Table 2.

Study characteristics and results.

References	Country	Intervention	Study design	Study objectives	Sample characteristics (N)	Outcomes/methods	Key results
Broms25	Sweden	Programme organised by Ersta Association for Diaconal Work (Ersta) to support Swedish survivor families of South-East Asian Tsunami 2004 Multi-agency support was provided between January 2005 and August 2007 including: (a) Support groups for bereaved (14 age specific groups) and non-bereaved survivors (b) Memorials and rituals (c) Drop in weekly meetings (d) Individual counselling (e) Three weekend gatherings (f) Day seminars with plenary and group sessions to deal with crisis and grief (g) Focused groups relaxation and sleep therapy	Retrospective evaluation (descriptive study and preliminary evaluation)	To identify what needs the survivors had and how professionals should support survivors during similar events in the future.	Support provided to 1362 Swedish survivors, adults, teenagers, children and grandparents who were grieving, injured and traumatised. Not clear how many participants were in receipt of different types of support	Evaluation included reports and documentation (personal communications and notes) of the initiatives during the 32-month period and a group discussion with participants from one of the bereavement support groups	Several benefits were identified for programme components: Support groups enabled sharing of experiences, understanding of own and others experiences, normalising of grief experiences, looking towards recovery and hope for the future. Seminars provided reassurance and promoted a sense of safety to participants. Weekend gatherings – participants valued connectedness with other survivors. It was also observed how those who did not take up professional support showed signs of resilience (naturally emerging groups who organised their own support)
Donahue et al.14 Donahue et al.15 Covell et al.16 Covell et al.17 Frank et al.18 Jackson et al.19 Jackson et al.20	USA	Project Liberty was a collaboration between New York Office Mental Health, local governments and nearly 200 local agencies. Its main goal was to alleviate psychological distress experienced by New York residents as a result of 9/11 terror attacks (September 2001) The programme provided free community-based disaster mental health services to over 1 million people, including public education, group and predominantly individual counselling The counselling services aimed to support clients to identify and understand their response to loss, review their options, provide emotional support and connect them with existing social support. Clients with more complex needs were referred to specialist local services	Longitudinal outcome evaluation14	1. To assess the relative impairment of individuals who received enhanced services, compared with those receiving only crisis counselling 2. To determine whether the provision of additional services resulted in better outcomes for enhanced services recipients	Crisis counselling (n = 153, T1 only) Enhanced service (n = 93 T1, n = 76 T2)	Outcomes below were used at T1 and T2 (on average 7 weeks later), to fulfil two objectives Complicated grief Depression Post-traumatic stress disorder (PTSD) Daily functioning	Enhanced services recipients had more symptoms of depression, grief traumatic stress and poorer daily functioning when compared to crisis counselling recipients (T1). At follow-up enhanced services, respondents reported significantly fewer symptoms of depression and grief and slightly less traumatic stress and improvement in three functioning domains (job/school, relationships and household activities)
		Crisis counselling services were available until December 2003. In June 2003, Project Liberty also introduced an enhanced therapy service delivered by specially trained, licenced mental health professionals, for people showing complicated grief symptoms (22 months + post-disaster) This support included techniques for recognising post-disaster distress; developing skills to cope with anxiety, depression and other symptoms; and teaching cognitive reframing. It also provided information about natural grieving processes and traumatic grief symptoms and included strategies for dealing with loss and for reengaging in satisfying life activities. The enhanced service closed to new clients in December 2003
			Analysis of service use data Donahue et al.15 Covell et al.16,17	To determine who used the service, how they used it and if reflective of local demographic characteristics and estimated need.15 To determine changes in the rates at which people sought access to services according to risk category16 To describe characteristics of counselling clients that predicted referral to intensive mental health treatments over the 2-year period after 91117	A total of 753,015 service encounter logs were analysed15 465,428 logs of first visit service encounters over 27 months16 684,500 logs of service encounters for individual counselling sessions17	Service logs analysed to (a) Determine rates of use by different demographic groups and to evaluate patterns of use over time15 (b) Proportion number of first visits across following risk categories16 (bereaved family member, persons directly affected, rescue workers, school children, displaced employed and unemployed, persons with disabilities and general population) (c) Organise recorded event reactions into domains relating to PTSD, functional impairment and depression(behavioural, emotional,	687,848 individual crisis counselling sessions were provided to an estimated 465,428 individuals, including large numbers of persons from racial or ethnic minority groups. Most services were provided in community settings rather than provider offices. Demographic characteristics were generally representative of the local areas and estimated need15 Individuals who lost family members accounted for 40% of visits in the first month but dropped to 5% or fewer visits by fifth months Uniform personnel used disproportionately larger percentages of services after the first year
						physical and cognitive) and identify characteristics that predicted referral to specialist services17	Occupationally displaced and unemployed workers sought counselling at relatively steady rates16 Overall, about 9% of individual counselling visits ended with a referral to professional mental health services The strongest predictor of referral was having reactions that fell into multiple of the four domains. Those who had greater attack-related exposure were also more likely to be referred17
			Cross-sectional survey19,20	To assess service user satisfaction with counselling services19 To determine the likelihood and predictors of Project Liberty counselling recipients’ achieving satisfactory life functioning 16–26 months post 91120	607 Project Liberty service recipients completed questionnaires, telephone interviews, or both Crisis counselling questionnaires (n = 453) Crisis counselling telephone interviews (n = 153) Enhanced service telephone interviews (n = 93) 38% (n = 229) had lost family members or friends in attacks	11 aspects of service quality and four domains of effectiveness was assessed for counselling services offered through Project Liberty19 The effectiveness domains were used to assess pre-attack and level of functioning at time of interview/questionnaire20 Effectiveness domains included Job/school, relationship, daily activities, physical health and community activities. Service quality dimensions included respect for client, willingness to listen, cultural sensitivity, speaking the same language as the client, amount of counselling time, convenience of meeting time and location, information received, whether the service would be used again/recommended to friends or family and overall quality of service	At least 89% of service recipients rated Project Liberty as either good or excellent across the 11 service quality dimensions and the four effectiveness domains The counsellor’s respect for clients and his or her cultural sensitivity were rated particularly favourably19 In the five effectiveness domains, 77%–87% of the sample reported good to excellent functioning in the month before the attacks, 55%– 68% reported returning to at least the same level of daily functioning after the attacks African Americans were two to four times more likely to report a return to good or excellent functioning after the attack in four domains Clients that lost their job were less likely to return to good pre-attack functioning in two domains20
			Analysis of project data18	A three-phase multifaceted, multi-lingual media campaign advertised the availability of counselling services. This study evaluated the association between patterns of spending and the volume of calls received and referred to a counselling programme	N/A	Spending on television, radio, print and other advertising was examined in relation to the corresponding volume of calls to the NetLife hotline seeking referrals to counselling services	From September 2001 to December 2002, $9.38 million was spent on Project Liberty media campaigns. Call volumes increased during months when total monthly expenditures peaked. Temporal patterns show that in periods after an increase in media spending, call volumes increased. This was independent of other significant events such as the 1-year anniversary of the attacks
Dyregrov23	Norway	A collective assistance approach consisted of four weekend gatherings over 18 months. The weekends involved rituals, plenary activities and small group meetings led by psychiatrists and psychologists The programme aims to normalise and validate people’s experiences and reactions, mobilise mutual support in families, support self-management and early identification and referral The paper discusses weekends that were run following a Norwegian maritime disaster (1999) in which 16 people died	Cross-sectional survey	Article describes development and implementation of collective assistance programme in response to Scandinavian disasters	Family members/loved ones bereaved by the disaster It is not known how many or which relatives/loved ones attended the programme	Assessment of family satisfaction with the programme using feedback questionnaires Reflections of group leaders on key processes and learning were sought	96% of participants reported that gatherings were useful and helped them in their journey. Important experiences were identified as follows: • The extent and duration of the support must be clear and communicated at the start of the programme. • Group leaders training and preparedness, with written feedback provided to mental health coordinator after each weekend. • Participant feedback used to inform real-time programme development. • Resourcing and readiness to assist in special circumstances (e.g. missing person/bereaved from other cultures)
Dyregrov et al.21	Norway	State funded and co-ordinated programme of support following terrorist attacks on government buildings in Oslo and the island of Utoya in Norway in July 2011. The programme involved the following: • Proactive, structured and continuous support offered to each bereaved person by local municipal services, involving a trained health/social care professional (weekly up to 1 year) • Practical assistance, advice and referral for specialist support Access to four weekend group interventions (see Dyregrov22)	Longitudinal mixed methods study	To investigate the experience of public service support for bereaved relatives of terror attack victims	67 parents and 36 siblings of 69 people killed during the attacks There were no significant differences in age or gender in the biological parents and siblings who participated, compared to the families of the deceased who did not participate (n = 19)	Paper reports on data collected in self-completed questionnaires 18 months post-event Questionnaires with open and closed questions were used to 1. Identify the nature of the services which were offered to the bereaved after the terror attacks 2. Assess whether the services offered were proactive and whether they met the needs of the bereaved	95% (n = 98) of all survey participants reported to have received support 67% (n = 69) of respondents reported a high or fairly high degree of need for help 76% (n = 51) of parents received support from their GP and family counselling services Roughly two-thirds of siblings and parents received support from psychologist/psychiatrist 42% (n = 15) of siblings received support through school 73% (n = 75) of all respondents were highly or fairly satisfied with the help received from professionals Themes from free text data included as follows: • Stressful experience Lack of competence/rapport/continuity of support • Advice for future support Proactive, empathic and competent support; access to multiple levels of support tailored to individual needs • Barriers to help Recognising need and feeling able to take help; practical and organisational barriers
Dyregrov22	Norway	Following the July 2011 terror attacks in Norway, four structured weekend gatherings were delivered by the Centre for Crisis Psychology (CCP), to provide support to bereaved family members The weekends included group sessions, plenary lectures, workshops and social activities, with a focus on processing and learning about grief Sessions were held 4, 8, 12 and 18 months after the attacks	Cross-sectional survey Qualitative feedback	To describe a programme of weekend family gatherings to help bereaved families who lost a close family member during the Utoya Island attack	Parents, siblings and close relatives of victims killed in the attack Participants in the four weekends ranged between 182 and 224. Between 50 and 60 of the participants were below the age of 18. Feedback was obtained from between 136 and 157 adults after the gatherings	Participant feedback gathered through questionnaires completed after each weekend Reflective group session conducted during final weekend Notes sent to weekend organisers	Over 90% of adult participants found weekends extremely or very helpful, compared with 80% of siblings under 18 Participants felt safe to share thoughts and feelings with leaders. Participant experiences were validated through connecting with others
Hamblen et al.24	USA	The InCourage programme was a mental health initiative setup 16 months after Hurricane Katrina by the Baton Rouge Crisis Intervention Centre to support local people experiencing PTSD symptoms The programme provided ten cognitive behavioural therapy post-disaster sessions delivered by trained therapists to individuals referred to the programme following screening	Quasi-experimental time-series design	To describe the effects of a cognitive behavioural therapy post-disaster (CBT-PD) intervention to assess cognitive, emotional and behavioural reactions in individuals affected by Hurricane Katrina	93 participants exposed to Hurricane Katrina completed the programme 88 provided completed data on four repeated assessments (referral, pre-treatment, intermediate and post-treatment.) 66 participated in 5 month post-treatment follow-up A family member was missing or dead in 35% of cases, a friend was missing or dead in 55% of the cases There was no control group	Individual change in PTSD across time points assessed using the 12-item short PTSD rating interview-expanded (SPRINT-E)	The CBT-PD reduced symptom distress in individuals presenting with moderate and severe distress levels at referral. A very high intervention fidelity was reported across all sessions. Key results: 1. Reduction of severe distress symptoms from 61% at pre-treatment to 14% at post-treatment 2. Treatment appeared to work equally for participants with severe and moderate levels of stress 3. Reduction in distress was maintained 5-month post-treatment 4. The main mechanism for change related to the components of psycho-education and for breathing retraining and behavioural activation instead of cognitive restructuring as initially hypothesised.

PTSD: post-traumatic stress disorder; GP: general practitioner; CCP: centre for crisis psychology; CBT-PD: cognitive behavioural therapy post-disaster; SPRINT-E: short PTSD rating interview expanded.