Crisis Intervention Handbook

Assessment, Treatment

and Research

 

 

 

 

 

 

 

 

 

 

Edited by

Albert R. Roberts, D.S.W.

Rutgers- The State University of New Jersey

 

 

 

 

 

Wadsworth Publishing Company

Belmont, California

A Division of Wadsworth, Inc.,1990


 

Post-Disaster Mobilization and Crisis Counseling: Guidelines and Techniques for Developing Crisis-Oriented Services for Disaster Victims

 

Raquel E Cohen, M.D., M.P.H.

 

 

 

 

Introduction

 

Increasing attention is being paid to the plight of individuals caught in overwhelming, stressful, accidental events that produce serious reactions and sequelae affecting both physical and psychological health. These events, which appear to be increasing in numbers and magnitude worldwide, are exemplified by disasters, both man-made and accidental, acts of terrorism, kidnapping, and violence.

            John, a 9-year-old boy, describes the experience of being a flood victim:

 

When the lights went down, my mother wondered if the wind had blown one of the electric poles down. Then the lights went out and the TV went off. It was pitch dark, and my mother found a candle and lit it. The wind was shaking the windows and doors. I had never heard that shrieky noise and became afraid. We heard a bullhorn announcement telling us to come out and get in the boats before the flood increased the danger. They took us to a church, but the water was coming near the church also. They said we had to get into some buses, and the people were pushing me away from my mother. They were afraid and so was I. I was crying.

 

John and his mother lost most of their possessions as the coastal storm destroyed their house. They were assisted by federal relief programs and the Red Cross in re-establishing their living quarters, and by the mental health crisis team in their psychosocial needs.

 

At the time an earthquake occurred, Henry, a maintenance worker, was driving to work and Mary was getting her daughter ready for school. Two younger children were still sleeping. The mother gathered all the children and started to run out of the house as the walls collapsed around them, threatening to trap them. The 4-year-old was screaming and started shaking, clinging to her mother. After reaching the street and noticing the destruction of their neighborhood, they huddled with a group of survivors until they were transported to a shelter. They waited anxiously for news about Henry. After Mary spent several days without news, wondering whether Henry was dead or alive, the authorities had the sad task of informing her that a cement block had killed her husband.

 

A woman living with a relative after the destruction of her house by the explosion of a tanker truck was referred to a crisis clinician. The family’s house had been badly damaged, and the husband, wife, and two children 6 and 8 years old had to live with the wife’s relatives for three weeks. During that time the husband was angry and depressed, expressing all his negative feelings for the irresponsibility of the public and private authorities who allowed “accidents like this” to happen to citizens. He also lashed out at his family, and the household was in constant turmoil. The wife, upset by her husband’s behavior and feeling she had to remain strong, repressed her feeling of anxiety, irritation, and frustration. Antagonism grew between the couple, and the relationship with their children deteriorated to the point that the children’s behavior regressed to infantile levels. It was at this point, three weeks after the event that the relatives asked for help from the crisis team assigned to the families which had suffered the explosion.

                The clinician’s initial function with this family was to explore the ways in which the event, the loss of the home, and the difficult living arrangements were influencing the interaction between them. The clinician interviewed the couple, the children, and the family as a whole in order to understand the effects of the disaster on their feelings and behavior. The clinician was able to help them see how their communication patters had suffered, how it was interfering in the mourning process of having suddenly lost their world, and how they were evading confrontation of the reality of their situation and the painful effects that lay ahead of them to reconstruct what they had lost. The clinician also helped them through the process of seeking and receiving assistance from the company that acknowledged responsibility for the accident.

 

            These examples set the stage in which the post-disaster crisis clinician can enter the front lines in an outreach, advocacy posture where role and function will demand specialized skills and methods. Professionals are not only interested in understanding human responses in these situations, but also through experiential participation and research operations they are interested in developing intervention programs designed to assist the victims of these stressful events. Many models are being developed to design these programs of organized mental health intervention. This approach of incorporating mental health assistance within disaster relief operations must have a clear focus in order to participate in collaboration with many other agencies already integrated into the relief effort. Although suffering from the lack of clear guidelines, well-designed research methodology, and scientifically founded evidence of effective outcome, mental health intervention in disasters in moving forward, based on the empirical and clinical activities of many professionals in the new area of work. Their observation and documentation have been used to build a body of knowledge upon which guidelines leading methodology and appropriate skills- still in a state of flux and needing further experimentation and validation- are being developed, used, and applied to help victims.

            This chapter will address some specific areas needed to implement crisis intervention to assist victims of disasters. It will first focus on the issues of mobilization to develop the resources and methodologies for crisis intervention. It will then single out the techniques necessary to develop crisis-oriented services linked within a major multilevel mental health emergency relief program designed, planned, organized, and implemented within the context of the reality of the situation, the event, the population affected, and the resources available during the post-impact period.

            It is important to point out that this chapter will not address the multiple components of mental health activities that are an integral part of the total program. Among such activities, consultation, training, and education are paramount. These methodologies implemented by mental health professionals can assist the non-mental health workers in discharging their responsibilities and increasing their capabilities for problem solving. The mental health assistance may also provide support to the public and private disaster emergency program staff to retard or alleviate burnout of the clinician in the front lines.

 

 

 

 

Review of Post-Disaster Mental Health Research Literature

 

Our mental health journals and books increasingly are presenting theoretical formulations of stress effects and crisis theory, the variety of approaches that have been applied in post-disaster situations, and research which attempts to measure successful outcome (Ahearn & Cohen, 1984). This emerging knowledge has helped professionals modify and reformulate traditional intervention treatment modalities to focus on the person-situation configuration as the unit of attention in psychosocial treatment (Sowdes, 1985)/ these formulations were documented by H.J. Parad and G. Caplan (1966), who outlined the mechanisms families characteristically use to solve the problems of a crisis situation. Another pioneer who applied these concepts to disasters was Lindemann (1944), who documented the bereavement reactions of individuals after the Coconut Grove fire in Boston. Tyhurst (1951) documented time sequences and phases of behavior across crisis resolution and began to point the way to crisis intervention during the specific phases. Cohen and Ahern (1980) contributed the basic and applied knowledge useful in developing strategies and methods for crisis intervention. Anther important contribution that incorporates the psychophysiology of crisis processes has been reported by researchers studying stress response syndromes and coping and adaptation processes and their relation to support systems. Lazarus (1966) has enriched the knowledge of coping by identifying the important role of the cognitive system as it affects the psychological “interpretation” of the traumatizing stressor event. Eth and Pynoos (1985) in their studies have differentiated psychic trauma response phenomenology from grief and mourning processes.

            In the area of applied knowledge of crisis intervention methodology, Cohen (1976, 1982, 1984, 1985) has reported her experiences during different post-disaster phases. In 1971, Congress enacted the Federal Disaster Relief Act, which stated that “the President is authorized through the National Institute of Mental Health to provide professional counseling service, including financial assistance to state and local agencies or private mental health organizations to provide such serve or training of disaster workers to provide such service, to victims of major disasters in order to relieve mental health problems aggravated by such major disasters or its aftermath.” Following the availability of funding for crisis intervention in a disaster declared as such by the president, many professionals have documented their experiences with crisis intervention services (Lystad, 1985).

 

Practice Framework: Key Concepts

 

Post-disaster crisis counseling is defined as a mental health intervention technique useful in post-disaster events that seeks to restore the capacity of the individuals to cope with the stressful situation in which they find themselves.

Crisis intervention is aimed at (a) restoring the capacity of victims to handle such stressful situations, (b) helping the reorder and organize their new world through the specialized techniques of psychosocial interactions, and (c) helping the victims deal with the formal, public bureaucratic relief assistance programs in order to obtain the available resources. The purpose of intervention is to bring about a change in the victims’ post-disaster beliefs, feelings, and behavior so victims can reclaim their healthy adaptive defenses for problem solving and negotiating the reconstruction of their lives. It is fundamental to have a clear focus and sense of direction in post-disaster counseling and reconstruction of the healthy capacity for self-management that most victims have.

            There is a relation between the approaches by which problems are defined and the interventions chosen and translated into action. Mental health problem definitions reflect influences and assumptions about the causes of the problem. In the case of a post-disaster crisis reaction, one useful conceptualization is based on bio-psycho-socio-cultural model of the individual’s functions. In it the individual’s reaction following the disaster’s sudden and intense impact is related to the following:

 

1. The individual’s personality structure

2. The individual’s age, gender, ethnicity, and economic status

            3. The individual’s usual coping (defensive styles

            4. The intensity of stressors (primary and secondary)

5. The available and appropriate “fit” between the individual’s needs and availability of support systems

6. The extent of personal loss suffered

7. The availability of relief emergency resources

 

Using these identifying data for each individual, the problems faced by the victims in their specific context of situation offer guidance to the crisis clinician.

            During crisis all of an individual’s biological, psychological, and behavioral systems are affected and tend to reorganize and re-equilibrate for survival. Each individual has a backup set of available bio-psychological mechanisms that are geared specifically to be mobilized at times of stress. The degree of success depends of many factors in the environment and within the individual. The recognition that there are sets of bio-psychological mechanisms that continually are available to correct and balance the physiological systems has been fully researched in somatic medicine (Canon, 1953). But this recognition is still in the process of being researched in psychological studies of man’s adaptation in crisis (Lazarus, 1966; Horowitz, 1986). The conceptual formula developed by Cohen and Ahearn (1980) to organize the multiple variables that play a role in the process of crisis resolution deals with the dynamic interaction of multiple systems within the individual and the external conditions. It focuses on the complex, interactive integration of multiple levels of the individual, each level with its own rhythm, rate, laws, and characteristic changes, which shift and change as the individual proceeds through the phases of post-disaster crisis resolution.

 

Stages/Phases of Post-Disaster Behavior

 

The disruption of lifestyles, property ownership, personal relationships due to the secondary effects of the loss of neighborhood and permanent or transitory relocations produces a variety of emotions, cognition, and behavior. Paradoxical emotional reactions are likely to be evident during therapeutic intervention, especially in the acute phase of the trauma.

            As the clinician encounters the clinical and behavioral manifestations of human reactions to traumatic events, it is helpful to keep in mind the developmental phases of crisis reaction across time (Cohen, 1986). Although we do not have a well-documented body of knowledge based on research, the changes in psychological, interpersonal, behavioral, and social interactions appear to follow a sequentially organized process. The adaptive defense mechanisms available to the individual are such human characteristics as health, age, lifestyle, and experience upon which to build a response., and behavior or social skills which act as a barrier, regulator system, or a filter to modify the impact of the crisis event.

            Analyzing the reactions documented by Cohen (1986), the post-disaster sequence appears to show the following manifestations:

 

Immediate Post-disaster Stage: Psychological and Emotional Reactions

 

            The range of emotions expressed immediately after individuals realize they have survived a traumatic event, largely revolve around fear and anxiety. Other emotions begin appearing as it becomes necessary to find safe shelter and locate loved ones. People experience worry, shame, and guilt as they become aware of their own, self-centered survival efforts. Self-awareness if their own perhaps unusual reactions and behavior towards their novel situation adds to the difficulties victims have in adapting and coping. Fear, anxiety, apprehension, and demoralization need to be controlled and managed by victims, who are struggling to survive and cooperate in the efforts of the emergency assistance agencies.

            The adaptive defenses observed during this phase can be grouped under the category of denial. Denial appears to act as a buffer to help individuals adapt and cope with the immediate, painful, and unbelievable changes in their lives. The phrase “It is true that we lost our home, but we are alive, thank God” is usually repeated by victims during the first few hours after a disaster.

            Relations between victims and helpers can vary from very docile and passive obedience to orders or regulations issues by rescue personnel, to rebellious, antagonistic behavior toward such rules, apparently reflecting the victims’ need to be in control of their individual “space.” Rebellious individuals are difficult to manage in emergency shelters and strive to develop their own routines dealing with meals, lights, taking turns, or waiting to be attended to. This attitude of demanding, complaining, and expressing a sense of entitlement or trying to scapegoat the authorities for the consequences of the disaster seems to represent an effort to control situations to avoid being overwhelmed by feelings that are too painful and intense.

            As time passes, behaviors reflect different ways of managing emotions produced by the losses and change of lifestyle. Variations of self-management include rigid, obsessive behavior in interactions with other individuals, vacillation, and ambivalent reactions to suggestions and advice. Some individuals congregate and form groups extending support toward victims or helpers. At times, the style of their support behavior is intrusive, inappropriate, or is resented by the recipient. Each individual’s effort, either to relate with others or to become isolated, seems to help the individual deal with the sense of crisis, emergency, and threat in the unfamiliar world into which he or she has been uncontrollable plunged.

            As weeks pass, the victims’ reactions change. A new psychological-emotional state and behavior emerges as the individuals leave the shelters and return to their neighborhoods, where they become aware of the consequences of the disaster on their properties. As the victims begin to ascertain what it will take to begin reconstruction of their lives, the well-documented emotional expressions of grief, mourning, and despair take their toll. The victims’ task of achieving resolution and accepting their fate parallels the developmental phases of crisis behavior. Due to the difficulty victims have dealing with personal emotions and interpersonal relations while at the same time having to fabricate a new world while attending to daily living tasks, crisis clinicians are apt to witness episodes of intense disorientation, confusion, and feelings of helplessness at not being able to control the environment. Feelings of vulnerability can strip individuals of their usual coping defenses for a limited time. Victims’ usual psychological mechanisms fail at times, making it very difficult to deal concurrently with multiple demands and decision making needed in reconstructing their lives.

            Understanding the variations and sequences of emotions, with the accompanying defenses, is at the heart of the crisis intervention. This requires knowledge, skills, and the correct attitude. The disaster situation changes some of the traditional understanding of crisis resolution processes that are part of out clinical practices in working with personal disasters. In the disaster setting, feelings of the victims are easily hurt. Conflicts arise from the victim’s need to ask for help and the clinician’s own brand of skills to deliver such assistance. The victim’s sense of humiliation at having to depend on emergency supplies influences the victim-clinician processes. The victim’s awareness of having lost a familiar sense of security and independence, without the knowledge of whether he or she will ever regain it, adds to the bitter pain of the present. A percentage of the victims assume a so-called “victim’s” role, with its accompanying expressions of entitlement, learned helplessness, expectations of assistance, and reactions of depression when frustration begins to accumulate (Krystal & Niederland, 1968). All these reactions begin to alter and distort relationships between the individual and his or her support system, since in order to obtain assistance the victim must negotiate and interact with a diversity of people who are just as frustrated and exhausted. For most individuals, these feelings of self-disparagement slowly disappear, replaced by a re-emergence of more characteristic personality traits and social skills.

            Around three months after the disaster the clinicians may begin to identify pathological adjustments in some disaster victims. Chronic anxiety and clinical syndromes increase in the patient rosters.

            However, the majority of the victims reconstruct their lives, physical community structures and homes recapture their old appearance, and the rhythm of normalcy returns to the neighborhoods. Assistance relief agencies finalize operations and leave the affected area. Levels of individuals’ healthy adjustment vary according to an array of variables that interact according to random chance and produce varying outcomes of adaptation. Most individuals seem to achieve resolution of the crisis situation and continue reshaping their individual patterns of adaptation and resignation to the experiences and losses they have survived. What their scars look like and what sad fantasies return when they hear, for example, a rumble reminding them of the beginning of an earthquake or storm are individual secrets.

            Victims show an increased and continuous use of their available support systems for a long time following a disaster. There is a need to share experiences, to have others participate in the traumatic events, and to validate acceptance of behavior that still feels alien to the individual many months after the event. These memories become a milestone that bonds individuals and allows them to share a sense of history unique to the survivors.

 

The Socio-cultural Context of Community Changes

 

All these individual reactions—the emotions, thoughts, and behavior—are embedded in their socio-cultural context. The community, in varying degrees of geographical and social cohesiveness, is also changed after the impact of a disaster. Its socio-cultural manifestations (including religious patters and characteristics) will continue to intersect with (a) the victims’ reactions, (b) the emergency relief operations, (c) the reconstruction, and (d) the support and facilitation of crisis intervention programs. Groups emerge to revitalize the community social structures and affected agencies in the stricken areas. It is important to recognize the characteristic cultural values of a community, identifying the subgroups of family tradition, belief values, and norms when developing post-disaster crisis counseling.

            An important area of such community-oriented post-disaster counseling deals with migrant or immigrant families recently arrived in the United States. The stress this population suffers is compounded by inexperience in dealing with relief assistance requirements. This situation can also be aggravated when the crisis clinician is insensitive to the families’ cultural values or cannot communicate in their language. The conceptual models to work trans-culturally in crisis intervention require additional skills from the clinician. An example of this situation presented itself to a clinician who was asked to assist a Hispanic family that had recently emigrated from Central America to the Los Angeles area. After their small apartment was damaged by an earthquake, they had to live in a rented cellar, where they stored their household supplies. They were asked to document their losses and estimate the funds necessary to purchase some of their lost belongings. When the crisis clinician, who was a professional from their own country, visited them at home, they spread before her their attempts to comply with the official requests. They appeared depressed, frightened, confused, and unable to determine how to proceed any further. They had used all their emotional energy compiling the material, but were not clear as to who should be presented with their handwritten pages. Though this is a typical problem of many disaster victims, it was exacerbated for this family because public agencies are geared mainly to aid mainstream citizens. The clinician helped the family fill out forms and made them aware that she would help them deal with the emotional reactions to their situation and bureaucratic network. The family; gradually revitalized, learned about their community assistance plan, and were able to begin assuming responsibility for their lives again.

            As time goes by for the disaster victim, a sense of competence is regained and victim assistance shifts from the relief operation staff; who begin to leave the community; to the community mental health agencies. Organized religious activity continues, at times with increased celebration of reactivated or re-established rituals, including prayers for the dead and thanksgiving for the living.

 

Planning and Mobilizing Mental Health Intervention

 

To design, organize, and implement crisis-oriented services for victims of disasters, and integrated, interactive, flexible linkage system must exist between mental health organizations and emergency management agencies. Emergency management staff have a long tradition of rapid response, clear operational guidelines for control of community disorganization, and effective methodology to help the victims with basic needs such as shelter, food, and clothing. In contrast, mental health professionals are newcomers to this trauma assistance field in attempting to find the best approaches to (a) collaborate with governmental emergency programs, (b) organize their own systems, and (c) develop models of mental health intervention using the techniques of consultation, collaboration, education, and direct crisis intervention. The next part of this chapter will address the specific steps of planning and mobilization for crisis intervention teams in order to meet the objective of post-disaster intervention in a phase-specific manner. There is a relationship between the time that has passed since the disaster and the appropriate intervention strategies. It is important to realize that while the mental health crisis team is helping the victims, multiple activities are taking place within their own mental health system and within the local, state, and occasionally federal relief operations.

            Although many theoretical conceptualizations exist to help understand the behavior of victims in a crisis situation, the key point in planning for intervention is to choose a model that meets the consensus of the professionals who will be participating in the efforts. Unless there are clear notions of what the mental health team accepts as its mission, the possibility for confusion and failure will influence efforts to alleviate the victims’ problems. The problems which need solutions and the options for modes of intervention are not only the result of the psychological state of the victims, but also result from the impact of the complex bureaucracy which participates in the victims efforts to reconstruct their physical world. The role bureaucracy staff members play in the aggravation or resolution of the victim’s crisis has to be considered an important influence when attempting to understand the victim’s feelings.

            The complexity of becoming acquainted with the multitude of relief agencies and learning how to access their disaster resources for the benefit of a victim is exemplified by the following report by a clinician. One ill elderly couple had contact with HUD and Red Cross before being referred to the crisis team. “In two months of intensive work with the this couple, we worked with HUD and the Mennonites to repair the storm damage to their house, with the Salvation Army and Catholic Charities for temporary financial relief, and with Social Security to investigate Medicare and Supplemental Security Income (SSI) benefits; they were eligible for the former, but not for the latter. We worked with the Department of Public Welfare for food stamps and with the town tax assessors for a tax abatement. One of the victims was hospitalized in the second month span, which involved us with the hospital, homecare, the visiting nurse program, and the Council on Aging. And attempted mortgage foreclosure caused us to contact the Legal Aid Society in the knowledge that the need for services might extend longer than the duration of our post-disaster crisis counseling project. The couple’s health problems, fixed income, and need for rebuilding their life would keep them vulnerable and dependant for some time.” The mobilization of resources after a disaster is an amalgam of traditional assistance and new techniques available to victims of disasters within certain conditions and for a specific duration. How the array of these resources is organized to assist victims of disasters must be a part of the repertoire of crisis clinician’s skills.

 

Planning and Mobilizing

The following principles should be considered when planning a crisis team:

 

  1. All team activities should be guided by tight, practical procedures which will result in economic, short-term, rapid assistance to victims.

 

  1. Decision making and problem solving cannot be effectively carried out without involving some other agencies in the emergency program.  Continuous linkages are part of the team’s efforts.

 

  1. Priority of resources controlled by mental health professionals will have to be apportioned according to careful assessment of the ratio between the very high needs of the victims and the very few available resources.  Mental health assistance activities and interventions must be limited to immediate, practical applications and the most effective modalities. 

 

  1. The mental health professionals will have to apportion a percentage of their time to developing and sustaining current knowledge of all the assistance/entitlements for victims all of which are continually changing.

 

  1. The characteristics of the team’s activities will shift daily as both the victims’ problems and the organization of the governmental disaster aid network develop and change.

 

  1. Effective institutionalized support system for mental health workers should be implemented from the beginning to prevent and control symptoms of burnout.  The “contagion” syndrome for clinicians who become exhausted, over-identified, and obsessed in the need to help victims has been amply documented (Lystad, 1985).

 

 

Implementing: Mobilization of Crisis Intervention Teams

In mobilizing the teams that will enter the field of action, the disaster site itself, the following areas of knowledge will be helpful:

 

  1. The intervention philosophy for mental health professionals will be based on their theoretical schools of thought.  The philosophical position of a mental health crisis team is related to the objectives of intervention as they are translated to (a) operation of assistance methods, (b) participation with human services in an emergency, and (c) relations with other agencies, such as the Red Cross or the local Civil Defense.

 

  1. The development of mental health resource allocation is closely related (a) the objectives of intervention, (b) the number of professionals participating, and (c) their mix of training and skills in emergency procedures.

 

  1. The administrative procedures relating to team formation should be flexible and rapid in order to (a) identify the available professionals, (b) recruit and employ them, (c) organize them, and (d) train them both conceptually and clinically so that they may best acquire the expertise necessary to work in the front lines of the post-disaster site.

 

  1. The framework for intervention implementation should be developed with the objective of a task-oriented, problem-solving approach.  The functions of programs within this objective necessitate specific individualized program action guidelines for the assigned professional in order to identify and respond to the victims needs.  The mental health professional identifies a victim’s problem, sets the therapeutic intervention objectives within the context of the post-disaster situation, selects the services needed, delivers the service, and monitors the outcome. 

 

During a blizzard, tidal flooding damaged a number of homes in a neighborhood.  The victims of this tragedy were left with the task of rebuilding their homes and their community.  Mrs. Brown, a 75-year-old widow living on Social Security, was visiting friends in another town at the time.  Upon her return, she found the first floor of her home covered with water and the foundation, roof, and porch, severely damaged.  Most of her furniture, clothing, and personal possessions were destroyed.  These losses were overwhelming to a woman living alone on a small fixed income.  Mrs. Brown felt upset, depressed, and destitute.  Although she had family living in another part of the state, they took no interest in her predicament and offered neither housing nor financial or emotional support.  A friend offered her assistance and took her into her home.  At first Mrs. Brown was grateful and put up with the lack of privacy, adapting to the family schedule and the discomfort of boisterous children in and out of the house.  After several weeks of this, however, she was unable to tolerate her living conditions but felt helpless and did not know what to do.

            It was at this point that she called the crisis team for help.  The clinician made and appointment and went to the house to meet with Mrs. Brown.  The clinician found her to be alert but sad and pessimistic.  She seemed confused about what she could do to get herself back on her feet.  She expressed anxiety about dealing with the bureaucratic red tape of the public relief assistance program and the length of time she anticipated before any response was received.  She had crying spells when describing how the damage to her home and lifestyle had left her feeling lost and overwhelmed.

            The clinician assessed the condition of her situation, her personality strength, and her level of crisis resolution.  It was clear that she was in need of support and guidance, as her host family could not devote the time and attention to relive her experience and mourn her losses.  Mrs. Brown also needed technical assistance in procuring government aid to fix her house and purchase new furniture and possessions.  The clinician both instructed and guided her through the bureaucratic maze of agencies assisting the elderly victims.  She also worked with Mrs. Brown to recover her self-caring skills.  Three months later, the clinician had to conclude the crisis work, leaving Mrs. Brown on her way to recovering from the impact of the disaster.

  1. The useful data that accumulates during a disaster come from professionals collecting statistics, the news media reporting daily events, and the government agencies that are in charge of disaster assistance planning.  The use of this increasing knowledge will aid in the prioritizing of resource allocation through choices of strategies and the deployment of personnel.

 

Roles and Sills in Post-Disaster Intervention

 

        The role of the post-disaster crisis clinician who is a member of the emergency program is still ambiguous.  Both subjective and objective aspects of the role contribute to these unclear perceptions.  The professional who participates in post-disaster work usually has developed clear guidelines to deal with individuals who are labeled “patients”.  When the clinician must assist and individual who is a victim of a disaster but is not “sick”, or when a Red Cross worker observes the work of a mental health professional in the front lines, misperceptions on both sides cloud the understanding of the role functions.

            The evolution of this role can be found in some counterpart of emergency trauma and hospital crisis units.  Novel expectations of mental health professionals, both for themselves and others, produce role discomfort and confusion.  Although clinicians are sincere in their interest to assist the victim, they convey a sense of being unsure of their own and others’ expectations in mental health activities.  They are hesitant and unclear as to the procedures of participatory activities.  It is important to train the clinician to be prepared to adjust to the unfamiliar situations of emergency disaster work and to develop methods for dealing with the reality of difficult access and rapid use of only minimal data.  Experience will help shift traditional attitudes to develop flexibility in collaborating with other disaster aid professionals.  In working with colleagues such as the Red Cross, a federal management agency, or the local Civil Defense, problems such as trust, communication style, and lack of familiarity of mutual tasks emerge.  These are long-standing traditions that guide the behavior of different emergency assistance agency workers.  Their guidelines have produced problems with mental health professionals in their quest to collaborate. 

            The problems that have been documented in several disasters are related to professional differences in cultural and value systems and conflicting ideologies of how to help disaster victims.  Problems also arise from different role expectations, within both the mental health teams and the relief agencies staff.  Status and professional behavior norms are coupled with differing methods of working within the various mental health disciplines (e.g., social workers, nurses, physicians) that generally comprise a disaster assistance team.  Professional boundaries, as they exist in a clinical setting, not only define the structure and capacity of the clinical services, but also the domain and responsibilities of the clinician.  A wide range of services is mobilized, including counseling, advocacy, moving assistance, transportation, in response to the enormous needs of the community.  This array of needed assistance presents a dilemma to the crisis clinician on the front line who may be the only professional assessing the crisis situation.  The clinician needs to set the limits and boundaries as well as prioritize, as it becomes painfully clear that the clinician cannot fulfill all the needs encountered.  Within the setting, two themes have emerged as difficulties to clinicians trained in traditional procedures.  One of these is the strategy of entering the victims personal “space” and intimate life without having been asked for help, in the ritualistic manner of making a priori assessment of the type of problem presented by the individual, and before appointments are given at most clinics.  The outreach methodology is the primary means of making contact with the victims in a crisis situation.

            The second area concern to clinicians is the substantially increased degree of dependency bonds in the midst of post-disaster events due to the level of trauma, suffering, pain, and the helpful and generally altruistic efforts of the clinicians in assisting in all types of capacities.  Some of the feelings are expressed by a clinician with whom I worked with in one post-disaster program: “Our goal as workers using an outreach program required that we adopt two seemingly conflicting roles of ‘active-advocate-mobilizer’ and ‘passive-receptive-counselor/therapist.’  We continually needed to shift between these roles as the victim’s situation dictated.  In a clinical situation, the worker’s role is clearly defined as a counselor-therapist; thus the issue of occupying different stances with the individual which we are aiming to help does not arise.  The issues we faced in disaster crisis counseling were, one, our need to define our role and the nature of the relationship; two, to set limits on that relationship as it developed; and three, the power that we had to assume to deal with all the agencies, tending to be perceived by the victim as their ‘hero’.  We also needed to become aware of our projected sense of omnipotence and rescue fantasies.” 

            When developing the role configuration, consideration must be given to the continuously shifting context in which the victims find themselves; there is a constant relocation of groups, different housing settings, and new directives from governmental authorities in charge. Standard behavioral guidelines should be developed and implemented to facilitate informed and efficient problem solving among all the organized disaster relief professionals, who continue to shift roles as time passes. Agreements on how to process resources as part of crisis intervention and techniques to diminish the intensity of conflicts must be achieved in order to function effectively.

 

Clinical Issues

Skill Needed to Develop Crisis Intervention Assessment

Assessing the current post-disaster situation surrounding the victim’s life setting guides the first approach in evaluating the current crisis stage.  The awareness of the post-disaster time frame impact-recoil will guide the procedures that should be instituted to help the victims cope by gaining a sense of control over their shifting, unfamiliar, and stressful environment.  Following are some helpful guidelines for post-disaster crisis intervention techniques.

            Generally, the clinician will make contact with the victim days or weeks after the disaster.  In order to develop and establish a relationship with a victim who is showing distressed behavior, the clinicians should familiarize themselves with the expected individual post-disaster reactions as documented in the literature.  Each phase of the post-disaster sequence will have a unique configuration of needs, crisis reactions, and available resources.  These variables have major influences on the choice of techniques to implement crisis intervention.  Throughout the phases, the clinician should combine an attitude of support within the utmost economy and efficiency of time usage, a diffi9cult factor for many traditionally trained clinicians.  A balance must be struck between expressing empathy and reinforcing and rewarding the so-called “victim’s” role.  The clinician should support the healthier parts of the victim’s personality and mobilize them to enhance the ability to hang on for the immediate future. Short time-lapse intervention on a daily basis, serving to increase the psychologically painful awareness of the trauma, characterizes the initial techniques to be applied the victims.

            After promptly establishing a helping relationship with the victims, the clinician must initiate on the spot a rapid appraisal of key problem areas and immediate assistance in mobilizing all disaster relief resources, including establishing a relationship with the relief or Red Cross workers.

            Techniques used to rapidly achieve these objectives are defined as any active interaction that tends to supplement, complement, reinforce, or promote the ego mechanisms of the victims.  The range of procedures (behavior, action, speech, face-to-face interactions) through which this therapeutic process occurs will depend on the characteristics of the situation encountered by the clinician.  The objectives of therapeutic crisis intervention encompass all types of activity by which the clinician seeks to relieve the distress and modify the behavior of the victim through psychological methods.  It encompasses all helping activities based on communication that is primarily, although not necessarily, based on language.  Many of these traumatized individuals display a sense of hopelessness and demoralization.  All forms of therapy use certain approaches to combat and control this painful effect.  The behavior of demoralized victims reflects the feeling of being unable to cope with the multiple problems they are expected to handle.  This state of mind can vary widely in duration and severity, but the following manifestations are often found among the victims:

1.      Diminished self-confidence

2.      Confused feelings and thoughts in reaction to the new, uncomfortable, unfamiliar world

3.      Belief that failure will be the outcome of all their actions and decisions

4.      Feelings of alienation, depression, and isolation

5.      Feelings of fluctuating resentment and anger resulting from the seeming inability or unwillingness of others, upon whom the victims depended, to help the unconscious feelings of entitlement that are part of the so-called “victim’s” role and the accompanying sense of frustration and disappointment create a vicious circle between the victims, families, and crisis workers.

6.      Increased negativistic reactions and diminished faith in the group

 

 

            The variations, complexity, and severity of crisis reactions encountered by the clinician as the weeks elapse present a challenge in developing intervention approaches.  The following example identifies the multilevel activities developed by a worker in her quest to assist a family.

 

Mr. Gordon, his wife, 47, and their five children are a white, middle class family who were the victims of disaster.  Mrs. Gordon, while housed in rooming donated by a church near the disaster site, contacted the post-disaster relief team to ask for help and because she wanted to find out if she was crazy.  She sat down in the clinician’s office and reported that she had noticed her feelings and behavior changing.  She had heard from neighbors that behavior changes were expected after the trauma of the tornado which had frightened the family and damaged their house.  In spite of this knowledge, she thought that what she was experiencing was beyond the normal post-traumatic reaction.  She described feeling of depression, crying spells, and the inability to carry out her usual household routines.  Nothing interested her, and she had difficulty managing her children.  Her social drinking patterns had increased and her friends were worried about it.

                The family’s home had been damaged, they had received assistance from government agencies, and workers were due to start repairs.  Although this part of the upheaval appeared to be proceeding in satisfactory manner, the family was experiencing serious difficulties.  Most of Mrs. Gordon’s complaints and expressions of her difficulties centered on a husband who was suffering from multiple sclerosis, resulting in restrictions on movement.  Despite this disability, he wanted to control all the house repairs and assistance money received from the agencies.  Mrs. Gordon felt this added to the complications caused by the house repairs and thought Mr. Gordon should be housed with relatives while the workers were in the house.  Her marital situation, already shaky, had worsened and she felt trapped.  In the past she had been able to function with strong, realistic defenses and support from her friends.  At the time she came to the clinician, everything seemed to be falling apart.

                The clinician interviewed the husband, the two as a couple, and the family as a whole in order to assess their psychological state and to hear their perception of the family’s problems.  The clinician was able to ascertain that Mrs. Gordon was exerting excessive control in order to deal with her feelings about the trauma, felt responsible for the family’s problems, and was unable to relinquish responsibility for the complex array of activities needed to deal with the disaster assistance bureaucracy.  Her ability to handle the reality of her life and process her emotions had suffered as the result of the tornado and its effects on the family’s living situation, was ineffective, and had precipitated a crisis.  The clinician helped Mrs. Gordon reassess and reevaluate her current situation.  By getting relief through verbal expression of her feelings, then by collaborating with her husband rather than trying to control his dealings with the repair workers, she gained better control of her emotions.  She was also helped to recognize her own internal feelings and how they related to the unfinished work of resolving the trauma she had sustained.  As she noticed an increase in her efficiency, she began feeling more positive about her family.  The clinician supported her in her difficult situation and expressed appreciation of how well she had managed the bureaucratic conditions to get the house repaired.

 

Such as example highlights the types of crisis intervention techniques used with victims after the basic, concrete assistance has been rendered to repair their living conditions, which for many individuals is simply not by itself adequate.  This family had many problems before the disaster took place.  The tornado unleashed latent family relations problems, aggravated by the unresolved crisis of Mrs. Gordon.  The intervention boundary between crisis resolution and family therapy remains a difficult issue for mental health clinicians who participate in this type of work.

            Aspects of crisis components can be categorized within certain sequences:

(a)  impact of the stressful event (the disaster),  (b)  the perception by the victim of the event as a meaningful threat,  (c)  the victim’s response to the stress, and  (d)  the adaptation outcome level of functioning at every sequential post-disaster level.

            Based on the theoretical construct, the understanding of the stress response, resolution, and reorganization behavior will guide the intervention procedures step by step.  This has important implications for the development of skills, the use of human resources, and the evaluation of the effectiveness of the intervention techniques.

           

 

Identification of temporal and phasic aspects of the affective and emotional expressions in the crisis counseling process includes the following:

  1. Cognitive confusion affected by anxiety:
    1. Assist in identifying the problem and clarify aspects of need.
    2. Guide evaluation of reality and help in reconstruction of event.
    3. Participate in formulating and evaluating priorities and make current knowledge of available resources for the victims.
  2. Structure disorganized behavior toward realistic goals:
    1. Correct the victim’s cognitive perception of the situation by acquiring and sharing knowledge about the impact of the disaster.  What “hardships” has the disaster produced for the victim?
    2. Help in the management of affect by assisting in labeling and expressing the victim’s emotions.  By being told that irrational attitudes are to be expected in such a catastrophic experience, the victim is assisted in restructuring expectations allowing internal sensations to change, and finding more comfortable behavior.
    3. Indicate the methods available in seeking additional help from the emergency resources by listing tasks necessary for problem solving.  This will reinforce the victim’s cognitive grasp of reality and sense of capability, and will assist in restructuring the victim’s new environment.

 

 

Intervention Techniques According to a Coping-Adaptation Model:

Steps in the Crisis Intervention Model

Post-Disaster Crisis Intervention

The following steps highlight the sequences followed by mental health teams assigned to work in post-disaster situation.  Before starting the assistance operations, the team will have obtained data available from the new media describing the type, extent and impact of the disaster.  The chance to mobilize a team to enter the disaster site a few days after public officials have organized relief operations offers the mental health clinicians a challenging opportunity.  The mental health clinician will need to obtain sanction and legitimacy to enter the relief operations setting, which is generally organized and controlled by local officials and the Red Cross.  The senior staff representative of the mental health crisis team can establish lines of communication with the head of the relief operations and receive permission to send in the mental health team.  Once the team enters the site, the stage is set for the first phase of crisis intervention within the shelters where victims are transitionally housed in large numbers.

            Three types of investigations are necessary to develop objectives and deploy the use of resources:

  1. What are the characteristics and schedules concerning victim housing?  Generally, victims are housed in buildings that have ample space, are safe and provide necessities such as bathrooms and kitchens.  If these are not available, makeshift spaces are provided by tents, mobile homes, or barracks.  In these settings, the team needs to identify and link into the network of other assisting individuals, guided by the knowledge of sanctions for the mental health operation obtained beforehand from the presiding representative in the formal hierarchy of the relief command.
  2. What are the characteristics of the victims (age, gender, ethnicity) that are gathered in the setting?  A rapid needs assessment of the displaced, traumatized population will aid in planning the team’s activities.  Fro example, do the victims have few resources with which to rebuild their lives (as with elderly, handicapped, single mothers)?  Are there many families that have lost one or more of their members through death or disappearance?  Whether the needs are minimal, moderate, or severe, a mental health intervention will have to be prioritized due to lack of sufficient resources to help all who need it.
  3.   How are collaborative procedures, including referral and follow-through, with governmental and voluntary agency staff to be identified, designed, established, and implemented.  One method is to have a representative of the mental health team introduce, describe, and explain the services offered by the team, as well as their schedule and location.

 

 

Procedures During the Acute Post-Impact Stage

A triage operation is instituted during this first phase of post-disaster assistance.  The triage operation precedes crisis operations, setting the stage for initial assessment of victims who are showing signs of psychological de-compensation and immediate need of assistance.  The triage operation entails assessing the severity of the symptoms, some of which may include insomnia, inability to swallow, continuous crying, disorientation, or inability to follow the rules of the shelter.  A rapid evaluation of the appropriateness of the victim’s reaction at this stage after the crisis will help decide what psychological and medical procedures are needed.  Through this method, a group of victims which will require crisis intervention for the first few weeks after the disaster is identified.

 

Recoil Post Disaster Phase 

The setting for crisis intervention is generally made when victims are moved to transitory housing or go back to their own, possibly still damaged homes.  The teams are organized to develop the outreach-advocacy objectives and begin to identify individuals in need of services through referrals, door-to-door research, or word of mouth.  Educational publicity in this respect can substantially increase the clinicians’ effectiveness.

 

A Red Cross worker requested assistance with a 38 year-old single white woman who appeared to be anxious and angry.  The woman was complaining of not receiving the services she was entitled to as a victim.  The responding clinician found that the woman had lost her apartment because of severe damage from a tornado and had been shifted to three transitional settings.  She was told to find a more permanent place by herself.  She complained of feeling weak and helpless to find a place at a rent she could afford.  She also felt entitled to government assistance but was not receiving it.  Due to her psychological distress, this woman was unable to use her usual capacity to mange her life or articulate her needs in a socially acceptable manner.  The mental health clinician helped her ventilate her anger and disappointment at her losses and, with the help of the Red Cross worker, guided her through the steps of locating a living place, obtaining rent assistance, and regaining her usual competence.

 

Phase-appropriate and stage-specific post-disaster work is related to the stages of crisis resolution in the majority of victims.  Some individuals will not show the signs of discomfort until several months after the disaster, while others will recuperate from a crisis quickly but will again show signs of de-compensation shortly afterward.  The bulk of the work is implemented within a certain period of time for which the team has been p[aid or assigned.  The outreach, selective approach of finding victims and working with them in association with the agencies deployed to assist in post-disaster programs has a time limit.  After this period, mental health clinicians return to their offices, where victims may later appear.  This gives the clinicians the opportunity to continue the crisis intervention techniques.

            Throughout all the phases, the following underlying guidelines characterize the procedures:

  1. Help the victim develop an awareness of the problems facing him or her, their extent, and the priority of solutions ------ “first things first.”  This challenges the clinician’s skill in precisely identifying the problem on the spot and, on the basis of rapid and accurate diagnostic assessment, helping to reduce the victim’s anxiety.  Data at this phase are generally absent, faulty, or minimal.
  2. Respect the use of denial as an initial reaction to stress and handle it slowly and gently, but firmly delineate the victim’s situation.
  3. Support active management on the part of the victim and discourage regression, passivity, and dependency.  Do not take over the victim’s life.
  4. Immediately demonstrate helpfulness by meeting some of the reality-based needs of the victim; anticipate this possibility.
  5. Express confidence in the victim’s ability to manage the situation, while offering support for the steps necessary to achieve solutions.  This hopeful, contagious feeling is important to impart to the victim, who is feeling helpless and hopeless, although it may be difficult for the clinician to sustain the feeling for long periods of time.  The support system for crisis clinicians in disasters (including specific rest and recreation periods) should be implemented in all service programs.

 

 

Summary

 

Post-disaster crisis intervention is emerging as a new type of intervention and participation of mental health teams in relief operations following a catastrophic disaster.  Well-organized and operationally defined structures are in place to help victims with shelter, food, loans and medical help.  The incorporation of mental health services must be designed to match many of the organizational characteristics of the total relief system, including speed of operation, flexibility of format, and collaboration and integration with the efforts of other professionals.  The total efforts generally operate under a schedule of intense activity, ending at a certain predefined date.  The mental health crisis team activities may end with the official efforts or may continue after team members return to their office settings.

            Crisis counseling to directly assist victims in the post-disaster stages of impact, recoil, and recovery may or may not parallel the stages of crisis resolution. 

Victims may show the typical sign of crisis stages, starting in the first weeks after the disaster and proceeding to resolution with the assistance of the mental health clinicians, or they may not display such signs immediately and may appear weeks later with acute crisis symptoms and asking for help.  The techniques that will prove useful are based on traditional skills, but differ substantially in their application due to the following:

  1. The intensity of the acute traumatic impact on the victims and their personal “space.”
  2. The complexity of interacting with professionals assigned officially by governmental relief operations having the power to dramatically affect the victims’ lives
  3. The high ratio of victims’ needs to mental health resources
  4. The rhythm and rate of change in the relief operations sites, from the acute stages to the transitional and final operations
  5. The novel, untried, unfamiliar, and conflicting roles of the crisis clinician in the different settings (e.g., shelters, door-to-door inquiries, storefront offices)
  6. The need to apply prompt crisis counseling assistance in situations where data are missing, where interview formats differ from the usual, and where privacy/confidentiality rules may not apply

 

            The specialized context in which the intervention must be applied demands from the clinicians, additional knowledge, skills, and attitudes not usually acquired in the day-to-day operation of mental health institutions.  Preparation and planning for disaster events is increasingly being instituted by many mental health units in the United States.