotional distress caused by MOPP conditions.

Leaders must be able to recognize the psychological symptoms of combat stress, which can overlap with physical and environmental factors. The following are common signs:

### Mood Changes
• Unusual impatience, frustration, or irritability.
• Unusual fatigue or sleepiness.
• Feelings of loneliness, isolation, or alienation.
• Feelings of helplessness.
• Claustrophobia.

### Thinking and Cognitive Impairment
• Forgetfulness or absentmindedness (especially errors in map plotting and message coding).
• Impaired decision making, reasoning, or judgment.
• Disorientation, confusion, or panic.
• Hallucinations or paranoia.

### Physical Signs
• Rapid breathing (hyperventilation) or rapid heart rate (tachycardia).
• "Cotton mouth" or nausea.
• Cramps or muscle tension.

These symptoms may be caused by psychological stress, fear, dehydration, heat illness, MOPP4 encapsulation, or exposure to chemical agents. Leaders must remain vigilant and seek medical evaluation if symptoms persist or worsen.

Procedure:

1. Recognize the impact of environmental factors on mental stamina:
- Isolation, long periods of darkness and light, and extreme weather conditions can affect mental stability.
- These effects may manifest as nervous tension or loss of mental equilibrium in different individuals.

2. Be aware of historical accounts of psychological challenges:
- Stories such as 'cabin fever' from trappers and prospectors, and 'moon sickness' among Indigenous peoples are not myths but real concerns.

3. Implement strategies to maintain mental health:
- Encourage regular communication with others to combat isolation.
- Establish routines and structure to help manage the psychological effects of long periods in extreme environments.

Duties of the Platoon Sergeant (PSG):

• Monitors the morale, discipline, and health of patrol members.

Key Actions:
1. Regularly assess the mental and physical well-being of all patrol personnel.
2. Identify and address any disciplinary issues promptly.
3. Promote a positive unit atmosphere to maintain high morale.
4. Ensure that health concerns are addressed through appropriate medical channels if necessary.

Purpose:
To ensure the patrol remains cohesive, disciplined, and operationally effective.

Procedure:
1. Discuss the importance of commitment and courage when dealing with difficult situations such as bloody bandages.
2. Highlight how these traits can influence decision-making and perseverance during survival training.
3. Emphasize that mental strength is crucial for overcoming adversity.

Objective: Maintain a strong will to survive by valuing life and overcoming obstacles.

Steps:
1. Place a high value on living.
2. Refuse to give into the problem and obstacles that face you.
3. Draw strength from individuals who rise to the occasion.

Recognize the emotional impact on responders involved in fatality management and body recovery operations.

• Understand that recovering bodies from an affected area will be a constant reminder of the number of people lost, causing extreme stress for emergency responders and recovery workers.

• Ensure your communications team is prepared to respond to questions about the health of responders with sensitivity and accuracy in order to maintain trust between organizations and your communications team.

• Do not minimize the psychological effects experienced by responders during this process.

• Communicate with first response organization management regarding how they would like to address the mental health needs of all responders involved in the operation.

• Work closely with licensed mental health professionals to meet the needs of your staff. If you are not a licensed mental health practitioner, do not make diagnostic judgments about the mental health status of your staff.

• Plan to collaborate with local mental health services and providers for ongoing support.

• In the absence of a dedicated mental health team, the deployed ICS safety officer should be tasked with observing staff for signs of mental distress.

Title: Access Mental Health Resources for First Responders

Procedure:
1. Visit the official website of the Center for the Study of Traumatic Stress at [https://vtt.ovc.ojp.gov](https://vtt.ovc.ojp.gov).
2. Locate and access '_First responders: Mental health consequences of natural and human-made disasters for public health and public safety workers_' from 2007: [https://vtt.ovc.ojp.gov/ojpasset/Documents/IMP_Responder_Mental_Health 508.pdf](https://vtt.ovc.ojp.gov/ojpasset/Documents/IMP_Responder_Mental_Health 508.pdf).

Purpose: This resource provides essential information on the mental health consequences for first responders following disasters, which is crucial for emergency planners and support services.

Keywords: Mental health, first responders, disaster impact, trauma support.

Morale and Social Well-being in Base Camp:

• Foster a happy and relaxed atmosphere in base camp to support team members who may feel isolated or homesick.
• Celebrate birthdays and other milestones with small gatherings or parties to boost morale, even in the field.
• The MO should be actively involved in general camp duties where possible, but must remain available for medical consultations at all times.
• Maintain confidentiality when handling personal or medical matters.
• Use meal times as a focal point for team interaction and well-being. Ensure that meals are served on time to avoid frustration and accidents caused by hunger and fatigue.
• Provide packed lunches for individuals who cannot return for regular meals due to work commitments.
• Consider setting aside one day per week (e.g., Sunday) as a special day, such as 'antimalarial day,' where the MO can distribute prophylaxis pills and ensure they are taken by all team members.

Procedure:

1. Rest often and ensure you are getting enough sleep to help your body recover.
2. Eat well with balanced meals that provide sufficient nutrients for energy and healing.
3. Engage in physical activity such as walking or light exercise, if possible.
4. Keep a manageable schedule, breaking tasks into smaller steps and focusing on one at a time.
5. Encourage children to express their feelings and reassure them that they are safe.
6. Watch for signs of stress or health issues in yourself and family members, such as changes in mood, appetite, or sleep patterns.
7. Take breaks to do something you enjoy, even if it’s just a short walk or listening to music.
8. Accept help from others, whether it's emotional support, practical assistance, or resources.
9. Seek professional help if feelings of distress persist for an extended period.

After ensuring their physical safety, focus on your children’s emotional needs by encouraging them to express their feelings. Drawing pictures and telling stories is a good way to do this. Listen carefully as they share and explain what really happened. Be honest and tell them of any further dangers that may still exist and that you will work it out together.

• As with adults, hugs are reassuring; give them liberally! Tell them things will be better again but don’t lie.

• Include children in any necessary cleanup activities. Having a job to do refocuses their attention on something more positive and creates a more comforting, normal environment.

• It is common for children to revert to immature behaviour for a few days. Some normal reactions are irritability, anger, sadness, diarrhea, headache, nightmares, and loss of appetite. Praise them for sharing their feelings and for helping around the house rather than focusing on this behaviour. However, if it persists for more than two weeks, seek professional advice.

• Be aware that for a time aspects of the disaster can trigger their fears (such as seeing flames or smelling smoke if there was a fire). Talk through their fear and reassure them they are safe.

• Return to a normal schedule as soon as possible but relax the rules for a while.

• Try to spend a little extra time with them, especially at bedtime.

• Work with their teachers, childcare givers, babysitters and others who need to understand how the disaster has affected your children.

Procedure:

1. Commit to performing a good turn every day for someone else.
2. Ensure the good turn is done quietly and without boasting.
3. Choose actions that are helpful, kind, and beneficial to others.
4. Reflect on the motive behind each good turn—ensure it comes from a genuine desire to help rather than seeking recognition.
5. Use this practice as proof of being a real boy scout.
6. Recognize that performing daily good turns is a form of practical religion, honoring God by helping others.
7. Strive to be consistent in this behavior, even if it means going above and beyond what is expected.

Procedure:

To conserve natural strength and maintain manliness in boys:

1. Understand the importance of the sex fluid: Recognize that this fluid is crucial for developing physical strength, mental power, and emotional depth.
2. Avoid habits that lead to the discharge of this fluid: Any habit that causes the loss of this fluid weakens a boy's strength, makes him more susceptible to disease, and may lead to harmful lifelong habits.
3. Maintain purity in thought and action: This is essential for conserving the sex fluid and ensuring its proper use in developing manly qualities.
4. Be aware of temptation: During times when temptation to wrong habits is strong, it is important to resist them to preserve strength and power.
5. Read educational material: For boys who want to learn more about this subject, it is recommended to read *"From Youth into Manhood"* by Dr. Winfield S. Hall.

Warning:
• Yielding to temptation weakens the body and mind.
• Poor habits formed early in life are difficult to break later.

Procedure:

1. Identify a small task or challenge that you find difficult or uncomfortable to do.
2. Commit to completing this task daily, no matter how small the progress seems.
3. Focus on consistency rather than perfection. Even if you only complete part of the task, continue with it the next day.
4. Track your progress by noting each time you successfully complete the task or make incremental improvements.
5. Reflect on your efforts daily, recognizing how small successes build into larger capabilities over time.
6. Apply this mindset to other areas of life, such as physical training, academic work, or personal goals.

Example: A boy nicknamed 'Blockey' was initially unable to catch a ball during games. By consistently practicing in the gym and focusing on improving his skills day by day, he eventually became a star player on the team.

Procedure:

1. Reflect on your current habits and behaviors that you wish to change.
2. Identify specific goals you want to achieve, such as quitting smoking, avoiding alcohol, or stopping gambling.
3. Make a firm decision to commit to these changes. This should be done with strong determination and a clear understanding of the consequences of failure.
4. Announce your resolution publicly, if possible, to increase accountability.
5. Avoid temptation by removing yourself from situations that might lead you back to old habits.
6. Stay committed even when faced with challenges or setbacks. Remember your goal and keep your promises to yourself.
7. Seek support from others who can encourage and help you stay on track.
8. Monitor your progress regularly, and adjust your strategies as needed to ensure long-term success.

Important: This procedure is based on the story of David Glasgow Farragut, who made a resolution at age ten to change his life and kept it for the rest of his life.

Procedure for Promoting Good Citizenship and Ethical Conduct:

1. **Practice the Ten Commandments and Golden Rule:
- Apply the principles of the Ten Commandments and the Golden Rule in everyday life, not just in exceptional circumstances.
- Demonstrate honesty, fairness, and respect in all interactions with others, including family, friends, and community members.

2. **Encourage Constructive Behavior:
- Promote a mindset of building up rather than tearing down. Encourage improvement and better living conditions in the community.
- Avoid self-indulgence, wastefulness, or other vices that can lead to personal or national decline.

3. **Develop Courage and Integrity:
- Cultivate courage to stand against external threats and internal weaknesses (e.g., fear, selfishness, dishonesty).
- Show unselfishness, gentleness, and consideration for others, especially those who are weaker or in need.

4. **Respect Family and Community Members:
- Treat family members with kindness and respect; this is a fundamental aspect of good citizenship.
- Respect women, children, and all individuals within the community.

5. **Practice Good Manners and Etiquette:
- Maintain courtesy, politeness, and good manners in all situations, as these are essential for harmonious living.

6. **Develop Physical and Mental Strength:
- Train the mind, eyes, and muscles to be strong and capable of making quick decisions during crises.
- Cultivate a sound body and a good mind through regular exercise, education, and self-discipline.

Important Notes:
• Scouts should lead by example in all aspects of life, demonstrating the values of courage, honesty, and service to others.
• These principles are not only important for personal development but also for contributing positively to society as a whole.

Steps to Cope with Disaster-Related Stress:

1. Recognize the signs of disaster-related stress, such as anxiety, depression, or difficulty sleeping.
2. Seek crisis counseling if you or a family member is struggling emotionally after a disaster.
3. Be aware that disasters can lead to discrimination and stigma, especially during outbreaks like COVID-19.
4. Combat discrimination by sharing accurate information with your community and educating others about the facts.
5. Understand the individual effects of a disaster on mental health, including long-term emotional impacts.
6. Reach out for help if you are experiencing stress or trauma related to the disaster.
7. For more information, visit [Ready.gov/coping-with-disaster](https://www.ready.gov/coping-with-disaster).

The emotional toll that disaster brings can sometimes be even more devastating than the financial strains of damage and loss of home, business, or personal property.

It is important to seek support from family, friends, and community resources.
• Consider reaching out to mental health professionals if needed.
• Take time to process your emotions and allow yourself to grieve any losses.
• Participate in community recovery efforts to regain a sense of control and purpose.

Seek professional help to manage the emotional impact of a disaster.

• Contact local faith-based organizations, voluntary agencies, or professional counselors for counseling.
• FEMA and state and local governments of the affected area may provide crisis counseling assistance.

Disasters can have a profound impact on mental health and emotional well-being.

• Everyone who sees or experiences a disaster is affected by it in some way.
• It is normal to feel anxious about your own safety and that of your family and close friends.
• Profound sadness, grief, and anger are normal reactions to an abnormal event.
• Acknowledging your feelings helps you recover.
• Focusing on your strengths and abilities helps you heal.
• Accepting help from community programs and resources is healthy.
• Everyone has different needs and different ways of coping.
• It is common to want to strike back at people who have caused great pain.

Children and older adults are of special concern in the aftermath of disasters. Even individuals who experience a disaster “second hand” through exposure to extensive media coverage can be affected.

Overview

Disasters can leave children feeling frightened, confused, and insecure. Whether a child has personally experienced trauma, has merely seen the event on television, or has heard it discussed by adults, it is important for parents and teachers to be informed and ready to help if reactions to stress begin to occur.

Common Reactions in Children
• Younger children: May return to earlier behavior patterns such as bedwetting, sleep problems, and separation anxiety.
• Older children: May display anger, aggression, school problems, or withdrawal.
• Children with indirect exposure (e.g., via TV): May develop distress even without direct experience of the disaster.

Risk Factors for Enduring Psychological Distress
• Direct exposure to the disaster, such as being evacuated, observing injuries or death of others, or experiencing injury along with fearing one’s life is in danger.
• Loss/grief: This relates to the death or serious injury of family or friends.
• Ongoing stress from secondary effects of the disaster, including:
- Temporarily living elsewhere
- Loss of friends and social networks
- Loss of personal property
- Parental unemployment
- Costs incurred during recovery to return the family to pre-disaster life and living conditions.

Vulnerabilities in Children
• In most cases, distressing responses are temporary unless there is a severe threat to life, injury, loss of loved ones, or secondary problems such as loss of home, moves, etc.
• Reminders of the disaster (e.g., high winds, smoke, cloudy skies, sirens) may cause upsetting feelings to return for those directly exposed.
• A prior history of some type of traumatic event or severe stress may contribute to these feelings.

Parental Role in Helping Children Cope
• Parents and adults can make disasters less traumatic for children by taking steps to manage their own feelings and plans for coping.
• Parents are almost always the best source of support for children in disasters.
• Involving children in preparing a family disaster plan before a disaster helps establish a sense of control and build confidence.
• After a disaster, children can contribute to a family recovery plan.

Objective: Reduce anxiety and confusion in children caused by media coverage of disasters.

Steps:
1. Monitor Media Consumption: Be aware that repeated exposure to news or images of the disaster can increase fear, especially in younger children.
2. Limit Exposure Appropriately: Restrict access to media content that may be distressing or overwhelming for your child.
3. Co-View with Supervision: If allowing media consumption, watch it together and provide explanations to help them understand what they are seeing.
4. Encourage Communication: Use the opportunity to talk about their feelings and concerns related to the disaster.
5. Model Healthy Behavior: Parents should also limit their own exposure to anxiety-provoking information to set a positive example for children.

Objective: Ensure staff are prepared to support children emotionally after an emergency.

Steps:
1. Provide training for staff on how to recognize and respond to emotional distress in children following emergencies.
2. Include strategies such as comforting techniques, reassurance, and referral to mental health resources if needed.
3. Encourage open communication with parents about the child’s emotional well-being.

Overview:

This procedure outlines how to access resources that can help children and adults cope with emergencies and traumatic events.

### Steps:
1. Consult Books and Publications:
- Refer to _“What Happened to the World? Helping Children Cope in Turbulent Times”_ by Jim Greenman (2001) for guidance on helping children deal with trauma.
- Read _“A Terrible Thing Happened”_ by Margaret M. Holmes, illustrated by Cary Pillo, published by Magination Press and the American Psychological Association (2000), to help children understand and process traumatic events.

2. Visit Official Websites:
- Go to [FEMA's website](http://www.fema.gov/rebuild/recover/cope_child.shtm) for resources on helping children cope after disasters.
- Visit the [CDC page on maintaining a healthy state of mind during emergencies](http://emergency.cdc.gov/preparedness/mind/parents/) for guidance from the Centers for Disease Control and Prevention (CDC).

3. Use Resources from Children's Hospitals and Organizations:
- Access materials from the International Center to Heal Our Children at Children's National Medical Center, which provides fact sheets and resources in both English and Spanish: [www.childrensnational.org/DepartmentsandPrograms/ICHOC/resources.aspx](http://www.childrensnational.org/DepartmentsandPrograms/ICHOC/resources.aspx).
- Visit the Center for Pediatric Traumatic Stress at Children’s Hospital of Philadelphia for parent and child handouts in both English and Spanish: [www.chop.edu/professionals/pediatric-traumatic-stress/traumatic-stress-materialsand-resources.html](http://www.chop.edu/professionals/pediatric-traumatic-stress/traumatic-stress-materialsand-resources.html).

4. Access Trauma and PTSD Resources:
- Explore information on trauma and PTSD at [www.trauma-pages.com](http://www.trauma-pages.com), a comprehensive resource for understanding and coping with traumatic events.

5. Use Materials from the National Institute of Mental Health (NIMH):
- Visit [NIMH's website](http://www.nimh.nih.gov/health/topics/coping-with-traumaticevents/index.shtml) to find information on how to cope with traumatic events.

6. Download Booklets and Guides:
- Access the booklet _“After the Disaster: Helping Children and Families Cope”_ from [the Oklahoma State Health Department](http://www.ok.gov/health/documents/disaster.pdf), which provides guidance for families on helping children through disasters.
- Download _“Helping Children Cope After a Disaster”_ from Penn State Hershey Medical Center at [www.childadvocate.net/disasterbooklet.pdf](http://www.childadvocate.net/disasterbooklet.pdf).

### Notes:
• These resources are available in both English and Spanish, making them accessible to a wider audience.
• They provide guidance for parents, teachers, healthcare providers, and children themselves.

Procedure:

1. Include a USB drive or portable hard drive with digital games, books, and entertainment options.
2. Store insurance documents, gold, and silver for financial security during emergencies.
3. Keep a Bible or other religious texts for spiritual comfort and guidance.

Procedure:

1. Recognize the signs of psychological strain. Be aware that even well-prepared individuals may experience depression, withdrawal, or emotional distress after prolonged exposure to disaster conditions.

2. Maintain a routine and structure. Establish daily tasks such as food preparation, shelter maintenance, and communication with others to help maintain a sense of normalcy and purpose.

3. Stay connected with your group. Encourage open communication among family members or survivors to foster support and reduce feelings of isolation.

4. Limit exposure to traumatic reminders. If possible, avoid prolonged contact with the remains of destroyed homes or areas filled with debris and dead bodies, as these can exacerbate psychological distress.

5. Seek temporary relief through evacuation if needed. Consider evacuating to a safer location if staying in place becomes too mentally taxing, even if it means leaving behind some of your belongings.

6. Be prepared for post-evacuation challenges. Understand that being removed from the disaster site may lead to an adjustment period or "after-action shell-shock." Be ready with coping strategies and support systems.

7. Stay mentally resilient. Focus on maintaining a positive mindset, even in difficult circumstances. Remind yourself of your preparedness and ability to survive.

8. Seek professional help if necessary. If psychological symptoms persist or worsen, seek assistance from mental health professionals once it becomes possible.

Objective: Keep group members occupied to maintain morale and prevent psychological issues such as boredom, depression, or defeat.

1. Keep everyone engaged in meaningful tasks:
- Assign work that provides a sense of purpose and accomplishment.
2. Promote social interaction:
- Encourage teamwork and collaboration among group members.
3. Provide mental stimulation:
- Offer activities such as reading, games, or creative projects to keep minds active.
4. Maintain hope and optimism:
- Reinforce the belief that survival is possible and that conditions will improve.
5. Address emotional needs:
- Provide support for individuals who may be struggling with stress or anxiety.
6. Avoid complacency and stagnation:
- Keep group members motivated by setting new goals and challenges.
7. Reinforce the importance of this step:
- Psychological well-being is crucial to long-term survival.

Mental health during crises

It is normal to experience concern, negative thoughts, poor sleep, and anxiety during times of uncertainty. To help manage these emotions:

• Focus on activities you can control that help you stay alert and gather your thoughts.
• Continue with regular routines such as mealtimes and personal hygiene as much as possible.
• Stay in contact with friends, family, and others to share experiences and support one another.

Definition: Something that aids or promotes well-being.

Action Steps:
1. Ensure the physical and mental health of animals by providing proper care, nutrition, and shelter.
2. Promote humane treatment of animals during handling, transportation, and processing.
3. Support initiatives that enhance human well-being through access to healthcare, education, and safe living conditions.
4. Advocate for policies and practices that improve the quality of life for both humans and animals.
5. Monitor and address factors that may negatively impact welfare, such as disease, stress, or environmental degradation.

Procedure:

1. Listen actively to the person in need, showing empathy and understanding without interrupting.
2. Acknowledge their feelings and concerns, validating their emotions rather than dismissing them.
3. Ask open-ended questions to encourage them to express themselves fully, such as 'What are you feeling right now?' or 'How can I help you?'
4. Provide reassurance and support, letting the person know they are not alone in their situation.
5. Offer practical solutions or resources if possible, such as medical care, shelter, or food assistance.
6. Encourage them to take small steps forward, helping them regain a sense of control over their circumstances.
7. Follow up with the person if needed, checking in on their progress and offering further support.

Combat Boredom in Survival Situations

To avoid psychological distress from boredom during prolonged survival situations, follow these steps:

1. Provide structured activity: Ensure that everyone has a daily routine and responsibilities to perform. This helps maintain motivation and intellectual engagement.
2. Offer diverse entertainment options: Include books, craft supplies, games, and other activities suitable for all ages in the shelter.
3. Implement educational programs: Use structured teaching sessions to reduce boredom while also educating individuals on survival topics and issues.
4. Encourage social interaction: Interaction with others can significantly prolong the time before psychological distress occurs.
5. Ensure 10-12 hours of daily activity: Research shows that this amount of activity is necessary for most people to avoid significant boredom.
6. Maintain a consistent routine: Establishing and following a regular schedule helps improve psychological well-being.

Manage Depression in Survival Situations

To address depression and low mood during survival scenarios:

1. Recognize symptoms: Look for signs such as pervasive hopelessness, inability to concentrate, changes in sleep or eating patterns, and loss of enjoyment in life.
2. Provide strong social support: Encourage group interaction and emotional support from others in the shelter.
3. Offer supportive psychotherapy: If possible, provide one-on-one counseling and reassurance to those suffering from depression.
4. Consider medication storage: Store a supply of antidepressants such as SSRIs (e.g., fluoxetine/Prozac) or herbal alternatives like St. John’s Wort for potential use in severe cases.
5. Monitor for incapacitation: If someone becomes completely unable to function or exhibits suicidal tendencies, difficult decisions may need to be made by the group.
6. Promote long-term recovery: Most people recover over 3-6 months with proper support and therapy.

Ensure Privacy in Survival Situations

To maintain mental health and reduce stress during prolonged confinement:

1. Create a private area: If possible, designate a partitioned-off space within the shelter where individuals can be alone without disturbance.
2. Provide noise privacy: Use insulation, earplugs, or mufflers to reduce constant background noise that may cause friction and anxiety.
3. Manage noise from children: Consider strategies such as controlling older children’s boredom to minimize noise from younger ones (e.g., crying babies).
4. Allow for timeout periods: Ensure individuals have the opportunity to retreat from crowded living conditions and social interactions when needed.

Address Compatibility Problems in Survival Groups

To manage interpersonal conflicts and compatibility issues during survival scenarios:

1. Recognize the potential for conflict: Understand that even close relationships may deteriorate under stress, especially after 10-14 days of confinement.
2. Practice group dynamics beforehand: Consider how individuals will interact in a confined space and plan accordingly.
3. Allow individual control where possible: Provide people with some autonomy over their daily activities to improve psychological well-being and reduce tension.
4. Maintain leadership but encourage participation: While having an authoritative figure is important, ensure that group members have opportunities for input and decision-making.
5. Prepare for difficult decisions: Be ready to manage conflicts if they arise, especially in larger or more diverse groups.

Procedure:

1. Be aware that foreign powers may use disinformation, misinformation, or propaganda to influence public opinion.
2. These efforts often occur through online platforms and social media with the goal of sowing mistrust and weakening collective resilience.
3. Common tactics include:
- Spreading lies or false narratives (even if partially true).
- Manufacturing fake images, videos, or voice recordings.
- Eliciting strong emotions to heighten suspicion or worry.
4. To contribute to collective resilience:
- Avoid sharing content that elicits a strong emotional reaction without verification.
- Only share information from reliable sources.
- Verify information using multiple sources.
- Confirm serious events through official government channels.

Objective: Offer emotional and practical support to individuals affected by trauma following an incident.

Steps:
1. Be attentive to those who wish to talk about their experiences after an incident.
2. Provide emotional support through active listening and empathy.
3. Monitor for persistent signs of distress such as prolonged anxiety, depression, or withdrawal from social activities.
4. If symptoms do not improve with informal support, encourage the affected individual to seek professional help.

Details:
• Additional resources are available on [GOV.UK/Prepare](https://www.gov.uk/prepare) and relevant NHS pages for coping with trauma after emergencies.

Procedure:

1. Assess the Need for Psychological Support:
- Identify individuals who may require psychological support, including survivors, families of victims, and emergency responders.
- Use screening tools to assess the level of trauma experienced by affected individuals.

2. Provide Immediate Support:
- Offer immediate access to trained mental health professionals for those in need of urgent care.
- Provide basic psychological first aid at shelters or temporary housing locations.

3. Long-Term Support Services:
- Establish long-term support services, such as counseling and therapy sessions, for individuals affected by the incident.
- Ensure that these services are accessible to all who need them, regardless of financial status or location.

4. Community Outreach Programs:
- Implement community outreach programs to raise awareness about available psychological support services.
- Encourage open discussions about trauma and mental health in affected communities.

Important Notes:
• Psychological support should be provided by qualified professionals with experience in trauma recovery.
• Ensure that all individuals have access to confidential and non-judgmental support services.

Severe stress or stress reactions can be recognized by:

• Inefficient performance (slow thinking, indecisiveness)
• Uncontrolled emotional outbursts (crying, screaming, laughing)
• Withdrawal from others
• Restlessness or aimless movement
• Indiscriminate aggression toward others
• Confusion or inability to follow simple commands
• Symptoms resembling head injuries (dazed appearance, wandering, disorientation, memory loss)

Action Steps:
1. Observe the service member for signs of meaningful activity, performance of duties, self-care, unusual behavior, or acting out of character.
2. If symptoms resemble a head injury (dazed appearance, wandering, disorientation, memory loss), rapidly medically evacuate the individual unless eyewitnesses confirm no head injury occurred.
3. Encourage service members to ventilate about the incident by talking extensively and repetitiously about their experience.
4. Provide support for those experiencing sleep disturbances or repetition of dreams related to the stressor.
5. If nightmares persist or the person reexperiences the event repeatedly, encourage them to ventilate and seek further assistance if needed.

Steps to Administer Psychological First Aid:

1. Ensure safety: Ensure the environment is safe for both you and the casualty.
2. Approach with empathy: Use a calm, reassuring tone and approach the individual in a non-threatening manner.
3. Listen actively: Allow the individual to express their feelings without judgment or interruption.
4. Provide reassurance: Offer comfort and support, emphasizing that help is available and that they are not alone.
5. Encourage professional help: If the stress reaction persists, encourage the individual to seek assistance from a mental health professional.
6. Monitor for worsening symptoms: Watch for signs of deterioration such as increased anxiety, aggression, or withdrawal.

Important Notes:
• Psychological first aid is not a substitute for professional medical care.
• Avoid making assumptions about the casualty's feelings or experiences.
• Be patient and avoid pressuring the individual to talk if they are not ready.

Normal stress reactions are common after traumatic events and include:

• Feeling shaky, sweaty, nauseated, or confused.
• These reactions are normal and not a cause for concern.

However, some short- or long-term reactions may require attention if left unchecked. See paragraph 8-13 for more information.

Emotional Reactions:

The most obvious combat stress reaction (CSR) is inefficient performance, demonstrated by:

1. Slow thinking or reaction time.
2. Difficulty recognizing priorities and seeing what needs to be done.
3. Difficulty getting started.
4. Indecisiveness and trouble focusing attention.
5. Tendency to do familiar tasks and be preoccupied with familiar details (may become very passive, such as sitting or wandering about not knowing what to do).

A less common reaction may be uncontrolled emotional outbursts, demonstrated by:

• Crying, screaming, or laughing.
• Some service members may become withdrawn and silent, trying to isolate themselves from others. These individuals should be encouraged to remain with their assigned unit.

Uncontrolled reactions may appear alone or in any combination (e.g., crying uncontrollably one minute and then laughing the next). In this state, the person is restless and cannot keep still. They may run about without purpose. Inside, they feel a great rage or fear, and their physical acts may show this. In anger, they may indiscriminately strike out at others.

Panic and Confusion:

In a desperate attempt to get away from danger, a service member may panic and become confused. Their mental ability may be so impaired that they cannot think clearly or follow simple commands. Judgment may be faulty, and they may not be aware of their actions (e.g., standing up in their fighting position during an attack).

Symptoms Similar to Head Injury:

Overwhelming stress may produce symptoms associated with head injuries, such as:

• Appearing dazed or wandering aimlessly.
• Confusion and disorientation.
• Complete or partial loss of memory.

In these cases, especially when no eyewitnesses can confirm the service member has not suffered a head injury, it is necessary for them to be rapidly medically evacuated. DO NOT allow the service member to expose themselves to further personal danger until the cause of the problem has been determined.

Procedure:

1. Assess the psychosocial impact of public health emergencies on individuals, families, and communities.
- Identify stressors such as isolation, fear, economic instability, and loss of loved ones.
- Monitor mental health trends among vulnerable populations (e.g., children, elderly, first responders).

2. Integrate mental health services into local bioterrorism or pandemic response planning:
- Collaborate with public health departments to develop protocols for psychological support during emergencies.
- Ensure access to trained mental health professionals and crisis counselors.

3. Promote community resilience initiatives:
- Develop programs that build emotional, social, and economic resources in communities.
- Encourage peer support networks and community-based coping strategies.

4. Provide training for healthcare workers on managing psychological stress during emergencies:
- Include topics such as trauma-informed care, self-care techniques, and communication skills.
- Offer ongoing mental health support for frontline workers (e.g., counselors, debriefing sessions).

5. Implement risk communication strategies to reduce anxiety and misinformation:
- Use clear, consistent messaging from trusted sources.
- Address public concerns through media, social platforms, and community meetings.

6. Support children and families affected by emergencies:
- Provide age-appropriate information about the situation.
- Offer counseling services to help children process trauma or fear.

7. Evaluate the effectiveness of psychosocial interventions:
- Track outcomes such as reduced anxiety, improved coping mechanisms, and increased community cohesion.
- Use feedback from stakeholders to refine support programs.

Procedure for Understanding and Applying the Warrior Ethos:

1. Commit to the Mission: Prioritize the mission above all else, even in the face of adversity.
2. Refuse Defeat: Maintain a mindset that refuses to accept defeat under any circumstances.
3. Never Quit: Demonstrate perseverance and determination in all tasks and challenges.
4. Never Leave Comrades Behind: Ensure that no fellow soldier is left behind, showing unwavering loyalty and support.
5. Exemplify Ethical Behavior: Adhere to the highest standards of ethical conduct at all times.
6. Uphold Army Values: Embody the core values of the U.S. Army: loyalty, duty, respect, selfless service, honor, integrity, and personal courage.
7. Maintain Absolute Faith in Comrades: Trust in the strength and capability of fellow soldiers to achieve victory together.
8. Exemplify Commitment in Peace and War: Demonstrate unwavering commitment whether in times of peace or conflict.

Notes:
• The Warrior Ethos is a guiding principle for all Soldiers, reinforcing the importance of unity, resilience, and ethical behavior.
• It serves as a foundation for both individual and collective success within the Army.

Objective: Recognize and manage psychological reactions that may arise during survival situations.

Steps:
1. Understand common internal reactions such as fear, anxiety, anger, frustration, depression, loneliness, boredom, and guilt.
2. Manage fear by being cautious in dangerous situations to avoid injury.
3. Reduce anxiety by performing tasks that ensure survival (e.g., securing shelter, finding food and water).
4. Address anger and frustration by focusing on problem-solving rather than irrational behavior.
5. Combat depression by maintaining a sense of purpose and seeking ways to stay mentally engaged.
6. Alleviate loneliness and boredom by keeping the mind occupied with productive activities.
7. Deal with guilt by acknowledging it but not allowing it to prevent living or taking action.