Skills for Psychological Recovery

1. Introduction

Version followed: Skills for Psychological Recovery (SPR) Field Operations Guide (Berkowitz, Bryant, Brymer, Hamblen, Jacobs, Layne, Macy, Osofsky, Pynoos, Ruzek, Steinberg, Vernberg & Watson; National Center for PTSD and National Child Traumatic Stress Network, 2010; English edition with Appendices A–G). I read modules 1–5 in the guide itself. For the Social Connections module and the Multiple Contacts section, the guide's main text is not drawn on, so those parts draw on the official appendix worksheets on the VA site and on two training decks: Watson's 2022 SPR training slides and the 2020 University of Washington SPR training deck by Bedard-Gilligan, Dworkin & Lindgren. Each of those passages is tagged with its source.

SPR is a manualised, modular programme for skills training and secondary prevention, not a single psychotherapy. It is meant for children, adolescents, adults and families in the weeks to years after a disaster, mass violence or terrorism. It follows Psychological First Aid (PFA), and the VA describes it as "not formal mental health treatment" [source: VA SPR page; FOG pp. 7–9]. The guide does not assume pathology. It assumes that distress persists when people lose a sense of control and competence. Change happens when survivors learn and practise a small number of concrete coping skills that fit their own priorities: problem-solving, positive activities, calming and managing reminders, helpful thinking and social reconnection. Recovery is then attributed to the survivor's own actions rather than to the helper [source: FOG pp. 8–9; Watson 2022 slides 4–7]. Teaching skills is presented as more effective than supportive counselling alone. SPR is more directive and educational, closer to coaching, and works by "doing with" rather than PFA's "doing for" [source: FOG p. 8; Watson 2022 slides 2–6].

For a psychotherapist, SPR works as a brief, low-intensity front end. You can use it in a clinic, school, family assistance centre, home or faith setting, and it hands off to trauma-focused treatment when that is needed [source: FOG p. 10; synthesis].

2. Framework

Timing. Start once safety and immediate needs are met. That is typically about a week after the event at the earliest, but it can be months or years later. Timing shapes content. Early contacts lean towards practical problem-solving. Later contacts lean more towards helpful thinking and positive activities [source: FOG pp. 8–9].

Dose and format.

• The guide's expert consensus is that at least three to five skill-building sessions are needed to reliably change behaviour. For significant problems, plan at least five contacts [source: FOG pp. 8, 14]. Watson describes SPR as designed as a five-visit programme in which every module can also stand alone [source: Watson 2022 slide 4].
• A single contact is acceptable when no more are possible. In that case, gather information and teach one skill well [source: FOG p. 8; Watson 2022 slides 11, 16].
• Each contact should take place in a private, quiet space with about 45 uninterrupted minutes [source: FOG p. 10]. Teach one skill well per visit rather than overloading the survivor [source: FOG p. 14].
• Skills can be taught in groups, but the guide says this is not group treatment [source: FOG p. 14]. With children, get permission from a parent or guardian first [source: FOG p. 14].
• Providers are mental health and other health workers in an organised response. They should complete basic training and ideally have prior disaster or traumatic stress experience [source: FOG p. 10]. Watson notes that paraprofessionals and trained community responders also deliver SPR [source: Watson 2022 slide 3].

Stages of an SPR course (the stages are the guide's own; the arrangement across contacts follows the 2020 UW deck):

1. First contact: information gathering and prioritising (10–15 min). Screen for anything that needs immediate attention or referral, identify and prioritise concerns, and agree an action plan. The plan names one skill to start with and a tentative number of meetings [source: FOG pp. 15–20; Bedard-Gilligan et al. 2020 pp. 8, 11]. Then begin the first skill: give the rationale, teach and practise it in session, set practice for home, summarise, and arrange follow-up [source: Bedard-Gilligan et al. 2020 p. 8].
2. Follow-up contacts. Each one starts with that skill's follow-up review. Did they do the practice, what happened, what got in the way? Then either apply the same skill to a new problem or teach the next skill. Reassess and set new practice [source: FOG pp. 28, 35, 49; Bedard-Gilligan et al. 2020 p. 8]. A survivor returning after a break goes through information gathering again [source: FOG p. 15].
3. Final contact. Review the rationale for each skill taught, what has been achieved, what to keep practising, and what to do if more help is needed later [source: Bedard-Gilligan et al. 2020 p. 9]. Appendix G of the guide (Multiple Contacts) includes a Preventing Setbacks Worksheet. Its content is not described here [uncertain].

Choosing skills (the guide's Skill Flowchart, paraphrased). Each presenting concern maps to a first-choice skill and backup skills [source: FOG pp. 19–20]:

Criteria for moving on [source: FOG pp. 13, 19, 28, 35, 49]:

• The practice worked and the problem is resolved: apply the same skill to a new problem, or move to the next prioritised concern.
• The practice was partly done or did not help: make the plan smaller and more doable, adjust it, or swap in a different strategy within the skill.
• A new type of concern appears: choose the matching skill from the flowchart.
• There is no improvement in distress or functioning over time: refer to mental health care. Watson adds that SPR should be stopped or replaced with treatment if it is not producing significant benefit [source: Watson 2022 slides 14, 53].

Who should be referred rather than (or before) starting SPR.

• Refer immediately if the survivor is actively suicidal, a danger to others, gravely disabled, acutely psychotic or severely cognitively impaired [source: FOG p. 14].
• Physical symptoms need medical review first [source: FOG p. 14].
• Persistent extreme depression, guilt, shame, worthlessness or thoughts of revenge call for a mental health referral. Acute physical symptoms such as chest pain call for a physician [source: FOG p. 37].
• Watson also lists poor motivation or inability to engage, a life too chaotic for practice, a severe alcohol problem, an unstable medical condition and hallucinations [source: Watson 2022 slides 9, 14, 53].

3. Guiding principles

[source: FOG pp. 7–14 unless tagged otherwise]

• Skills, not supportive counselling. Every contact should end with something learned and practised, not just talked through.
• No assumption of pathology; secondary prevention. Frame reactions as understandable and skills as tools, avoid diagnostic language, and refer anyone who needs treatment.
• Rapport first. Validate, show empathy and offer comfort before teaching. Teaching without trust will not stick.
• Survivor-led priorities. Let the survivor name the concerns, then work on the one they choose and feel able to tackle now.
• Teach only what fits. Use the flowchart to choose skills. Do not run all modules on everyone.
• Give the rationale for every skill [Watson 2022 slides 13–14]. Explain why before how, using everyday analogies such as learning to cook or play a sport [Watson 2022 slide 10].
• Follow all the steps of a skill [Watson 2022 slide 53]. Do not skip steps or rush. Work at the survivor's pace.
• Build on existing strengths and coping. Ask what has already helped and use it as the starting point for each skill.
• Active participation and self-efficacy. The survivor generates options, chooses actions and attributes success to their own effort [Watson 2022 slide 6].
• Realistic expectations. Say what SPR can and cannot do, that practice is needed, and that benefits build gradually.
• Small steps. Make every homework task small enough that the survivor will actually do it [Watson 2022 slide 53].
• Use written materials. Hand over the worksheet or handout for each skill so the survivor can use it after the contact [Watson 2022 slides 13–14; FOG p. 38].
• More contacts are better, and a single contact still has value. Offer follow-up, but make each visit self-contained [Watson 2022 slides 4, 53].
• Respect the survivor's right to stop. Accept it if they decline further contact, and leave information on how to get help later.
• Do not skip skills you find uncomfortable to teach. The choice of skill follows the survivor's need, not your preference.
• Monitor progress and refer. Track distress and functioning, and refer if there is no improvement over time.
• Developmental adaptation. Every module has child, adolescent and caregiver versions. Assess caregivers too, because children's adjustment can track caregiver distress closely [FOG pp. 13–14, 53].
• Cultural humility. Ask about grieving customs, decision-making structures (for example elders or councils) and the role of faith before planning activities or solutions [FOG pp. 14, 27, 32].
• Link to services. Connect the survivor with local resources for practical, medical and mental health needs.
• Safety and stabilisation first; no memory work beyond the guide's writing exercise. SPR does not include exposure therapy or memory processing. Hand trauma-focused treatment to a suitably trained clinician [synthesis, consistent with FOG pp. 8–9, 45].

4. Intervention inventory

The guide has six skills (modules) and a Multiple Contacts section. Each skill follows the same pattern: explain the rationale, take the steps in order, then do a follow-up review at the next contact. All worksheets and handouts named below are in the guide's Appendices A–G and are free to download from the VA and NCTSN. Use them as published rather than recreating them [source: FOG; VA SPR page]. All example wording is mine.

4.1 Introducing SPR and setting expectations

• Purpose: Orient the survivor, build hope that recovery is possible, and set expectations that practice will be needed [source: FOG pp. 9, 11–12; Watson 2022 slides 10, 15–17].
• Steps: (1) Introduce yourself and your role. (2) Describe SPR as learning a few practical skills for the stresses that follow a disaster. The guide's handout "What is Skills for Psychological Recovery?" (Appendix A) can help here. (3) Say what SPR can and cannot do. Skills need practice, and the aim is to find out where each skill helps most. (4) Agree how many contacts you will tentatively have, and make clear the survivor can stop at any time [source: FOG pp. 11–12, 19; Bedard-Gilligan et al. 2020 pp. 8, 11].
• Example language (illustrative): "What we'll do together is less like talking things over and more like coaching. I'll show you a few tools many people find useful after something like this. You try them out between our meetings, and we see which ones work for you."
• Watch for: The survivor expecting you to fix practical problems for them, which is the PFA "doing for" stance. Gently shift to doing the work together.

4.2 Gathering information: identifying current needs and concerns (Module 1, Step 1)

• Purpose: Decide whether anything needs immediate attention or referral, and list the survivor's current concerns. Use it with every new contact and with anyone returning after a break. It takes 10–15 minutes. Materials: the SPR Screening Form (Appendix A) or your agency's own tool [source: FOG pp. 15–17].
• Steps: (1) Explain the three purposes: check for urgent needs or referral, identify practical needs, and set priorities. (2) Ask whether anything needs dealing with right now. (3) Let the survivor name their concerns, and respond without probing further. (4) If they struggle to put concerns into words, go through the Screening Form domains. (5) For each concern, ask how urgent it is. (6) If anything needs immediate attention, stop screening and deal with it now. This covers physical health problems, suicidal or homicidal thoughts, severe mood or anxiety symptoms, substance problems and immediate safety needs, and often means a referral to another service [source: FOG pp. 16–17].
• Example language (illustrative): "So I can work out how best to help, can I ask you a few questions? Before we start, is there anything that needs sorting out today?"
• Watch for: Screening running past 15 minutes or turning into a full trauma history. Do not go there. If the survivor asks for a provider of a particular gender, age, ethnicity or faith, let that guide the referral [source: FOG p. 16]. Use your usual suicide risk assessment whenever risk comes up [synthesis].

4.3 Prioritising areas to address (Module 1, Step 2)

• Purpose: Agree which concern to work on first [source: FOG pp. 17–18].
• Steps: (1) Summarise the concerns back to the survivor and check you have them right. (2) Ask which matters most now and which they want to start with. (3) Give your own observation and recommendation, then check whether they agree. (4) If several concerns are equally pressing, use guiding questions: which bothers you most, which needs attention soonest, which is getting worse, would solving one help the others, which can you realistically tackle now, is anything coming up that will make it harder, has something recently made it worse? (5) Weigh the guide's criteria: the survivor sees it as major; it causes serious distress or impairment; it is urgent or worsening; solving it would ease other problems; the survivor prefers it and feels able to start; SPR skills can address it.
• Example language (illustrative): "It sounds as if the big ones are the insurance claim, not sleeping, and feeling cut off from your sister. Which of those feels most important to get going on this week?"
• Watch for: The survivor choosing the hardest problem first when an easier win would build confidence. Offer your view, but respect their choice [synthesis].

4.4 Action plan and skill selection (Module 1, Step 3)

• Purpose: Match the priority concern to an SPR skill, or decide on referral [source: FOG pp. 18–20].
• Steps: (1) Decide whether SPR can address the concern or whether it needs referral. Urgent medical and mental health issues come first. (2) Describe the relevant skills briefly and ask about the survivor's past experience with them and their preference. (3) Use the Skill Flowchart (section 2) to choose a primary skill and secondary skills. (4) If the concern warrants it, recommend more than one meeting and check the survivor can attend [source: FOG p. 19].
• Example language (illustrative): "For a problem like this one, a step-by-step way of tackling it often helps. If the worrying thoughts keep getting in the way, we could also look at those. Where would you like to start?"
• Watch for: Agreement that is only polite. Ask what would make it hard to come back.

4.5 Problem-solving: define the problem and decide who owns it (Module 2, Step 1)

• Purpose: Module 2 is for survivors who feel overwhelmed, stuck, demoralised or unable to find solutions, or whose family members struggle with problem-solving. A session takes 30–45 minutes. Materials: the Problem-Solving Worksheet, or the Problem Busters Worksheet for children (Appendix B) [source: FOG pp. 22–24].
• Steps: (1) Give the rationale. Unsolved problems pile up stress, lower mood and strain relationships, and breaking them into pieces restores a sense of control. Introduce the four steps and hand over the worksheet. (2) Help the survivor describe the problem concretely: who is involved, when and where it happens, how often. (3) Break a large problem into smaller chunks and pick one. (4) Decide who owns it. If the problem is between the survivor and someone else, they own at least part of it. If it mainly belongs to other people, the survivor can help but should not take primary responsibility, so choose a different problem to work on [source: FOG pp. 23–25]. (5) If a family member wants to use the skill to help others, have them practise it on their own problem first. Individual or joint sessions are both options [source: FOG pp. 23–24].
• Child adaptation: Start with a strengths exercise to build rapport. List the child's concerns and explore each one (how often, who is involved, how it feels). Write each on an index card and have the child sort the cards from most to least upsetting (a Q-sort). Start with the top card [source: FOG p. 24].
• Example language (illustrative): "'Everything since the flood' is too big to solve in one go. Let's take one piece. Which part is causing the most trouble this week?"
• Watch for: The survivor taking on other people's problems, such as fixing an adult child's finances. Ownership is the stage at which to redirect.

4.6 Problem-solving: set the goal (Step 2)

• Purpose: Turn the problem into a goal that reflects the survivor's underlying need [source: FOG pp. 25–26].
• Steps: (1) Use sentence starters for wants, needs, fears and concerns, such as "I want…", "I need…", "I'm afraid that…". (2) Look beneath the stated problem for the underlying need, such as control, safety, respect, being taken seriously, recognition or growth. The guide's example is a crowded temporary home, where the real need is privacy or time alone. (3) Write the goal on the worksheet.
• Example language (illustrative): "If this were sorted, what would be different for you? … So underneath the arguments about the kitchen, what you need is some time to yourself."
• Watch for: Goals that depend entirely on other people changing. Reword them into what the survivor can do.

4.7 Problem-solving: brainstorm (Step 3)

• Purpose: Generate options freely, without judging them [source: FOG pp. 26–27].
• Steps: (1) List as many options as possible, including impractical or silly ones. Judging comes later. (2) If the survivor gets stuck, ask how someone they respect would handle it. (3) Prompt across the guide's option types: calming yourself, acting on the parts you can control, helpful self-talk, doing more of what already helps, past successes, changing the situation, learning new skills, getting support, and using available services. (4) Keep going until there are at least 10 ideas, several of them workable, and you have both run out [source: FOG p. 27].
• Example language (illustrative): "No idea is too silly at this stage. Wild ones sometimes lead to good ones. What else could you do?"
• Watch for: The survivor rejecting ideas as they go. Remind them that evaluation comes next.

4.8 Problem-solving: evaluate, choose and plan action (Step 4) and follow-up review

• Purpose: Choose realistic, small actions and commit to them [source: FOG pp. 27–28].
• Steps: (1) Go through the pros and cons of each option. Combining options often works best. (2) Choose small, realistic steps. (3) Ask whether anyone else expects a say. In many cultures, elders, healers or councils decide interpersonal and group matters [source: FOG p. 27]. (4) Fix each action step: what, which day and time, what help is needed, and likely obstacles with a plan for each. Give referral information if needed. (5) Children: have them mark pluses and minuses, star the options they will try and cross out unhelpful ones. The content should come from the child. Involve a parent when adult help is needed. (6) Follow-up review: ask which actions were taken and what happened. If nothing was done, explore what got in the way and make the plan easier. Then modify the plan, try another starred option or brainstorm again. Once the problem is resolved, apply the four steps to a new one. Praise effort and recap the steps [source: FOG p. 28].
• Example language (illustrative): "Which of these feels doable before we next meet? Let's pin it down: Tuesday morning, phone the adjuster. What might stop you, and what would you do then?"
• Watch for: The plan is working when the survivor starts to generate steps without you and talks about having more control.

4.9 Positive activities: identify and plan (Module 3, Step 1)

• Purpose: Module 3 is for survivors who feel down or apathetic, whose routines are disrupted, or who have stopped doing enjoyable things. It also covers children who have stopped playing or whose play has become risky. A session takes 20–30 minutes. Materials: the adult and child Positive Activities handouts and worksheets, and the parent handout (Appendix C) [source: FOG p. 30].
• Steps: (1) Give the rationale. Thoughts, feelings and behaviour affect each other. Feelings are the hardest to change directly, so changing what you do is the practical way in [source: FOG p. 31]. With children, the guide uses an image of filling time with good feelings [source: FOG p. 32]. (2) Warn the survivor that activities may not feel as enjoyable as before, and that enjoyment is not the point at first [source: FOG p. 32]. (3) Use the handout lists to choose one to three activities for the coming week, including some they enjoyed before the disaster. Choose things they will actually do even without motivation [source: FOG pp. 33–34]. (4) Children: at least one activity alone and one with a friend, family member or trusted adult, plus one family activity if possible. "Family" can include close friends or community members. (5) Older adults: take physical, financial and travel limits into account [source: FOG p. 33].
• Example language (illustrative): "When we're low we wait to feel like doing things, but it usually works the other way round. Doing comes first, and the feeling follows, often slowly. What used to give you even a little satisfaction?"
• Watch for: Cultural rules after a death. In some traditions, enjoyable activities soon after a bereavement are disrespectful, so ask about mourning customs first [source: FOG p. 32]. Do not suggest activities in places that are now unsafe [source: FOG p. 34].

4.10 Positive activities: schedule (Step 2) and follow-up review

• Purpose: Turn intentions into dated plans and get past low energy [source: FOG pp. 34–35].
• Steps: (1) Put each activity on a calendar for the coming week. (2) Normalise low energy and the feeling of not deserving fun. Call the first attempt a "jump start". (3) Plan the practicalities: who will come, what supplies are needed, and what to do if a trauma reminder, grief, tiredness or guilt pushes towards cancelling. (4) Children: work with caregivers or act as the child's "secretary". Young children can mark the calendar with stickers, drawings or colours. (5) If scheduling itself is the obstacle, use Problem-Solving. If the place or time is a reminder, use Managing Reactions [source: FOG p. 34]. (6) Follow-up review: ask what they tried and praise any attempt. If nothing was done, make the task smaller. If mood lifted, add sessions or activities. If it did not, say that benefits build gradually and consider a different activity, or doing it with a trusted person rather than alone. Ask whether anyone around them blocks these activities, and if so, problem-solve it [source: FOG p. 35].
• Example language (illustrative): "Let's write it in: Saturday at ten, a walk to the market with your neighbour. If you wake up not feeling like it, what will you tell yourself?"
• Watch for: The goal is gradual increases in activity and mood. Treat "I did it but didn't enjoy it" as partial success.

4.11 Managing reactions: identify reactions and triggers (Module 4, Step 1)

• Purpose: Module 4 is for survivors whose physical or emotional reactions to the disaster, to reminders or to current stress are distressing. It teaches calming, managing reminders and putting experiences into words. A session takes about 45 minutes. Materials: the Managing Reactions Worksheet and the Appendix D handouts on posttraumatic stress reactions, anger and irritability, sleep, chronic stress, depressed mood, post-disaster fears, grief, supporting someone, drug and alcohol problems, a children's fear handout and six parent handouts [source: FOG p. 36; VA SPR page].
• Steps: (1) Explain that reactions can be physical (racing heart, tension) or emotional (fear, anger, sadness). They can last weeks to years and affect sleep, substance use, relationships, work, school and parenting [source: FOG pp. 36–37]. (2) Help the survivor name their main reactions and the situations that set them off. (3) Ask which reaction bothers them most, which is hardest to manage and which to tackle first. (4) Record the reaction and the situation on the worksheet [source: FOG pp. 37–38]. (5) Go through the handouts that match their reactions, so they can reread them later [source: FOG p. 38]. (6) Children: have the child draw or colour on a body outline where they feel each reaction [source: FOG p. 37].
• Example language (illustrative): "When does the jumpiness hit hardest? What's happening just before it starts?"
• Watch for: Persistent extreme depression, grief, guilt, shame, worthlessness or thoughts of revenge mean a mental health referral. Severe physical symptoms such as chest pain mean asking about medical review and referring if needed [source: FOG p. 37].

4.12 Calming: breathing retraining (Module 4, Step 2A)

• Purpose: Reduce the physical arousal that fast, shallow breathing makes worse. Use it for survivors with anxiety, panic-like or arousal symptoms [source: FOG pp. 39–40].
• Steps: (1) Give the rationale. Anxious breathing is fast and shallow, which upsets the body's balance and amplifies physical symptoms. Slow, even breathing settles them. For children, the guide contrasts a panting puppy with a big dog resting [source: FOG pp. 39–40]. (2) Ask about past experience of breathing exercises. Build on what helped. If breathing exercises have upset them before, adapt, for example by keeping eyes open. Warn that anxiety can rise briefly before it falls [source: FOG p. 40]. (3) The survivor sits supported with arms and legs uncrossed. (4) They breathe in slowly through the nose, pause, then breathe out slowly and for longer than the in-breath, saying a calming word on the out-breath (e.g. "calm" or "relax"). The guide gives counts of about five in, a pause, and about seven out [source: FOG pp. 41–42]. Check them against the Breathing Exercise handout (Appendix D) [uncertain]. (5) Stress that the slow out-breath is what matters, and that big deep breaths are not usually helpful. (6) Demonstrate, then have the survivor do about five cycles on their own in session. (7) Set daily practice of 10–15 breaths, mostly while calm, and identify the situations where they will use it [source: FOG pp. 41–42]. (8) Children: use shorter counts (about three in, five out) with hands on the belly. Add games or bubbles, or have them breathe in one colour and out another. Children can teach the skill to their family [source: FOG p. 42].
• Example language (illustrative): "Breathe in gently through your nose… hold for a moment… now let it out slowly, longer than the in-breath, and say 'calm' to yourself as it goes."
• Watch for: Light-headedness from over-breathing. Slow the pace and make breaths smaller. You know it is working when the survivor uses it on their own in mild stress and reports quicker settling.

4.13 Putting experiences into words: the writing exercise (Module 4, Step 2B)

• Purpose: Help the survivor organise and process intrusive memories, distress and current worries through structured writing. This is SPR's only element that works directly with distressing memories [source: FOG pp. 42–45].
• Readiness and contraindications: The guide says writing is not for everyone. It may be unsuitable for people with extreme guilt about harm they caused, active suicidal thoughts, a history of psychosis, extreme anxiety, emotional lability or current substance dependence [source: FOG p. 45]. Before starting, I would also check that the survivor is currently safe, has at least one calming skill and has someone to contact afterwards [synthesis].
• Steps: (1) Give the rationale. Pushing memories away tends to keep them coming back, and structured writing helps sort them out. The guide uses images of digesting a heavy meal and sorting a cupboard full of papers [source: FOG pp. 42–44]. (2) Rehearse in session: about 10 minutes of writing, then talk through their reactions [source: FOG p. 45]. (3) At home: at least 30 minutes in a quiet place, writing about what is distressing now. Include sensory details, feelings and thoughts. Add what they did to cope or to help others. Note unhelpful thoughts and more realistic alternatives. Finish with how things could improve or be prevented [source: FOG pp. 44–45]. (4) Repeat on several occasions, adding helpful thoughts as they emerge [source: FOG p. 45]. The exact number of sessions is [uncertain]. (5) Closure: plan a recovery activity straight afterwards, and do not write just before a stressful event [source: FOG p. 45]. (6) Bereavement: they may write a letter to the person who died, about moving forward while keeping that person's memory [source: FOG p. 45]. (7) Alternatives: voice recording, drawing, collage or a memory box [source: FOG pp. 44–45; Watson 2022 slides 32–33]. (8) Children: older children write on their own with a trusted adult nearby. Younger children dictate to an adult or draw, starting with a safe place and then the event, with gentle questions such as what they did to get to safety. Young children may need a caregiver to help them build the account [source: FOG p. 46].
• Example language (illustrative): "Write about what's weighing on you most at the moment: what you saw, heard and felt, and what went through your mind. Then write about anything that helped you get through. Afterwards, do something soothing that you've planned in advance."
• Watch for: Distress that does not settle within the session, dissociation or intrusive images getting worse. Stop, ground, and do not push (see section 5). Treat what is written as the survivor's experience and do not probe for missing details or "hidden" memories [synthesis]. Signs that it is working: the account becomes more organised, distress after each session falls, and intrusive memories are less frequent.

4.14 Managing reactions to triggers and reminders (Module 4, Step 2C)

• Purpose: Prepare the survivor to cope before, during and after internal triggers (thoughts, memories, body sensations) and external ones (places, people, sounds, smells), as well as daily hassles and challenges such as a job interview [source: FOG pp. 46–47].
• Steps: (1) Explain what triggers are and why managing them reduces distress and builds confidence. (2) Choose one recent or upcoming trigger situation. (3) Go through the guide's menu of strategies and choose a few for before, during and after: look after your health (eating, exercise, sleep); schedule positive activities; use calming (breathing, distraction, peaceful imagery); tell the reminder apart from the event ("then" versus "now"); use helpful thinking; get social support; write about feelings; use spiritual or religious practices [source: FOG pp. 47–48; Watson 2022 slide 37].
• Example language (illustrative): "When the siren goes, your body reacts as if it's that night again. Let's practise noticing what's different now: where you are, who's with you, that you're safe today."
• Watch for: Avoidance spreading to more places or activities. Strategies should help the survivor face reminders, not avoid them more widely [synthesis]. Watson's slides also show activities from Healing After Trauma Skills (HATS), such as "Feelings Strips", "Stop Sign" and "Goals Jar", for use with children. Their procedures are not specified [uncertain].

4.15 Managing reactions: the management plan (Step 3) and follow-up review

• Purpose: Turn the chosen strategies into a rehearsed plan [source: FOG p. 49].
• Steps: (1) Use the Managing Reactions Worksheet to record which strategy to use, when and where. (2) Rehearse the steps in session, and explain that practice makes the strategies work better. (3) Children: rehearse how they will tell a parent that a reminder has happened. Involve caregivers with young children. (4) Follow-up review: was the plan used, and how well did it work? Praise the effort. Keep what helped, and refine or replace what did not. Ask whether particular people make the skill easier or harder to use, and problem-solve if needed. Move to another skill if a different reaction now needs attention [source: FOG p. 49].
• Example language (illustrative): "Let's walk through it. You're in the car park and you smell smoke. What's the first thing you'll do?"
• Watch for: Plans that live only on paper. Ask for a specific example each time.

4.16 Psychoeducation on specific reactions (Module 4 handouts)

• Purpose: Normalise common reactions and give self-help guidance on sleep, anger, grief, fears, depressed mood, chronic stress and substance use. There are also parent handouts on children's fears, sleep, intrusive thoughts and reminders, clinging, tantrums and grief [source: FOG p. 38; VA SPR page].
• Steps: Choose the handouts that match the reactions identified in 4.11, read through the key points together, and link each one to a strategy in the plan. The main text of the guide does not give separate step-by-step procedures for these topics [source: FOG p. 38].
• Example language (illustrative): "This sheet covers sleep after a disaster. Which of these suggestions might suit you this week?"
• Watch for: Heavy substance use or unrelenting insomnia. Both suggest a referral rather than relying on the handout alone [synthesis, consistent with FOG p. 14].

4.17 Helpful thinking: rationale and identifying unhelpful thoughts (Module 5, Step 1)

• Purpose: Module 5 is for survivors with distressing reactions, self-criticism, or fear and anxiety. They learn to notice what they tell themselves about the disaster or their situation. A session takes 30–45 minutes. Materials: the Helpful Thinking Handout and Worksheet, the Payoff Matrix Worksheet, and the children's handout and Good Coach, Bad Coach worksheet (Appendix E) [source: FOG p. 50; VA SPR page].
• Steps: (1) Give the rationale with an everyday example, such as different thoughts in the same traffic jam leading to different feelings. Thoughts are words or images. Emotions are felt in the body [source: FOG pp. 51–52]. (2) Children: two children wake up to the same rainy day and think about it differently. The child draws two stick figures with thought balloons, one unhelpful and one helpful, and colours in the feeling each one produces [source: FOG p. 52]. (3) Make clear that this is not forced positive thinking. Some negative thoughts are accurate. The question is whether a thought helps [source: FOG pp. 53–54; Watson 2022; SPR21 Overview]. (4) Show only the "unhelpful" side of the Helpful Thinking Handout (fold it). It groups thoughts into categories such as poor coping, helplessness, lack of safety, guilt and blame. Ask which ones are familiar [source: FOG pp. 53–55]. (5) Put the thought in "if… then…" form to separate the accurate part from the unhelpful assumption. The guide's example is the realistic possibility of another flood, with the unspoken assumption underneath that the survivor would not cope [source: FOG p. 55]. (6) If thoughts are hard to identify, start from a feeling and work back to the thought [source: FOG p. 55].
• Example language (illustrative): "It's true another storm could come. What's the 'then' part, the bit that follows in your head? 'If it floods again, then…'?"
• Watch for: Arguing about whether the thought is justified. The guide advises against debating it and suggests looking at how the thought affects feelings and actions instead [source: FOG pp. 53–54]. Ask about religious or spiritual beliefs, which can protect or, if the disaster is seen as punishment, add to distress [source: FOG pp. 53–55]. For young children, briefly assess the caregivers' thoughts too [source: FOG p. 55].

4.18 Helpful thinking: identify helpful alternatives (Step 2)

• Purpose: Develop alternative thoughts that support the survivor's goals and give a sense of control, safety and hope [source: FOG pp. 55–56].
• Steps: (1) Show the helpful side of the handout and use the Helpful Thinking Worksheet. (2) Have the survivor come up with alternatives, linked to their goals. Suggest options only if they are stuck. (3) If needed, ask what their goals are for getting through this, then which thoughts would move them towards those goals. The guide's example turns a fear of making mistakes at work into a thought tied to earning money to repair the home, plus a plan for handling stress if a mistake happens [source: FOG p. 56]. The UW deck adds two prompts: what you would say to a friend, and what is in your control. It also warns against falsely cheerful "Pollyanna" thoughts [source: Bedard-Gilligan et al. 2020 pp. 29–30].
• Example language (illustrative): "If a good friend said 'I'll never cope if it floods again', what would you say to them? And what is in your hands to prepare?"
• Watch for: Shared, community-level beliefs, such as feeling deliberately neglected by authorities. These are hard to shift one person at a time and may partly reflect reality. Working with community leaders may help more [source: FOG p. 55].

4.19 Helpful thinking: child exercises (Module 5 alternatives)

• Purpose: Teach helpful thinking through play, matched to developmental level [source: FOG pp. 56–57].
• Steps: Choose one. Go Fish (preschool to primary): the child "catches" paper fish labelled with thoughts or strategies using a magnetic rod, keeps the helpful ones and throws back the unhelpful ones, then says how they would use a kept one and practises it. Memory Game (preschool to primary): a face-down matching game pairing unhelpful thoughts with bad feelings and helpful thoughts with good feelings. Good Coach, Bad Coach (primary to adolescent): the child says what a good coach and a bad coach would tell a player after a lost game, then applies this to their own inner coach on the Appendix E worksheet and practises swapping the bad coach's words for the good coach's. Advise a peer: the child gives advice to an imaginary child who went through the same disaster, judging which thoughts would help [source: FOG pp. 56–57].
• Example language (illustrative): "What would a really good coach say to you right now? And what's the mean coach in your head saying?"
• Watch for: The child repeating "right answers" without any change in feeling. Link the kept thoughts to a real situation coming up that week.

4.20 Helpful thinking: rehearse, the Payoff Matrix, and practice (Steps 3–4) with follow-up

• Purpose: Strengthen the new thoughts through rehearsal and practice in real situations [source: FOG p. 57; Bedard-Gilligan et al. 2020 p. 31].
• Steps: (1) Rehearse: the survivor imagines the trigger situation and says the helpful thought out loud. They do not need to believe it fully yet. Check that they understand [source: FOG p. 57]. (2) Stubborn thoughts: use the Payoff Matrix Worksheet to weigh what keeping the old thought costs and gains against adopting the new one. Use Problem-Solving to brainstorm other options [source: FOG p. 57; Watson 2022 slides 44–45]. Watson also suggests changing only part of a thought, or applying the new thought only in certain situations [source: Watson 2022 slides 40–45]. (3) Assign practice: use the helpful thought the next time the trigger happens over the coming days, and notice whether it changes how they feel [source: FOG p. 57; Bedard-Gilligan et al. 2020 p. 31]. (4) Follow-up review: the guide's text for Step 4 and this module's follow-up review is not drawn on here [uncertain]. Following the pattern of the other modules, ask what happened, praise attempts, and refine the thought or the practice [synthesis].
• Example language (illustrative): "Picture yourself back at your desk, about to send that report. Say the new thought out loud, as if you meant it."
• Watch for: Thoughts that are about real, ongoing danger. Problem-solve the danger rather than reframing it.

4.21 Rebuilding healthy social connections: rationale and the Social Connections Map (Module 6, Step 1)

• Purpose: Module 6 is for survivors who are isolated, separated from their usual network, have few supportive people, miss family, want to help others, or have no one to talk to under stress [source: Watson 2022 slides 47–49; Bedard-Gilligan et al. 2020 p. 32]. The guide's main text for this module is not drawn on here. The steps below come from the official Appendix F worksheet and the two training decks [uncertain on details of timing and alerts in the guide text].
• Steps: (1) Give the rationale. Disasters cut people off through relocation, loss, low mood and low motivation. Positive support buffers stress, while missing or negative support makes outcomes worse. Good support helps people feel understood, that they belong, that they are needed and reassured, and that they can handle problems [source: Watson 2022 slides 47–48; SPR13 worksheet]. (2) On the Social Map Worksheet, the survivor writes their name in the centre and adds the people in their network around it. The worksheet also invites pets, professionals and organisations [source: SPR13 worksheet; Bedard-Gilligan et al. 2020 p. 34]. (3) The Social Connections List and the children's Social Map Worksheet (Appendix F) can support this step. They are not drawn on here [uncertain].
• Example language (illustrative): "Put yourself in the middle and add everyone in your life right now: family, friends, neighbours, people at work or church, even your dog or your GP. We'll see where the support is and where the gaps are."
• Watch for: Grief as the map is drawn, especially when people on it have died or moved away. Acknowledge the loss before planning [source: Watson 2022 slide 52].

4.22 Social connections: reviewing the map (Step 2)

• Purpose: Identify which kinds of support are available and what is missing [source: SPR13 worksheet; Bedard-Gilligan et al. 2020 pp. 34–36].
• Steps: Go through the worksheet's prompts, paraphrased here. Part A: Who are your most important connections right now? With whom can you share experiences and feelings? Who can give advice on recovery? Who would you like to spend time with in the next couple of weeks? Who can help with practical tasks such as errands, paperwork or homework? Who might need your support right now? Part B: What is missing or needs to change? Prompts include a missing type of support, reconnecting with someone, spending more or less time with particular people, improving a strained relationship, helping others, adding social activities, and joining a community group [source: SPR13 worksheet]. Appendix F also has a Types of Social Support Worksheet for naming kinds of support. It is not drawn on here [uncertain].
• Example language (illustrative): "Looking at your map, who could you call at 10 pm if you were upset? And who might be glad to hear from you this week?"
• Watch for: Relationships that are negative or harmful, and gaps that come from social skill difficulties rather than circumstances. Watson's key points say to address both [source: Watson 2022 slide 52].

4.23 Social connections: the Social Support Plan (Step 3) and putting it into action

• Purpose: Turn the review into concrete steps for getting and giving support [source: SPR13 worksheet; Watson 2022 slide 49; Bedard-Gilligan et al. 2020 p. 37].
• Steps: (1) Write specific actions with dates. The UW deck's example plan includes contacting a friend to support them, checking in regularly with several people, talking to a sibling when upset, and reaching out more to a co-worker [source: Bedard-Gilligan et al. 2020 p. 37]. (2) Warn that the first contacts may feel awkward and need not go smoothly, and encourage flexibility [source: SPR13 worksheet]. (3) Appendix F has two handouts, Getting Social Support in Six Steps and Giving Social Support in Six Steps, for survivors who need help with how to ask for or offer support. Their steps are not described here [uncertain]. (4) Follow-up review: check which contacts were made and how they went, then revise the plan [synthesis, by analogy with other modules].
• Example language (illustrative): "What's one contact you could make before we next meet? Let's choose the day and what you might say first."
• Watch for: Watson's provider alerts. Rebuilding is harder after a recent bereavement, for someone with a history of choosing unreliable relationships, and for someone whose lost network took decades to build (for example an older adult who has been relocated) [source: Watson 2022 slide 50].

4.24 Multiple contacts: structuring the course and the final contact

• Purpose: Keep a multi-contact SPR course coherent and end it in a planned way [source: Bedard-Gilligan et al. 2020 pp. 8–9; Watson 2022 slides 11–12].
• Steps: (1) Each follow-up contact: check in, do the follow-up review of the last skill's practice, reassess priorities briefly, then extend the same skill to a new problem or teach the next one. Rehearse it in session and set new practice. (2) Final contact: review the rationale for each skill used, what the survivor has achieved, which skills to keep practising and in which situations, and what to do and whom to contact if more help is needed. (3) Appendix G of the guide provides a Preventing Setbacks Worksheet for this stage. It is not drawn on here [uncertain]. Using it to name likely high-risk times such as anniversaries, warning signs and the skill to use for each is my suggestion [synthesis].
• Example language (illustrative): "Let's look back at what you've learned: the problem-solving steps, the breathing and the activity plan. Which ones will you keep using, and what will tell you it's time to get in touch again?"
• Watch for: Anniversaries and further adversity. Leave clear instructions for coming back, as returning survivors go through information gathering again [source: FOG p. 15].

5. Handling problems

Guidance from the sources

• Practice not done (any module). Explore what got in the way without blame, shrink the task until it is clearly doable, and praise any attempt. Use Problem-Solving on practical barriers [source: FOG pp. 28, 35, 49].
• Activities do not lift mood. Explain that benefits build gradually. Try a different activity, or the same one with a trusted person rather than alone. Check whether someone in the survivor's circle is undermining it, and problem-solve that [source: FOG p. 35].
• A thought will not shift. Do not argue about whether it is valid. Use the Payoff Matrix, change only part of the thought, apply the new thought only in certain situations, or use Problem-Solving if the thought reflects a real problem [source: FOG pp. 53–54, 57; Watson 2022 slides 40–45].
• Group-level grievance ("they abandoned us"). Accept that it may be partly true. Address it at community level with leaders rather than reframing it one person at a time [source: FOG p. 55].
• Breathing increases anxiety. Warn the survivor about this beforehand, keep eyes open, and adapt the method based on what they have tried before [source: FOG p. 40].
• Writing is unsuitable or too distressing. Screen against the guide's contraindications (extreme guilt, active suicidal thoughts, history of psychosis, extreme anxiety, emotional lability, substance dependence). Offer drawing or recording instead, plan a recovery activity afterwards, and avoid writing before stressful events [source: FOG pp. 44–45].
• Extreme or persistent emotions (depression, guilt, shame, worthlessness, revenge), risk to self or others, psychosis, severe cognitive impairment, unstable medical illness, severe alcohol problems. Refer, urgently where indicated [source: FOG pp. 14, 37; Watson 2022 slides 9, 14, 53].
• No improvement over time. Refer to mental health treatment, and stop or replace SPR if it is not producing significant benefit [source: FOG p. 13; Watson 2022 slides 14, 53].
• Survivor declines further contact. Respect the decision and give information on how to get help later [source: FOG p. 12].
• Cultural conflicts. Before setting plans, ask who else should be involved in decisions and whether mourning customs restrict activities. Explore whether faith beliefs protect or burden the survivor [source: FOG pp. 27, 32, 53–55].
• Your own discomfort. Do not skip skills you are less comfortable teaching, and monitor your own comfort and progress [source: FOG pp. 12–13]. The VA links to a Provider Self-Care Toolkit [source: VA SPR page].

Problems the sources do not address [synthesis: my own guidance]

• Overwhelm or dissociation in session (most likely during the writing rehearsal or when discussing triggers). Stop the task. Orient the survivor to the present: name the room, the date and that they are safe. Ask them to feel their feet on the floor and describe five things they can see. Then do slow breathing with eyes open. When they have settled, ask what happened, shorten or postpone the writing, and do not end the contact until arousal is back to baseline. If dissociation recurs or is severe, stop memory-focused work and refer for trauma assessment.
• Recovered-memory risk. If the survivor reports gaps or asks you to help them remember more, explain that SPR does not try to recover memories. Work with what they already recall, and never use imagery or suggestion to fill gaps.
• The survivor wants trauma processing. Recognise this as a sign they may need trauma-focused treatment (e.g. TF-CBT, CPT, PE or EMDR) from a suitably trained clinician. Make the referral and continue SPR skills as a bridge if helpful.
• Ongoing adversity or chaotic life (displacement, insurance battles, a disaster that is still unfolding). Prioritise Problem-Solving and linking to services. Keep each contact self-contained and expect fewer contacts.
• Ruptures (e.g. "this homework stuff is patronising"). Acknowledge it openly and take responsibility for your part. Revisit the rationale and the survivor's own goals, and offer more choice over which skill and how much practice.
• Passive resistance or "yes-but". Go back to the prioritising questions in 4.3. The focus may not be the survivor's real priority.
• Grief dominates. Use Positive Activities and Social Connections carefully and with attention to culture. Consider the bereavement letter from the writing exercise. Refer for grief-focused treatment if grief is intense, prolonged and impairing.
• Substance use as coping. Use the drug and alcohol handout, add substance use to the trigger plan, and refer if use is heavy or dependent.
• Remote or telehealth delivery (not covered by the sources). Send the worksheets in advance and have the survivor fill them in during the contact. Confirm their location and a safety contact at the start of each session.
• Suicidal thoughts emerging mid-course. Pause SPR, carry out a standard risk assessment and safety plan, including lethal-means counselling on secure storage or removal, and refer as indicated.

Sources

Sources:

• SPR Manual (Field Operations Guide), University of Washington Psychiatry copy. Modules 1–5 read; the text extraction stopped in Module 5.
• SPR Manual (Field Operations Guide), UNLV copy. Module 5 read up to Step 3.
• Skills for Psychological Recovery, National Center for PTSD (VA). Programme description and list of appendix documents.
• SPR13 Social Connections (Social Map) Worksheet, VA
• SPR21 SPR Overview and Review of Skills, VA
• Watson, P. (2022). Skills for Psychological Recovery, training slides (ISSUP Ukraine)
• Bedard-Gilligan, M., Dworkin, E. R., & Lindgren, K. P. (2020). Skills for Psychological Recovery, training deck, Trauma Recovery Innovations, University of Washington
• NCTSN resource listing for PFA and SPR

Cited as "FOG" throughout (book/manual):

• Berkowitz, S., Bryant, R., Brymer, M., Hamblen, J., Jacobs, A., Layne, C., Macy, R., Osofsky, H., Pynoos, R., Ruzek, J., Steinberg, A., Vernberg, E., & Watson, P. (2010). Skills for Psychological Recovery: Field Operations Guide. National Center for PTSD and National Child Traumatic Stress Network.

Not drawn on [uncertain]: the guide's main text for Rebuilding Healthy Social Connections, Module 5 Step 4 and its follow-up, and Multiple Contacts; the Appendix F handouts (Social Connections List, children's Social Map, Types of Social Support, Getting and Giving Social Support in Six Steps); the Appendix G Preventing Setbacks Worksheet; the Breathing Exercise handout. NCTSN's SPR resource page and the VA-hosted full manual are also not drawn on.