Crisis Intervention
Handbook
and Research
Edited by
Albert R.
Roberts, D.S.W.
Wadsworth Publishing Company
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.
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.
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
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:
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.
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
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.
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.
The following
principles should be considered when planning a crisis team:
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:
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.
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:
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:
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:
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:
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