Disasters can have a significant effect on survivors' mental and religious/spiritual (R/S) health and well-being. On the one hand, they can lead to various forms of psychological distress (e.g., depression, anxiety, posttraumatic stress disorder [PTSD], or substance abuse) and R/S distress (e.g., R/S struggle such as doubt, questioning, or anger toward God). On the other hand, they can catalyze a process of perceived or actual posttraumatic growth (e.g., psychological or R/S growth as the result of the survivors' disaster-related experiences; Aten & Boan, 2016; Aten et al., 2015, 2018; Aten, O'Grady, Milstein, Boan, & Schruba, 2014; Park, 2016; cf. Park, Currier, Harris, & Slattery, 2017).

There is vast and growing scholarly literature that describes the importance of incorporating religion and spirituality into the holistic care of disaster survivors (e.g., Aten & Boan, 2016; Aten et al., 2014, 2015, 2018; Koenig, 2006; Massey, 2006; Roberts & Ashley, 2017). However, there has been relatively little examination of how this incorporation actually happens in disaster response efforts in the real world. Therefore, the purpose of this qualitative study was to develop a grounded theory explaining how disaster spiritual and emotional care (DSEC) providers actually tend to practice DSEC in the field.

Disaster Spiritual and Emotional Care

What is Disaster Spiritual and Emotional Care?

DSEC refers to any R/S or psychological intervention provided to disaster survivors in order to (a) mitigate their psychological and R/S distress and (b) promote their mental and R/S health and well-being. DSEC can be offered in response to natural and human-caused disasters, as well as during all stages of a disaster (e.g., short-term response and long-term recovery). It can be provided by professionals (e.g., religious, mental health, humanitarian aid, and emergency management professionals) or by trained laypersons. Moreover, DSEC can be offered to people of all developmental levels (e.g., child, adolescent, and adult survivors) and all cultural groups, and it can be delivered in individual, family, or group formats. In addition, it can be provided both at a microlevel (i.e., a person-focused level) and at a macrolevel (e.g., a community-focused level; Aten, 2012; Aten & Boan, 2016; Aten et al., 2014, 2015; Roberts & Ashley, 2017).

A Historical Overview of Disaster Spiritual and Emotional Care

Over the last 25 years, there has been increasing recognition that religion and spirituality play a central role in the lives, experiences, and recovery of many (if not most) disaster survivors (e.g., Aten & Boan, 2016; Aten et al., 2014, 2015, 2018; Koenig, 2006; Massey, 2006; Roberts & Ashley, 2017). Correspondingly, there has been increased integration of R/S elements into formal disaster response efforts at the international, federal, state, and local levels (Koenig, 2006; Roberts & Ashley, 2017), including formal incorporation of religious professionals (e.g., clergy, chaplains, etc.) and organizations into disaster relief and recovery. A growing number of governmental and nongovernmental organizations have been founded to assist in this process, such as the U.S. Department of Homeland Security's Center for Faith-Based and Neighborhood partnerships and the New York Disaster Interfaith Services.

In addition, the Emotional and Spiritual Care Committee of the National Voluntary Organizations Active in Disaster (National VOAD)--a large nonprofit association of over 100 disaster relief organizations--has championed the development of resources, standards, and guidelines for providing DSEC. Most notably, they have published the National VOAD "Points of Consensus" (i.e., ethical standards and operating principles) for disaster spiritual care (National VOAD, 2009) and disaster emotional care (National VOAD, 2015), as well as the National VOAD Disaster Spiritual Care Guidelines (National VOAD, 2014). Both nationally and internationally, these three documents are generally considered the authoritative standards and guidelines for DSEC providers to follow (Roberts & Ashley, 2017). National VOAD has also published Light Our Way: A Guide for Spiritual Care in Times of Disaster (Massey, 2006), which is a resource that is widely used to help inform the provision of DSEC. Another well-utilized resource that often guides the provision of DSEC is the Psychological First Aid: Field Operations Guide for Community Religious Professionals (Brymer et al., 2006b), a religiously/spiritually adapted version of the Psychological First Aid: Field Operations Guide (2nd ed.; Brymer et al., 2006a), which is generally considered the authoritative resource for guiding evidence-informed disaster emotional care (Allen et al., 2010; Vernberg et al., 2008).

The Practice of Disaster Spiritual and Emotional Care

As mentioned above, there are two main levels at which DSEC tends to be practiced--the microlevel (person-focused level) and the macrolevel (community-focused level; Aten et al., 2014, 2015). Microlevel DSEC typically occurs as DSEC providers work with particular individuals and families, addressing their needs and concerns in a uniquely tailored way. Oftentimes these microlevel DSEC interventions are provided in ways that draw solely or heavily on seminal DSEC resources, such as Light Our Way (Massey, 2006), Psychological First Aid Field Operations Guide for Community Religious Professionals (Brymer et al., 2006a, 2006b), Disaster Spiritual Care (2nd ed.; Roberts & Ashley, 2017), or Disaster Ministry Handbook (Aten & Boan, 2016).

Macrolevel DSEC is a bit more varied in how it is practiced. Most typically, it involves DSEC providers consulting and collaborating with religious leaders and communities in order to meet the needs of large groups of disaster survivors (Aten, Topping, Denney, & Hosey, 2011; Aten et al., 2015; Curtis et al., 2017). Aten and colleagues (2011) have described such consultation and collaboration as usually occurring at three levels:

* Tier 1: DSEC providers offer training to clergy and other congregational leaders (e.g., on how to provide DSEC),

* Tier 2: DSEC providers collaborate with religious leaders to educate congregation members (e.g., on common psychological and R/S reactions to disasters and how to respond adaptively to these reactions), or

* Tier 3: DSEC providers collaborate with religious leaders and congregations to provide outreach services to their surrounding community (e.g., DSEC, disaster relief, education, etc.).

Qualitative research has identified several conditions that can optimize such macrolevel DSEC collaborations (e.g., mutual respect; preestablished professional relationships), as well as some barriers that can hinder it (e.g., cultural mistrust and suspicion; perceived ulterior motives; and differences in service delivery expectations; Curtis et al., 2017; see also McMinn, Aikins, & Lish, 2003; McMinn, Chaddock, Edwards, Lim, & Campbell, 1998). Fortunately, there are several models that can help guide macrolevel DSEC intervention, such as (a) Aten and colleagues' (2013) Clergy, Academic, and Mental Health Partnership (CAMP) model; (b) Milstein and Manierre's (2010) adaptation of the Clergy Outreach and Professional Engagement (COPE) model (Milstein, Manierre, Susman, & Bruce, 2008; Milstein, Manierre, & Yali, 2010); and (c) the American Red Cross's Integrated Care Team (ICT) model (Adams, 2016).

The Current Study

Although there are many models, resources, standards, and guidelines for providing DSEC, there has been virtually no research on (a) how it actually tends to be practiced in the field, (b) what specific DSEC interventions are effective (vs. other DSEC interventions) for whom and under what circumstances, and (c) what elements of DSEC tend to be effective in general (e.g., similar to how researchers have identified the elements of the therapy relationship that are effective in promoting positive psychotherapy outcomes in general; Norcross, 2011). In short, scientific inquiry into DSEC is still in its infancy. Consequently, there is a significant gap between DSEC research and practice. Furthermore, the DSEC field lacks any robust theory or theories that can help guide the provision of DSEC.

For these reasons, the purpose of this qualitative study is to develop a grounded theory explaining how DSEC providers actually practice DSEC in the field. We decided to conduct a qualitative study because we were interested in developing understanding in this less-explored area (i.e., DSEC; Levitt et al., 2018), and we chose to use a grounded theory strategy for data analysis because we hoped to develop a theory that was grounded in data from the field (Corbin & Strauss, 2015; Creswell & Poth, 2018; Glaser & Strauss, 1967).

Methods

Participants

Sample. Because of these aims, we used purposive sampling to ensure participants were experts and exemplars in the provision of DSEC in the field (Bronk, 2012; Coyne, 1997). Specifically, we asked members of the National VOAD's Emotional and Spiritual Care Committee to nominate DSEC exemplars who (a) were well-respected as experts in the provision of DSEC and (b) had served as DSEC providers in the field for at least five years. We obtained eight participants through this purposive sampling and then obtained an additional six participants through snowball sampling, whereby recruited participants nominated other DSEC providers who met the aforementioned two inclusion criteria.

Ultimately, the sample consisted of 14 peer-nominated, exemplar DSEC providers. Grounded theory studies typically consist of 20 to 30 participants (Creswell, 2013), but sample sizes vary widely and are usually determined by the number of participants needed to obtain data saturation (i.e., the point at which the researcher no longer obtains new information adding to understanding of the emerging categories; Creswell, 2013; Mason, 2010). For our study, 14 participants was sufficient to obtain saturation, perhaps because grounded theory studies with experts or exemplars are sometimes able to achieve saturation with lower sample sizes (e.g., Jette, Grover, & Keck, 2003; Oddli & Ronnestad, 2012; Williams & Levitt, 2007).

Our sample was comprised of nine men (64%) and five women (36%). Eleven of these DSEC providers were White (79%), two were Asian (14%), and one was Black (7%). All participants identified as U.S. citizens, with five residing in the Northeast, one in the East, three in the Midwest, two in the South, one in the Southwest, and two in the Northwest. Participants ranged in age from 49 to 73 years old (M = 57.75, SD = 7.83). Nine providers (64%) identified as Christian in religious affiliation and specified their denominational affiliation as Baptist (n = 2), Presbyterian (n = 1), Lutheran (n = 1), Episcopalian (n = 1), Nondenominational (n = 1), Mainline Protestant (n = 2), and Roman Catholic (n = 1). Three providers (21%) identified as Jewish in religious affiliation, and they each specified their denominational affiliation as Reformed. One provider (7%) identified as Buddhist in religious affiliation and specified her branch affiliation as Mahayana, and another provider (7%) identified as Scientology in her religious affiliation.

In terms of their professional experiences, participants reported having an average of 20.42 years (SD = 11.03; range: 8-48) of involvement in providing DSEC. Everyone had offered DSEC in the context of both natural and human-caused disasters (e.g., Hurricane Sandy, 9/11 attacks, Newtown school shooting). Similarly, most participants reported having provided DSEC across the full spectrum of disaster relief efforts, including efforts at the local (n = 11), regional (n = 11), national (n = 11), and international (n = 9) levels. Most participants also indicated they had experience offering DSEC across all stages of the disaster, including within 24-hours (n = 10), one week (n = 12), 6 months (n = 12), and one year postdisaster (n = 11). Importantly, many of the DSEC providers in our sample either were currently serving on the National VOAD's Emotional and Spiritual Care Committee, or they had done so in the past.

Researcher description. The primary researcher (ANS) is a single, White, Christian woman who is in her late 20s and is a doctoral candidate in clinical psychology, studying at Wheaton College in a faith-based doctoral psychology program accredited by the American Psychology Association. She has four years of experience conducting research and receiving DSEC training as part of the Wheaton College Humanitarian Disaster Institute, a faith-based academic disaster research center.

The second through fourth authors (two men, one woman) are each experts in the academic study of disasters, psychology, and religion/spirituality, and they have from 6 (EBD) to 13 (JDA) years of experience doing so. They all are researchers affiliated with the aforementioned academic disaster research center. Each one is a married, White Christian who is highly religious. Two are in their late 30s and one is in his early 40s.

Several validity and reliability strategies were utilized in order to clarify and manage the potential influence of any researcher biases, assumptions, and perspectives on data collection and analysis. These strategies are described below in the Methodological integrity section.

Procedures and Materials

Focus group. Before recruiting the sample, the first author (ANS) hosted an in-person focus group with four members of the National VOAD's Emotional and Spiritual Care Committee (experts in DSEC). The purpose of that focus group was to enhance methodological integrity (e.g., fidelity to the study's subject matter and utility toward accomplishing the study's goal) by gaining expert feedback on the study's purpose, research design, inclusion criteria, interview protocol, and demographic questionnaire (Lambert & Loiselle, 2008; Levitt et al., 2018). Overall, the focus group's feedback affirmed the study purpose, design, and materials. Even so, they offered suggestions for making minor adjustments in terminology used in the study materials (e.g., using the term spiritual care provider minimizing the use of clinical psychology terms such as rapport and conceptualization). They also recommended adding one question to the interview protocol, asking what assessment techniques the DSEC provider uses.

Study materials. Ultimately, the semistructured interview protocol consisted of 17 questions (see Appendix A), and 12 of those questions included one to four follow-up prompts to ask as necessary. This interview protocol was initially developed by the study's first and second author (ANS and JDA), and it was subsequently refined after obtaining the aforementioned feedback from an expert focus group. The questions asked about various aspects of DSEC, such as how participants (a) defined, provided, and conceptualized DSEC; (b) built relationships with the people they served; (c) collaborated with other providers and organizations; and (d) practiced self-care. In addition, the providers completed a demographics questionnaire, asking about demographics (e.g., age, sex, race/ethnicity, and religious and denominational affiliation) and professional experiences (e.g., years providing DSEC; contexts and settings providing DSEC).

Data collection. The first author collected all data by using the study's semistructured interview protocol to conduct phone interviews individually with each participant. The average interview time was 68.79 minutes (SD = 20.62). All interviews were audiotaped and then transcribed verbatim. During and following each interview, the first author engaged in the validity strategy of writing field notes and memos, including notes about (a) emerging concepts and categories, (b) similarities and differences in information emerging within and between interviews, (c) relevant observations of what transpired internally and interpersonally during each interview, (d) rationales for research decisions made during or across interviews, and (e) possible researcher biases and assumptions that may become apparent (Corbin & Strauss, 2015).

Data Analysis

Data-analytic strategy. A grounded theory method (Corbin & Strauss, 2015; Glaser & Strauss, 1967) was utilized for data analysis, which was conducted using Nvivo 11 software. Grounded theory analysis consisted of three phases. Phase 1 (open coding) involved inductive line-by-line coding, in order to identify basic concepts (subthemes) and broad categories (themes), including their properties (characteristics) and dimensions (variations). Phase 2 (axial coding) involved consolidating and interconnecting these concepts and categories, relating them to one another. Lastly, Phase 3 (selective coding) involved building a storyline that explained these interconnected concepts and categories (Corbin & Strauss, 2015; Creswell, 2013).

Methodological integrity. First, qualitative reliability (consistency and stability) was demonstrated through the use of a standard interview protocol. Next, the first author meticulously double-checked all the transcripts to ensure they did not contain mistakes. Also, throughout the data collection and analysis process, the first author regularly met with and obtained feedback from the second and third authors and from her research team of 10 graduate psychology students, partly to evaluate and achieve the development of consensus and stable perspectives on the emerging grounded theory (Creswell, 2013; Levitt et al., 2017, 2018).

Several strategies were employed to enhance qualitative validity (accuracy) as well. For example, as mentioned previously, the first author engaged in the reflexivity practice of writing memos and field notes, partly to help clarify and limit the effects of her biases, assumptions, and perspectives on data collection and analysis. She regularly discussed such issues with her research team, engaging in the validity strategy of peer review or debriefing.

In addition, an external auditor was used. This auditor was a White woman who was a doctoral candidate in another doctoral psychology program accredited by the American Psychological Association. She was religiously unaffiliated and was previously unfamiliar with the project. Following the completion of data collection and analysis, the external auditor reviewed two deidentified interview transcripts and the researcher-identified categories (themes) and concepts (subthemes). Her task was to evaluate the researcher's coding accuracy and data interpretation. After completing her audit, the auditor met with the primary investigator to provide feedback. Overall, the feedback confirmed the accuracy of the researcher's coding and interpretation. Nonetheless, the auditor pointed out two potential points of divergence. But after discussing these potential points of divergence with the primary investigator, the auditor agreed with the researcher's original coding and interpretation of them.

Member checking was also utilized to offer participant feedback on the emergent grounded theory and identified themes. Specifically, one participant was selected to serve this member-checking role, given his 20 years of experience providing DSEC across all disaster contexts and given his expressed interest in the utility of the current study. This participant (a White, Mainline Protestant man in his 60s) was provided with a summary of the proposed grounded theory and a list of all the identified themes. He and the primary investigator then had a 90-minute phone call in which the participant offered feedback; overall, the participant's comments were supportive of the theory and the data interpretation. The participant indicated that the theory and themes resonated with his experience and expertise in the practice of DSEC. The main two pieces of constructive feedback he had was that (a) the grounded theory needed to differentiate between preparing to offer DSEC and actually offering DSEC and (b) the identified theme about views of suffering needed to use the term theodicy because that term is what most DSEC providers tend to use.

Figure 1. Grounded theory explaining how disaster spiritual and
emotional care (DSEC) providers practice DSEC in the field by offering
"practical presence" (i.e., meeting survivors' immediate practical
needs while being physically, emotionally, and spiritually present in
ways that facilitate survivors' holistic health and well-being).

Preparing to offer practical presence

* Viewing self as the primary tool of DSEC

* Cultivating their ability to be fully present

* Commitment to their ongoing growth

* Growing in their capacity for self-awareness

* Developing their ability to practice self-care

* Answering a sacred calling

* Developing benevolent theodicies

Characteristics of practical presence

* Short-term (time-limited)

* Stage-specific (tailored to the disaster stage)

* Needs-driven (tailored to survivor needs/concerns)

* Strengths-based (affirms internal and external strengths)

* Culturally responsive (guided by cultural awareness,
sensitivity, and humility

Offering practical presence in microlevel DSEC
(to individuals and families)

* Proactively initiating DSEC relationships with survivors

* Implicitly and explicitly assessing survivors' current needs,
concerns, distress, and health/well-being

* Creating a safe holding space for survivors

* Validating and normalizing survivors' experiences

* Meeting survivors' immediate practical needs

Offering practical presence in macrolevel DSEC
(to communities)

* Connecting with and mobilizing community resources

* Fostering interprofessional and interagency collaboration

* Facilitating community healing through community rituals

Lastly, in the Results section that follows, we have provided participant quotes to demonstrate the findings were grounded in the interview data. Moreover, we have offered rich, thick (i.e., in-depth) descriptions in order to provide relevant information that elucidates and contextualizes our findings (Corbin & Strauss, 2015; Creswell, 2013; Levitt et al., 2017, 2018).

Results

Grounded Theory

Ultimately, data analysis yielded a grounded theory explaining how DSEC providers practice DSEC in the field. The central theme emerging from the data was that the key component of how DSEC is practiced is what providers called "practical presence"--that is, meeting survivors' immediate practical needs while being physically, emotionally, and spiritually present in ways that facilitate survivors' holistic health and well-being. In short, practical presence entailed providers being a safe, attuned, and supportive presence for survivors. Participants described the characteristics of this practical presence within the DSEC context, as well as the process by which they (a) prepared for offering practical presence, (b) offered practical presence in microlevel DSEC (to individuals and families), and (c) offered practical presence in macrolevel DSEC (to communities). This grounded theory model is depicted in Figure 1 and described below. In what follows, several illustrative quotes are offered, and for these quotes, all indicated participant names are pseudonyms.

Characteristics of Practical Presence

Participants indicated that, in the context of DSEC, this practical presence has several characteristics, namely that it is short-term, stage-specific, needs-driven, strengths-based, and culturally responsive. Collectively, these characteristics guide how DSEC providers approach their work and interact with the people and communities they serve. For example, the short-term nature of this practical presence entails that DSEC providers recognize their work with survivors is time-limited; therefore, they aspire to be quick and adept at offering practical presence with the people whom they serve. Relatedly, DSEC providers must offer their practical presence in a stage-specific way, recognizing the type of presence survivors need tends to vary across different stages of the disaster (e.g., practical presence looks different in DSEC offered immediately following a disaster than in DSEC offered several months after a disaster). For instance, "Angela" (an Asian, Protestant-Christian woman in her 60s) explained:

   In the initial phases of disaster ...
   people are not ready to talk about
   how they feel about things. They
   just need some basic safety needs
   met. Providing care at that time is
   just about helping people feel safe.
   And then I think that as we move
   through that process and the emergency
   is over, then it's about meeting
   basic needs.... And then
   gradually, as people begin to think
   about what has happened, we facilitate
   the fact that they can talk about
   that process and find meaning for
   themselves in the experience.

Indeed, DSEC providers recognized that practical presence must be needs-driven in that it is tailored to whatever survivors' immediate needs and concerns are. It also must be strengths-based in that practical presence entails affirming survivors' internal and external sources of strength, resilience, and support. Lastly, DSEC providers indicated that practical presence needs to be culturally responsive, such that the DSEC's practical presence is guided by cultural awareness, sensitivity, and humility, including the ability to recognize relevant cultural factors (e.g., survivors' cultural background; cultural characteristics of the setting) and tailor or adapt their provision of DSEC accordingly (cf. Hook, Davis, Owen, & DeBlaere, 2017; Smith, Rodriguez, & Bernal, 2011).

Preparing to Offer Practical Presence

Participants consistently viewed themselves as the primary tool for providing DSEC. By extension, they emphasized the importance of preparing themselves as the tool for offering practical presence to survivors. For example, this preparation process involved the DSEC provider cultivating their ability to be fully present with themselves and others. "Ben" (a White, Catholic-Christian man in his 50s) described this goal:

   I believe that disaster spiritual care
   providers [can] prepare [for deployment]
   to a disaster scene [by] making
   sure that they are grounded
   and connected in their own faith.
   That they have strong anchors, in
   case they get overwhelmed and
   pulled away by the overwhelming
   need that is in front of them.

More broadly, this preparation involves a commitment to their ongoing personal and professional growth, in which the DSEC provider continually seeks to grow in their character and in their knowledge, skills, and attitudes for offering effective DSEC (e.g., being a lifelong learner). Preparation also entails DSEC providers growing in their capacity for self-awareness, including their ability to be aware of their own limitations and their present needs and concerns (e.g., spiritually, emotionally, relationally, and physically). Before, during, and after deploying, providers will need to utilize this self-awareness to offer practical presence. Likewise, DSEC providers must prepare for presence by developing their ability to practice effective self-care. Participants identified several self-care practices that DSEC providers commonly employ: prayer, meditation, worship (individual and corporate), listening to music, reading religious texts, observing religious traditions (e.g., keeping kosher), exercising, sleeping, spending time in solitude, and spending time with loved ones.

DSEC providers indicated that two other ways they prepare for offering practical presence are by answering a sacred calling and developing benevolent theodicies (i.e., views of suffering). Participants described how their ability to offer practical presence was directly tied to their belief a Higher Power has called and equipped them for offering DSEC. That is, DSEC providers saw themselves as a tool and representative of a Higher Power, answering a sacred calling to serve disaster survivors. In addition, they explained how benevolent theodicies can help DSEC once they are in the field, by offering ongoing comfort (e.g., allowing them to remind themselves and others that God is present with them in the midst of suffering, uses suffering to build people's character, and providentially controls suffering, using it for a higher and benevolent purpose; cf. Wilt, Exline, Lindberg, Park, & Pargament, 2017).

Offering Practical Presence in Microlevel DSEC

Participants described how DSEC providers offer practical presence in microlevel DSEC (to individuals and families) and in macrolevel DSEC (to communities). At the microlevel (person-focused level), DSEC providers first offer practical presence by proactively initiating DSEC relationships with survivors. Once they deploy to a disaster zone and receive appropriate access to survivors (e.g., via their sponsoring disaster relief agency), DSEC providers take the initiative to seek out survivors, making themselves available to care for individuals and families in need. Participants shared that this type of proactive relationship initiation will most often occur as DSEC providers approach individuals and families, introducing themselves and describing their role as a DSEC provider. Through proactively offering the gift of their physical, emotional, and spiritual presence, DSEC providers invite survivors to share their stories and burdens within the context of a safe, attuned, and supportive helping relationship. As survivors share, the DSEC provider implicitly and explicitly assesses survivors' current needs, concerns, distress, and health/well-being (cf. Brymer et al., 2006a, 2006b; Pargament, 2007). This assessment includes making astute observations and asking clarifying questions that will help understand survivors' immediate physical, psychological, social, and spiritual needs. "Angela" discussed the importance of assessing holistically across the various dimensions of survivors' lives:

   I think that as a spiritual care
   provider, if we haven't assessed for
   medical, physical, and relational
   things, then we're missing it,
   because people can't even talk
   about spiritual things until many of
   those [other] things are taken care
   of first.

Participants shared that much of this provision of practical presence involves creating a safe holding space for survivors. By offering survivors a safe and accepting relationship within which to share about their burdens and stories, DSEC providers bear witness to survivors and their experiences. Doing so helps survivors feel seen, heard, supported, and accepted. For instance, "Aiko" (an Asian, Buddhist woman in her 50s) explained:

   Listening ... and [just] being with
   them. That's the basic [practice].
   We don't talk.... We [just] start a
   dialogue [and] listen to them. And
   most of the time, they really [just]
   need to talk to somebody about
   what's happened, [starting] from
   the moment the disaster hit. So
   we [merely] have a chance to listen
   to [them].

In creating this opportunity for survivors to share, DSEC providers use their empathic, attuned presence to offer a safe space for survivors to acknowledge their struggles, grief, and losses. DSEC providers can thereby share the weight of these burdens and compassionately accompany survivors in their journey of suffering and recovery.

Part of offering this safe holding space involves validating and normalizing survivors' experiences. In particular, participants mentioned how DSEC providers frequently offer practical presence by validating and normalizing common reactions to disasters, such as distress, shock, confusion, grief, and anger (cf. Brymer et al., 2006a, 2006b; Roberts & Ashley, 2017).

But according to participants, the most important way that DSEC providers offer practical presence at the microlevel is to meet survivors' immediate practical needs. Oftentimes this DSEC practice will involve helping survivors meet basic needs (e.g., food, water, clothing, or shelter) or other practical needs (e.g., repairing their disaster-affected residence, connecting them with needed assistance and resources, searching for lost pets or loved ones). Addressing these immediate practical needs and concerns can help survivors know that other people (e.g., DSEC providers) are compassionately present with them, supporting them in the midst of their suffering and recovery. In so doing, it helps alleviate survivors' distress and promote their health and well-being.

Offering Practical Presence in Macrolevel DSEC

In addition to describing what it entails to offer practical presence at the microlevel, DSEC providers described what it entails to offer practical presence in macrolevel DSEC as well. For instance, participants discussed how DSEC providers offer practical presence through connecting with and mobilizing community resources. Here they highlighted the importance of DSEC providers building strong and vast professional networks before disasters strike, so that once a disaster occurs, the DSEC provider can draw on these preexisting professional relationships to help care for disaster-affected communities (cf. Curtis et al., 2017).

Relatedly, participants explained that much of macrolevel DSEC involves fostering interprofessional and interagency collaboration in ways that mitigate community distress and promote community health/well-being. In fact, all participants emphasized the importance of DSEC providers collaborating with other professionals (e.g., community leaders and religious, mental health, humanitarian aid, and emergency management professionals) and organizations (e.g., government, nongovernment, and faith-based organizations) in order to offer practical presence to disaster-affected communities. Fostering such collaboration can help communities better meet the needs of their members, connecting them more readily to assistance and resources. It might involve sharing resources, making referrals, and coordinating efforts. "Ben" identified humility as an essential ingredient in this collaboration: "So being effective [involves] being a good team player, being able to work together with all disciplines and actually building bridges.... It's not about you; it's about the [people] you're serving."

Lastly, DSEC providers described one way they offer practical presence in macrolevel DSEC is by facilitating community healing through community rituals. In other words, DSEC providers help community leaders and agencies offer events that will communicate to disaster-affected communities that we are all in this grieving and healing process together. For example, several participants noted the importance of helping coordinate memorial and anniversary services, providing opportunities for communally acknowledging and experiencing loss, grief, and healing. "David" (a White, Reformed-Jewish man in his 50s) elaborated on the role of DSEC providers in community rituals:

   The communal aspect of bringing
   people together ... is some of the
   long-term disaster spiritual care
   work that really must take place,
   because it's the communal aspect
   of healing, [which need to coincide
   with] the individual aspect. It
   allows the community to help the
   individual grieve and grow,
   because, on a regular basis, it says
   to the grieving person, "We have
   not forgotten you." And that's why
   i think things like memorial services
   [and] anniversary services are
   so essential.

Similarly, participants discussed the role DSEC providers can play in facilitating interfaith worship services, which can unite diverse communities and enhance community cohesion.

Ultimately, in offering practical presence at the macrolevel, DSEC providers let disaster-affected communities know that other people are compassionately present with them in the midst of their suffering and recovery. In this way, DSEC providers can help disaster-affected communities recognize they are not alone--other people see them, hear them, and care about them. Even as DSEC providers can communicate that powerful message to survivors at the microlevel, they can communicate that same message at a much larger scale when providing macrolevel DSEC. In doing so, disaster-affected communities can feel validated, supported, and empowered, again thereby helping alleviate their distress and promote their health, well-being, and recovery.

Discussion

The grounded theory that emerged from the data suggests the key component of how DSEC is actually practiced in the field is practical presence--meeting survivors' immediate practical needs while being physically, emotionally, and spiritually present in ways that facilitate survivors' holistic health and well-being. This finding is quite significant in advancing understanding of DSEC. First of all, it underscores the vital importance of relationships and social connection when it comes to recovery from traumatic events such as disasters. This finding is consistent with Charuvastra and Cloitre's (2008) social ecology model, an evidence-informed framework explaining how both trauma risk and recovery are heavily dependent on social phenomena. More broadly, it is consistent with the well-established connection between social support and health/well-being, both in general (Gleason & Iida, 2014) and in the postdisaster context specifically (Kaniasty & Norris, 2008; Platt, Lowe, Galea, Norris, & Koenen, 2016).

Likewise, our results are resonant with the well-established finding that relationships are at the crux of what makes psychotherapy, counseling, and other forms of helping effective (Cozolino, 2017; Norcross, 2011). For example, the grounded theory that emerged in this study suggests that, even as the empathy and the therapeutic alliance are two of the most demonstrably effective elements of psychotherapy and counseling (Norcross, 2011), empathy and the DSEC provider-survivor alliance may similarly be two of the most effective elements of DSEC as well.

In particular, our findings are consistent with growing empirical evidence that empathic, attuned presence is perhaps the most crucial ingredient of effective psychotherapy and counseling (Geller & Greenberg, 2012; Siegel, 2010). Indeed, in their empirically supported model of therapeutic presence, Geller and Greenberg (2012) have explained it in this way:

   Therapeutic presence is the state of
   having one's whole self in the
   encounter with a client by being
   completely in the moment on a
   multiplicity of levels--physically,
   emotionally, cognitively, and spiritually.
   Therapeutic presence
   involves being in contact with
   one's integrated and healthy self,
   while being open and receptive to
   what is poignant in the moment
   and immersed in it, with a larger
   sense of spaciousness and expansion
   of awareness and perception.
   This grounded, immersed, and
   expanded awareness occurs with
   the intention of being with and for
   the client, in service of his or her
   healing process. (p. 7)

Similar to our grounded theory of practical presence in DSEC, Geller and Greenberg's (2012) model of therapeutic presence differentiates preparing for presence (e.g., by practicing it in one's personal life and by maintaining an ongoing commitment to personal growth and self-care) from the process of practicing presence in psychotherapy and counseling. Yet one distinction between therapeutic presence and practical presence is that therapeutic presence is offered solely at the microlevel (e.g., with individual psychotherapy/counseling clients) whereas DSEC is offered both at the microlevel (with individuals and families) and macrolevel (with communities).

Another crucial distinction between therapeutic presence and practical presence is that, as its name implies, practical presence includes an emphasis on meeting people's immediate practical needs, whereas therapeutic presence does not. This distinction is significant in that it demonstrates that being present with disaster survivors is even more comprehensive than being present with psychotherapy clients. In a disaster context, being present means that DSEC providers not only need to be attuned to survivors spiritually, emotionally, cognitively, and physically (cf. Geller & Greenberg, 2012), but they also need to be attuned to them practically. Stated differently, DSEC providers of course need to meet survivors empathically in the midst of their spiritual and emotional struggles, but they also need to meet them empathically in the midst of their practical struggles. Doing so is vital to the process of caring for disaster-affected individuals, families, and communities (Brymer et al., 2006a, 2006b; Roberts & Ashley, 2017). Longitudinal evidence suggests that practical support (i.e., tangible social support) is not directly predictive of survivors' postdisaster health/well-being; instead, emotional social support seems to play the more influential role (Platt et al., 2016; Spence, Lachlan, & Burke, 2007). Even so, results from the current study suggest that practical support from DSEC providers might play a key part in laying the relational groundwork for survivors subsequently to accept emotional and spiritual support from DSEC providers (e.g., by establishing trust and a strong working alliance; cf. Bordin, 1979).

A similarity between Geller and Greenberg's (2012) model of therapeutic presence and the current study's model of practical presence is that both models affirm that the provider is the main tool in providing care, and therefore the person of the provider is of paramount importance. Consequently, even as psychotherapists and counselors need to cultivate their own health/well-being (Siegel, 2010), their ability to be present fully with themselves and others (Geller, 2017), and their ability to use their whole selves in the service of their clients (Aponte & Kissil, 2016) in order to be effective, DSEC providers may need to do the same. Training in DSEC may therefore need to incorporate some of these elements.

One final similarity between this "use of self" in psychotherapy/counseling and in DSEC is that both types of providers have the sacred privilege of journeying with people who are suffering. In fact, both types of providers not only have the privilege of entering into sacred spaces of pain with people, but they often also have the privilege of being experienced as a sacred representative and conduit of a Higher Power (cf. Bland & Strawn, 2014; Hoffman, 2011). Indeed, our study's participants spoke of being a safe holding space for survivors, similar to Winnicott's (1960) notion of a "holding environment" (p. 591). In fact, Winnicott (1960) described this "holding" as essentially involving "living with" (p. 589), and our theory of practical presence suggests DSEC providers offer practical presence in part as a sacred form of "living with" disaster survivors. That is, they become an embodied way that survivors can experience the presence, love, and care of God in the midst of their suffering (cf. Brown & Strawn, 2012; Rolheiser, 2014). In so doing, survivors may even perceive DSEC providers as being a conduit through which they experience divinely initiated growth from their struggles (cf. Exline, Hall, Pargament, & Harriott, 2017; Wilt, Exline, Grubbs, Park, & Pargament, 2016; Wilt et al., 2017), perhaps both at the microlevel (e.g., as individuals and families) and macrolevel (e.g., as a community).

Limitations and Future Directions

The current study reflects typical limitations of qualitative research, such as relatively low sample size and potential selection and researcher biases. As described above, we employed several reliability and validity strategies in order to enhance the methodological integrity of this study. Even so, our study has noteworthy limitations. For example, our grounded theory might not be transferable to DSEC providers in other countries, because all our participants were U.S. citizens who mainly had offered DSEC in U.S. disaster contexts. Moreover, the transferability of our findings is also limited in that all providers were somehow affiliated with National VOAD. Even though National VOAD is one of the world's largest associations of disaster response organizations, the DSEC providers affiliated with it may have a certain way of conceptualizing and practicing DSEC, and that way of conceptualizing and practicing DSEC may not be transferable to DSEC providers who are affiliated with other organizations.

Like most study samples, our sample was limited in its demographic representativeness. For instance, there were only three (out of 14) racial/ethnic minorities, and none of these participants was Latino/a or multiracial. Similarly, participants were all between 49 and 73 years old, and hence the perspectives of younger DSEC providers was not obtained. Furthermore, there were only three religious minorities, and none of these participants was Buddhist or Hindu. Studies with more racial/ethnic, age, and religious diversity would be helpful.

On a related note, the study authors and two-thirds of the study participants were Christians in their religious affiliation. Hence, this study's data analysis and interpretation may have been biased by Christian assumptions and perspectives, whereas assumptions and perspectives from other faith traditions were not given enough weight in data analysis and interpretation. Again, this possibility may limit the transferability of our study's findings.

Taken together, we suggest our study's findings are most readily applicable and transferable to understanding the practice of DSEC in U.S. disaster contexts by DSEC providers affiliated with National VOAD. In particular, these findings perhaps best reflect the perspectives of White, Christian DSEC providers who are in middle or older adulthood.

Despite these limitations, the current study provides important insights in DSEC and advances scientific understanding of how it is practiced in the real world. Future research could evaluate whether this model of DSEC is indeed effective in promoting positive psychological or R/S outcomes, for whom, and under what circumstances. Process-oriented research could examine which components of the model are most versus least effective in promoting positive outcomes. Likewise, researchers could focus on asking the recipients of DSEC what they found most versus least effective in mitigating their distress and promoting their health/well-being, and this data could be compared and contrasted with DSEC-provider perspectives, similar to how psychotherapy researchers often compare therapist and client perspectives of psychotherapy process and outcome (cf. Norcross, 2011).

The field of DSEC is still quite young, and the scientific study of DSEC is even younger still. There are so many open questions for researchers to explore, and we are excited to see what unfolds as scientists and practitioners join together to understand better how to help disaster survivors cope, recover, and flourish.

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Alice N. Schruba

Jamie D. Aten

Edward B. Davis

Wheaton College

Laura R Shannonhouse

Georgia State University

This publication was made possible through the support of a grant from the John Templeton Foundation (Grant #44040). The opinions expressed in this publication are those of the authors and do not necessarily reflect the views of the John Templeton Foundation. Correspondence concerning this article should be addressed to Alice N. Schruba, Psychology Department, 501 College Ave, BGC Mezzanine, Wheaton, IL; a.n.schruba@gmail.com

Authors

Alice Schruba (Psy.D, Wheaton College) is a postdoctoral fellow at Alexian Brothers Behavioral Health Hospital. Dr. Schruba's professional interests focus on the integration of psychological science and spiritual care within acute contexts, including hospital and disaster settings.

Jamie D. Aten (Ph.D. in Counseling Psychology, Indiana State University) is the Dr. Arthur P. Rech and Mrs. Jean May Rech Associate Professor of Psychology and the Founder and Executive Director of the Humanitarian Disaster Institute at Wheaton College. Dr. Aten's primary professional interests include the psychology of religion/spirituality and disasters, spiritually oriented disaster psychology, and psychology in disaster ministry.

Edward B. Davis (Psy.D, Regent University) is an Associate Professor of Psychology at Wheaton College (IL). His research focues on the psychology of religion and spirituality, especially relational spirituality, God representations, disasters, and positive psychology.

Laura Shannonhouse (Ph.D. in Counseling and Counselor Education, University of North Carolina at Greensboro) is an Assistant Professor at Georgia State University. In K-12 schools and district systems, Dr. Shannonhouse conducts training and research to prevent youth suicide (suicide first aid), and with disaster-impacted populations, she conducts training and research to foster meaning making through one's faith tradition (spiritual first aid).

Appendix A

Semistructured Interview Protocol for DSEC Providers

1. Please define DSEC.

a. Prompt: Do you view spiritual care and emotional care as separate entities? Or some other way? If so, how? How do you view spiritual care and emotional care?

2. Please describe the way you provide DSEC.

a. Prompt: Does it change over the disaster life cycle (e.g., planning, preparing, responding, mitigating, and recovery)?

3. What are the most common types of spiritual and emotional issues that arise?

4. Please describe in detail an exemplar time when you have provided DSEC.

5. What guides your approach to working with disaster survivors when providing DSEC?

a. Prompt: Are there theories or concepts that guide your provision of DSEC? If so, please briefly describe them.

b. Prompt: Are there theologies, beliefs, or values that guide your work?

c. Prompt: How has as your conceptualization or approach changed over time?

6. What is the role of religion/spirituality in your approach?

a. Prompt: Are there personal religious practices that inform your provision of DSEC? If so, please briefly describe them.

b. Prompt: Are there group religious practices that inform your provision of DSEC? If so, please briefly describe them.

7. Please describe how, if at all, you help people make meaning of the event?

a. Prompt: How do you promote spiritual growth?

b. Prompt: How do you promote psychological growth?

c. Prompt: How do you address issues of God or faith?

8. What interventions or techniques do you employ when providing this care?

a. Prompt: Are there spiritually oriented interventions you use?

9. Are there assessment techniques you employ for identifying needs or providing care? If so, please describe them.

10. Please describe how, if at all, the way you provide DSEC varies across different types of disasters, such as natural or human-caused disasters?

a. Prompt: Does this process change based on the population you are serving? If yes, how so?

b. Prompt: If the type of disaster affects the way you provide care, does this care look different at different stages of the disaster? If so, how?

11. How do you initiate or build relationships with those whom you are helping?

a. Prompt: How do you establish rapport?

b. Prompt: What factors influence the care you provide?

c. Prompt: Does religion/spirituality play a factor in this process?

d. Prompt: How do you determine when your services are not needed?

Semistructured Interview Protocol for DSEC Providers

12. In providing DSEC, do you ever refer individuals to others or collaborate with others? If so, in what instances?

a. Prompt: With whom have you collaborated--across professional fields, across religions, and across organizations (government, nongovernment, and faith-based organizations)?

13. Please describe the way culture impacts your process of providing DSEC, if at all??

a. Prompt: Does your method of care change based on the culture of the person or communities you are serving?

b. Prompt: How, if at all, does your process of providing DSEC change based on whether your faith affiliation is different from the individual or community you are serving, versus if it were the same?

14. What do you think makes you an effective spiritual care provider?

a. Prompt: What might be an example of when you felt effective?

15. What is the role of self-care in your identity as a spiritual care provider?

16. What is your motivation or reason for providing DSEC?

a. Prompt: Is it a calling?

17. Is there anything that I have not asked you that you think might be important for me to know?