The COMPA Bulletin
Volume I, Issue 6 October 1, 2001
Contents:
Chapter 1 - Mental Health Consequences of Disaster
Chapter 2 – Principles of Psychosocial Intervention
1-800 LIFENET
A Call to Action
The September 11th attack on the World Trade Center left over 6,400 dead and countless others seriously affected. The immediacy of this tragedy was reflected in the terror and controlled panic of tens of thousands that morning in downtown Manhattan. In the days following, it was reflected in the silence experienced on the NYC transit system, the uncertainty, denial and suffering evident at the Family Assistance Center at Pier 94, in the record attendance at church. And in the months and years to come, it will be reflected in memories of loss and uncertainty of the future. As a nation we have been traumatized, and will continue to be so, for a long time to come. Our thoughts and prayers go out to those who have lost neighbors, friends, colleagues and loved ones, and to those who have been traumatized in some way by this unfortunate event. We also owe a tremendous debt of gratitude to the brave men and women who rushed to the WTC to assist in the rescue and recovery efforts, many of whom lost their lives when the towers collapsed; to the Mayor and our political leaders as they responded to and continue to guide us through this crisis; and to the many others who have lent a hand in the relief and recovery efforts.
Thankfully, the immediate impact upon the city’s methadone treatment system was minimal. Trinity Clinic, which was near ground zero, closed and subsequently moved to 150 Essex Street near the NYU Downtown Medical Center. With the lockdown of the city and the evacuation and restriction of access to downtown, many patients were also forced to seek services from clinics other than their own. And as usual, the methadone treatment system of the city rose to the challenge as programs opened their doors to provide medication and emergency assistance to those in need.
Looking to the future, however, the impact upon our clinics is likely to increase significantly. Many people have lost friends, family, coworkers and acquaintances. An estimated 15,000 children throughout the metropolitan area have lost a parent or care giver. Millions of others have watched the horrifying events of that day over and over until the images streaming through TV became a permanent part of their daily existence. Rescue and relief workers, including police, fire, and construction crews continue to toil clearing debris and searching for remains. The country is gearing up for a war against terrorism, and our economy is struggling to stabilize. Life has changed, and the effects of this trauma are likely to multiply rapidly.
Staff, patients, family and our community at large have all been affected, and many people will likely exhibit signs of physiological, cognitive and emotional distress over the coming months and years. Some will need grief counseling, others will require treatment for anxiety, depression and other symptoms related to post traumatic stress. Children, survivors, relief workers (including construction crews where many of our patients are employed) and the elderly are particularly vulnerable. Thousands of jobs have also been lost already with more to come, and it is likely that the working poor will be particularly impacted. And as the future unfolds, there will likely be a tremendous increase in alcoholism and substance abuse as many seek to blunt their private pain.
As a field, our job has shifted once again, and we can soon expect to be on the front lines. It is time to work together and prepare in order to ensure that our patients, staff and communities have complete access to services they may need. Adequate linkages must be in place, as should a commitment to cross system collaboration and cross training between mental health and substance abuse professionals. Individual counseling; relapse prevention, stress management, anger management, and support groups; parenting classes; medical and psychiatric services; as well as pharmacological supports all need to be included as part of our response. Appropriate vocational, social and case management services must be made available to those in need, and prevention efforts must also be significantly increased. In order to accomplish these tasks and put the necessary resources in place to deal with the problems we will likely face, we must plan accordingly now. Towards this end, a considerable part of this issue of the COMPA Bulletin is devoted to information related to understanding and responding to disasters, and we hope that the information stimulates and assists with the development of an adequate and appropriate response.
Again, to those who suffered a loss of a friend or loved one, our sympathies and support. To those who lent a hand during this time of crisis, our thanks. And to those who will need our help in the future, our commitment and pledge of assistance, as we strive to return to normal but with a renewed focus and dedication to helping people in a holistic and comprehensive manner.
A Community That Cares / A Message from ASAP
The men and women who work in the chemical dependency treatment and prevention field are very special. We do very difficult work every day. We believe in miracles. We are united in our commitment to healing and health promotion. As we grapple with the events unfolding in NYC, in our nation, and in our world we are uniquely gifted with insights and skills that can contribute to healing and health.
ASAP would like to help facilitate any assistance that may be needed as our programs are confronted with unprecedented challenges. If anyone becomes aware of the specific needs of programs (staff or clients) affected by the terrorism which has occurred, please call, fax, or e-mail a brief description of need. We will use our broadcast fax, list serve, and website to help identify potential resources to address those needs. Our field can be counted on in this time of need.
ASAP has had calls from Florida, Nebraska, and other members of the State Associations of Addiction Services (SAAS), our national association, with offers of help. Please feel free to call any need you are aware of to our attention. We will do our best to promptly get the word out and, I am certain, there will be a groundswell of support from all directions.
As the death toll mounts and as the denial begins to erode, we will have a real challenge before us. We can be there for each other and we can make a difference for each other. ASAP will be happy to facilitate the process in any way that would be helpful. As always, we are very open to your suggestions.
Our prayers and love go out for those in our field who have lost family and friends. Our prayers of thanksgiving go out for all those who are safe and well at home.
State, City, and Provider Coalitions Meet In Wake of September 11th Attack
On September 28th the New York City Department of Mental Health, Mental Retardation, and Alcoholism Services convened a meeting of the ASA Council and Select ASA Umbrella Organizations. The meeting was chaired by Martha A. Sullivan, D.S.W., Deputy Commissioner for Health Promotion and Chemical Dependency. COMPA was represented by our Executive Director, Henry Bartlett. The purpose of this meeting was to discuss the need for expanded and enhanced services in the wake of the September 11th attack. Also discussed was the need for additional financial resources to support these services. Ms. Sullivan and her staff outlined six major components to an overall response plan for ASA treatment and prevention services.
Theses are:
Aftercare Relapse Prevention Program Enhancements
Mobile, Post Disaster Readiness Training for ASA Program Staff
Intensive Outpatient Treatment Program Enhancements
Post Disaster Readiness Training for Improved Treatment of Dually-Diagnosed MICA Clients
Prevention / Early Intervention Program Enhancements
Public Information and Education Initiatives
This outline became the springboard for a wide ranging discussion of a variety of specific and general needs in the aftermath of the attack. Some very relevant information was provided by the Black & Puerto Rican / Latino Substance Abuse Task Force, regarding the need for treatment services after the Oklahoma City bombing. While the Oklahoma City Community lost 168 people in the bombing of the Federal Building, approximately 75,700 people received treatment for Post Traumatic Stress Syndrome and related disorders in a variety of substance abuse and mental health settings. This translates to a 450 to 1 ratio.
While it is impossible to predict how analogous the Oklahoma City experience will be to the World Trade Center attack, it is very clear that there will be a significant increase in demand for treatment. We need to communicate this fact to Washington, and we are urging every COMPA member to send a strongly worded letter to Secretary Tommy Thompson at the following address:
Tommy G. Thompson
Secretary
United States Department of
Health & Human Services
200 Independence Avenue, S.W.
Washington, DC 20201
While the letter should be in your own words, it would be useful to make the following points:
The traumatic events of September 11th will spur the additional use of alcohol and other drugs, which will in turn lead to a significant increase in need for treatment.
Federal disaster relief must be specifically targeted and earmarked for Alcohol and Substance Abuse Treatment and Prevention needs.
The need is both short and long term, since some of the people who will eventually need treatment arising from this trauma, may not seek treatment for a number of months or even years.
Methadone treatment programs are anxious to expand there services to provide a more comprehensive and intense level of care to their clients, but lack the fiscal resources to do so. (Note: You may want to emphasize the need for additional mental health services for our clients, especially in the wake of the attack.)
Ask specifically for the Federal Government to make money available to address physical plant improvements in our programs. The physical plant limitations often preclude our programs from considering expansion either in volume of patients served or expansion in terms of scope of services.
It would also be useful if you could send a cc of your letter to COMPA at our NYC Office. We would like to start keeping a record of the our provider’s efforts to secure additional resources in the wake of this disaster.
It should also be noted that in a September 21st press release Secretary Thompson announced that $126 million in Federal Funds would be available for "disaster-impacted health and social services". The press release provided the following breakdown:
Support for Health Care Services - $55 million
Mental Health Services - $28 million
Social Services - $25 million
Environmental Hazard Control - $10.4 million
HHS Security & Other Activities - $7.75 million
The money for substance abuse treatment is contained within the $28 million earmarked for Mental Health Services. That section of the press release reads:
"This includes $6.8 million for crisis mental health services beyond the initial counseling supported by the Federal Emergency Management Agency. These funds will also be used for assessment of longer term needs in affected states. In addition, $21.2 million will be made available to support the existing mental health and substance abuse system in the disaster areas."
While this is a step in the right direction, we need to make the point that more dollars are needed and that dollars must be specifically earmarked for substance abuse treatment. The group convened by Deputy Commissioner Sullivan will continue to meet to work on these issues, and COMPA will continue to be an active participant.
Disaster Needs Survey
OASAS and the New York Association of Alcoholism & Substance Abuse Providers (ASAP) recently sent out a survey in order to gather information on the impact of the terrorist attack on the treatment and prevention field. We strongly encourage our providers to complete this survey promptly and to return it to our colleagues at ASAP. When you complete this survey try to be as comprehensive as possible. You should address not only increased costs, but also any lost revenues associated with the disruption of normal service delivery patterns. ASAP will share with COMPA the results of this survey, and we will work together to try to secure the additional resources our field will need in order to cope with this disaster.
Andrea Barthwell Nominated as Deputy Director of Demand Reduction
From Legal Action Center Washington Roundup, September 7, 2001
This week President Bush announced his intention to nominate Dr. Andrea Barthwell to serve as the Deputy Director for Demand Reduction at the White House Office of National Drug Control Policy. Dr. Barthwell is presently the Executive Vice President of the Human Resources Development Group, the President of the Encounter Medical Group, and the President and CEO of BRASS Foundation, an addiction treatment Center in Chicago, Illinois. Additionally, Dr. Barthwell serves as the President of the Board of the American Society of Addiction Medicine and sits on the boards of several alcohol and drug treatment and prevention organizations, including the American Methadone Treatment Association and Legal Action Center.
Dr. Barthwell’s nomination already has received significant support from the alcohol and drug treatment and prevention field. Many field leaders expressed their excitement about the fact that the Administration has selected such an exceptional professional from the addiction treatment and prevention field to hold this key position in the Office of National Drug Control Policy. Several individuals praised Dr. Barthwell’s combination of clinical and policy expertise, citing that these qualifications will make her invaluable in Washington. Additionally, many field leaders applauded President Bush and John Walters, the nominee for Drug Czar, for Dr. Barthwell’s nomination, and viewed it as a positive statement about the Bush Administration’s commitment to working on drug and alcohol treatment and prevention issues.
The position of Deputy Director for Demand Reduction requires Senate confirmation. It is unclear at this time when the Senate Health, Education, Labor, and Pensions Committee will hold a confirmation hearing on Dr. Barthwell’s nomination. John Walters, whom President Bush nominated in early May to serve as the Director of the White House Office of National Drug Control Policy, will appear before the Senate Judiciary Committee for his confirmation hearing next Tuesday.
Remaining General Membership Meetings for Fall 2001
The following General Membership Meetings have been scheduled for the Fall in both downstate and upstate locations. Come meet our new Executive Director, listen to what you can expect from COMPA in the future, hear the latest regarding accreditation and other key issues, share your thoughts and concerns as we look towards the future, and meet your colleagues.
Friday, November 2nd 10:00 – 12:00 noon
Greenwich House, 55 Fifth Avenue, 18th Floor, Manhattan
Guest: Dr. Frank Lipton, NYC Human Resources Administration
Wednesday, November 7th 10:00 –12:00 noon
Crouse Memorial Hospital, Syracuse
GRANT AND FUNDING OPPORTUNITIES
The September 11th Fund
The United Way and The New York Community Trust have established the September 11th Fund to help respond to the immediate and longer-term needs of the victims, their families, and communities affected by the events of September 11th. The fund is now accepting proposals for grants to address certain limited and immediate needs in the wake of the disaster. Eligibility criteria and proposal requirements are quite specific, and far too detailed to mention here. However, some of our programs may wish to consider making application. The contact person for assistance in completing applications is Jacqueline Ebanks, (212) 251-4109.
AIDS Institute Deadline Extended
Due to the recent WTC tragedy, the deadline has been extended to November 2, 2001 for response to the NYS Department of Health AIDS Institute Request for Application for State and Federal funds for HIV Prevention and Care Services for Substance Abusers Who Are In and Out of Treatment. Funds are available in the following categories: HIV Prevention Services to Substance Users in Drug Treatment and Their Sexual and Drug Sharing Partners; Outreach and Prevention Services to Active Users and Consortium Based capacity Building Models for Providing HIV Prevention services to Recovering Users in Treatment; HIV Primary Care services for HIV Infected Substance Users in Drug Treatment; and Transitional Case management Services to Assist Active Injection Drug Users. The RFA may be obtained from the AIDS Institute by calling 212-268-6111.
CONFERENCE AND TRAINING OPPORTUNITIES
2001 AMTA Conference
The American Methadone Treatment Association Conference 2001, Opioid Treatment in the 21st Century – Implementing the Vision is scheduled for October 7– 10, 2001 at the Millennium Hotel in St. Louis, Missouri, with CSAT and NIDA supported pre-conference sessions beginning on October 6, 2001.
According to conference chair Keith Spare, "The conference represents a unique and highly effective partnership, among the American Methadone Treatment Association and the National Institute of Drug Abuse, the Center for Substance Abuse Treatment, the Office of National Drug Control Policy, and the Drug Enforcement Administration." Plenary sessions will feature treatment professionals as well as government officials, including Missouri’s governor Bob Holden.
The conference, jointly sponsored by the American Methadone Treatment Association and the American Society of Addiction Medicine, has traditionally attracted more than 1,600 participants from throughout the nation as well as 25 other nations. Missouri hosts are the Missouri Department of Mental Health - Division of Alcohol and Drug Abuse and the Missouri Methadone Treatment Association. The conference will feature major presentations on public policy, legislation, research, and state-of-the-art treatment interventions for opiate dependence. The increasing public discussions on health care, welfare reform, and criminal justice systems highlight the importance of the positive impact methadone treatment offers to individuals in need of such care and the public. This conference serves as a national focal point for treatment providers, researchers, patient advocates and government officials, demonstrating the effectiveness of opioid treatment as a foundation for sound public health policy. For additional details on the conference, or for registration information, call (856) 423-7222, extension 360, or visit www.americanmethadone.org.
ASAP Fifth Annual Treatment and Prevention Conference
"Advancing the Conversation" has been selected as the theme of this year’s Alcoholism and Substance Abuse Providers of NYS (ASAP) conference, which will be held in Saratoga Springs from October 21 – 24, 2001. Conference information can be obtained by calling 518-426-3122 or through the ASAP web site at www.asapnys.org.
OASAS and ASAP have also joined forces to offer five Julio A. Martinez Professional development Scholarships to support non-administrative staff development. Each scholarship is for $1,000 and is intended for individuals working in the field who wish to pursue CASAC or Prevention credentials. Nominations are due September 14th and further information and nomination forms may be obtained from ASAP.
The State of the Art in Addiction Medicine – From Molecules to Managed Care
The American Society of Addiction Medicine has announced a three day conference highlighting the most recent findings in addiction research. The conference will be held November 1-3, 2001 at the Omni Shoreham Hotel in Washington, DC. For more information call 301-656-3920 or www.asam.org.
Joint Commission Standards and Survey Process for Organizations that
Provide Addictions Services
Tuesday, October 30, 2001, just outside Chicago at the Joint Commission Conference Center, One Renaissance Boulevard, Oakbrook Terrace, IL 60181
JCAHO recommends this program for addictions services providers. The content focuses on how accreditation can be used as a tool to improve quality within organizations that provide addictions services. The content will address the standards, intents, and survey process that specifically address treatment services to individuals with a range of addictions, including alcoholism, drug abuse, and gambling.
The program will focus on:
* Improving the quality of addictions treatment services
* Defining and applying accreditation standards
* Defining the link between quality and improved business performance
* Credentialing and current competency
* Protecting the rights and confidentiality of individuals served
* Planning treatment and assessment
* Applying effective outcome measurements
Agenda
8:30 am - 11:30 am Morning Session
* Leadership related to addictions
* Rights, responsibilities and ethics related to addictions
* Assessment and care related to addictions
11:30 am - 12:30 pm Lunch
Three concurrent lunch hour presentation options:
* Application Issues
* Methadone Project Updates
* Networking Lunch
12:30 pm - 4:30 pm Afternoon Session
* Performance measurement
* Education related to addictions
* Continuum related to addictions
* Management of human resources related to addictions
* Surveillance, preventions, and control of infection related to addictions
* Behavioral health promotion related to addictions
The fee of $325.00 includes seminar materials, lunch and refreshment breaks.
For additional information and registration call JCAHO Customer Service at 630-792-5800 and mention program code 2312 or log on to www.jcrinc.com
ABOUT COMPA
The Committee of Methadone Program Administrators of New York State is a not-for-profit coalition representing New York State’s methadone treatment system which serves over 46,000 individuals suffering from opioid addiction and other substance abuse disorders.
Opioid addiction is a chronic, relapsing medical disorder, with serious consequences related to public health and safety. Methadone treatment has proven to be the most effective means of treating this disorder.
COMPA’s mission is to further the treatment of opioid addiction and other substance abuse disorders in order to address the medical, social and psychological consequences of use, prevent the spread of HIV and other infectious diseases, reduce criminal behavior, promote employment and self-sufficiency, and support the return to a healthy and productive lifestyle.
In order to support this mission, COMPA and its member organizations are committed to the promotion and expansion of methadone treatment through education of elected officials, providers, consumers, and the public at large. COMPA advocates for expanded models of service delivery, co-located services and consumer empowerment to provide increased access to treatment. COMPA supports enhanced services, a comprehensive continuum of care, the provision of high quality treatment and ongoing professional staff development. COMPA encourages the involvement of membership in the development of public policy, standards of care, and regulatory oversight.
COMPA Board of Directors
Peter Coleman, NYC Health and Hospitals Corporation, President
Ira Marion, AECOM-Montefiore, Vice President
Johanne Morne, Whitney Young MMTP, Secretary
Richard Woytek, Long Island Jewish MMTP, Treasurer
Herbert Barish, Lower Eastside Service Center
Willard Campbell, Suffolk County Division of Alcohol and Substance Abuse Services
Robert Krauss, Long Beach Hospital MMTP
Robert Sage, A.R.T.C.
Sheila Tierney, Crouse Hospital
Ira Wolfe, St. Luke’s Hospital
COMPA Executive Director
Henry Bartlett
COMPA has established this newsletter to ensure that New York State providers of opioid treatment services have an effective mechanism of communication which facilitates the dissemination of information and encourages dialogue. The COMPA Bulletin includes information regarding best practices, research, demonstration projects, accreditation, training opportunities, conferences, and other items of interest to the field and will be distributed via email on a monthly basis. COMPA encourages readers to submit news, articles, research, and other items of interest for possible inclusion. Submissions should be titled "COMPA Bulletin Submission" and directed to info@compa-ny.org.
Please send us your email address. Addresses should be titled "Subscription List" and directed to info@compa-ny.org as well.
Past issues of the COMPA Bulletin are available on our web site www.compa-ny.com.
The COMPA Bulletin is compiled, written and distributed by:
The Committee of Methadone Program Administrators of NYS Inc.
250 Fifth Avenue, Suite 210
New York, N.Y. 10001
212-447-6682
or
518-281-8965
PLEASE COPY AND DISTRIBUTE
Scroll down. Excerpts from
Coping With Disaster:
A Guidebook to Psychosocial Interventions
begin on the next page.
Coping With Disaster: A Guidebook to Psychosocial Interventions
The following materials have been excerpted from Coping With Disaster: A Guidebook to Psychosocial Interventions, prepared for Mental Health Workers without Borders by John H. Ehrenreich, PhD and Sharon McQuaide, MSW, PhD, September 20, 2000. It is presented in order to educate member organizations regarding typical symptoms and responses to critical incidents and to assist with program planning and service enhancement during the coming year as we respond to the aftermath of the World Trade Center disaster. Complete copies may be downloaded on-line at http://www.mhwwb.org/
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Chapter 1 - Mental Health Consequences of Disaster Imagine yourself and your family the victim of a disaster: an earthquake, a tornado, a flood, an airplane crash in your community, the threatened meltdown of a nearby nuclear plant, a terrorist attack. What happens to those who go through a disaster? Almost instantly, in response to the sights and sounds of the event itself, our heart pounds, our mouth goes dry, our muscles tense, our nerves go on alert, we feel intense anxiety or fear or terror. If there has been little or no warning, we may not understand what is happening to us. Shock, a sense of unreality, and fear dominate. Long after the event the sights, sounds, smells, and feelings of the event persist as indelible images in our memory. As our immediate shock and terror dissipates, longer-term effects appear. The disaster challenges our basic assumptions and beliefs. Most of us, most of the time, believe that our personal world is predictable, benevolent, and meaningful. We assume we can trust in ourselves and in other people and that we can cope with adversity. Disaster destroys these beliefs. We become aware of our vulnerability. We feel helpless and hopeless. We despair in our inability to make decisions and to act in ways that would make any difference to our families and ourselves. In the wake of the disaster, we grieve for the death of loved ones and we marvel at own survival. We also grieve for our home, for treasured personal memorabilia, for lost documents, lost familiar neighborhoods. If the disaster has disrupted our community’s traditional subsistence activities or our community itself, we may feel intense feelings of loss tied to our cultural and social identity, as well. The loss of our personal world, of a sense of safety, of belief in ourselves, in the trustworthiness of others or even in the benevolence of God are not just thoughts; they trigger deep feelings of loss and grief. In the days and weeks following the disaster, we may experience a wide variety of emotional disturbances. For some, chronic grief, depression, anxiety, or guilt dominate. For others, difficulties controlling anger, suspiciousness, irritability and hostility prevail. Yet others avoid or withdraw from other people. For many, sleep is disturbed by nightmares, the waking hours by flashbacks in which they feel as if the disaster is happening all over again. Not a few begin to abuse drugs or alcohol. There may be cultural variations in the precise patterns in which disaster-related symptoms appear, but reports from countries as diverse as China, Japan, Sri Lanka, Mexico, Colombia, Armenia, South Africa, the Philippines, Fiji, England, Australia, and the United States, among others, show that the emotional responses to disaster are broadly similar everywhere in the world. Secondary Traumatization: It is not only those who directly experience the disaster (the "primary" victims) who feel its emotional effects. "Secondary victims" – the families of those directly affected, onlookers and observers, and relief workers who seek to rescue the primary victims also may experience serious emotional effects. Medical and mental health workers and relief officials who subsequently work with the primary and secondary victims are constantly exposed to the physical and emotional effects of the disaster on others and may themselves be victims of "vicarious traumatization." The "Second Disaster": The primary source of emotional trauma is, of course, the disaster itself. But the sources of traumatization do not end when the disaster is over (in a literal sense) and when the victims have been rescued. After the disaster comes "the second disaster"-- the effects of the response to the disaster. The rapid influx of well-meaning helpers, who must be fed and sheltered, adds to the confusion and the competition for scarce resources. In some instances, poor people from outside the disaster area have flooded into a disaster area seeking their own share of the food and other supplies relief agencies are providing to disaster victims. This still further increases the burden on disaster workers and on the already stricken community. Those forced to take refuge in a shelter for shorter or longer periods of time are forced to confront the consequences of the disaster in an ongoing, unrelenting way. To personal and material losses, we now add loss of privacy, loss of community, loss of independence, loss of familiarity with the environment, and loss of certainty with respect to the future. Family roles and ordinary work roles are disrupted. Poor sanitation, inadequate shelter, and contaminated water and food may produce epidemics, with widespread illness and death resulting. In the shelter, personal assaults and rapes may endanger women, the elderly, and other vulnerable people. As the weeks and months go by, anger at the slowness of reconstruction or at corruption that prevents relief supplies from getting to victims may add to distress. In some instances, such as Nicaragua after the 1972 earthquake and Mexico after the 1985 earthquake, such dissatisfaction produced widespread political unrest. Delayed Effects of Disaster: Some emotional effects of the disaster may not appear until after a considerable delay. For some victims, initial relief at having been rescued and initial optimism about the prospects of recovery may produce a "honeymoon stage." Over a period of months or even years, this may give way to a realization that personal and material losses are irreversible. Loved ones who died will not return. Disruptions in the family are permanent. Old jobs will not reappear. A long-term reduction in standard of living has occurred. Depression and anxiety may now appear for the first time in some victims, and the suicide rate may actually rise. Other victims of disaster appear initially to be "doing well." This may be illusory, however. To protect themselves, they may suppress or inhibit the processing of the impact of the disaster upon them. After a delay (considerable at times), stimuli associated with the disaster may trigger memories, pulling previously suppressed material back into consciousness. As a result, psychological responses to the disaster may "suddenly" appear, months or even years afterward. The Prevalence of Adverse Psychological Effects Following Disaster Although the precise figures vary from situation to situation, up to ninety per cent or even more of victims can be expected to exhibit at least some untoward psychological effects in the hours immediately following a disaster. In most instances, symptoms gradually subside over the weeks following. By twelve weeks after the disaster, however, twenty to fifty per cent or even more may still show significant signs of distress. The number showing symptoms generally continues to drop, but delayed responses and responses to the later consequences of disaster continue to appear. While most victims of disasters are usually relatively free of distress by a year or two after the event, a quarter or more of the victims may still show significant symptoms even then and some victims who had previously been free of symptoms may first show distress a year or two after the disaster. Anniversaries of the disaster may be especially difficult times for many survivors, with temporary but unexpected reappearance of symptoms which they had thought were safely in the past. Reports of widespread emotional distress ten years and more after disasters such as the 1972 flood at Buffalo Creek (USA) and internment in Nazi concentration camps have been well substantiated. The prevalence of strong physiological, cognitive, and emotional responses to disasters indicates that these are normal responses to an extreme situation, not a sign of "mental illness" or of "moral weakness." Nevertheless, the symptoms experienced by many victims in the days and weeks following a disaster are a source of significant distress and may interfere with their ability to reconstruct their lives. If not dealt with and resolved relatively quickly, they can become ongoing sources of distress and dysfunction, with devastating effects for the individual, their family, and their society. Factors Affecting Vulnerability to Adverse Psychological Effects Not everyone is equally affected by a disaster, and not all disasters are equally devastating in psychological terms. Several factors may increase the risk of adverse psychological consequences:
The Stages of Psychological Response to Disasters It is customary to conceptualize the aftermath of disaster in terms of a series of stages of phases, each of which has its own characteristics. The phases, we hasten to say, are not rigid. There is much variation at each stage and the stages overlap. The "Rescue" Stage In the first hours or days after the disaster, most relief activity is focused on rescuing victims and seeking to stabilize the situation. Victims must be housed, clothed, given medical attention, provided with food and water. During the rescue stage, various patterns of emotional response may be seen. Victims may shift from one pattern to another. Some victims do not show any of these patterns.
Many of these behaviors have an adaptive quality. They ensure short term survival and permit the victim to take in information at a controllable rate. But the symptoms themselves may be perceived by the victims as socially inappropriate, as a source of shame, guilt, and failure, as an evidence of inadequacy. Caregivers and rescue workers, in turn, may respond with irritation or withdrawal from the victims. The "Inventory" Stage Once the situation has been stabilized, attention turns to longer-term solutions. Heroic rescue efforts give way to bureaucratized forms of help. Over the next year or eighteen months, organized assistance from outside gradually diminishes and the reality of their losses dawn on victims. In the first weeks after the disaster, victims may go through a "honeymoon" phase, characterized by relief at being safe and optimism about the future. But in the weeks that follow, they must make a more realistic appraisal of the lasting consequences of the disaster. Disillusionment may set in. The effects of the "second disaster" are felt. During this phase, any of a wide variety of post-traumatic symptoms appear.
Post-traumatic Symptoms · avoidance of thoughts about the disaster and avoidance of places,
Post Traumatic Stress Disorder: The characteristic symptoms of Post Traumatic Stress Disorder include (a) Persistent re-experiencing of the traumatic event: recurrent and intrusive recollections of the events of the disaster; recurrent distressing dreams in which the disaster is replayed; intense psychological distress or physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event; or experiences in which the victim acts or feels as if the event is actually re-occurring. (in children, repetitive play in which themes or aspects of the trauma are expressed may occur; trauma-specific re-enactments of the events may take place, and there may be frightening dreams without recognizable content). (b) Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness: efforts to avoid thoughts or feelings or conversations about the disaster; efforts to avoid activities, places, or people that remind the victim of the trauma; inability to recall important parts of the disaster experience; markedly diminished interest or participation in significant activities; feelings of detachment or estrangement from others; restricted range of affect; or a sense of a foreshortened future, without expectations of a normal life span or life. (c) Persistent symptoms of increased arousal: difficulty falling or staying asleep; irritability or outbursts of anger; difficulty concentrating; hypervigilance; exaggerated startle response. This general cluster of symptoms has been reported in every part of the world. In less industrialized parts of the world and among people coming from these areas, the avoidance and numbing symptoms have been reported to be less common and dissociative and trance-like states, in which components of the event are relived and the person behaves as though experiencing the events at that moment, may be more common. Generalized Anxiety Disorder: The characteristic symptoms of Generalized Anxiety Disorder include: (a) Persistent and excessive anxiety and worry about a variety of events or activities (not exclusively about the disaster and its consequences (b) The person finds it difficult to control the worry and the worry is far out of proportion to reality. It interferes with attention to tasks at hand. (c) The anxiety and worry are associated with symptoms such as restlessness or feeling on edge; being easily fatigued; difficulty concentrating or the mind going blank; irritability; muscle tension; and difficulty falling asleep or staying asleep Although individuals with Generalized Anxiety Disorder may not always identify their worries as "excessive," they report subjective distress due to their constant worry and it may affect them in social, occupational, marital, or other areas of function. Somatic symptoms (e.g., cold clammy hands, dry mouth, nausea or diarrhea, urinary frequency) and depressive symptoms are also commonly present. There is considerable cultural variation in how anxiety is expressed. In some cultures, it may be expressed more through somatic symptoms, in others through cognitive symptoms. Children may reveal their anxieties through concern about their competence, (e.g., at school), excessive concerns about punctuality, over-zealousness in seeking approval, and a conforming, perfectionistic personal style. Abnormal Bereavement: Normally, after the death of a loved one, a sequence of stages of bereavement are expected. Often the first response is disbelief and denial. Feelings of numbness may give respite and allow the realization to seep in slowly. Then, as we begin to realize the reality and significance of the loss, feeling of distress, yearning for the lost person, anger at the loss, and anxiety at one’s ability to cope without them may appear. A period of mourning ensues, as we review our memories of the lost loved one, and then gradually let go of the psychological bonds and free ourselves for life without the departed person. All cultures have rituals that, however much they vary, seem intended to facilitate this process. Trauma may interfere with the ability to go through this process normally, however. The victim’s own injuries, the loss of social supports and familiar communities, survivor guilt, and the victim’s own psychological trauma may interfere with both expected rituals and internal grieving processes. Memories of the deceased may trigger the victim’s own memories of the disaster. Post-traumatic rumination may block the victim from confronting the memories and thoughts that are central to grieving. Post-traumatic numbing may interfere with the victim’s engaging in supportive social interactions. There may be other, practical obstacles to saying goodbye, as well. For instance, legal processes may delay funeral proceedings or concerns about the bereaved seeing the body of the deceased due to injuries it may have sustained in the disaster may lead to the bereaved not having the opportunity to view the body. Most studies have indicated that not seeing the body of the deceased may contribute to abnormal bereavement and that seeing the body, even when it is disfigured, is not inherently damaging. Few victims who have been allowed to see the remains and have accepted the offer regret doing so. These psychological and practical obstacles to a "normal" response to the death of a loved one may contribute to a lack of feelings of closure or permit magical fantasies that the deceased person has not, in fact, died. Any of several abnormal bereavement syndromes may appear. (Note: Different cultures vary widely with respect to what is "expected" after the death of a loved one. Among some peoples, open expression of emotion is frowned upon. Among others, public displays of emotion are expected and lack of overtly expressed emotion is suspect. In some cultures, people are expected to publicly grieve only briefly and then to return to normal activities. In others, a prolonged grieving period is expected. Evaluation of the significance of the following patterns depends on an awareness of what the cultural norms are in the particular culture). (a) Inhibited grief: The bereaved exhibits a pattern characterized by psychic numbing, over-control and containment of emotions, little display of affect. They may be seen as "coping well," yet this pattern is associated with later depression and anxiety. (b) Distorted grief: The bereaved shows intense anger and hostility dominating over their sadness and guilt. This anger may be directed at anyone the bereaved associates with the deceased’s death (e.g., relief workers). (c) Chronic grief: The feelings of sadness and loss do not dissipate. Frequent crying, pre-occupation with the loss are unremitting. (d) Depression: The bereaved lapses into depression, with prolonged grief, despair, and a sense that life is not worth continuing. Sleep and appetite disturbances may appear. The bereaved may have active fantasies of being reunited with the deceased and suicidal ideation or attempts may occur. (e) Excessive guilt: The bereaved may show excessive self-recrimination and guilty pre-occupations, which eclipse their sadness. Self destructive, yet not overtly suicidal behaviors, such as frequent accidents or excessive drinking may occur. Post Traumatic Depression: Protracted depression is one of the most common findings in studies of acutely or chronically traumatized people. It often occurs in combination with Post Traumatic Stress Disorder. Trauma can produce or exacerbate already existing depression. Common symptoms of depression include sadness, slowness of movement, insomnia (or hypersomnia), fatigue or loss of energy, diminished appetite (or excessive appetite), difficulties with concentration, apathy and feelings of helplessness, anhedonia (markedly diminished interest or pleasure in life activities), social withdrawal, guilty ruminations, feelings of hopelessness, abandonment, and irrevocable life change, preoccupations with loss, and irritability. In some cases, the person may deny being sad or may complain, instead, of feeling "blah" or having "no feelings." Some individuals report somatic complaints, including widespread aches and pains, rather than sadness. Suicidal ideation or attempts may appear. With children, somatic complaints, irritability, social withdrawal are particularly common. In some cultures, depression may be experienced largely in somatic terms, rather than in the form of sadness or guilt. Complaints of "nerves", headaches, generalized chronic pain, weakness, tiredness, "imbalance," problems of the "heart," feelings of "heat," or concerns about being hexed or bewitched may appear. Culture-specific disorders: The boundaries between anxiety, depression, dissociation, and emotional disorders that have predominantly somatic symptoms are very porous. Victims often have symptoms running across these categories. In many societies and cultural groups, traditional patterns of expression of emotional distress take the form of combinations of symptoms that have no exact equivalent in standard international categories of mental illness. The intermediate term response to disaster may take the form of one of these "culture-specific disorders." These may include, for example, susto and ataques de nervios (Latin America and the Caribbean), amok (the South Pacific), dhat (India), and latah (Southeast Asia and the South Pacific). (Susto is prevalent among some Latinos in the United States and among people in Mexico, Central America, and South America. Typical symptoms include appetite disturbances, inadequate or excessive sleep, troubled sleep or dreams, feelings of sadness, lack of motivation, feelings of low self-worth, and somatic symptoms. Ataques de nervios is recognized among many Latin American, Latin Mediterranean, and Caribbean Latinos. Commonly reported symptoms include uncontrollable shouting, attacks of crying, trembling, heat in the chest rising into the head, verbal and physical aggression, a sense of being out of control, and sometimes dissociative experiences, seizure-like or fainting episodes, and suicidal gestures. Amok is recognized in Malaysia and, under varying names, in the Philippines, Puerto Rico, and elsewhere. It is described as a dissociative episode characterized by a period of brooding followed by an outburst of violent, aggressive, or homicidal behavior directed at people and objects, ending with exhaustion. Dhat is a term used in India to describe a syndrome of severe anxiety, headaches and body aches, loss of appetite, hypochondriacal concerns associated with the discharge of semen, and feelings of weakness and exhaustion. Latah, found under various names in the South Pacific and Southeast Asia, involves hypersensitivity to sudden fright, often with an apparently senseless and automatic repetition of the words or actions of others and dissociative or trance-like behavior). In many parts of the world, the conventional idiom for expressing emotion may be somatic (e.g., chronic fatigue, generalized aches and pains, gastrointestinal disturbances, feelings of "heat)" or fears of somatic illness (e.g. hypochondriasis, fears of infection). In some cultural groups, the distress of a disaster may also take the form of a "trance disorder." A "trance" is a temporary, marked alteration in the state of consciousness or a loss of the customary sense of personal identity, associated with either stereotyped behaviors or movements that are experienced as beyond one’s control or by a narrowing of awareness of one’s immediate surroundings. The "Reconstruction" stage A year or more after the disaster, the focus shifts again. A new, stable pattern of life may have emerged. In any event, the distinction between disaster relief and the larger pattern of national social and economic development begins to diminish and eventually disappears. During this phase, although many victims may have recovered on their own, a substantial number continue to show symptoms much like those of the preceding ("inventory") stage. A significant number who were not symptomatic earlier may now exhibit serious symptoms of anxiety and depression, as the reality and permanence of their losses becomes evident. The risk of suicide may actually increase at this time. Other characteristic late-appearing symptoms include chronic fatigue, chronic gastrointestinal symptoms, inability to work, loss of interest in daily activities, and difficulty thinking clearly. The notion of "post traumatic stress disorder" described earlier derives mainly from observations of the symptoms of survivors of relatively circumscribed traumatic events. A number of studies suggest that more complex syndromes may appear in survivors of prolonged, repeated, intense trauma, such as those who have been held hostage, who have been repeatedly tortured or exposed to chronic personal physical or sexual abuse, who have been interned in a concentration camp, or who have lived for months or years in a society in a chronic state of civil war. Among victims of such disasters, a "survivor syndrome" may appear. People showing this syndrome have been described as walking though life "without a spark." Chronic depression, anxiety, and survivor guilt appear, or, alternately, chronic aggression and an "addiction to hate." Social withdrawal, sleep disturbances, somatic complaints, chronic fatigue, emotional lability, loss of initiative, and general social, personal, and sexual maladaptatian are present. The "joy of life" is gone, replaced by a "pervasive pattern of sluggish despair." Relationships with spouses and children are disturbed, often creating significant disturbances in later generations. Other victims of prolonged or repeated and severe traumas have been described as exhibiting "complex post-traumatic stress disorder." Symptoms of "complex post-traumatic stress disorder" include:
Effects of Disaster on Specific Population Groups Children Two myths are potential barriers to recognizing children’s responses to disaster and must be rejected: (1) that children are innately resilient and will recover rapidly, even from severe trauma; and (2) that children, especially young children, are not affected by disaster unless they are disturbed by their parents’ responses. Both of these beliefs are false. A wealth of evidence indicates that children experience the effects of disaster doubly. Even very young children are directly affected by experiences of death, destruction, terror, personal physical assault, and by experiencing the absence or powerlessness of their parents. They are also indirectly affected through identification with the effects of the disaster on their parents and other trusted adults (such as teachers) and by their parents’ reactions to the disaster. Another barrier to recognizing children’s responses to disaster is the tendency of parents to misinterpret their children’s reactions. To parents who are already under stress, a child’s withdrawal, regression, or misconduct may be understood as willful. Or, parents may not wish to be reminded of their own trauma or, seeking some small evidences that their life is again back in control, may have a need to see everything as "all right." In either case, they may ignore or deny evidence of their children’s distress. The child, in turn, may feel ignored, not validated, not nurtured. This may have long term consequences for the child’s development. In the short run, feeling insecure, the child may inhibit expression of his or her own feelings, lest he or she distress and drive away the parents even more. Most children respond sensibly and appropriately to disaster, especially if they experience the protection, support, and stability of their parents and other trusted adults. However, like adults, they may respond to disaster with a wide range of symptoms. Their responses are generally similar to those of adults, although they may appear in more direct, less disguised form. Symptoms Shown by School-Aged Children Among pre-school children, anxiety symptoms may appear in generalized form as fears about separation, fears of strangers, fears of "monsters" or animals, or sleep disturbances. The child may also avoid specific situations or environments, which may or may not have obvious links to the disaster. The child may appear pre-occupied with words or symbols that may or may not be associated with the disaster or may engage in compulsively repetitive play which represents part of the disaster experience. The child may show a limited expression of emotion or a constricted pattern of play may appear. He or she may withdraw socially or may lose previously acquired developmental skills (e.g., toilet training). As children approach adolescence, their responses become increasingly like adult responses. Greater levels of aggressive behaviors, delinquency, substance abuse, and risk-taking behaviors may be evident. Adolescents are especially unlikely to seek out counseling. Children or all ages are strongly affected by the responses of their parents or other caretakers to disaster. Children are especially vulnerable to feeling abandoned when they are separated from or lose their parents. "Protecting" children by sending them away from the scene of the disaster, thus separating them from their loved ones, adds the trauma of separation to the trauma of disaster. For an adult, although the effects of disaster may be profound and lasting, they take place in an already formed personality. For children, the effects are magnified by the fact that the child’s personality is still developing. The child has to construct his or her identity within a framework of the psychological damage done by the disaster. When the symptoms produced by disaster are not treated, or when the disaster is ongoing, either because of the destruction wrought (e.g., by an earthquake) or because the source of trauma is itself chronic (e.g., war or relocation to a refugee camp), the consequences are even more grave. The child grows up with fear and anxiety, with the experience of destruction or cruelty or violence, with separations from home and family. Childhood itself, with its normal play, love, and affection, is lost. Longer-term responses of children who have been chronically traumatized may include a defensive desensitization. They seem cold, insensitive, lacking in emotion in daily life. Violence may come to be seen as the norm, legitimate. A sense of a meaningful future is lost. The Elderly Reports on the responses of the elderly to disaster are inconsistent. In some disasters, they seem no more vulnerable than younger people. In others, they appear more vulnerable. Despite the inconsistency in formal research studies, there are reasons to believe that that the elderly are at increased risk for adverse emotional effects in the wake of disaster. Depression and other forms of distress among the elderly are readily overlooked, in part because they make not take on exactly the same symptom pattern as among younger people. For instance, disorientation, memory loss, and distractibility may be signs of depression in the elderly. The elderly are also more vulnerable to being victimized. In the context of increased stress on the family and community, meeting their special needs may take on a lowered priority. One particular issue that may appear is feelings that they have lost their entire life (loss of children, homes, memorabilia) and that, due to their age, there is not enough time left in their life to rebuild and recreate. The elderly are also more likely to be physically disabled (see below). The Physically, Mentally, or Developmentally Disabled Although people who are physically disabled, mentally ill, or retarded have distinct needs from one another, all three groups are at especially high risk in disasters. For those in each group, the normal patterns of care or assistance that they receive and their own normal adaptations to produce acceptable levels of functioning are disrupted by disasters. For instance, supplies of medication, assistive devices such as wheelchairs, familiar caretakers, and previously effective programs of treatment may become unavailable. This has both direct effects and increases anxiety and stress. Stress, in turn, may exacerbate pre-existing mental illness. Those who were mentally ill or developmentally delayed may also have fewer or less adaptable coping resources available and less ability to mobilize help for themselves. They are especially vulnerable to marginalization, isolation, and to "secondary victimization." They are at greater risk of post-disaster malnutrition, infectious disease (e.g., in a shelter situation), and of the effects of lack of adequate health care. Disaster Relief Workers Disaster workers, including both those involved in rescue efforts immediately following the disaster and those involved in longer term relief work, are at very high risk of adverse emotional effects. · They may themselves be primary victims of the disaster, with the same burdens In addition to post traumatic responses much like those of the primary victims of the disaster, relief workers may evidence anger, rage, despair, feelings of powerlessness, guilt, terror, or longing for a safe haven. These feelings may be distressing and may make the worker feel that there is something wrong with them. Their sense of humor may wear thin, or they may use "black humor" as a way of coping. Toleration for others’ failings is reduced and the anger of other relief workers or victims may feel like a personal attack. Belief in God or other religious beliefs may be threatened by a feeling of "How could God let this happen?" After a prolonged period of time on the job, evidence of "burn-out" may appear. Disaster workers face additional stress when they complete their tasks and return home, to their "regular" life. Their experience has diverged in a variety of ways from the experiences of their families and in the absence of preparation of both workers and their families, a variety of marital and parent-child conflicts and stresses may appear. Distressing or problematic emotional responses are extremely common among relief workers. For example, in one air crash, more than eighty per cent of the rescue workers who had to deal with the bodies of victims showed some post traumatic symptoms, more than half moderately severe symptoms. Almost two years after the crash, a fifth of the rescue workers were still symptomatic. Rescue and relief workers are rarely prepared ahead of time either for their own reactions or to deal with the reactions of primary victims. Providing psychosocial assistance to these workers and providing them with adequate shelter, food, and rest, even when these are not available to the victims themselves, is a very high priority in disasters. It may seem unfair, but if the rescue and relief workers are unable to function efficiently, they can not help any one else Community and Social Impacts of Disasters Disasters directly affect their individual victims. But beyond that disasters create tears in the tissue of social life. Sometimes this is direct and total, as when, as a result of disaster, people are forced to leave their land and migrate to cities. In other cases, the rapid influx of helpers, the presence of government officials, press, and other outsiders (including mere curiosity seekers), the flood of poor people from outside the disaster area into a disaster area seeking their own share of the food and other supplies relief agencies are providing to disaster victims, combine to further disrupt the community. But even when the formal structure of a community is maintained, the disaster can disrupt the bonds holding people together, in families, communities, work groups, and whole societies. When those bonds are destroyed, the individuals comprising the affected groups lose friends, neighbors, a community, a social identity. These collective effects of disaster may ultimately be as devastating as the individual effects. The consequences of disaster for families, neighborhoods, communities, and societies are many: Family dynamics may be altered. Disaster-produced deaths or disabilities, family separations, and dependency on aid givers may undercut the authority of the traditional breadwinners, supplant traditional activities in the home, and force people out of traditional roles or into new ones. Symptoms of individual family members affect their interactions with other family members. The intimate penetration of a community by outsiders may upset or challenge traditional child rearing practices and traditional patterns of male-female relationships. In the wake of disaster, marital conflict and distress rises; increases in the divorce rate in the months following disasters may occur. Parent-child parents also increase. In several instances, increases in intra-family violence (child abuse, spouse abuse) have been reported. Disasters may physically destroy important community institutions, such as schools and churches, or may disrupt their functioning due to the direct effects of the disaster on people responsible for these institutions, such as teachers or priests. Traditional patterns of authority are disrupted along with customary social controls on individual behavior. Several studies have shown an increase in the rates of community violence, aggression, drug and alcohol abuse, and rate of legal convictions in the wake of disaster. Disasters disrupt the ability of communities to carry out customary or traditional activities central to people’s individual, community, and social identity, ranging from work and recreational activities to accustomed rituals. Some of these disruptions are temporary, but others are hard to reverse. For example, a flood may permanently damage farm land, making a return to traditional farming untenable, or an oil spill off the coast may permanently alter traditional fishing grounds. With people forced away from their homes and land for shorter or longer periods and with personal and community records lost due to a disaster, opportunities appear for looting. This may be limited to personal possessions or may lead to permanent loss of tools, animals, and land. The community whose members can no longer farm their traditional land, carry out traditional craft production activities, or hunt or fish in traditional ways is disrupted and its sense of identity attacked. Disasters place a strain on traditional community social roles, patterns of social status, and leadership. Police, local housing agencies, local health facilities are overwhelmed and face a new task of integrating their work with that of volunteers, often from outside the community. There may be anger at inequities in the distribution of post-disaster aid. These inequities may exacerbate the gap between rich and poor. Outside aid agencies may threaten the traditional roles of local agencies and institutions. Outside experts may pose a threat to local professionals. In the wake of disaster, new leaders may emerge in a community, due to the role of these people in responding to the disaster. Conflicts between these new leaders and traditional community leaders may appear. Outside assistance may be necessary in the wake of a disaster, but it can also promote a sense of community dependency. Insofar as the necessities of life are supplied from outside, incentives to resume traditional work activities are reduced. This is not just a matter of psychological "dependency." Provision of food and other supplies may compete with local production, disrupting traditional pricing and wages and damaging attempts to recreate the old productive patterns. Added to this, the disaster itself may have destroyed the tools, workshops, animals, or other necessities of production. Disaster may lead, directly or indirectly, to permanent changes in productive patterns, especially patterns of land ownership and use. Shifts from subsistence agriculture to wage labor, land looting, migration and uprooting and resettlement play a role. Schisms may appear in a community, as cohesion is lost. One danger is that of scapegoating, either of individuals or using traditional divisions in the community (e.g., along religious or ethnic lines). In communities with a history of past disaster, whether naturally caused or man-made, the trauma produced by a new disaster may re-arouse old feelings. Memories of genocide, civil war, social oppression, or racial or ethnic division and of the feelings they produced, and feelings of marginalization and helplessness may be exacerbated. In some communities that have had to deal with repeated natural disasters such as flooding, on a more or less regular basis, disaster and the response to it may be integrated into community rituals and belief systems, as well as into community structure and people may ascribe cultural meaning to disasters. Communities may have traditional rituals for dealing with the effects of disaster. Not only the disaster, but outside intervention may interfere with these traditional rituals, responses, and attributions of meaning and may be experienced as an ambiguous blessing or even as a source of additional stress. |
Chapter 2 – Principles of Psychosocial Intervention
A wide variety of specific techniques have been used to provide immediate relief of distress and to prevent or mitigate the longer-term emotional effects of disasters. To be useful, the techniques have to be adapted to the specific situation – the kind of disaster, the human and material resources available, the specifics of local culture and tradition. This section of the manual focuses on the core principles that guide both the specific techniques and their adaptations.
I. Interventions Should Be Matched To The Disaster Phase
The types of response that are offered should match the phase of emotional responses and the needs of disaster relief operations.
The "Rescue" Phase:
Immediately after the disaster, the most urgent needs of victims are for direct, material relief (rescuing lives, preventing further physical damage and loss of life, providing medical care, providing victims with food, water, shelter). Psychosocial interventions during this phase are primarily directed to serving these ends. In doing so, they contribute to longer-term mental health.
Relief Workers: The highest priority for psychosocial services is relief workers, whose continued effective functioning is essential. This may involve "defusing" and "debriefing" (See Chapter III). Many very small concrete services may also be emotionally as well as practically helpful. Bring relief workers coffee, lend a hand in helping clean up, give a hug, express interest.
Direct Victims of the Disaster. With direct victims of the disaster, early primary efforts should be directed to providing "first aid": i.e., assistance for those whose acute distress and difficulties functioning interfere with the victim’s cooperation with rescue and relief efforts and ability to help provide for their own safety. Look for signs of intense anxiety or panic, continuous crying, depressive withdrawal, disorientation, incoherence, difficulty complying with requests by relief workers or with the rules of the shelter.
Short term interventions may be helpful in reducing anxiety, assisting the rescue and relief process, and preventing later maladaptive responses. These include comforting and consoling victims (a word or a hug); helping people reunite with family members or get information about loved ones; helping defuse conflicts with other victims or between victims and relief workers; supporting victims in such "reality tasks" as identifying the dead or making decisions about animals and other property. Let victims express feelings, but focus on helping them regain a sense of control. Seek to elicit competence and independence from the very beginning.
Begin very broad preventive activities and activities that set the stage for later interventions: Provide accurate information as to what is happening, using all available mechanisms (e.g., mass media, meetings, leaflets).. Reassure victims that acute reactions are normal and should not be sources of fear or of feelings that one has lost control.
Interventions that are cognitively complex (e.g., "debriefing;" see Chapter 3) are premature when people are still in a stunned state. However, helping to reduce anxiety may help prevent later distress, and making contact with survivors even at very early stages after the disaster may create feelings towards the counselor that can make later interventions more acceptable and effective.
The "Inventory" Phase
The days or weeks following the disaster may be a "honeymoon" phase, in which people’s feelings of relief and optimism about the future dominate. A spirit of generosity and mutuality may appear, and individuals may be in a state of denial about their losses and the problems of the future. During this stage many people will not be receptive to psychosocial interventions or feel they need them. Others, however, may welcome the chance to talk through their reactions within a few days of the disaster.
The bulk of psychosocial interventions directed at victims themselves occur in the subsequent period. Discouragement and disillusionment with relief and reconstruction efforts may set in. Anxiety, sadness, irritability, frustration, and discouragement now combine with disaster-produced losses and post-traumatic stress effects to produce a relatively high level of need. Focusing on identification of those at risk and on interventions to reduce the longer-term impact is essential.
In most circumstances, the number of people trained in responding to the emotional consequences of disaster will be insufficient to meet the demand. Training of auxiliary disaster counselors will, of necessity, be a high priority during this period. Primary care health workers, teachers, religious leaders, traditional healers, and others can be enlisted.
The "Reconstruction" Phase
Emotional consequences of the disaster may continue to appear for up to two years or more post-disaster. In part this represents delayed reactions, in part responses to a growing recognition of the irreversible consequences of the disaster. The experience of several disasters suggests that mental health assistance should remain available for about two years or more after the disaster. Such services also permit longer-term follow-up of those treated earlier. Even after disaster counselors leave the site of the disaster, maintain a telephone "hot line" or other ways for people to contact counselors if the need arises.
Tasks at Different Stages Following a Disaster
I. The Rescue Stage (immediate post-impact):
Provide information, comfort, practical assistance, emotional "first aid"
Provide "defusing" and "debriefing" services for relief workers
II. The Early Inventory Stage: First month
Continue "defusing" and "debriefing" services for relief workers
Educate local professionals, volunteers, and community with respect to
effects of trauma
Train additional disaster counselors
Provide short term practical help and support to victims
Begin survivor "debriefing," crisis intervention, assessment and referral
III. The Late Inventory Stage: Months two on
Continue "defusing" and "debriefing" services for relief workers
Provide "debriefing" and other services for disaster survivors
Provide community education
Develop outreach services to identify those in need
Develop school-based services and other community institution-based
services
V. The Reconstruction Phase
Continue to provide defusing and debriefing services for relief workers and disaster survivors
Maintain a "hot line" or other means by which survivors can contact
counselors
Follow up those survivors treated earlier
Ii: assume emotional responses to disaster are normal
The emotional responses to disaster are normal responses to overwhelming stress. They are not, in themselves, signs of "mental illness." Many of the "symptoms" described earlier can be understood as adaptive mechanisms, by which people seek to protect themselves against the overwhelming psychic impact of the disaster. Both individuals and communities have natural healing processes. The central task of psychosocial intervention is to elicit, facilitate, and support these healing processes and to remove the obstacles to their operation, in order to prevent lasting dysfunction and distress. Interventions are aimed, above all, at minimizing the number of people who will require later "treatment." Among other things, this means reassuring people, helping provide short term relief of symptoms which may be alarming, and acting to prevent symptoms from becoming entrenched.
Victims do not usually see themselves as mentally ill, and they may fear or avoid involvement with mental health workers and the mental health system. They do not spontaneously reach out for the assistance of mental health workers. Psychosocial assistance in the wake of disaster is best presented in a form that does not require people to see themselves as "ill" or "mentally ill."
III: Safety and Material Security Underlie Emotional Stability
It is difficult for people to maintain a stable mental state, after a disaster or in any other circumstances, unless certain basic needs are met. First, they must be assured access to food, water, clothing, and shelter. Second, their need for physical safety and security must be met. In the case of disasters, this includes not only freedom from fear for one’s life, due to the disaster itself, but security from banditry, from the fear of looters, and from the fear that the disaster will lead to the permanent loss of one’s land or one’s home. Third, the safety and integrity of one’s family must be ensured. This "hierarchy of needs" has several implications:
IV. Integrate Psychosocial Assistance with Overall Relief Programs
It is difficult, if not impossible, to provide effective psychosocial services without the cooperation and support of those directing and providing medical and material relief efforts, at the local as well as the regional or national level. Governmental officials (at local or national level) often do not recognize or give much priority to the psychosocial effects of disasters. Relief workers, who are necessarily focusing on the urgent and concrete tasks of saving lives, protecting property, ensuring the provision of food, clothing, and shelter, and rebuilding the material infrastructure of the community may see psychosocial services as unnecessary or even as getting in their way. Educating both of these groups about the impact of psychosocial processes on the relief effort itself and on the long run consequences of not responding to the mental health effects is essential.
Early development of liaison with those directing relief work is essential. Forming a task force made up of experts in psychosocial intervention, formal community leaders (e.g., the mayors of towns), representatives of influential groups in the community (e.g., churches, unions), leaders of the relief effort, and representatives of the victims to guide and support psychosocial work may be very useful.
One potential source of contention is that preexisting social stratification (by class, caste, gender, rural vs. urban, etc.) may lead to certain groups (e.g., women, poorer people) being left out of the process. Conforming to traditional patterns of stratification in the name of efficiency reinforces those patterns. Implementing programs along more egalitarian and participatory lines may produce conflict and new forms of stress, but it may also ultimately result in serving a far larger group of victims and producing a more integrated, cooperative post-disaster community.
Several useful foci for early liaison work are:
V. Interventions Must Take People’s Culture into Account
People from different cultural groups (including different sub-cultural groups within a larger society) may express distress in different ways and may make different assumptions about the sources of distress and how to respond to it. Techniques originally devised in industrialized countries must be applied sensitively, if they are to be used elsewhere. (Fortunately, there is a body of evidence suggesting that these techniques can be successfully adapted to a wide variety of situations.
Some of the cross-cultural differences which may need to be taken into account include the following:
Interventions need to be sensitive to these differences and may effectively draw on them, as well. To cite several examples, in working with victims of a volcanic eruption in the Philippines, counselors incorporated prayer into "debriefing" sessions; in working with traumatized Navaho Indian war veterans (U.S.A.), traditional healers were enlisted both to help provide services and to organize traditional rituals aimed at cleansing warriors returning from battle.
One path which helps create such sensitivity is to involve local people in every phase of psychosocial services. Local health workers, priests, traditional healers, union leaders, teachers, and local community leaders should be educated about the psychosocial consequences of disaster and enlisted to serve as psychosocial counselors. Modifications of the techniques described in Chapter III can be developed with their aid and participation.
In this context, differences between men and women in coping styles and in what is deemed socially appropriate can also be regarded as a form of "cultural difference." Interventions need to be sensitive to the possibly differing expectations and needs of women (e.g., with respect to speaking about emotional concerns in a family meeting or a public setting).
VI. Direct Interventions Have an Underlying Logic
A variety of specific techniques may be useful in responding to the emotional impact of disaster on individuals, families, and other groups. In any particular disaster situation, these techniques may have to be modified or adapted, and there are many other, less formal interventions that may be useful.
In what follows, our focus is on the logic and underlying purposes of interventions, rather than the details or specific mechanics of interventions. The latter is addressed for a number of specific techniques in Chapter III.
Talking: People need to make sense of a disaster, in the context of their lives and their culture. Telling a story about what happened is a way of creating a meaning for the events. Many victims find that simply telling other about their experiences in the disaster or about their experiences in the days and weeks after the disaster is helpful. Telling what happened to another person also permits the victim to check that his or her perceptions of what happened are accurate. Telling one’s story "externalizes" thoughts and feelings, subjecting them to examination by oneself and others. Emitting feelings a little bit at a time when the experience is safely in the past, by talking to others or by crying, reduces stress. Public opportunities for mourning, celebrating, and otherwise expressing feelings can also relieve stress. Note: While talking about experiences is generally healthy, "rumination" (repetitive, obsessive retelling of a story) is associated with higher levels of depression and should be discouraged by engaging the victim in alternative activities or diversions.
For children, other means of communication, including playing, art work, and dancing, may play the same role that talking does in an adult.
Communication of information: Uncertainty increases victims’ level of stress. Incorrect information produces confusion, can interfere with appropriate responses, and can lead to tensions among victims or between victims and relief workers. Provide victims with accurate and full information, as quickly as possible, using both individual, direct forms of communication and general public announcements (e.g., via the mass media). Combat rumor mongering. It is essential to have a single source of information which victims can rely upon.
Empowerment: One of the most psychologically devastating aspects of a disaster is the victim’s sense of having lost control over his or her life and fate. Interventions that help those affected by the disaster change from feeling themselves as "victims" (i.e., as passive, dependent, lacking control over their own lives) to "survivors" (who have a sense of control and confidence in their ability to cope) are central to preventing or mitigating subsequent emotional difficulties. Discourage passivity and a culture of dependency. Seek to engage victims in solving their own problems. Victims should be encouraged to participate in making decisions that affect their lives and to take part in implementing those decisions. They should not be denied an active role in solving problems, in the interests of "efficiency." For adults, a return to work (either their usual work or other productive or personally meaningful activity) helps increase their sense of control and of competence. For children, a return to school performs the same function. Even when people must remain in a shelter for prolonged periods, developing small scale income generating productive activities, permitting victims to help run the shelter and the relief administration, and providing skills training are useful parts of psychosocial rehabilitation.
Normalization: While unfamiliar emotional responses are normal following a disaster, victims may find their own reactions distressing. The best antidote is education. Reassure victims that their responses are not a sign that they are "going crazy." Explain the typical time course (i.e., that, in most cases, symptoms can be expected to remit over a period of weeks or months). Warn victims that the anniversary of the disaster, environmental stimuli that remind them of the disaster and other events such as funerals or legal actions growing out of the disaster may lead to a brief return of symptoms that had faded. Victims should also know that not everyone experiences the same symptoms or even any symptoms at all. They are not condemned to have symptoms.
Social Support: Recovery from disaster is inherently social. Restoring or creating networks of social support is essential in dealing with the extreme stresses created by disaster. Avoid breaking up existing communities. Combat isolation of individual victims. Reuniting families has the highest priority. Reuniting people from the same neighborhood, work teams, and other pre-existing groupings is helpful, and separating members of such pre-existing groups (and especially members of the same family) is harmful. Only in the most extreme situations should children be separated from their parents (e.g., if the child’s parents are abusive or rejecting because they are unable to cope with their own trauma or that of their child). If separation of a child from its parents is necessary (or if the parents are injured or killed), keeping the child with another trusted adult known to them (e.g., a relative, a teacher) is urgent. "Sending the children away for their own protection" is almost never advisable. Returning children to school, adults to accustomed social environments (e.g., work) are important. In some instances, no natural support groups are available. In this situation, creating artificial networks (e.g., creation of ongoing peer or self-help groups for treatment, helping to reorganize and rebuild communities) is helpful. In most instances, group treatment modalities should be a central part of the psychosocial response to disasters. When possible, the group that is the unit for treatment should be a naturally occurring group, such as