Disaster Response Tips for Shelter Workers and Counselors After a Hurricane

So I'd like to welcome everybody to today's presentation on tips for responding after a disaster. This is based in part on SAMHSA Tip 57, trauma informed care in Behavioral Health Services. I'm your host, Dr. Donnelly Snipes. In this presentation we're going to review common reactions to disaster and some interventions. We'll identify some common stressors in shelters, some common issues when sheltering in place, and explore how to help reduce stress and anxiety through facilitated and independent activities and facilitated groups. It's important that we remember that acute stress is a very normal reaction to a very abnormal event. People are going to be stressed if they are aware that a, you know, 155 mph storm is barreling their way. That is a normal reaction. The majority of people will recover with no long term effects. Even if, heaven forbid that there is widespread destruction, you know there is going to be a rebuilding phase and people may struggle through that, but the majority of people are probably going to recover with no long term effects. Now people who are already dealing with mental health issues, substance abuse issues, etc, may be at a greater risk for developing long term effects. People who've been through catastrophic storms or events before may also be at greater risk for developing a traumatic stress reaction. So we do want to be sensitive to the fact that there are people that are more at risk sheltering in place. Let's just jump right in. Sheltering in place means staying in your home and there can be anxiety about the situation and your safety. You're like, okay, well I'm in my house, I've boarded up the windows, I've done everything that I can do, but it's safe. Still anxiety provoking. To not know what's going to happen, to not know how bad it'll be. And it's important to use mindfulness and distress tolerance skills to deal with that. It doesn't mean to ignore the anxiety. It means distress tolerance helps people sit with the anxiety and say, okay, I accept the fact that I feel anxious right now and it really sucks. But however, I also recognize that there's nothing that I can really do about it. Refreshing the weather channel every 30 minutes or 30 seconds is not going to change what's going on. It's not going to speed it up or slow it down. So it's important to recognize that and we're going to talk about these interventions more at the end. But anxiety is normal, don't it? It's important to try not to should yourself or should other people about you shouldn't be Anxious about this? Well, if people are, they are, and meeting them where they are is really important, they may have concerned about loved ones who are elsewhere. If as as I mentioned, people who are in New York or Tennessee or somewhere else may have loved ones that are in the path of the storm and have concerns about their loved ones who are in that particular place. Or, you know, you may have people who are spread out and all of you are in the path and there's concern about those people. You can't get to them right now. You can't hop a plane and get down to South Florida right now and help anybody out. So there's a certain amount of powerlessness that we all are facing. There may be feelings of isolation, loneliness, sadness or boredom. And this is particularly prevalent if people are sheltering in place in their homes, especially if they don't have anybody with them. They may feel kind of caged in, so to speak. And there's also a lot of boredom when you switch back and forth from being anxious about what's going to happen and then thinking, well, gosh, you know, I'd really like to do something, I'm bored, but I can't focus my mind. There may be guilt about not being able to perform your normal duties, like going to work or help out to try to help people get power back on or whatever you feel you need to do. And that guilt may persist some after the storm has gone through. And there can be fear over loss of income or the cost of repairs. And that's one of the main issues that a lot of people cite for their anxiety. And when the storm is heading their way, and during the storm it's like, oh my gosh, what's going to happen? Unfortunately, we don't know. And it's important for people to recognize that, acknowledge how they feel, acknowledge their anxiety, and recognize that stewing on it is just burning up a lot of energy that they're going to need in a few hours or a few days. And when people shelter in place, and we learned this over the past couple of years, there can of often be changes to sleeping and eating patterns. People may be sleeping throughout the day, grazing on food throughout the day, so the body circadian rhythms get out of whack. And when your circadian rhythms get out of whack, it alters your neurotransmitters, your godal hormones, everything else. And I have videos on circadian rhythms. But it is important, suffice it to stay. It is important to make sure that people try as best as they can. To maintain their schedule. It's important to remember that people who are in shelters have suffered a trauma and as a result of having to leave their home, that's traumatic. Even if their home ends up being there when they get back, having to leave, it is traumatic. They don't have a sense of control, they feel helpless, and there's a sense of a lack of safety. It's also important to recognize that people who are experiencing this trauma, if they've experienced traumas in the past, whether they're disaster related or not, that feeling of being unsafe and disempowered can trigger memories, can trigger flashbacks, can trigger reactions from their past traumas. So people who've experienced significant trauma in their past may be more vulnerable to emotional disregulation and vulnerable to developing traumatic stress injury as a result of this. We need to be compassionate, and I'm going to say this a bunch today, compassionate and, and curious. If somebody is reacting with anger or anxiety that is greater in proportion than you would expect, let's get curious. Where is that anxiety and anger coming from? Remember, anger and anxiety, those are our threat responses. So clearly it means they're feeling a threat from something. So let's figure out what that is. People who are in shelters may experience significant losses, including possessions or pets. And even if they're in a pet friendly shelter, a lot of times the pets are not allowed to be with the people. They have to be sequestered somewhere else because of the risk of allergies and all kinds of other things. If the pet, especially if it is a informal emotional support animal, which pets generally are for a lot of us, then the people who aren't able to access their pets may feel more anxiety because they can't pet Fluffy and they may not know where some of their loved ones are, which is really important to recognize if they're not able to get in touch with their loved ones, especially after the storm passes. But, but while people are still in shelters or having to shelter in place because the roads are blocked and the power's down and all that other stuff, anxiety can start ramping up really, really quickly. It's important for us to make sure that people remember that the towers may be down, the towers may be overloaded. If the power's down, somebody's phone may have, you know, the battery may have died. It's important to make our assumptions, if you will, based on facts and not jump immediately to based on feelings and expecting the worst. Additional stressors and shelters, including an environment that's crowded, noisy or overstimulating this is especially true for people who are ner. Neuro atypical people who have a history of trauma or people who are just plain introverts. A lot of people who are introverted find it exhausting to be around huge crowds and think about what a shelter looks like or think about what it's like if you have, you know, think about the holidays when people come over. Your family, they, they. They are your family, but they come over and they bring the grandkids and stuff and it can be kind of overwhelming. Well, multiply that by 20 and that's kind of what you might be looking at in a shelter environment. So we want to recognize that some people may start feeling just completely overstimulated and overwhelmed in a shelter. Now this is not sheltering in place, but in a shelter itself, it's less secure than home. The people have their possessions with them, usually under their cot or in their. In their particular area, but they don't have the ability to lock things up. And yes, there are people on duty supervising and all that stuff. But think about being in an airport or in a bus station or somewhere where you have your possessions with you, things that are important to you, and you can't just lock it up. So they may feel more edgy, they may feel less safe in the environment. Even if it's a safe environment, they may feel less safe. And we need to acknowledge that and help them figure out what they can do in order to feel more secure. And that's really what we keep coming down to. Be compassionate, get curious and figure out how can we arrive at a mutually agreeable solution to improve the next moment. And some of these environments may be trauma triggering. There are a variety of things that can trigger traumas. And if somebody is in a shelter and other people in the shelter remind them of people who traumatized them in the past, they. That can be trauma triggering. Like I mentioned, just the feeling of being unsafe and disempowered can trigger trauma memories. So we do want to recognize that people's past, especially right now, when they're feeling. When they're in a situation where they are already disempowered and to a certain extent feeling unsafe, they are more primed, they're more vulnerable to, to call on those memories from the past and feel more edgy, anxious, irritable. Poor sleep is another issue, especially in shelters because those cots are not comfortable as a result of a disrupted routine. People may not be getting adequate sleep as a result of not feeling safe. They may not Be able to relax enough to get good sleep. And ergonomics of those cots, not great. We're doing the best we can, but still, you know, it's not going to be like sleeping on a sort of pillow top or whatever they're called. So it's important to recognize that poor sleep contributes to irritability, it contributes to cognitive fogginess, and it contributes to more difficulty suppressing intrusive and unwanted thoughts. So those stress related thoughts are going to be more common and more persistent in people who are sleep deprived. If people are sheltering in place, you know, they're sheltering in their home or they're in a treatment center, in a hospital where they were beforehand, we may see some of these things anyway, a disruption of routine or changes that keep keep them from being able to sleep as well. Pain is another issue that may happen in shelters and even at home as a result of poor ergonomics. You're doing things differently. You may be sitting on the couch longer or you may be in environments where there isn't good ergonomic seating and stuff. So people may experience more pain which is going to make them more cranky. Nutritional changes are also prevalent whether you're sheltering in place or sheltering in a shelter. Many times people will gravitate toward high fat, high sugar foods. Why? Because those foods produce or trigger your body to release serotonin and endorphins. They're looking to self soothe in any way possible in shelters. A lot of times people don't have open access to food all day long. So if they're not able to access that stuff stuff, then they may start feeling edgier, especially if that's one of the ways they normally cope. A lot of times during this situation, caffeine and nicotine use go way up. Caffeine because people aren't sleeping well and they think, oh, if I just have a cup of coffee it'll help me calm down. If I just drink some caffeine, it'll help me calm down. Which I understand that think thought. But we also need to recognize that caffeine is a stimulant. And nicotine does have some calming effects on people. Not that I'm advocating for it, but many times in shelters people can't access their nicotine either at all or as much as they would like to, which increases stress and irritability. They're detoxing. You know, let's face it, they are experiencing a physiological detox. There can be ambiguity about what lies ahead. And this is true no matter where you are. That ambiguity of what exactly is it going to look like tomorrow morning when we wake up? And then there's boredom or time to dwell. You don't have your normal things that you can do when you are in a shelter or in a hospital or in a treatment setting center. So it's important to use that distress tolerance skill of activities to help people occupy themselves until they can identify what's going on. Remember, distress tolerance helps us tolerate the distress until we can figure out what we need to do to improve the next moment. Until the storm goes through, there's a lot of ambiguity. There's not much that we can do. So switching people's focus, instead of dwelling and perseverating on what might happen to, let's just do something else completely. And if we can help people past 15 minutes, great. If we can help them past five hours, even better. Common responses in adults and adolescents Difficulty communicating thoughts when you are in the fight or flight response. When that HPA axis gets triggered, your brain is flooded with glutamate, norepinephrine, dopamine. Your body's saying, here's a bunch of energy, use it to protect yourself. It's not saying, hey, let's get in touch with that executive control network and think about how we're feeling and what we're thinking. That's not where your head is, so to speak. It's important to recognize that give people time. If they're having difficulty communicating, don't interrupt. Don't, you know, assume you know what they're saying, but listen and give them time. If they're having difficulty coming up with words, you might ask, I'm wondering if you're trying to say that you're feeling anxious or I'm wondering if you're trying to say this. Instead of jumping in and filling in the word for them, ask them, is this the word you're looking for? They have difficulty sleeping. We already talked about that. Difficulty with balance in life, and this is true in the shelter as well as afterwards. During the reconstruction period, they will have a low frustration threshold. When you're in a stressful environment during a stressful situation, guess what? You're already stressed out. That pressure cooker is already up at max pressure. So it doesn't take much for people to feel or get triggered and have their frustration come out a little bit more than they normally would. There can be increased use of drugs or alcohol. Obviously, if you're in a shelter, that's probably not going to happen. But if you're sheltering at home, there is likely going to be an increased use of drugs or alcohol if that's how the person copes. And it's important for us to recognize that addiction is continuing to use a substance or activity despite experiencing multiple negative consequences as a result of use. If somebody is using during this period, it doesn't necessarily mean that they are an alcoholic. Okay, so let's not start labeling people. Right in the midst of a hurricane. People are going to try to survive the best way they know how. There's limited attention span and poor work performance. Well, that goes back to that. HPA axis is activated. Your body is saying or your brain is saying, fight or flee, fight or flee. Not pay attention to the details and let's work on an Excel spreadsheet. People may have headaches or stomach problems. When we are stressed, it actually alters our gut microbiome. And a lot of times with stress, people will clench their teeth and tighten their neck and shoulder muscles, which can contribute to stress headaches. Additionally, people who have chronic migraines are at risk of triggering those migraine attacks. Some people may develop colds or flu like symptoms. When you're stressed, your immune system is suppressed disorientation or confusion. Now if it's severe, it's definitely something that needs to be intervened in. If somebody was drinking heavily before they came to the shelter and then all of a sudden they're in the shelter, they can't drink alcohol and they start becoming disoriented, that is potentially Weirnicky Korsakoff syndrome and a medical emergency. However, what I'm talking about here more specifically, or more generally, I guess, is if somebody wakes up at the shelter and they can't remember for a minute where they are, or they keep forgetting things or getting confused, that's a sign of stress. Let's not pathologize something that is a normal reaction to an abnormal event. There may be a reluctance to leave home after the storm has passed, especially if leaving home means leaving your loved ones. Because for people, even if you know intellectually that the hurricane has passed, you know, it's not gonna, another one's not coming anytime soon. There can be a desire to stay closer to those with whom you have relatively secure attachments. Depression, sadness and hopelessness. Depression is characterized by a sense of hopelessness and helplessness. Well, guess what? When this goes through and it's, I experience, you know, the same thing. When, when pretty much any hurricane or tornado goes through any devastation, even if I'm not part of it, there's a part of me that's very sad and feeling helpless for those people. I empathize with the people who are going through it. People who are going through it obviously are having these feelings because they're looking around going oh crap. But it's important to recognize that other compassionate people in the world are probably also looking on this and their heart is hurting and we need to be sensitive to that. Just because somebody's not in the midst of a disaster doesn't mean it's not going to impact their emotions, their cognitions, their stress levels. There can be mood swings and overwhelming guilt. That's very common, especially if some people survive and some people don't. Fear of crowds, strangers or being alone is another symptom, especially in younger adolescents because they want to be close to their, to their adults. And argumentativeness, refusing to follow rules or being overly controlling. For some people when they're in this situation that they feel powerless, they feel like everything is spinning out of control. Their automatic response may be to try to grab the reins and take control because that makes them feel like they're in control of something. And so they may become argumentative, they have a better way of doing it, whatever it is, they have a better way of doing it. And they may start shooting other people in the, in the shelter because that is how they cope with feeling completely powerless is to try to take control of everything. We need to be curious and compassionate and also obviously set boundaries, help them recognize what they can control and redirect that to something. Maybe give them something that they can focus on so they are not invading other people's boundaries and shoulding them. We know that in general, when people are stressed, if somebody comes up to you and starts telling you all the things you should or shouldn't be doing, probably not going to be received very well in children. Birth to 2 years. Irritability, crying more than usual, wanting to be held and cuddled. And for the two year old, regression to an earlier age. So they may quit walking, they may start crawling or saying Mama D. One of the things that we recognize in shelters, for example, is if other children are getting the attention they want, then they will mimic those children. So if they see infants getting a lot of attention, they may regress some and and start acting that way. However, children also may do this subconsciously in order to get that comfort. If they're not getting the responsiveness from the caregivers that they are craving, their behaviors may regress to an earlier stage where that caregiver did give them that and it's not a conscious choice on the part of the child where they go oh, that baby over there is getting attention. Maybe if I act like a baby it's really a lot more subtle and subconscious than that. But we want to recognize that children are extremely perceptive of their caregivers emotional states and of change. And if their caregivers are feeling stressed out, then the child somewhere in their primitive brain is going oh, this is not good. If my caregiver is feeling anxious then I'm really vulnerable right now. So children tend to pick up on parents vibes, if you will. That doesn't mean the parents have to ignore their feelings, but it's important to recognize if, if little Johnny's getting more irritable, then it may be that he's mirroring the what you're putting off. They found that the biggest influence on children of this age is how their parents cope. If their parents are having difficulty coping, then the child will also have Difficulty coping. Preschool 3 through 6 years old Preschool children often feel helpless and powerless in the face of an overwhelming event. They see what's going on. A two year old's really just not getting it. But three through six, they, they kind of understand a little bit. Because of their age and small size, they lack the ability to protect themselves or others. As a result they may feel intense fear and insecurity about being separated from their caregivers. So we may see a lot more clinginess, a lot more separation anxiety, a lot more acting out. Preschoolers can't grasp the concept of permanent loss either. So they may expect that, you know, something goes away, but it's going to come back again. And this is an ongoing issue after the disaster that may have to be dealt with with the preschooler when, if they continue to expect something that they lost to come back. In the weeks following a traumatic event, preschoolers play activities may reenact the incident or the disaster over and over again. It's important to remember if you haven't been through one of these situations that once the storm passes, that doesn't mean people can leave the shelter and go home. A lot of times they're stuck in the shelter for days or even weeks until power is restored and the and the streets are cleared and other things. So you may be seeing some of these things in the shelter after the storm passes. Preschoolers also are more prone to crying and depression than when not in a disaster situation. Difficulty concentrating Bedwetting is another common response that is a regressive response that is not unusual in children. If they've been potty trained and they're six years old and they start wetting the bed again. It's important for us to recognize that that may be a reaction to the current situation and again not pathologize something or make them feel bad or guilty about something. That is a natural reaction. Withdrawal and isolation. Thumb sucking. Not wanting to attend school which again goes with being, oh, separated from their caregivers. Nightmares, headaches, Clinging fear of being left alone. Changes in eating and sleeping habits. Regression which we already talked about. Excessive fear of darkness or storms. When storms happen again, guess what? They have a schema about storms now and it's a big one. So when new storms come it's going to trigger that schema that was formed during this hurricane. And they may expect somewhere in their head that the bad stuff is going to happen again in the future. When they hear high winds it may trigger their memory of this event and trigger flashbacks. We need to be sensitive to that. There could be more fighting and increase in physical complaints. A lot of times children will do what we call somaticizing or instead of being emotive and crying, they internalize it and it comes out as belly aches or headaches or, or something else. Recognizing that some of their physical symptoms may be stress related is important and then we can take steps to try to address this. School Age 7 through 10 years the school age child can understand the permanence of loss. Whether that's a blessing or a curse, it is what it is. Some children become intensely preoccupied with the details of the event and want to talk about it continually. They're going to keep talking about it until they feel like they understand it, until they feel like maybe they've mastered it or have some sense of control over it. Well, guess what? You can't have control over a hurricane. So it's going to be important to help them, as they're talking about it, identify what they did that helped them stay safe and what the impacts were. This preoccupation can interfere with the child's concentration at school and prompt irritability from adults. The adults are like, you know what, I don't want to hear about this again. We've already talked about it 77 times. Well, we're going to talk about it. 78. The child get curious. Why is the child going over this again? What is it that they haven't quite figured out yet when? And you can go back and look at Piaget's developmental stages and there's assimilation and accommodation. When we get new information, we either need to change our expectations or change our memory of what happened to fit our expectations. And a lot of times that's what's happening for children when they keep retelling it and replaying it. They may be trying to figure out, okay, I don't know what file to put this in. Help me figure out how to understand this and how to integrate it. We also need to recognize that 7 through 10 years children may hear inaccurate information from their peers or from the media. So it can be important to step in and make sure that the information they have is accurate. They may display a wide range of reactions, including sadness, generalized fear or specific fears of the disaster happening again. Guilt over action or inaction during the disaster. If they left a prized possession at their house and then their house gets destroyed, they may feel guilt over leaving that. They may feel guilt if their house is fine and one of their friends houses is not. They may have anger that the event was not prevented. Now remember, we're talking about 7 to 10 years old. They may not understand the problem with this. I mean, we can write building codes as well as we can write building codes, but ultimately there's only so much that we as humans can do. There may be fantasies of playing rescuers, regression to earlier behaviors. This is common in this age group as well. Irritability or oppositional behavior to either distract or get the caregivers to set secure limits when the routine goes out the window. That can feel very anxiety provoking for children. And many times oppositional behavior is a way of getting caregivers attention and saying, hey, I need some structure here, tell me what I can do. When my son was little and this wasn't during a disaster, but it's an example of the behavior. We went to my grandmother's house and he was not supposed to touch the television and he knew that we had already talked about that, but he was about 2 and he looked at me and he said, pointed to the television and he said no touch. And I said, you're right, no touch. And he looked at me and he promptly walked over to the television and he touched it. Then he looked back at me and he said timeout. I said, yep, timeout. So in his little two year old way he was trying to figure out what are the limits here and do the same rules that apply at home apply here. And children may not be quite that demonstrative when they do it. But especially if the oppositional behavior is new, then we need to assume that it's probably being triggered as a result of the disaster. And try to figure out what it is the child is needing and trying to get through their behavior. 7 habits and shelters be and this is based on the 7 habits of highly effective people. Be proactive. Seeing alternatives and opportunities, not roadblocks. For people who are sheltering in place or in shelters during a stressful time, anger is often a sign of the person feeling completely powerless. So, okay, the person feels angry right now. Their body's giving them a bunch of energy to fight or flee. How can we harness that energy? What can they do with that energy right now? Proactive means not waiting until they get angry and they're exploding all over the place. Proactivity means saying, okay, we recognize this is going to be a really stressful situation. So let's set these activities. Let's set these wheels in motion. Begin with the end in mind. Defining a win win with practical and realistic outcomes. What is it that you're wanting and what is it, you know, what are the bounds of what we can do here and how can we find a compromise to help you be as comfortable or content as possible? Put first things first. Recognizing that some things are just not worth the energy or effort and other things are more important. And this is where we turn people's attention to. All right, I hear you're feeling really angry right now. Let's talk about what's important in your rich and meaningful life and what can we do to help you move towards that. Seek first to understand the other person's point of view and the whole situation. Then to be understood, it's important to hear a person. If they come to you. Maybe you're a shelter worker or a counselor in a residential facility and somebody comes to you and they are just irate about somebody, something. All right, let me hear about what's going on. Let me understand the situation. But also let me think about why might this situation be triggering this level of anger and understanding, for example, that the person may. This may be triggering prior traumas for them. So let me hear what's going on. Let me understand why this is so triggering for you at this point in time. And then let's talk about my point of view. But I need to understand you first. I want to respond and, and acknowledge your feelings. Synergize to use each person's strengths. When you're in a shelter environment or in a treatment center, or even if you're sheltering in place, each person has strengths. Some people will be good about. They'll enjoy cleaning or swiffering. Some people will be great about trying to keep the, the coffee station going. Other people will have other strengths that they can do, like leading the children's group where they can supervise some children's activities, sharpen the saw, take time for relaxation and recreation every day, and practice positive health behaviors to prevent vulnerabilities. This goes for the people who are residing in the shelter as well as the treatment center, as well as the workers. If you're in, if you're a worker in a shelter, if you get burned out, you're not going to be any good to anybody. If you get burned out, then you're going to likely start reacting with more anxiety, more anger, more frustration, and it's going to have a negative downward spiral. So it's important to recognize you need time too. Interventions Prepare a go bag or if people didn't have a go bag prepared when they came to the shelter, help them get the essentials they need so they're not worried about toothpaste and toothbrushes or razors or brushes. When people feel groomed, they tend to feel better. If they feel grungy, then they may feel that that's going to impact how they emotionally feel and potentially how they react. Try to stop media overload during and after the incident. Checking in with the news once a day, maybe twice a day can be helpful for some people. But keeping it on 24, 7 so people are just sitting there soaking it in, it doesn't give them a break. They need to be able to turn it off and reflect on this situation in this context. Right now. Maybe not my ideal situation, but I'm safe, you know, I'm in this environment where I'm protected from that bad thing out there. Keep routines as stable as possible and practice mindfulness each day personally, whether you're the counselor or the worker and, and as a family. And this is true for survivors and staff. So you may, if you're sheltering in place, practice your own mindfulness activities, but then also have a moment where everybody in the family or in the shelter takes two minutes to just do a mindfulness check in and figure out what they need and what they're where they're going that day. When communicating, validate each other's feelings and identify tangible solutions. Even if you don't agree with their feelings. If they're ticked off about something you did and you don't see a big deal with it, arguing about whether it's something to be angry about is not productive. Acknowledging that that person feels angry about it is important and and recognizing boundaries. Try to replace buts with ands. If somebody says yes, I know that, but that often translates to yes, I know that and I'm going to completely ignore it. We want to have people try to find agreeable solutions and not negate each other in during this time Lights up and lights out at the same time each night. Start the day with mindfulness and planning as an entire group, whether it's a home or a treatment center or or a shelter. Start the day with everybody just taking a few minutes to figure out what does the day hold. Try to have meals at the same time in large shelters. Divide the groups into A, B and C and each group gets to go first for one meal each day. That's that way the C group doesn't feel like they always get the leftovers. Physical Activity Walking, calisthenics, stretching for kids. They can do Duck Duck Go or Duck Duck Goose. I mean put on kids music and encourage dancing. Maybe have them do a performance at the shelter. A lot of shelters are in schools so you can go down to the gymnasium and just let them be loud for a few minutes. One of the ways that kids burn off steam is by just being loud. So that can be an option where they can let off their steam and give the grown ups a break and in shelters Chores each day in your zone Shelters tend to be very big so if somebody knows that this is my zone here, this room or this part of this room, then they can do their their chores as needed and then they feel like they've accomplished something environmentally. Have quiet spaces, both visual and auditory that people can go if they start feeling over stimulated. This is true for anybody. Doesn't mean that somebody has to have a particular diagnosis. Quiet spaces are essential. Quiet times can be helpful, but if you've got a lot of kids in the environment it may not be doable. So quiet spaces can be great. Try to have earplugs and headphones available. This can be helpful not only to block out some of the cacophony in the shelter, but if another storm comes through or when the storm's coming through. Providing an alternative so the person's not hearing the storm and every time the rafters creak. Getting stressed out Encourage awareness of personal space so people aren't getting in each other's personal space. Whether that's body too body or around their stuff. Keep it clean. Now a lot of people are sensitive to smell so you're not going to want to use a bunch of air fresheners. But keeping it clean is important and trying to help PE make sure People are able to bathe with regularity and be sensitive to allergens and other sensitivities in groups. You can do groups on goal identification and radical acceptance for goal identification. And obviously this is more for adults. What things, people, and experiences are most meaningful to you and what values are most meaningful to you or most important to you? What are your goals after this, when you get out of here? What people do you want to reconnect with and nurture? What experiences are important for you to have radical acceptance? You can do a group that asks people what has happened right now that cannot be changed? And embracing the fact that, okay, some things can't be changed. What? And this encourages people to identify what aspects they do have control over. All right, this happened. Now I can't change the fact that there was rampant flooding. What can I change? What can I do? Encouraging people to acknowledge how they feel right now is. Is how they feel. It's not good. It's not bad. It's just is. And what can you do to improve the next moment and move closer to your goals and the values that you hold dear? So what's happened can't be changed? You're really angry about it. All right, I get that. What is it that you can do to use all that energy to move towards the things that are important to you? Talked about distress tolerance a lot. And I have distilled distress tolerance activities down into the mnemonic T.