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,
Washington (1992)

ental 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 Saragoza, Texas, in May 1987, an area inhabited primarily by Mexican American families.

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 United States from Honduras when a tornado damaged their home. Mrs. Gonzalez contacted the mental health team located in a church near the disaster site to ask for help to find out “if she was crazy.” She met with the worker in the mental health team office and reported noticing that her feelings and behavior were changing. She had heard from neighbors that behavioral changes were to be expected after the trauma of the tornado. Despite this knowledge, she thought that her experiences went beyond the normal “posttraumatic reaction.” She described feelings of depression, crying spells, and inability to make up her mind about household routines. She had no interest in anything and found it difficult to manage her children. Her normal social drinking had increased, and her friends had expressed concern about it.
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.
Immediate Postdisaster State
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 United States populations.”
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 United States are sparse (Sandoval and Dc Ia Roza 1986). A biopsychosocial intervention model in posttraumatic crisis stresses the individual’s capabilities for adaptation, which develop in interaction with the family and community environment. Variations in coping styles are related to cultural “human programming” and psychophysiologic reactions to stressors. Although the area of research into reaction to catastrophic stressors in families of diverse cultural background is still evolving, and sufficient knowledge of the specific cultural repertoires of different families does not currently exist, awareness of the transcultural stance, sensitivity, and a need to obtain the victims’ “woridview” of the situation are being addressed in the training of professionals working with such families in crisis (Szapocznik and Kurtines 1979). As we apply some of the knowledge obtained in different studies, the relationship of competence and socialization to attitude, self-esteem, and self-concept will affect postdisaster crisis resolution. These variables, supported by cultural mores and personality structure, will have an effect on the adaptive success of an individual’s interaction within the environment of postdisaster reorganization.
Another area of importance having a bearing on many of the diverse cultural groups in the United States is the experience of “uprooting” (Coelho and Ahmed 1980). Uprooting, as a human experience, may be accompanied by depression and desolation. The same experience can, however, also offer a challenge, increasing coping and adaptation skills. As individuals are separated from their familiar social and cultural support systems, they are vulnerable to the consequences of change, while also challenged to develop different approaches to life patterns. The adaptation outcome may be an area of inquiry when working with a postdisaster multicultural population. It can be conceptualized by the interactions of vulnerability measures (migration and crisis), as reflected by the level of acculturation of the family and participation within the affected social environment after the disaster.
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.
The training of mental health professionals for participation with our colleagues in postdisaster assistance work merits the attention of educational institutions. In the United States, all categories of mental health workers are learning to intervene and participate in postdisaster assistance work. Well organized and operationally defined structures are already in place to help victims obtain shelter, food, loans, and medical help. The incorporation of mental health services, targeted to families of different cultures affected by a disaster, must be designed to match many of the special characteristics of the cultural norms of the group. Additionally, these services must be designed to interact with the organizational characteristics of the overall relief system, embodying rapidity of operations, flexibility of format, and collaboration and integration with the efforts of the other relief workers and service components.
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 United States (Los Angeles and Miami are good examples) necessitate adoption of a transcultural perspective for effective training of professionals working in the “front lines” of a disaster.
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
Religious belief systems
Child-rearing practices
5. Use of support systems (including extended family)
Clinical issues
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
Use of a transcultural frame of reference to interpret the crisis resolution behavior patterns of the family
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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