Chapter 4
Training
Mental Health Professionals to Work With Families in
Diverse Cultural Contexts
Raquel E. Cohen,
M.D., M.P.H.
A Guide for Mental Health Professionals
(Ed)
Linda Austin, APPI,
Mental health intervention following disasters is becoming an important
area of participation for mental health professionals (Ahearn and Cohen 1984).
Its evolution has been influenced by national and international events that
have highlighted the importance of psychological trauma in catastrophic life
events. These events fall under several categories, including natural
disasters, catastrophes caused by humans, and combinations of the two, The
Three Mile Island radiation accident in March 1979 10 miles south of
Harrisburg, Pennsylvania (Bromet 1980), the June 1972
destruction in two counties in Pennsylvania (Luzerne and Wyoming counties) by
Hurricane Agnes, and the Buffalo Creek Valley, West Virginia, flood in February
1972 (“Disaster at Buffalo Creek” 1976; Gleser et al.
1981) are good examples of these categories. Although such disasters involve
large numbers of individuals, national concern arises also for single
individuals who are the victims of kidnapping or hostage sitiations.
If national expectations demand a well-trained cadre of mental health
professionals, the form and requirements of such training must be determined.
Such training must take into account the need to deal with diverse situations of
multicultural societies that are affected by the disaster. This is especially
true when the disaster occurs in an area where certain cultural groups
congregate within small geographical boundaries: such as the tornado that
devastated the town of
RESPONDING
TO DISASTER
In this chapter I address these cross-cultural issues. Certain
components of high priority in the training of mental health professionals are
emphasized.
The Caregiver
The training of mental health professionals must take into
consideration the knowledge, attitudes, and skills arising from a diversity of
cultural and educational backgrounds that they will bring with them. Cultural
attitudes strongly influence the communication and response style of a disaster
worker. These attitudes are deeply ingrained in the psychological systems of
giving and asking for help. They also play a role in the psychology of victimization
so that understanding and respecting the cultural values of the victims are
part of the knowledge needed in disaster response.
These factors will have to be considered when designing a curriculum or
practicum exercises. A simple questionnaire can be given to the workers,
itemizing some key characteristics of their own cultural backgrounds. This will
be helpful to the trainers developing the curriculum, who can then incorporate
helpful guidelines addressing the interaction between the worker and the
victim.
Role Definition
The role of the mental health professional within the postdisaster emergency relief agency staff is currently
poorly defined (Cohen and Ahearn 1980). Mental health professionals are
beginning to enter the well-organized governmental and Red Cross programs,
which have operated for a substantial time in this field and which have already
developed roles, responsibilities, and clear guidelines for responding to
individuals who are victims rather than “patients.”
The theoretical focus of the mental health professional must be shifted to a
new system of guidelines that foster the development of knowledge, skills, and
attitudes for working with individuals who are not sick, but traumatized. The
evolution of such a role can already be found in some emergency trauma and
hospital crisis units. The novel expectations of mental health professionals,
both for themselves and others, can produce role discomfort and confusion.
Diverse
Cultural Contexts
Although professionals are sincere in their
desire to assist victims, mental health workers are still not sure of their own
and others’ expectations regarding their activities. As they are trained, they
should be prepared to adjust to the unfamiliar situations of emergency work in
disasters and to develop methods of dealing with the reality of only minimal
available data. Experience will help them to shift traditional attitudes in
order to develop comfort and flexibility in collaborating with other disaster
aid professionals. It becomes the task of the mental health team leader to
define the mission and scope of the team’s efforts and to communicate these to
the team.
In working with colleagues from such agencies as the Red Cross, the Federal
Management Agency, Civil Defense, and local law and rescue agencies, problems
in certain areas may develop, such as disclosing confidential material,
combining responsibility for mutual iasks, and
respecting other value systems and communicating styles. Mental health workers
may find themselves in conflict with long-standing traditions that guide the
behavior of other disaster and emergency program workers. Often, the authority
o make broad decisions rests with the lead government postdisaster agency. Some of these decisions may, at times,
be made without consultation pr consideration of the mental health implications
for victims. Such events have produced problems for mental health professionals
in their attempts to pursue collaboration and cooperation (Lystad
1988).
Role Configuration
Mental health workers are aware of status and professional
behavior norms, which form a value system and “school of thought” within
professional groups. In traditional clinical settings, professional boundai es are relatively clear,
defining the structure and responsibilities of clinical services. A very
different situation exists postdisaster, where there
are enormous demands placed on mental health professionals in response to the
needs of the community. The professional must set the limits and boundaries and
prioritize the needs and resources as it becomes painfully clear that all needs
encountered cannot be met. In this outreach situation, the mental health
professional may be required to move from the role of “passive-receptive
therapist” to “activeadvocate mobilizer.”
As these role configurations develop, consideration must be given to the
continuously sifting context in which the victims find themselves, reacting to
abrupt relocation, differing shelter arrangements, and daily announcements of
new directives from governinental authorities.
These constantly shifting scenarios changc
the mental health worker setting, demanding new, nontraditional mental health
skills and attitudes. As both the public media and the governmental
disaster assistance workers tackle major human issues arid problems, they often
turn to the “expert” for help. Such demands may include responding to newspaper
reporters, participating on a television special, presenting a talk to school
personnel, or acting as a consultant to the housing authority. These types of
expectations from the community at large mold the role configuration of the
disaster assistance personnel.
As workers become more experienced and comfortable with active outreach
behavior, they may begin to anticipate needs and “invite themselves in” to
become part of the community disaster response. This occurred in a community
that had part of its city devastated by an ocean storm. The mental health
worker phoned the medical reporter of the principal newspaper and suggested
printing in the next edition a list of the expected psychological reactions to
the disaster by age occurrence, so as to alert the readers and establish the
fact that these were normal responses to a disaster. This list was printed in
the next edition of the newspaper, and the responses of the public validated
the helpfulness of the mental health approach.
The
Victim
Many factors influence the degree of stress response experienced by
a family system in a crisis, including the nature of the disaster (e.g.,
earthquake, hurricane, tornado, chemical spill), the type of property affected
(urban or rural), and the community resources available for prevention and
treatment of the secondary stressful effects of disorganized agency systems.
Characteristics of the families affected, such as ethnicity, acculturation
levels, socioeconomic status, value systems, and traditional methods of dealing
with stressors, will also play a role in the recovery from the trauma. A
particularly important value is the relationship of human beings to nature,
which can be critical in understanding differences in the pattern of disaster
response in diverse cultures.
Diverse
Cultural Contexts
For example, familiarity with the traditional kinship structure of
Hispanic families (Kiuckhohn and Strodtbeck
1961) shapes an understanding of how such individuals will respond to a
disaster when facing issues such as search and rescue, providing aid to
survivors, and sharing precious resources (e.g., food, water, and shelter).
This understanding is necessary to develop organized mental health intervention
programs. The Hispanic family is a kinship-oriented group and exhibits a
reluctance to interact with the more formalized, nonkinship
disaster operation approach with its shelters, organized work groups, and
scheduled logistics.
Another social institution that must be considered together with cultural
groups is organized religion. Religious groups are often involved
organizationally in a wide scope of assistance activities, such as providing
clothing, food, and shelter to victims, as well as providing traditional
religious functions, such as burials and offering solace to the survivors.
The variability in form and severity of crisis reactions encountered by
professionals working in a postdisaster Situation
presents a challenge to developing intervention approaches. The following exam-
pie illustrates the multilevel activities developed to assist a family:
Mr. Gonzalez, age 49, his wife, age 47, and their five children had recently
immigrated to the
The family’s home had been damaged, but they had already received financial
assistance from government agencies, and workers were preparing to begin
repairs. Although this component of the upheaval was proceeding in a
satisfactory manner, the family was still experiencing serious troubles. Most
of the wife’s complaints and expressions of difficulties centered on a husband
who was suffering from multiple sclerosis, resulting in difficulty of movement
and mood swings. Despite this disability, the husband wanted to control all
aspects of the home’s repair and the distribution of the funds received from
government agencies. Mrs. Gonzalez felt her husband’s attitude added to the
complications associated with the repairs and thought he should be housed with
relatives while the workers were in the house, Her marital situation, already
shaky, had worsened, and she felt trapped. Although previously she had been
able to function with strong, realistic defenses and with support from her
friends and relatives, she now felt that everything was falling apart as her
nearest family members had also suffered in the disaster and had been forced to
move to other parts of the state.
The crisis intervention professional interviewed the husband, the couple, and
the family to assess their psychological condition and hear their perceptions
of the family’s problems. She was able to perceive that the wife was using
excessive control to deal with her feelings about the trauma, felt responsible
for the problems that the family was having, and was unable to relinquish
responsibility for the complex array of activities required. The ego capacity
needed to handle the reality of her life and process the emotions resulting
from the tornado and its effects was ineffective and had precipitated a crisis.
The professional also learned that the family’s cultural tradition regarded the
husband as the head and in control of the family, a role he did not want to relinquish.
The professional, sensitive to this traditional value system, helped the wife
to reassess and reevaluate her situation, showing her how the mix of traumatic
events, traditional values, and her need for extended family ties were
exacerbating the postdisaster crisis resolution
process. By allowing Mrs. Gonzalez relief through verbal expression of her
feelings, then guiding her into collaboration with her husband, rather than
attempting to control his interactions with the repair workers, the professional
helped her gain control of her emotions.
The wife was also helped to recognize her own internal feelings and how they
remained a part of the unsolved and unfinished processing of the experiences of
immigration and the subsequent disaster trauma. As Mrs. Gonzalez became aware
of her increased efficiency, she began to feel more positive about her family.
The worker supported her in her difficult reality situation and showed
appreciation of her management of the bureaucratic requirements to get her home
repaired despite her unfamiliarity with the “Anglo” procedures for obtaining
the needed resources to assist her family after the disaster.
Diverse
Cultural Contexts
Such an example highlights the types of crisis intervention needed
for victims after the basic, concrete postdisaster
assistance is rendered 10
normalize living conditions. For many individuals, such assistance
is not all that is required. The Gonzalez family had many problems before the
tornado struck. The disaster unleashed latent problems in family relations,
which were aggravated by the unresolved family crisis.
Basic Principles to
Formulate Postdisaster Mental Health Intervention in
a Multicultural Setting
How mental health problems are defined influences the interventions
that are chosen and implemented. In the case of a postdisaster
crisis reaction, one useful conceptualization is based on a bio-psycho-sociocultural model of the individual’s functions. The
human crisis reaction that occurs in an individual after a disaster’s sudden
and intense impact is related to 1) age, gender, ethnicity, and economic
status; 2) personality structure and usual coping defenses; 3) perception of
stressor impact on his or her life; 4) the “fit” between the individual’s needs
and the availability of support systems; and 5) length of the period for
resolution of the problems produced by the disaster. As the victim’s
biological, psychological, social, and cultural systems are affected, the
victim strives to recover his or her usual level of functioning (Cohen and
Ahearn 1980). The degree to which such processes succeed depends on many
factors in the environment and within the individual. As the professional
encounters the manifestations of human reactions to traumatic events, it is
helpful to conceptualize the developmental phases of such manifestations (Cohen
1985).
The postdisaster sequences appear to be
associated with the following psychological and emotional reactions.
The range of emotions expressed immediately after an individual
realizes he or she is alive but traumatized by an event can include fear and
anxiety, often masked by defenses such as denial and projection. Other emotions
begin to appear as physical efforts become necessary to obtain safe shelter and
knowledge regarding the location and condition of loved ones. Fear, anxiety,
tension, and worry continue to manifest themselves, adding to the burden of the
victims’ wish for control as they struggle to survive and cooperate with the
efforts of emergency assistance teams.
As time passes, behaviors change to show different ways of managing emotions,
including many levels of depression produced by the victims’ losses and changes
of life-style. Frequent moves between temporary shelters may interfere with
individuals’ abilities to cope. Many cultural issues are raised by these living
conditions, where individuals of different cultures are congregated and managed
by an agency staff who have little knowledge of the victims’ traditions or who
may, themselves, be overwhelmed by their responsibilities and disruption of
their own lives. An understanding of the variations and sequences of emotions
and behaviors, based on cultural traditions and values, is at the heart of
crisis intervention. Transcultural issues require
modifications of aspects of crisis resolution processes that have been
incorporated into clinical practice when dealing with “mainstream
In disaster settings, the victims’ self-esteem may be easily damaged as
conflicts arise when victims’ need to ask for help collides with workers’ own
beliefs about and skills in delivery of assistance. This conflict may be
accentuated when victims perceive themselves as dependent on caregivers from a
different culture or country. An empathic position is vital in responding to
the victim’s humiliation when forced to seek emergency supplies. These are but
a few examples of situations that will influence the transculturally
oriented configuration of the victim-helper (dependency-authority/power)
relationship. Cultural traditions and values cut across all of these
situations, affecting the amount of help that can be accepted or offered.
Postdisaster: Late State
The majority of the population will recover within 6—12 months
after a disaster, returning to predisaster
personality traits and social skills. Some victims may have difficulty reaching
this normalization stage, presenting some of the pathological adjustments of
chronic anxiety, mild to moderate depression, and difficulty with their jobs
and family life. The degree of individuals’ healthy adjustment will vary
according to an array of variables interacting with characteristics of the
disaster and the social aftermath.
This social aftermath, which is shaped by the
victims’ sociocultural context, interacts with 1) the
victims’ psychophysiologic reactions, 2) the
emergency relief operations, 3) reconstruction efforts, and 4) the support and
facilitation of crisis intervention programs. As time passes, the community
regains Its functional level. Organized religious
activity is generally found in locations with large numbers of immigrant
families, characterized by increased celebrations of reestablished rituals,
including prayers for the dead and thanksgiving for the living.
Theoretical
Basic Knowledge to Assist in Transcultural Crisis
Intervention
Studies exploring the related problems of loss, mourning,
separation. coping, and adaptation in families
of different cultures in the
Another area of importance having a bearing on many of the diverse cultural
groups in the
As a representative of a community effort, the menta1 health professional will
be part of the influential organized postdisaster
response of the community as it attempts to assist victims in an effective
manner. By incorporating a transcultural intervention
model, the professional will have the opportunity to anticipate and minimize
the effect of the stressful situation produced by the disaster on an immigrant
population. Components of the transcultural
perspective are outlined in Table 4—1.
Summary
The training of mental health professionals for
participation with our colleagues in postdisaster
assistance work merits the attention of educational institutions. In the
Knowledge, skills, and attitudes for working with families of different
cultures should be incorporated into the overall curriculum content of postdisaster training. The process of crisis resolution is
influenced by internal and external factors, incorporating internalized value
systems, role expectations, and traditional use of support systems and
community resources. The multicultural living patterns of populations
congregating in differnt parts of the
The techniques that should be modified and incorporated into postdisaster intervention are based on traditional skills.
They differ substantially, however, in their application, according to 1) the
intensity of the acute traumatic impact on the family and their “life space,”
2) the complexity of interaction with professionals officially assigned by
governmental relief operations who have the power to affect the families’ lives
dramatically, 3) the high ratio of families’ needs to mental health resources,
and 4) the novel, untried, unfamiliar, and conflicting roles of the crisis
intervention professional in atypical disaster settings (e.g., shelters,
damaged homes, motels, storefront offices).
Table 4—i. Components of the transcultural
perspective
Cultural factors to be
considered In crisis Intervention
1. Migration and citizenship
status—level of acculturation
2. Gender
and parental roles
3. Religious belief
systems
4. Child-rearing
practices
5. Use of support systems (including extended family)
Clinical issues
1. Language dominance—assessment of use of language to ascertain
reporting of symptoms, level of distress, and explanation of victim’s
“worldview”
2. Application of appropriate methodology to identify the
cultural characteristics of the stressed family
3. Use of a transcultural
frame of reference to interpret the crisis resolution behavior patterns of the
family
4. Use of a transcultural methodology to
organize the data obtained through different evaluation modalities
(bio-psycho-socio-cultural) so as to identify the appropriate level of coping,
crisis signs, dysfunction, or any DSM-lll-R (American
Psychiatric Association 1987) syndromes
5. Use of hypotheses, incorporating crisis theory and a transcultural perspective, to understand the influences
bearing on coping and postdisaster adaptation as a
final process of adaptation and resigation. V
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