COPING WITH DISASTERS
A GUIDEBOOK TO PSYCHOSOCIAL INTERVENTION
John H. Ehrenreich, Ph.D.
Center for Psychology and Society
Sharon McQuaide, M.S.W., Ph.D.
INTRODUCTION AND OVERVIEW
People all over the world know the destruction produced by weather, the devastation of geological disaster, the havoc of industrial and transportation accidents. Many know, as well, the misery of terrorism, chronic political violence, and war. Over the last quarter of a century, more than 150 million people a year have been seriously affected by disasters.
The physical effects of a disaster are usually obvious. Tens or hundreds or thousands of people lose their lives. The survivors suffer pain and disability. Homes, workplaces, livestock, and equipment are damaged or destroyed. The short-term emotional effects of disaster -- fear, acute anxiety, feelings of emotional numbness, and grief -- may also be obvious. For many victims, these effects fade with time. But for many others, there may be longer-term emotional effects, both obvious and subtle.
Some of the emotional effects are direct responses to the trauma of disaster. Other effects are longer-term responses to the interpersonal, societal, and economic effects of the disaster. In any case, in the absence of well-designed interventions, up to fifty per cent or more of the victims of a disaster may develop lasting depression, pervasive anxiety, post-traumatic stress disorder, and other emotional disturbances. Even more than the physical effects of disasters, the emotional effects cause long-lasting suffering, disability, and loss of income.
There is no single, universally applicable recipe for responding to disasters. Disasters come in many forms. Some, like earthquakes, hurricanes, and tidal waves, are natural; others, like wars and terrorist attacks, are made by humans. Some, like a rape or a fire in a home, immediately affect only one person or one family; others, like a bomb blast or a tornado may affect hundreds of people or, like an earthquake or a war, may affect entire communities and nations. Some, like personal assaults and ethnic cleansing, are inflicted intentionally on their victims; others, like airplane crashes or industrial accidents, though the result of human or technological error, are unintended. Disasters may be relatively short lived, although devastating, or, as is the case with famine and war, may last for years.
Perhaps the greatest source of variability, both in the effects of disaster and in the most appropriate responses, stem from differences between the countries and cultures in which a disaster occurs. There are two major components of this variability.
First, the level and patterns of economic development vary from country to country. Wealthy countries face disasters with a wealth of human and material resources, a well-developed medical and mental health infrastructure, highly structured emergency planning, and efficient transportation and communication systems. While these are no protection against the direct effects of a disaster, they greatly facilitate responses to disaster. By contrast, poor countries lack these resources.
Second, many characteristics of poorer countries make their people more vulnerable to the effects of a disaster. Substandard housing is more easily destroyed by the high winds of hurricanes and cyclones. The dwellings of the poor, crowded onto flood plains and unstable hillsides, are especially vulnerable to floods. Deforestation destabilizes hillsides and contributes to the devastation of floods. Chronic malnutrition and poor health status reduces resistance to infectious diseases in shelters and refugee camps. Inefficient, understaffed, and unprepared government bureaucracies mismanage relief efforts.
For these reasons, although disasters are no more likely to strike poor countries than rich ones, the poor countries of the world share the overwhelming burden of the human consequences of disaster. Africa and Europe have about the same total population. But from 1992 to 1996, in the relatively wealthy countries of Europe, an average of 2352 people were killed and 54,820 made homeless by disasters each year. During the same period, in the much poorer countries of Africa, an average of 7595 people were killed and 555,858 were made homeless each year. In this manual, we will not assume that extensive pre-existing resources are available. To the extent they are available, the task of response is made simpler and easier, but many of the same underlying principles of response to disaster apply, everywhere in the world.
Cultural variations from one country to another and even within a given country may also alter the course and consequences of disaster. They certainly are important in planning responses to disaster. Communities in areas that are regularly struck by disaster (e.g., villages in flood plains or in areas frequently hit by hurricanes) often evolve traditional ways of understanding and responding to disaster. Patterns of family structure in a community and social divisions along class, ethnic, religious, or racial lines may affect patterns of mutual aid (or of mutual recrimination). Different cultural groups have various beliefs about death and injury and about health and mental health and may respond in unexpected ways to outside medical and mental health professionals. Antagonistic relationships between local communities and central authorities affect the ways in which outside warnings of impending disaster and outside offers of assistance are experienced.
Disasters affect not only individuals, but can tear the fabric of social life in larger communities, even whole countries. They threaten the bonds attaching people to each other and to a sense of community. Because both disaster and responses to disaster affect different social strata differently, they can exacerbate social tensions (or, conversely, may temporarily, at least, draw communities together).
It would be both impossible and inappropriate to give suggestions as to how to respond to every possible variation of these. The ability to engage communities in a process of mutual learning, to allow people to define their own needs, and to respect local beliefs and traditions are as essential as specific mental health skills. Fortunately, the principles involved in planning interventions appear widely applicable and, with imagination and sensitivity, can be adapted for use in a wide variety of situations.
Because disasters affect communities and societies, because they affect different countries and different cultures differently, and because many of the psychological effects of disaster are created or affected by the direct social and economic effects of disaster, we will conceptualize both the effects of disaster and appropriate responses to disaster not as purely psychological and not as purely social/economic, but as psychosocial.
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This manual outlines a variety of psychosocial interventions aimed at helping people cope with the emotional effects of disasters. It is intended for use by mental health workers (psychiatrists, psychologists, social workers, and other counselors), by primary medical care workers (doctors, nurses, and other community health providers), by disaster relief workers, by teachers, religious leaders, and community leaders, and by governmental and organizational officials concerned with responses to disasters. It is intended as a field guide or as the basis for brief or extended training programs in how to respond to the psychosocial effects of disasters.
Chapter I of the manual outlines the effects of disasters on mental health, including the several stages of responses to disaster. Chapter II focuses on the particular needs of several specific groups of people – children, women, the disabled, the elderly, rescue and relief workers, and those investigating disasters, such as journalists and human rights workers. Chapter III explores issues related to assessing the responses and needs of disaster victims. Chapter IV focuses on the broad principles underlying a wide range of psychosocial interventions. Chapter V describes several specific techniques for responding to the mental health effects of disaster which have been found helpful in a variety of situations. The Appendices at the end of the manual include a variety of materials that may be useful and information on additional resources.
In order to keep this manual to a manageable size, I had to make a number of decisions:
It could be argued that measures to prevent disaster (e.g., early warning of storms), measures to lessen the effects of disaster (e.g., building codes to lessen the likelihood homes will be destroyed), and sustainable economic development are more effective than psychosocial interventions with individuals or groups as ways of reducing the toll of disasters. I have no argument with this position. Nevertheless, disasters do happen (even when preventive measures, mitigative measures, and sustainable development have occurred). The victims of disaster, in rich and poor countries alike, cannot be ignored in the name of what could have been or should have been.
Throughout the manual, I have used the terms “victim” and “survivor” interchangeably to indicate the individuals whose lives the disaster has devastated. Despite my somewhat careless use of the two terms, the distinction made by Lourdes Ladrido-Ignacio and Antonio P. Perlas, describing the response to a series of earthquakes, typhoons, and volcanic eruptions in the Philippines in the early 1990s, serves as the underlying theme of this manual:
The most basic issue in psychosocial intervention following disasters is to transform those affected from being victims to survivors. What differentiates a victim from a survivor is that the former feels himself [sic] subject to a situation over which he has no control over his environment or himself, whereas a survivor has regained a sense of control and is able to meet the demands of whatever difficulty confronts him. A victim is passive and dependent upon others; a survivor is not – he is able to take an active role in efforts to help his community and himself recover from the disaster.
PSYCHOSOCIAL CONSEQUENCES OF DISASTER
An Overview of the Psychological Consequences of Disaster
On Thursday, March 5, 1987, two earthquakes occurred in Ecuador, about 85 kilometers from the capital city, Quito. Heavy rains over the preceding weeks had softened the soil in the surrounding area and the earthquake caused massive landslides in the mountainsides. Debris dammed up the rivers, causing flashfloods and destroying villages along the banks and polluting the water supply throughout the region. The main highway linking the region with the rest of Ecuador, as well as the secondary roads were destroyed. The oil pipelines linking the country’s main oil fields with ports was shut off, cutting the nation’s oil revenue by 50%. Thousands of people were put out of work Rivers, a primary source of water, transportation, and food, and agricultural land, the source of livelihood for thousands of people, became unusable. Over 70,000 homes, as well as schools, hospitals, and public buildings were leveled. A thousand people were killed and another five thousand made homeless.
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On the night of December 2/3, 1984, the city of Bhopal in central India was covered by a cloud of methyl isocyanate, a poisonous gas which had leaked from a tank at the Union Carbide India Ltd. factory. Around midnight, people downwind of the factory woke up with feelings of suffocation, intense irritation, and vomiting. Panic spread. People ran desperately to escape the gas. Many died on the spot; others fell while running to escape. Still others reached safety only after hours of running. About 300,000 people were exposed to the deadly gas. About 2500 died.
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Hundreds of squatters make their living by picking through the main dump for the ten thousand tons of garbage produced in Manila, the Philippines, each day. On July 17, 2000, after a week of monsoon rains, the huge garbage mountain, fifty feet high and covering more than seventy-four acres, collapsed. Although the complete toll may never be known, at least eight hundred of them died, smothered to death. Complicating the rescue effort were the poisonous fumes emitted by the rotting garbage and the stench of decaying bodies.
Imagine yourself and your family the victim of a disaster: an earthquake, a tornado, a flood, an airplane crash in your community, the threatened meltdown of a
nearby nuclear plant, a terrorist attack. What happens to us when we go through a disaster? What do we feel and experience under such circumstances?
Almost instantly, in response to the sights and sounds of the event itself, our hearts pound, our mouths go dry, our muscles tense, our nerves go on alert, we feel intense anxiety or fear or terror. If there has been little or no warning, we may not understand what is happening to us. Shock, a sense of unreality, and fear dominate. Long after the event the sights, sounds, smells, and feelings of the event persist as indelible images in our memories.
As the immediate shock and terror dissipates, longer-term effects appear. The disaster challenges our basic assumptions and beliefs. Most of us, most of the time, believe that our personal world is predictable, benevolent, and meaningful. We assume we can trust in ourselves and in other people and that we can cope with adversity.
Disaster destroys these beliefs. We become aware of our vulnerability. We feel helpless and hopeless. We despair in our inability to make decisions and to act in ways that would make any difference to our families and ourselves.
In the wake of the disaster, we grieve for the death of loved ones and we marvel at own survival (and we may feel unworthy or guilty for having survived). We also grieve for our home, for treasured personal memorabilia, for lost documents, lost familiar neighborhoods. If the disaster has disrupted our community’s traditional subsistence activities or our community itself, we may feel intense feelings of loss tied to our cultural and social identity, as well. The loss of our personal world, of a sense of safety, of belief in ourselves, in the trustworthiness of others or even in the benevolence of God are not just thoughts; they trigger deep feelings of loss and grief.
In the days and weeks following the disaster, we may experience a wide variety of emotional disturbances. For some, chronic grief, depression, anxiety, or guilt dominate. For others, difficulties controlling anger, suspiciousness, irritability and hostility prevail. Yet others avoid or withdraw from other people. For many, sleep is disturbed by nightmares, the waking hours by flashbacks in which they feel as if the disaster is happening all over again. Not a few begin to abuse drugs or alcohol.
There may be cultural variations in the precise patterns in which disaster-related symptoms appear, but reports from countries as diverse as China, Japan, Sri Lanka, Mexico, Colombia, Armenia, Rwanda, South Africa, the Philippines, Fiji, Bosnia, England, Australia, and the United States, among others, show that the emotional responses to disaster are broadly similar everywhere in the world.
Secondary Traumatization: It is not only those who directly experience the disaster (the “primary” victims) who feel its emotional effects. “Secondary victims” – the families of those directly affected, onlookers and observers, and relief workers (both paid and volunteer) who seek to rescue the primary victims also may experience serious emotional effects. Medical and mental health workers and relief officials who subsequently work with the primary and secondary victims are constantly exposed to the physical and emotional effects of the disaster on others and may themselves be victims of “vicarious traumatization.” Even those investigating the disaster – journalists, relief organization workers doing needs assessments, human rights workers – may be traumatized.
The “Second Disaster”: The primary source of emotional trauma is, of course, the disaster itself. But the sources of traumatization do not end when the disaster is over (in a literal sense) and when the victims have been rescued. After the disaster comes “the second disaster”-- the effects of the response to the disaster.
The rapid influx of well-meaning helpers, who must be fed and sheltered, adds to the confusion and the competition for scarce resources. In some instances, poor people from outside the disaster area have flooded into a disaster area seeking their own share of the food and other supplies relief agencies are providing to disaster victims. This still further increases the burden on disaster workers and on the already stricken community.
Those forced to take refuge in a shelter or a refugee camp for shorter or longer periods of time are forced to confront the consequences of the disaster in an ongoing, unrelenting way. To personal and material losses, we now add loss of privacy, loss of community, loss of independence, loss of familiarity with the environment, and loss of certainty with respect to the future. Family roles and ordinary work roles are disrupted. Poor sanitation, inadequate shelter, and contaminated water and food may produce epidemics, with widespread illness and death resulting. In the shelter, personal assaults and rapes may endanger women, the elderly, and other vulnerable people.
As the weeks and months go by, anger at the slowness of reconstruction or at corruption that prevents relief supplies from getting to victims may add to distress. In some instances, such as Nicaragua after the 1972 earthquake and Mexico after the 1985 earthquake, such dissatisfaction produced widespread political unrest.
Delayed Effects of Disaster: Some emotional effects of the disaster may not appear until after a considerable delay. For some victims, initial relief at having been rescued and initial optimism about the prospects of recovery may produce a “honeymoon stage.” Over a period of months or even years, this may give way to a realization that personal and material losses are irreversible. Loved ones who died will not return. Disruptions in the family are permanent. Old jobs will not reappear. A long-term reduction in standard of living has occurred. Depression and anxiety may now appear for the first time in some victims, and the suicide rate may actually rise.
Other victims of disaster appear initially to be “doing well.” This may be illusory, however. To protect themselves, they may suppress or inhibit the processing of the impact of the disaster upon them. After a delay (considerable at times), stimuli associated with the disaster may trigger memories, pulling previously suppressed material back into consciousness. As a result, psychological responses to the disaster may “suddenly” appear, months or even years afterward.
The Prevalence of Adverse Psychological Effects Following Disaster
Although the precise figures vary from situation to situation, up to ninety per cent or even more of victims can be expected to exhibit at least some untoward psychological effects in the hours immediately following a disaster. In most instances, symptoms gradually subside over the weeks following. By twelve weeks after the disaster, however, twenty to fifty per cent or even more may still show significant signs of distress. The number showing symptoms generally continues to drop, but delayed responses and responses to the later consequences of disaster continue to appear. While most victims of disasters are usually relatively free of distress by a year or two after the event, a quarter or more of the victims may still show significant symptoms while others, who had previously been free of symptoms, may first show distress a year or two after the disaster. Anniversaries of the disaster may be especially difficult times for many survivors, with temporary but unexpected reappearance of symptoms which they had thought were safely in the past. Reports of widespread emotional distress ten years and more after disasters such as the 1972 flood at Buffalo Creek (USA) and internment in Nazi concentration camps have been well substantiated.
The extraordinary prevalence of such strong physiological, cognitive, and emotional responses to disasters indicates that these are normal responses to an extreme situation, not a sign of “mental illness” or of “moral weakness.” Nevertheless, the symptoms experienced by many victims in the days and weeks following a disaster are a source of significant distress and may interfere with their ability to reconstruct their lives. If not addressed and resolved relatively quickly, such reactions can become ongoing sources of distress and dysfunction, with devastating effects for the individual, their family, and their society.
Factors Affecting Vulnerability to Adverse Psychological Effects
Not everyone is equally affected by a disaster, and not all disasters are equally devastating in psychological terms. Several factors may increase the risk of adverse psychological consequences:
The Stages of Psychological Response to Disasters
It is customary to conceptualize the aftermath of disaster in terms of a series of stages or phases, each of which has its own characteristics. The phases, we hasten to say, are not rigid. There is much variation at each stage and the stages overlap.
The “Rescue” Stage
In the first hours or days after the disaster, most relief activity is focused on rescuing victims and seeking to stabilize the situation. Victims must be housed, clothed, given medical attention, provided with food and water.
During the rescue stage, various types of emotional response may be seen. Victims may shift from one kind of response to another or may not show a “typical” response of any evident response at all.
Many of these behaviors have an adaptive quality. The behaviors of the majority of those affected by disaster, even when they seem abnormally intense or entirely unfamiliar, should be understood as normal reactions to abnormal or devastating conditions or events. They ensure short term survival and permit the victim to take in information at a controllable rate. But the symptoms themselves may be perceived by the victims as socially inappropriate, as a source of shame, guilt, and failure, as an evidence of inadequacy. Caregivers and rescue workers, in turn, may respond with irritation or withdrawal from the victims.
The “Inventory” Stage
Once the situation has been stabilized, attention turns to longer-term solutions. Heroic rescue efforts give way to bureaucratized forms of help. Over the next year or eighteen months, organized assistance from outside gradually diminishes and the reality of their losses dawn on victims.
In the first weeks after the disaster, victims may go through a “honeymoon” phase, characterized by relief at being safe and optimism about the future. But in the weeks that follow, they must make a more realistic appraisal of the lasting consequences of the disaster. Disillusionment may set in. The effects of the “second disaster” are felt.
During this phase, any of a wide variety of post-traumatic symptoms appear. Any of these symptoms may appear in isolation, but frequently victims show a number of these symptoms. Several distinct clusters of symptoms are common. Several of these –- “Post Traumatic Stress Disorder,” “Generalized Anxiety Disorder,” “Abnormal Bereavement,” “Post Traumatic Depression” -- deserve special attention. In addition, many patterns restricted to particular cultures may appear.
Post Traumatic Stress Disorder: The characteristic symptoms of Post Traumatic Stress Disorder include:
(a) Persistent re-experiencing of the traumatic event: recurrent and intrusive recollections of the events of the disaster; recurrent distressing dreams in which the disaster is replayed; intense psychological distress or physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event; or experiences in which the victim acts or feels as if the event is actually re-occurring. (in children, repetitive play in which themes or aspects of the trauma are expressed may occur; trauma-specific re-enactments of the events may take place, and there may be frightening dreams without recognizable content).
(b) Persistent avoidance of stimuli associated with the trauma and continued numbing of general responsiveness: efforts to avoid thoughts or feelings or conversations about the disaster; efforts to avoid activities, places, or people that remind the victim of the trauma; inability to recall important parts of the disaster experience; markedly diminished interest or participation in significant activities; feelings of detachment or estrangement from others; restricted range of affect; or a sense of a foreshortened future, without expectations of a normal life span or life.
(c) Persistent symptoms of increased arousal: difficulty falling or staying asleep; irritability or outbursts of anger; difficulty concentrating; hypervigilance; exaggerated startle response.
This general cluster of symptoms has been reported in every part of the world. In less industrialized parts of the world and among people coming from these areas, the avoidance and numbing symptoms have been reported to be less common and dissociative and trance-like states, in which components of the event are relived and the person behaves as though experiencing the events at that moment, may be more common.
Generalized Anxiety Disorder: The characteristic symptoms of Generalized Anxiety Disorder include:
(a) Persistent and excessive anxiety and worry about a variety of events or activities (not exclusively about the disaster and its consequences
(b) The person finds it difficult to control the worry and the worry is far out of proportion to reality. It interferes with attention to tasks at hand.
(c) The anxiety and worry are associated with symptoms such as restlessness or feeling on edge; being easily fatigued; difficulty concentrating or the mind going blank; irritability; muscle tension; and difficulty falling asleep or staying asleep
Although individuals with Generalized Anxiety Disorder may not always identify their worries as “excessive,” they report subjective distress due to their constant worry and it may affect them in social, occupational, marital, or other areas of function. Somatic symptoms (e.g., cold clammy hands, dry mouth, nausea or diarrhea, urinary frequency) and depressive symptoms are also commonly present.
There is considerable cultural variation in how anxiety is expressed. In some cultures, it may be expressed more through somatic symptoms, in others through cognitive symptoms. Children may reveal their anxieties through concern about their competence, (e.g., at school), excessive concerns about punctuality, over-zealousness in seeking approval, and a conforming, perfectionistic personal style.
Abnormal Bereavement: Normally, after the death of a loved one, a sequence of stages of bereavement are expected. Often the first response is disbelief and denial. Feelings of numbness may give respite and allow the realization to seep in slowly. Then, as we begin to realize the reality and significance of the loss, feeling of distress, yearning for the lost person, anger at the loss, and anxiety at one’s ability to cope without them may appear. A period of mourning ensues, as we review our memories of the lost loved one, and then gradually let go of the psychological bonds and free ourselves for life without the departed person. All cultures have rituals that, however much they vary, seem intended to facilitate this process.
Trauma may interfere with the ability to go through this process normally, however. The victim’s own injuries, the loss of social supports and familiar communities, survivor guilt, and the victim’s own psychological trauma may interfere with both expected rituals and internal grieving processes. Memories of the deceased may trigger the victim’s own memories of the disaster. Post-traumatic rumination may block the victim from confronting the memories and thoughts that are central to grieving. Post-traumatic numbing may interfere with the victim’s engaging in supportive social interactions.
There may be other, practical obstacles to saying goodbye, as well. For instance, legal processes may delay funeral proceedings or concerns about the bereaved seeing the body of the deceased due to injuries it may have sustained in the disaster may lead to the bereaved not having the opportunity to view the body. Most studies have indicated that not seeing the body of the deceased may contribute to abnormal bereavement and that seeing the body, even when it is disfigured, is not inherently damaging. Few victims who have been allowed to see the remains and have accepted the offer regret doing so.
These psychological and practical obstacles to a “normal” response to the death of a loved one may contribute to a feeling of lack of closure or permit magical fantasies that the deceased person has not, in fact, died. Any of several abnormal bereavement syndromes may appear. (Note: Different cultures vary widely with respect to what is “expected” after the death of a loved one. Among some peoples, open expression of emotion is frowned upon. Among others, public displays of emotion are expected and lack of overtly expressed emotion is suspect. In some cultures, people are expected to publicly grieve only briefly and then to return to normal activities. In others, a prolonged grieving period is expected. Evaluation of the significance of the following patterns depends on an awareness of what the cultural norms are in the particular culture).
(a) Inhibited grief: The bereaved exhibits a pattern characterized by psychic numbing, over-control and containment of emotions, little display of affect. They may be seen as “coping well,” yet this pattern is associated with later depression and anxiety.
(b) Distorted grief: The bereaved shows intense anger and hostility which dominate over their sadness and guilt. This anger may be directed at anyone the bereaved associates with the deceased’s death (e.g., relief workers).
(c) Chronic grief: The feelings of sadness and loss do not dissipate. Frequent crying, pre-occupation with the loss are unremitting.
d) Depression: The bereaved lapses into depression, with prolonged grief, despair, and a sense that life is not worth continuing. Sleep and appetite disturbances may appear. The bereaved may have active fantasies of being reunited with the deceased and suicidal ideation or attempts may occur.
(e) Excessive guilt: The bereaved may show excessive self-recrimination and guilty pre-occupations, which eclipse their sadness. Self destructive, yet not overtly suicidal behaviors, such as frequent accidents or excessive drinking may occur.
Post Traumatic Depression: Protracted depression is one of the most common findings in studies of acutely or chronically traumatized people. It often occurs in combination with Post Traumatic Stress Disorder. Trauma can produce or exacerbate already existing depression.
Common symptoms of depression include sadness, slowness of movement, insomnia (or hypersomnia), fatigue or loss of energy, diminished appetite (or excessive appetite), difficulties with concentration, apathy and feelings of helplessness, anhedonia (markedly diminished interest or pleasure in life activities), social withdrawal, guilty ruminations, feelings of hopelessness, abandonment, and irrevocable life change, preoccupations with loss, and irritability. In some cases, the person may deny being sad or may complain, instead, of feeling “blah” or having “no feelings.” Some individuals report somatic complaints, including widespread aches and pains, rather than sadness. Suicidal ideation or attempts may appear. With children, somatic complaints, irritability, social withdrawal are particularly common.
In some cultures, depression may be experienced largely in somatic terms, rather than in the form of sadness or guilt. Complaints of “nerves”, headaches, generalized chronic pain, weakness, tiredness, “imbalance,” problems of the “heart,” feelings of “heat,” or concerns about being hexed or bewitched may appear.
Culture-specific disorders: The boundaries between anxiety, depression, dissociation, and emotional disorders that have predominantly somatic symptoms are very porous. Victims often have symptoms running across these categories. In many societies and cultural groups, traditional patterns of expression of emotional distress take the form of combinations of symptoms that have no exact equivalent in standard international categories of mental illness. The intermediate term response to disaster may take the form of one of these “culture-specific disorders.” These may include, for example, susto and ataques de nervios (Latin America and the Caribbean), amok (the South Pacific), dhat (India), latah (Southeast Asia and the South Pacific), and khoucheraug (Cambodia).
In many parts of the world, the conventional idiom for expressing emotion may be somatic (e.g., chronic fatigue, generalized aches and pains, gastrointestinal disturbances, feelings of “heat)” or fears of somatic illness (e.g. hypochondriasis, fears of infection). In some cultural groups, the distress of a disaster may also take the form of a “trance disorder.” A “trance” is a temporary, marked alteration in the state of consciousness or a loss of the customary sense of personal identity, associated with either stereotyped behaviors or movements that are experienced as beyond one’s control or by a narrowing of awareness of one’s immediate surroundings.
The “Reconstruction” stage
A year or more after the disaster, the focus shifts again. A new, stable pattern of life may have emerged. In any event, the distinction between disaster relief and the larger pattern of national social and economic development begins to diminish and eventually disappears.
During this phase, although many victims may have recovered on their own, a substantial number continue to show symptoms much like those of the preceding (“inventory”) stage. A significant number who were not symptomatic earlier may now exhibit serious symptoms of anxiety and depression, as the reality and permanence of their losses becomes evident. The risk of suicide may actually increase at this time. Other characteristic late-appearing symptoms include chronic fatigue, chronic gastrointestinal symptoms, inability to work, loss of interest in daily activities, and difficulty thinking clearly.
The notion of “post traumatic stress disorder” described earlier derives mainly from observations of the symptoms of survivors of relatively circumscribed traumatic events. A number of studies suggest that more complex syndromes may appear in survivors of prolonged, repeated, intense trauma, such as those who have been held hostage, who have been repeatedly tortured or exposed to chronic personal physical or sexual abuse, who have been interned in a concentration camp, or who have lived for months or years in a society in a chronic state of civil war.
Among victims of such disasters, a “survivor syndrome” may appear. People showing this syndrome have been described as walking though life “without a spark.” Chronic depression, anxiety, and survivor guilt appear, or, alternately, chronic aggression and an “addiction to hate.” Social withdrawal, sleep disturbances, somatic complaints, chronic fatigue, emotional lability, loss of initiative, and general social, personal, and sexual maladaptatian are present. The “joy of life” is gone, replaced by a “pervasive pattern of sluggish despair.” Relationships with spouses and children are disturbed, often creating significant disturbances in later generations.
Other victims of prolonged or repeated and severe traumas have been described as exhibiting “complex post-traumatic stress disorder.” Symptoms of “complex post-traumatic stress disorder” include:
Community and Social Impacts of Disasters
Disasters directly affect their individual victims. But beyond that disasters create tears in the tissue of social life. Sometimes this is direct and total, as when, as a result of disaster, people are forced to leave their land and migrate elsewhere. In other cases, the rapid influx of helpers, the presence of government officials, press, and other outsiders (including mere curiosity seekers), the flood of poor people from outside the disaster area into a disaster area seeking their own share of the food and other supplies relief agencies are providing to disaster victims, combine to further disrupt the community.
Even when the formal structure of a community is maintained, the disaster can disrupt the bonds holding people together, in families, communities, work groups, and whole societies. When those bonds are destroyed, the individuals comprising the affected groups lose friends, neighbors, a community, a social identity. These collective effects of disaster may ultimately be as devastating as the individual effects. The consequences of disaster for families, neighborhoods, communities, and societies are many:
Family dynamics may be altered. Disaster-produced deaths or disabilities, family separations, and dependency on aid givers may undercut the authority of the traditional breadwinners, supplant traditional activities in the home, and force people out of traditional roles or into new ones. Symptoms of individual family members affect their interactions with other family members. The intimate penetration of a community by outsiders may upset or challenge traditional child rearing practices and traditional patterns of male-female relationships. In the wake of disaster, marital conflict and distress rises; increases in the divorce rate in the months following disasters may occur. Parent-child conflicts also increase. Increases in intra-family violence (child abuse, spouse abuse) have been reported.
Disasters may physically destroy important community institutions, such as schools and churches, or may disrupt their functioning due to the direct effects of the disaster on people responsible for these institutions, such as teachers or priests. Traditional patterns of authority are disrupted along with customary social controls on individual behavior. Several studies have shown an increase in the rates of community violence, aggression, drug and alcohol abuse, and rate of legal convictions in the wake of disaster.
Disasters disrupt the ability of communities to carry out customary or traditional activities central to people’s individual, community, and social identity, ranging from work and recreational activities to accustomed rituals. Some of these disruptions are temporary, but others are hard to reverse. For example, a flood may permanently damage farm land, making a return to traditional farming untenable, or an oil spill off the coast may permanently alter traditional fishing grounds. With people forced away from their homes and land for shorter or longer periods and with personal and community records lost due to a disaster, opportunities appear for looting. This may be limited to personal possessions or may lead to permanent loss of tools, animals, and land. The community whose members can no longer farm their traditional land, carry out traditonal craft production activities, or hunt or fish in traditional ways is disrupted and its sense of identity attacked.
Disasters place a strain on traditional community social roles, patterns of social status, and leadership. Police, local housing agencies, local health facilities are overwhelmed and face a new task of integrating their work with that of volunteers, often from outside the community. There may be anger at inequities in the distribution of post-disaster aid. These inequities may exacerbate the gap between rich and poor. Outside aid agencies may threaten the traditional roles of local agencies and institutions. Outside experts may pose a threat to local professionals. In the wake of disaster, new leaders may emerge in a community, due to the role of these people in responding to the disaster. Conflicts between these new leaders and traditional community leaders may appear.
Outside assistance may be necessary in the wake of a disaster, but it can also promote a sense of community dependency. Insofar as the necessities of life are supplied from outside, incentives to resume traditional work activities are reduced. This is not just a matter of psychological “dependency.” Provision of food and other supplies may compete with local production, disrupting traditional pricing and wages and damaging attempts to recreate the old productive patterns. Added to this, the disaster itself may have destroyed the tools, workshops, animals, or other necessities of production.
Disaster may lead, directly or indirectly, to permanent changes in productive patterns, especially patterns of land ownership and use. Shifts from subsistence agriculture to wage labor, land looting, migration and uprooting and resettlement play a role.
Schisms may appear in a community, as cohesion is lost. One danger is that of scapegoating, either of individuals or using traditional divisions in the community (e.g., along religious or ethnic lines).
In communities with a history of past disaster, whether naturally caused or man-made, the trauma produced by a new disaster may re-arouse old feelings. Memories of genocide, civil war, social oppression, or racial or ethnic division and of the feelings they produced, and feelings of marginalization and helplessness may be exacerbated.
In some communities that have had to deal with repeated natural disasters such as flooding, on a more or less regular basis, disaster and the response to it may be integrated into community rituals and belief systems, as well as into community structure and people may ascribe cultural meaning to disasters. Communities may have traditional rituals for dealing with the effects of disaster. Not only the disaster, but outside intervention may interfere with these traditional rituals, responses, and attributions of meaning and may be experienced as an ambiguous blessing or even as a source of additional stress.
Disasters have impacts on individuals, families and communities. These are not distinct, separable effects. The devastating effects of disaster on the individuals making up a family or a community play a major role in creating the family and community effects. Even more important, social support systems play an extremely important role in protecting individuals from the impact of the disaster and from the impact of stress in general. Social disruption both reduces and interferes with the healing effects of the family and the community and is itself an enormous source of stress on the individuals who make up the family or community. Disruption of the family or community may be more psychologically devastating, both in the short run and especially in the long run, than the disaster itself.
EFFECTS OF DISASTER ON SPECIFIC GROUPS
Disasters do not affect everyone in the same way. At an individual level, some may experience a disaster with few or no psychological consequences, while others will go through the same disaster and be emotionally devastated. Beyond individual variation, certain categories of people are especially vulnerable or vulnerable in specific ways.
People’s responses to emergencies are grounded in their on-going relationships with their community. Differences in power or access to power and different pre-disaster stressors and pre-disaster social roles affect how individuals experience a disaster. In general, those with the least power and resources are most exposed to the adverse effects of the disaster and its aftermath and have a harder time recovering from it. Pre-disaster high levels of stress, lack of resources, lack of information, lack of access to power, lack of access to transportation, lack of marketable skills, lack of literacy, all take their toll.
For example, structural changes in the world economy have adversely affected women in many societies, reducing their standard of living, undermining their household-based security, and intensifying their load of paid and/or unpaid work. For impoverished, uprooted peasants, urbanization may mean less substantial housing, relocation to more environmentally dangerous locales (e.g., flood plains, mudslide-prone hillsides), and exposure to toxic materials. Ethnic tensions, manageable before a disaster, may become the source of scapegoating and acute ethnic conflict in the wake of disaster. To the degree that inequality in the impact of disaster is rooted in the unresolved dilemmas of global political, economic, and social development, issues of social justice and sustainable development can be understood as disaster preparedness and response issues.
In this chapter, we focus on practical issues specific to each of several groups – their health care needs, legal rights, compensation issues, employment and self-employment issues, and the like, as well as psychological issues. This discussion should not be understood in too rigid a fashion. Not everyone in a given category has the experiences described, and an individual may fall into more than one group (e.g., be female and aged). They are intended to alert the reader to some issues that may apply. Goals, experience, and needs must be assessed on an individual basis.
Two myths are potential barriers to recognizing children’s responses to disaster and must be rejected: (1) that children are innately resilient and will recover rapidly, even from severe trauma; and (2) that children, especially young children, are not affected by disaster unless they are disturbed by their parents’ responses. Both of these beliefs are false. A wealth of evidence indicates that children experience the effects of disaster doubly. Even very young children are directly affected by experiences of death, destruction, terror, personal physical assault, and by experiencing the absence or powerlessness of their parents. They are also indirectly affected through identification with the effects of the disaster on their parents and other trusted adults (such as teachers) and by their parents’ reactions to the disaster.
Another barrier to recognizing children’s responses to disaster is the tendency of parents to misinterpret their children’s reactions. To parents who are already under stress, a child’s withdrawal, regression, or misconduct may be understood as willful. Or, parents may not wish to be reminded of their own trauma or, seeking some small evidences that their life is again back in control, may have a need to see everything as “all right.” In either case, they may ignore or deny evidence of their children’s distress. The child, in turn, may feel ignored, not validated, not nurtured. This may have long term consequences for the child’s development. In the short run, feeling insecure, the child may inhibit expression of his or her own feelings, lest he or she distress and drive away the parents even more.
Most children respond sensibly and appropriately to disaster, especially if they experience the protection, support, and stability of their parents and other trusted adults. However, like adults, they may respond to disaster with a wide range of symptoms. Their responses are generally similar to those of adults, although they may appear in more direct, less disguised form.
Among pre-school children (ages 1-5), anxiety symptoms may appear in generalized form as fears about separation, fears of strangers, fears of “monsters” or animals, or sleep disturbances. The child may also avoid specific situations or environments, which may or may not have obvious links to the disaster. The child may appear pre-occupied with words or symbols that may or may not be associated with the disaster in obvious ways or may engage in compulsively repetitive play which represents part of the disaster experience. The child may show a limited expression of emotion or a constricted pattern of play may appear. He or she may withdraw socially or may lose previously acquired developmental skills (e.g., toilet training).
Older children (ages 6-11 or so) may engage in repetitious play in which the child reenacts parts of the disaster or in repeated retelling of the story of the disaster. The child may express (openly or subtly) concerns about safety and preoccupation with danger. Sleep disturbances, irritability, or aggressive behavior and angry outbursts may appear. The child may pay close attention to his or her parents’ worries or seem to worry excessively about family members and friends. School avoidance (possibly in the form of somatic symptoms) may appear. The child may show separation anxiety with primary caretakers, “magical” explanations to fill in gaps in understanding, and other behaviors usually characteristic of much younger children. Other changes in behavior, mood, and personality, obvious anxiety and fearfulness, withdrawal, loss of interest in activities, and “spacey” or distractible behavior may appear.
As children approach adolescence, their responses become increasingly like adult responses. Greater levels of aggressive behaviors, defiance of parents, delinquency, substance abuse, and risk-taking behaviors may be evident. School performance may decline. Wishes for revenge may be expressed. Adolescents are especially unlikely to seek out counseling.
Children of all ages are strongly affected by the responses of their parents or other caretakers to disaster. Children are especially vulnerable to feeling abandoned when they are separated from or lose their parents. “Protecting” children by sending them away from the scene of the disaster, thus separating them from their loved ones, adds the trauma of separation to the trauma of disaster.
Symptoms Shown by School-Aged Children
For an adult, although the effects of disaster may be profound and lasting, they take place in an already formed personality. For children, the effects are magnified by the fact that the child’s personality is still developing. The child has to construct his or her identity within a framework of the psychological damage done by the disaster. When the symptoms produced by disaster are not treated, or when the disaster is ongoing, either because of the destruction wrought (e.g., by an earthquake) or because the source of trauma is itself chronic (e.g., war or relocation to a refugee camp), the consequences are even more grave. The child grows up with fear and anxiety, with the experience of destruction or cruelty or violence, with separations from home and family. Childhood itself, with its normal play, love, and affection, is lost. Longer-term responses of children who have been chronically traumatized may include a defensive desensitization. They seem cold, insensitive, lacking in emotion in daily life. Violence may come to be seen as the norm, legitimate. A sense of a meaningful future is lost.
Women’s roles and experiences create special vulnerability in the face of disaster. In poorer countries, women are more likely to die in disasters than men are. In richer countries, as well, women often show higher rates of post disaster psychological distress – depression, PTSD, and anxiety. Several aspects of women’s experience of disaster may contribute to these results:
Women are often assigned the role of family caregivers. As such, they must stay with and assist other family members. This may affect their willingness to leave their homes when a disaster (such as a storm) threatens. While their own threshold for leaving may actually be lower than men’s, their actual willingness to go may depend on their being able to leave with their children.
Women may be more isolated and home-bound, due to their traditional roles and occupations. As a result, they may have less access to information (both before a disaster and after). They may also be more vulnerable to the physical effects of a disaster on their house itself, both with respect to their physical safety and to the integrity of their work areas.
In the aftermath of disaster, women may face another threat: violence. This threat may take several forms. Within the immediate family, disaster may initially lead all members of the family to unite in their efforts to deal with the crisis. Over the course of weeks or months, however, the continued strain may be divisive. As family stress mounts, women may become more exposed to physical or emotional abuse from their spouse. Other women, who have previously fled their marriage to avoid beatings, may be inadvertently re-exposed to their abusers (e.g., in shelters). Women may also be exposed to rape and other forms of violence in shelters or refugee camps. In war situations, women and girls may be specifically targeted.
Post-disaster, women often get less assistance. Their husband, as “head” of the household, often becomes the conduit for assistance to the family, which may or may not be equitably shared within the family. In some instances of food shortage, women have been given the lowest priority for getting a portion of what food is available. Discrimination with respect to food and medical attention in shelters has also been a problem in some instances. Health care facilities in shelters and refugee camps often do not attend to women’s needs with regard to reproductive health, and providing for relief of other sources of strain on women, such as responsibilities for childcare, often get a low priority.
In the aftermath of disaster, women who have been widowed by the disaster may find it harder to remarry than men. Lacking skills that are saleable in the paid job market, they may be left destitute. Alternately, husbands may leave the disaster community, seeking paid work elsewhere, leaving their wives more dependent on outside assistance and more isolated.
The experience of women in disaster, it should be emphasized, can create opportunities for women, as well. Women may have better social networks and hence, more social support than men. They may emerge as the leaders of grass-roots level organizations. They may be able to use disaster aid to develop skills and acquire tools and take on non-traditional roles. These changes are not without risk, however, since they may lead to intrafamily conflict.
Reports on the responses of the elderly to disaster are inconsistent. In some disasters, they seem no more vulnerable than younger people. In others, they appear more vulnerable. Despite the inconsistency in formal research studies, there are reasons to believe that that the elderly are at increased risk for adverse emotional effects in the wake of disaster. They may live alone and lack help and other resources. Depression and other forms of distress among the elderly are readily overlooked, in part because they may not take on exactly the same symptom pattern as among younger people. For instance, disorientation, memory loss, and distractibility may be signs of depression in the elderly. The elderly are also more vulnerable to being victimized. In the context of increased stress on the family and community, meeting their special needs may take on a lowered priority. One particular issue that may appear is feelings that they have lost their entire life (loss of children, homes, memorabilia) and that, due to their age, there is not enough time left in their life to rebuild and recreate. The elderly are also more likely to be physically disabled (see below).
The Physically, Mentally, or Developmentally Disabled
Although people who are physically disabled, mentally ill, or mentally retarded have distinct needs from one another, all three groups are at especially high risk in disasters. For those in each group, the normal patterns of care or assistance that they receive and their own normal adaptations to produce acceptable levels of functioning are disrupted by disasters. For instance, supplies of medication, assistive devices such as wheelchairs, familiar caretakers, and previously effective programs of treatment may become unavailable. This has both direct effects and increases anxiety and stress. Stress, in turn, may exacerbate pre-existing mental illness. There may also be special needs with regard to housing or food.
Those who were mentally ill or developmentally delayed may also have fewer or less adaptable coping resources available and less ability to mobilize help for themselves. The ongoing problems of the disabled may seem to the other victims of the disaster to be of only minor importance in comparison to their own acute and unaccustomed suffering. Their disabilities may even seem like an obstacle to dealing with the disaster itself. The disabled are especially vulnerable to marginalization, isolation, and to “secondary victimization.” They are at greater risk of post-disaster malnutrition, infectious disease (e.g., in a shelter situation), and of the effects of lack of adequate health care.
Refugees from War and Other Forms of Political Violence
Most of the discussion in this manual focuses on victims of “disasters” in the usual sense. The experience of refugees from war and political violence (and even from famine and other economic hardship) bears many similarities to the experience of the victims of natural disasters, however. Those who have been tortured or the victims of systematic violent political terrorization are especially vulnerable to adverse psychological effects (as well as lasting physical effects) from their experience.
Many of the comments in this manual apply directly to refugees. In addition, even when “former” refugees have been “resettled” in host countries far from home, although they may no longer be physically separated out from others as identifiable “refugees,” they may continue to bear the emotional consequences of their history. When new disasters (earthquakes, hurricanes, etc.) hit, their previous experiences may complicate their responses.
At any given time in the last decade, some fifteen million people were refugees. Another twenty million were “internally displaced persons,” refugees who have left their homes but have not crossed international boundaries.
Refugees have, typically, experienced personal terror or witnessed the physical abuse or death of loved ones. They have suffered the destruction of their homes and communities, the loss of their traditional livelihoods and of material possessions. They may have been forcibly detained or spent periods in concentration camps and may, prior to arrival in the refugee camp, have been tortured, raped, or otherwise physically abused. Their personal status, belief in themselves, trust in others, and hopes for the future have been shattered. They feel vulnerable and mistrustful. They have become dependent on others for the physical necessities of life. In refugee camps, they may experience poor housing, disruption of personal networks, lack of medical care, interruption of their children’s schooling, uncertainty regarding their rights and legal status and future. The refugee camp itself is likely to be a source of ongoing stress, with overcrowding, lack of privacy, poor sanitation, long periods of inactivity, noise, disrupted sleep, and dangers of assault or rape.
Many of these experiences are especially problematic for women. Since they are often the ones responsible for preserving their home and their family, disruption of home and family may be especially distressing. As “little” a thing as not being able to cook for their family may be a source of stress. They may also suffer from changes in family relationships. If their husband is dead, missing, injured, traumatized, or separated from the family, the woman becomes the “head” of the family and must take on unfamiliar and traditionally male roles. This may confuse the children or lead to intrafamily conflict. Alternately, an immature son may be forced to take on age-inappropriate roles. There may not be any socially accepted role for a female single parent or widow. The woman may find herself victimized by relatives. Lack of education or marketable skills may make reintegration into a new social environment especially difficult.
Another danger for women, while fleeing and in refugee camps and shelters, is rape. Rape may be a source of shame, guilt, denial of the woman’s own needs. She may “escape” into illness or become socially isolated. In war settings, rape may take the form or mass or repeated rape. This may be a form or torture, aimed at extracting information from the woman or from her family, or it may be part of a systematic program of terrorization of a civilian population.
Children, especially those who have been separated from their families are also especially vulnerable. One unique group is children who have served as soldiers. In addition to being traumatized and brutalized by their experiences at a developmentally sensitive time in their lives, they are a stigmatized group, isolated from their former communities.
For men and for women, being a “refugee” may prolong the trauma and prevents self-healing. The usual model of response to disaster assumes that once the disaster is “over,” the victim is in a safe, peaceful, “post-traumatic” environment. For refugees, this is not true. They remain in a highly stressful, even repeatedly traumatic situation, and may have little prospect of escaping it.
Just as with other forms of trauma, responses may vary from person to person. A central theme that may emerge is mistrust. The experience of many refugees has been that their trust has been repeatedly and violently violated. They have been exposed to death, danger, and fear, often at the hands of neighbors or government officials. Initially, the refugee camp may seem like a haven, but after several weeks, with no permanent refuge in sight, the refugee’s hopes seem once again to have been betrayed. In this context, feelings of anger, betrayal, skepticism, and hostility are both common and normal. Refugees may express or enact distrust of camp officials, aid givers, mental health workers, and relatives back home. Scapegoating, ostracizing others in the refugee camp, victimization of individuals or ethnic minorities may also occur. Apparently “irrational” fears for personal safety may dominate behavior. For instance, a visit to a medical facility may trigger memories of torture experiences.
Other common responses seen among refugees are prolonged mourning, homesickness, prominent fears, dissociative disorders, and prominent somatic reactions, even several years after initial flight. In refugee camps, suicide attempts are relatively common (especially among rape victims). Domestic violence, physical and sexual abuse of women and children, apathy, hopelessness, sleep disturbances, and learning difficulties may be endemic.
Being a refugee continuously distorts people’s reactions. What was useful or adaptive before they became refugees (skills, beliefs, knowledge, relationships) is no longer so. This poses many problems for assessing the needs and responses of refugees. Is a child’s violence, for instance, a response to traumatization? A means of assessing others in the context of the refugee camp? A pre-existing personality pattern?
Rescue and Relief Workers (and Journalists, Human Rights
Workers, and Other Observers)
Disaster workers, including both those involved in rescue efforts immediately following the disaster and those involved in longer term relief work, are at very high risk of adverse emotional effects. Many of the same factors affecting direct rescue and relief workers affect human rights workers, officials of humanitarian organizations, reporters, and others who investigate disasters and their aftermaths.
In addition to post traumatic responses much like those of the primary victims of the disaster, rescue and relief workers may evidence anger, rage, despair, feelings of powerlessness, guilt, terror, or longing for a safe haven. These feelings may be distressing and may make the worker feel that there is something wrong with them. Their sense of humor may wear thin, or they may use “black humor” as a way of coping. Toleration for others’ failings is reduced and the anger of other relief workers or victims may feel like a personal attack. Belief in God or other religious beliefs may be threatened by a feeling of “How could God let this happen?” After a prolonged period of time on the job, evidence of “burn-out” may appear.
Professional rescue workers, such as policemen and firemen, have some unique sources of vulnerability. Their professional identity may depend on a self-image of themselves as strong and resilient. Allowing themselves to “feel” their emotions about the situations to which they are exposed may challenge their self respect or make them feel like they are letting down co-workers or make them feel they are risking the ridicule of other workers. In addition, professional rescue workers may have been exposed to many previous traumatic situations. The new experiences may activate unresolved feelings from past traumatic events.
Symptoms of “Burnout” Among Relief Workers
Those providing mental health services to disaster victims and to relief workers and those investigating disasters (e.g., journalists, human rights workers, officials of humanitarian organizations doing “needs assessments”) also face special stresses. Their central role is as witness to the sufferings of others. They may identify with their clients and share their emotions. “Vicarious traumatization” is not uncommon. In contexts of continuing conflict (e.g., civil conflict, political repression, war refugee camps), health care workers of all sorts are themselves increasingly targets of violence. Contact with survivors and providing advice and support to the local population may be seen as a threat to the state, to one or the other side in the conflict, or to powerful forces in the refugee camp. They may face harassment, arrest, detention, or assault. In some situations, they can not evoke the law for their own protection, because the police or the army are “part of the problem.” The result may be a heightened sense of powerlessness, anger, fear and anxiety, and a pre-occupation with clients’ safety and one’s own safety. There may be feelings of betrayal and loss, of vulnerability, of loss in a belief in an orderly or just world.
Disaster workers of all kinds face additional stress when they complete their tasks and return home, to their “regular” life. Their experience has diverged in a variety of ways from the experiences of their families and in the absence of preparation of both workers and their families, a variety of marital and parent-child conflicts and stresses may appear.
Distressing or problematic emotional responses are extremely common among relief workers. For example, in one air crash, more than eighty per cent of the rescue workers who had to deal with the bodies of victims showed some post traumatic symptoms, more than half moderately severe symptoms. Almost two years after the crash, a fifth of the rescue workers were still symptomatic.
Rescue and relief workers are rarely prepared ahead of time either for their own reactions or to deal with the reactions of primary victims. Providing psychosocial assistance to these workers and providing them with adequate shelter, food, and rest, even when these are not available to the victims themselves, is a very high priority in disasters. It may seem unfair, but if the rescue and relief workers are unable to function efficiently, they can not help any one else.
ASSESSING THE PSYCHOLOGICAL IMPACT OF DISASTERS
In the wake of large scale disasters (e.g., hurricanes, earthquakes, refugee crises), identifying which individuals are most at risk of becoming or remaining symptomatic is a high priority. Inquiries may also be undertaken to determine exactly what happened (e.g., to help prevent repetition of the disaster or to identify deficiencies in the relief efforts or, in some situations, to reveal human rights violations).
Individuals affected by a disaster exhibit a wide range of reactions. Some may require support or other services immediately and urgently, others only after a delay, and still others not at all. Some victims may experience initial relief at being safe; some refugees may go through a several-week-long or several-month-long “honeymoon.” If people are assessed too early and found not to be in need of services, it is easy to miss these later reactions. Follow-up several days, weeks, or months later may identify people in need who were initially passed by.
For the most part, victims and relief workers are unlikely to seek out assistance on their own. Do not assume that, because a person has not sought out assistance, they do not need assistance. Several approaches to identifying those in need of services may be used:
Some Diagnostic Issues
Other coping mechanisms are less adaptive and may indicate a need for intervention. For instance,
Distinguish an absence of marked distress that is the result of good coping from that which reflects numbing, avoidance, denial, or other less adaptive forms of coping. Absence of emotional responsivity may be one indicator of the latter.
Assessment can harm those being assessed
A victim of a disaster may perceive assessment as a further violation of their already tenuous sense of control over the traumatic experience. In the period immediately after the disaster, the environment may be chaotic and there may be immediate stressors and challenges to deal with. Subjects may seem fragile as they strive for control over the environment. Assessment may seem like a continuation of the traumatic experience or revive feelings. Even after a delay of days or weeks, evoking traumatic memories may lead to feelings of shame or embarrassment or may trigger emotional turmoil or may activate images of previous times in the victim’s life when he or she has been victimized. It may activate defenses, including denial and avoidance. It may be resisted by victims or may lead to avoidant or hostile responses directed at the counselor or other inquirer.
Cross Cultural Issues
Usually, those providing disaster counseling in the wake of disasters are the victims’ fellow countrymen and the counselors are familiar with the language and culture of the victims. At times, however, counselors from other countries are involved. (This may be the case in the wake of large-scale disasters in poorer countries).
I have already noted that symptoms may present in “culturally specific” ways (Chapter I). In the context of assessment, this implies that counselors must learn local symptom patterns and local idioms for expressing distressing or other negative feelings. They must also beware of (a) historical animosities between the national or cultural groups represented by client; and (b) potential misunderstandings of the roles to be expected of a helper (the counselor) and the one being helped (the victim); and (c) potential misunderstandings of the relationship between individual and family. (With respect to assessment, in many “Western” cultures the family is important primarily as a source of ancillary information about the individual. In many other societies, however, a problem experienced by an individual is shared by all in his or her family. The unit of assessment may be the family rather than the individual).
A few more specific examples of cultural variants:
There is no simple formula to cover all the possibilities. The counselor must learn -- from books, from informants, and, most of all, from his or her clients.
One particular issue that may arise when counselors from a foreign country are involved in disaster relief is the need to use translators or to recruit local people (who may or may not have relevant prior training or experience) to function as co-counselors. Such use of co-counselors or translators may affect the assessment process. At best, it facilitates communication. In other cases, some victims may mistrust an outsider (especially if the outsider is from a nation that formerly colonized the nation where the disaster has occurred), and the use of a co-counselor or a local translator may ease the relationship. But in still other cases, victims, fearing shame or retribution, may be less likely to share their experiences with someone from their own community than with an outsider.
Even when these issues do not arise, use of translators may create some other problems. The translator may lack the ability to translate accurately. Even if there is no question of linguistic ability, other factors may interfere with the accuracy of translations, however. These include: (a) The translator’s own experience of the disaster or his or her own reactions to it may interfere with his or her ability to translate accurately. (b) The relation of the translator to the victim and to the victim’s community may introduce distortions into translations. (c) The translator may experience shame at what has happened to the victim and may inaccurately report their experience. (d) The translator’s versions of the victim’s story may be distorted by the translator’s and victim’s roles in ethnic or political conflicts in the disaster community.
In any case, use of children as interpreters for their families is especially problematic and should be avoided if at all possible. It may violates traditional family roles. It may make children privy to information normally considered inappropriate for them. It may violates cultural expectations about the role of children with respect to strangers.
There is no simple solution to these problems. When local counselors are not available, use of a bilingual counselor from outside the immediate community may be the best alternative.
Risks to those doing assessment
Those assessing disaster victims place themselves at risk of adverse emotional reactions. This issue has been discussed above (Chapter II) in terms of burnout and “secondary traumatization.” Some of these reactions (e.g., inability to concentrate, excessive fatigue, avoidance of tasks) can lessen work efficiency. Other reactions more directly interact with assessment tasks. For instance, experiences recounted by victims may trigger recollections or reexperiences of traumatic events in their own history. This can lead to unconscious tendencies to avoid asking about some issues or may produce subtle messages to those being interviewed not to tell about certain experiences or feelings. Alternately, the interviewer may distance himself or herself from those he or she are interviewing, interfering with the emotional connection that facilitates the assessment process. Interventions and self-help to respond to these issues is discussed below, in Chapter IV.
PRINCIPLES OF PSYCHOSOCIAL INTERVENTION FOLLOWING DISASTERS
There are two major aspects to intervention with the direct victims of disasters: rebuilding the community affected by the disaster and intervening with individual victims. (In addition, interventions must be aimed at rescue and relief workers and others less directly affected by the disaster).
Sometimes these two aspects have been seen as being in opposition to each other. For instance, in the context of huge disasters (e.g., a major earthquake, refugee camps for victims of ethnic cleansing), some humanitarian aid workers have argued that to focus on the mental health of individuals is a hopelessly large task. In any case, to focus on individual recovery from the disaster deflects attention and resources from the more urgent task of promoting broader social and economic recovery. From this perspective, rebuilding informal networks of social support, reuniting families and communities, and supporting the physical rebuilding of the shattered community take precedence over interventions aimed at individuals or families.
The individual and community approaches are not really in opposition to one another. The healing and rebuilding of the community is an essential underpinning for the healing of individuals and families, and the healing of individuals and families is necessary for the successful reconstruction of the community. In each case, the underlying principle is to encourage healing processes, in individuals, families, and communities. In this manual, the focus is on individual and small group interventions.
A wide variety of specific techniques have been used to provide immediate relief to individuals in distress, to prevent or mitigate the longer-term emotional effects of disasters. Later in this manual (Chapter VI), a number of these specific techniques will be discussed in detail. To be useful, the techniques have to be adapted to the specific situation – the kind of disaster, the human and material resources available, the specifics of local culture and tradition. This section of the manual focuses on the core principles that guide both specific techniques and their adaptations.
Principle I: Safety and Material Security Underlie Emotional Stability
It is difficult for people to maintain a stable mental state, after a disaster or in any other circumstances, unless certain basic needs are met. First, they must be assured access to food, water, clothing, and shelter. Second, their need for physical safety and security must be met. In the case of disasters, this includes not only freedom from fear for one’s life, due to the disaster itself, but security from banditry, from the fear of looters, from fear of rape or other assault in shelters or refugee camps, and from the fear that the disaster will lead to the permanent loss of one’s land or one’s home. Third, the safety and integrity of their family must be ensured. Fourth, their long term need for stable jobs, adequate housing, and a functioning community must be met. This “hierarchy of needs” has several implications:
Principle II: Assume Emotional Responses to Disaster are Normal
A wide range of emotional responses to disaster are normal responses to overwhelming stress. They are not, in themselves, signs of “mental illness.” They do not signify that the person suffering from the symptoms is “weak” or is “going crazy.” They are focuses of intervention for two reasons: (1) The symptoms themselves may be distressing to the person experiencing them. (2) The symptoms may interfere with the person doing things that are important for his or her immediate safety or well being or taking part in the recovery of their community.
Many of the symptoms described earlier can be understood as adaptive mechanisms, by which people seek to protect themselves against the overwhelming physical and emotional impact of the disaster. Both individuals and communities have natural healing processes. The central task of psychosocial intervention is to elicit, facilitate, and support these healing processes and to remove the obstacles to their operation, in order to prevent lasting dysfunction and distress. Interventions are aimed, above all, at minimizing the number of people who will require later “treatment.” One major implication is that it is essential to reassure people, to help provide short term relief of symptoms which may be alarming to them, and to act to prevent symptoms from becoming entrenched. Education as to the kinds of reactions people may experience may help people understand and “normalize” their feelings.
Victims do not usually see themselves as mentally ill and they may fear or avoid involvement with “mental health” workers and the “mental health” system. Many do not spontaneously reach out for the assistance of mental health workers. Psychosocial assistance in the wake of disaster is best presented in a form that does not require people to see themselves as “ill” or “mentally ill.”
Leaflets describing common responses to disasters, signs of distress, and services available may be directed at primary victims, parents and teachers of children affected by the disaster, rescue and relief workers, and families of relief workers. Several sample pamphlets can be found in Appendix C.
Principle III. Interventions Should be Matched to the Disaster Phase
The types of response that are offered should match the phase of emotional responses and the needs of disaster relief operations.
The “Rescue” Phase:
Immediately after the disaster, the highest priority for psychosocial services is rescue and relief workers, whose continued effective functioning is essential. This may involve crisis management, crisis intervention, conflict resolution, assisting with problem solving, or “defusing” (See Chapter VI). Many very small concrete services may be emotionally useful as well as practically helpful. Bring rescue workers coffee, lend a hand in helping clean up, give a hug, express interest.
Immediately after the disaster, the most urgent needs of victims are for direct, concrete relief (e.g., rescuing lives, ensuring physical safety, providing medical care, providing victims with food, water, shelter, reuniting families). Psychosocial interventions aimed at victims during this phase are primarily directed to serving these ends. In doing so, they contribute to longer-term mental health.
The “Inventory” Phase
Continuing to provide services to relief workers remains a high priority during this period.
The first days or weeks following the disaster may be a “honeymoon” phase, in which people’s feelings of relief and optimism about the future dominate. A spirit of generosity and mutuality may appear, and individuals may be in a state of denial about their losses and the problems of the future. During this stage many people will not be receptive to psychosocial interventions or will feel they do not need them. Others, however, may welcome the chance to talk through their reactions within a few days of the disaster or to find someone who can help them plan how to overcome the obstacles they are facing.
The bulk of psychosocial interventions directed at victims themselves occur in this period. Discouragement and disillusionment with relief and reconstruction efforts may set in. Anxiety, sadness, irritability, frustration, and discouragement now combine with disaster-produced losses and post-traumatic stress effects to produce a relatively high level of need. Focusing on identification of those at risk and on interventions to reduce the longer-term impact is essential.
In most circumstances, the number of people trained in responding to the emotional consequences of disaster will be insufficient to meet the demand. Training of auxiliary
disaster counselors will, of necessity, be a high priority during this period. Primary care health workers, teachers, religious leaders, traditional healers, and others can be enlisted.
The “Reconstruction” Phase
Emotional consequences of the disaster may continue to appear for up to two years or more post-disaster. In part this represents delayed reactions, in part responses to a growing recognition of the irreversible consequences of the disaster. The experience of several disasters suggests that mental health assistance should remain available for about two years or more after the disaster. Such services also permit longer-term follow-up of those treated earlier. It may be helpful to establish and maintain a telephone “hot line” or other ways for people to contact counselors if the need arises, for the period after counselors leave the site of the disaster.
Tasks at Different Stages Following a Disaster
I. The Rescue Stage (immediate post-impact):
Provide “defusing” and crisis intervention services for relief workers
Ensure safety of victims and ensure that physical needs (housing, food,
clean water, etc.) are met
Seek to reunite families and communities
Provide information, comfort, practical assistance, emotional “first aid”
II. The Early Inventory Stage: First month
Continue tasks of Rescue Stage
Educate local professionals, volunteers, and community with respect to
effects of trauma
Train additional disaster counselors
Provide short-term practical help and support to victims
Identify those most at risk and begin crisis intervention, “debriefing,” and
Begin reestablishing community infrastructure: jobs, housing, community
institutions and processes
III. The Late Inventory Stage: Months two on
Continue tasks of Rescue and Early Inventory Stages
Provide community education
Develop outreach services to identify those in need
Provide “debriefing” and other services for disaster survivors in need
Develop school-based services and other community institution-based services
IV. The Reconstruction Phase
Continue to provide defusing and debriefing services for relief workers and
Maintain a “hot line” or other means by which survivors can contact counselors
Follow up those survivors treated earlier
Principle IV. Integrate Psychosocial Assistance with Overall Relief Programs
It is difficult, if not impossible, to provide effective psychosocial services without the cooperation and support of those directing and providing medical and material relief efforts, at the local as well as the regional or national level. Governmental officials (at local or national level) often do not recognize or give much priority to the psychosocial effects of disasters. Rescue and relief workers, who are necessarily focussing on the urgent and concrete tasks of saving lives, protecting property, ensuring the provision of food, clothing, and shelter, and rebuilding the material infrastructure of the community may see psychosocial services as unnecessary or even as getting in their way. Educating both of these groups about the impact of psychosocial processes on the relief effort itself and on the long run consequences of not responding to the mental health effects is essential.
Early development of liaison with those directing relief work is essential. Forming a task force made up of experts in psychosocial intervention, formal community leaders (e.g., the mayors of towns), representatives of influential groups in the community (e.g., churches, unions), leaders of the relief effort, and representatives of the victims to guide and support psychosocial work may be very useful.
One potential source of contention is that preexisting social stratification (by class, caste, gender, rural vs. urban, etc.) may lead to certain groups (e.g., women, poorer people) being left out of the process. Conforming to traditional patterns of stratification in the name of efficiency or of “restoring community structure” reinforces those patterns. Implementing programs along more egalitarian and participatory lines may produce conflict and new forms of stress, but it may also ultimately result in serving a far larger group of victims and producing a more integrated, cooperative post-disaster community.
Several useful focuses of early liaison work are:
a) the importance of keeping primary groups (families, work crews, groups of people from the same neighborhood or the same village) together, if conceivably possible
b) the importance of not separating children from their parents, if in any way possible
c) the importance of having victims play a role in the relief and recovery efforts
d) the importance of avoiding unnecessary evacuations and of letting people return to their homes as rapidly as possible
e) the importance of allowing the bereaved to see the bodies of those who have died, if they desire to do so.
f) The importance of pet rescue and maintenance of pets in special animal shelters. This is often neglected but is very important for the emotional well-being of many people.
One effective way of encouraging integration of social assistance with overall relief programs is for those providing psychosocial assistance to thoroughly integrate themselves into the relief team. Go out with food distribution teams. Run a “play” center for children, which will also draw in mothers. Be part of the “briefing” or “orientation” team for newly arriving relief workers. Attend early morning or late night team meetings.
Principle V. Interventions Must Take People’s Culture into Account
People from different cultural groups (including different sub-cultural groups within a larger society) may express distress in different ways and may make different assumptions about the sources of distress and how to respond to it. Techniques originally devised in industrialized countries must be applied sensitively, if they are to be used elsewhere. (Fortunately, there is a body of evidence suggesting that these techniques can be successfully adapted to a wide variety of situations.
Some of the cross-cultural differences which may need to be taken into account include the following:
Interventions need to be sensitive to these differences and may effectively draw on them, as well. To cite several examples, in working with victims of a volcanic eruption in the Philippines, counselors incorporated prayer into “debriefing” sessions; in working with traumatized Navaho Indian war veterans (U.S.A.), traditional healers were enlisted both to help provide services and to organize traditional rituals aimed at cleansing warriors returning from battle.
One path which helps create such sensitivity is to involve local people in every phase of psychosocial services. Local health workers, priests, traditional healers, union leaders, teachers, and local community leaders should be educated about the psychosocial consequences of disaster and enlisted to serve as psychosocial counselors. Modifications of the techniques described in Chapter III can be developed with their aid and participation.
In this context, differences between men and women in coping styles and in what is deemed socially appropriate can also be regarded as a form of “cultural difference.” Interventions need to be sensitive to the possibly differing expectations and needs of women (e.g., with respect to speaking about emotional concerns in a family meeting or a public setting).
Principle VI. Direct Interventions Have an Underlying Logic
A variety of specific intervention techniques may be useful in responding to the emotional impact of disaster on individuals, families, and other groups. In any particular disaster situation, these techniques may have to be modified or adapted, and there are many other, less formal interventions that may be useful.
In what follows, the focus is on the logic and underlying purposes of interventions, rather than the details or specific mechanics of interventions. The latter is addressed for a number of specific techniques in Chapter III.
For children, other means of communication, including playing, art work, dancing, or role playing may play the same role that talking does in an adult. For some adults talking about the events may be painful, or talking about bad events may be culturally proscribed, and similar non-verbal means of communication may provide a way to express themselves.
In some instances, no natural support groups are available. In this situation, creating artificial networks (e.g., creation of ongoing peer or self-help groups for treatment, helping to reorganize and rebuild communities) is helpful. In most instances, group treatment modalities should be a central part of the psychosocial response to disasters. When possible, the group that is the unit for treatment should be a naturally occurring group, such as the family.
Note: While social support generally helps people deal with stress, expectations that one should support others, if excessive, and feeling too much empathy for too many people can exacerbate stress. Resistance to involvement in social networks should be evaluated on a case-by-case basis.
A sense of community, a sense of social identity, and a network of social support are essential underpinnings of mental health. Interventions and advocacy to restore community morale, traditional economic activities, pre-existing welfare and personal services, schools, leisure and recreational patterns are useful.
Communities have a wealth of traditional strengths and resources. Use indigenous healers and local residents, both drawing on their traditional skills and training them in psychosocial rehabilitation techniques. Identify traditional rituals and ceremonies, such as healing rituals and purification rituals used by the community to deal with crisis, and facilitate their use. Where traditions don’t exist, new community rituals may be created, such as a day of mourning or daily bell ringing or processions.
There are potential pitfalls in efforts to rebuild the pre-disaster community. Some of these are created, directly or indirectly, by the disaster itself. For instance, conflicts may arise between emergent leaders “created” by the crisis of disaster and traditional leaders or between local leaders and outside experts and elites. Traditional elites may use their traditional positions to monopolize post-disaster resources or to further pre-disaster ambitions. The crisis created by disaster may open long-dormant faults in societies or communities and may lead to new relations within families or within a community. A crisis is an opportunity for change to emerge in a community. “Building on community strengths” does not mean automatically seeking to restore the old structure of the community in the interests of “efficient” relief efforts, nor does it mean pursuing one’s own beliefs in how communities or families “ought” to be structured. It is engagement in a community, rather than a particular structure of the community, that represents an area of hope for victims.
Principle VII. Children Have Special Needs
For the most part, the same principles that apply to adults apply to children, with appropriate adaptations for their age (i.e., use language appropriate to the child’s age; be concrete). The various child-specific reactions to disaster discussed earlier suggest several additional principles for work with children:
Additional suggestions on how parents can help their children in the wake of disaster can be found in Appendix C (“Children and Disasters”).
VIII. Women Have Special Needs
The needs of women in the wake of disaster has to be understood in the context of the roles, experience, and status of women in the pre-disaster society. At the same time, it should be stressed that not all women have the same needs. Differences in nationality, ethnicity, age, social class, marital status, as well as particular differences in personality or history of past trauma affects their needs. Elderly or disabled women may carry a double burden of vulnerability.
Women are often underrepresented in formal organizations concerned with disaster preparedness, warning, and response. As a result, their needs may not be heard, taken into account, or responded to by those making decisions about responses to disasters.
More positively, women's formal and informal organizations and networks can be a source of strength, both to individual women and to the disaster response process as a whole. Promote women's participation, empower women within the disaster response process, open opportunities to non-traditional jobs and roles, and use women's existing skills.
Rape also has direct consequences, possibly including physical injury, acquisition of sexually transmitted disease (including HIV), pregnancy, or loss of virginity (in settings in which this may have profound cultural meaning). Women may have difficulty talking about such assaults. Shame, fear, and anger may prevent women from revealing these events. The woman may deny the occurrence of these events (with herself as victim or with another family member, such as a daughter, as victim) to protect herself or others . She may become socially isolated.
Rape victims should be approached by same-sex counselors. Make contact with rape victims at a rate and in a manner that the client can accept. Avoid any moral judgment of the victim: Rape is never the fault of the victim. Ensure privacy for the interview and take extra measures to ensure confidentiality. Note that denial and repression may be survival mechanisms, not signs of emotional disturbance. Provide mechanisms to protect victims against stigmatization and against direct reprisal. Seek to end the isolation of the victim.
Education of victims and community and creating alliances with community and religious leaders to combat the stigmatization of rape are essential. Rape, it can be emphasized, is not primarily a sexual act. It is an act of anger or of power or of exerting control or of terrorization enacted sexually.
Self-conscious efforts to locate women isolated in their homes and to protest them from further abuse should be part of the disaster response plan.
IX. Residents of Refugee Camps Have Special Needs
The approaches to intervention used in a wide range of post-disaster situations may require modifications for refugees, especially those in long-term refugee camps.
-- In cultural environments where ritual ablution before prayer is required, limited access to washrooms first thing in the morning can be a source of distress, even if, over the course of the day, there is adequate access for maintaining normal hygiene.
-- The process of distribution of food in a shelter or refugee camp may conflict with traditional notions of who serves whom.
-- Limitations on the ability to carry out proper mortuary ceremonies (including providing food for the dead as well as for the living) may lead to fears that improperly cared for deceased family members may reappear as vengeful spirits.
-- The role played by humanitarian aid officials may threaten the authority of old leaders or seem to threaten traditional control over children.
Sensitivity to issues such as these requires involvement of camp residents in setting camp procedures.
Victims of torture: A full treatment of the needs of refugees who have been victims of torture is beyond the scope of this manual. The World Health Organization manual, Mental Health of Refugees, provides a wealth of useful ideas. (See “Further Resources”). However, note the following:.
X. Rescue and Relief Workers (and Journalists and Human Rights Workers) Have Special Needs
Rescue and relief workers are both at high risk for adverse emotional responses and a high priority for intervention. Their needs are often ignored, since their training and willingness to work makes it appear as if they have more emotional resources than the direct victims of the disaster. Their needs may be seen as “less important” than those of the primary disaster victims, and they themselves are often poorly prepared for their own emotional reactions to their experiences doing disaster relief. (Much of what follows also applies to human rights workers, journalists, and others with prolonged or repeated exposures to disasters and their consequences).
Relief workers (including policemen, firefighters, and soldiers who may be involved in disaster responses) often develop a culture of “defensive distancing.” They may deal with stress by using “black humor,” superficial callousness, and a belief that getting the job done right is more important than expressing their feelings. They do not seek out assistance and may resist being drawn into interventions.
After a period of time on the job, the accumulated stress may lead to “burnout,” a syndrome in which the rescue worker loses his or her enthusiasm for the work, becomes less efficient, feels chronically fatigued, feels besieged with unfair demands, and feels chronically irritable with and critical of fellow workers and clients.
a) Reducing bureaucracy and paperwork
b) Promoting a sense of camaraderie and mutual support among relief workers
c) Interventions to defuse conflicts among workers or between workers and their supervisors
d) Providing adequate information about tasks and the overall disaster
e) Providing adequate supplies for the work demanded
f) Developing work rules and schedules that permit relief workers to follow through on task assignments
g) Maintaining communication between workers and their own families,
h) Providing adequate facilities for rest, sleep, washing, and eating
i) Providing adequate food, shelter, and rest time for relief workers
j) Environmental interventions to reduce noise, improve traffic flow, and provide space to take a break
k) Providing recognition and appreciation for the sacrifices the relief workers are making
One of the most important ways to reduce stress for relief workers is to provide adequate “break time” or “down time.” This should be provided away from the relief site (e.g., in a separate tent on the edge of the relief operation site, or in a room in the back of a shelter). Food, supplies, and napping facilities should be provided.
SPECIFIC INTERVENTION TECHNIQUES
Crisis Intervention (Individual)
What It Is: A set of techniques for helping individuals gain control over a
People It Is Aimed At: Individual relief workers, disaster victims
When to Use it: At any time after a disaster, when individuals present “in crisis”
A “crisis” occurs when a person is faced with a dangerous or other seriously stressful situation for which their habitual problem-solving mechanisms are unsuccessful. Anxiety, fear, guilt and shame, feelings of helplessness or hopelessness, a sense of disorganization, or anger may result. The disaster itself represents a crisis for most victims, of course. In the days and weeks and months following a disaster, additional crises may appear, for victims and for relief workers. Some unexpected incident or simply the buildup of stress over time can constitute the “crisis.”
Crisis intervention is a set of techniques aimed at helping the person in crisis gain control over the crisis situation. A little support and focused help at such a time, aimed at helping the victim to gain control over the crisis situation, may prevent later difficulties. Crisis intervention may be focused on an individual, several people together, or small groups (including a family unit).
The crisis intervention process involves, first, identifying and clarifying the elements of the crisis (the problem or issue or situation); second, developing problem-solving strategies; and third, mobilizing the person to act on these strategies.
Simply identifying the elements of the crisis may, in itself, may help the client regain a sense of mastery. Ventilation of feeling and making the client aware that intense feelings do not represent “going crazy” may be helpful, but the flow of affect should be monitored so that the client doesn’t become frightened of losing control and so that his or her thought does not become further disorganized. The subsequent task is to help the client discover solutions, access support networks and resources and concrete services. This may be a very informal process, accomplished in as little as a few minutes, or it may be more formal and may require several meetings.
Some guidelines for crisis intervention:
What It Is: An informal procedure to help groups of relief workers deal with
their reactions to specific incidents
People It Is Aimed At: Relief workers
When to Use it: Within 24 hours after the incident
Defusing is a brief, informal procedure to help relief workers deal with the feelings and reactions created by a specific incident or event. It may be a response to some unexpected incident in the course of relief work (e.g., an accident or a gruesome discovery of a disfigured body during rescue operations), or to a conflict (between two relief workers, between a worker and a supervisor, or between a relief worker and a victim). Defusing provides a chance for those affected by the incident to focus on defining the problem and to develop problem-solving strategies that will preserve the productivity of the work unit.
Defusing can be conducted with a group of individuals who were involved in a single incident or situation or with an individual. When the precipitating situation involves a conflict between two or more people (e.g., between relief workers and victims), it is better to work with each party separately, at least initially. Defusing should be done with relief workers and victims separately and with relief workers and their supervisors separately.
In a defusing session, the affected individual or group meets with a disaster counselor. The session typically lasts twenty to forty minutes.
Stage 1: Lay the groundwork for the session. Let relief workers know the goal is for them to return to work as soon as possible. Find out what happened: Ask the members of the group to tell about the event that led up to the meeting.
Stage 2: Explore the thoughts and feelings and reactions of the several individuals involved: “What did you think when this happened?” “How did you feel about this event when it occurred?” “What was the worst part for you?” “How do you feel about it now?” Reassure group members about their feelings. Be supportive.
Stage 3: Explore the coping strategies the group members are using: How are they dealing with the event or incident. Do they still have needs that are unmet? What would help for them right now? What are their plans for dealing with this event (or similar events) in the future? What would help in the future?
Stage 4: In some instances, a brief rest or diversion (a cup of coffee, a short walk) or a directed relaxation exercise (e.g., breathing, visualization – see below) may suffice to enable the person to recover their own sense of competency and direction.
Stage 5: Follow up: Maintain an expectation that the person will rapidly return to the activities they need to perform. Where a relief worker’s return to work after a short break is the expected result of intervention, it may be appropriate to follow up within a very short period (e.g. twenty minutes).
Critical Incident Stress Debriefing
What It Is: A structured technique to help individuals and groups process
their disaster experience and bring closure to it.
People It Is Aimed At: relief workers, disaster victims (direct and indirect)
When to Use it: with relief workers, periodically and before returning to
non-relief activities. With victims, several days to a year
after the disaster
Debriefing was initially developed for use with emergency and relief workers, as part of a larger program of interventions aimed at forestalling the emergence of disabling symptoms or minimizing their enduring effect. Its use with direct victims of disaster is somewhat controversial. It should not be used as a "one-off" intervention (i.e., a single intervention, with no other follow-up or support offered) or if it does not include instruction on coping with stress. Its routine use with disaster victims who are not showing unusual signs of distress or who are not seen as being especially at risk is questionable. It is also inappropriate insituations in which severe stress and danger are ongoing. It has been used, with reported success, with groups of disaster victims identified as having symptoms or otherwise being at especially high risk, however.
Critical incident stress debriefing (CISD) is a structured group discussion. Its goal is to help people build an account of traumatic experiences so as to help prevent the intense emotions and experiences of the experiences from becoming entrenched in the form of disabling symptoms. It allows people to share powerfully charged feelings of anger, helplessness, or fear, in a way that helps diffuse them. They learn that these reactions are experienced by others, too, and are “normal.” They learn that, though they may have had different specific experiences in the disaster, they are not alone.
Debriefing is usually done in a group setting. The group may consist of a work team of relief workers, a pre-existing work team (e.g., the crew of a train, a work team in a factory), a group of neighbors, a family, or a group of survivors assembled on an ad hoc basis. The group may consist of up to fifteen or so members.
Debriefing is carried out at least a few days after the traumatic event. If it is attempted too soon after the disaster, the short-term emotional reactions (e.g., disbelief, denial, a sense of unreality, delayed reactions) and preoccupation with dealing with practical issues may interfere, and repeated retelling of the disaster story may reinforce a sense of helplessness. Other techniques to help people regain a support network, reduce anxiety, and establish a sense of mastery can be carried out in the meantime.
Debriefing may continue to be a useful technique months or even several years after the disaster. At this stage, correcting cognitive distortions and inaccurate evaluations of victims’ own roles and inaccurate estimations of ongoing threat, providing knowledge of common responses, and dealing with reactions to the relief and recovery process assume greater importance.
Debriefing usually involves a single session, lasting about two to three hours. If the participants show lingering or especially intense reactions, additional sessions may be added or individual counseling may be used as a follow up activity. If necessary, a shortened version may also be carried out. (With relief workers, who continue to be exposed to trauma, multiple shorter sessions are often used).
When possible, it is helpful to have two disaster counselors meeting with the group. One plays the primary role of leading the group discussion process, questioning, listening, and giving information. The second is available to spend time with any participants who need to leave the group due to their distress as well as helping guide the overall process of the group. (As an additional benefit, the two counselors can debrief each other about their responses to the session).
Critical Incident Stress Debriefing proceeds through a series of pre-planned phases. It can be modified in a variety of ways, to take into account the needs of individual victims, cultural differences, the effects of different kinds of disasters, etc. The guidelines that follow are meant to be suggestive, rather than a rigid set of rules.
Phase 1: Introduction: Introduce yourself and explain what the purpose of the session is. Give an overview of the process: (i.e., it will last about two hours; people will be asked to tell their stories of the disaster and their reactions; information about normal reactions to disasters will be offered). Describe the goals (helping people understand what is happening to them and why, so that they can manage their reactions more effectively and with minimum anxiety and disruption to their lives.). Seek to normalize people’s experiences: unusual emotional symptoms are to be expected, although lack of symptoms is also normal. Answer questions. Address participants’ fears and possible misconceptions (e.g., it is not psychotherapy; participation does not mean they are “abnormal”).
The rules for the session should be stated: (a) No one is required to speak, although they are encouraged to do so. (b) Judgement or blaming others will not be allowed. (c) Everyone must listen to the others and let them have their say. (d) Participants should speak for themselves, not for others. (e) If anyone is very upset, they should still try to stay in the group. If they have to leave to recompose themselves, they may (accompanied by one of the counselors, if two are leading the group), but they should return promptly. (f) The proceedings are confidential: no one can talk about the substance of what others said outside the group (no “gossip”).
Phase 2: Narratives: In this phase, the aim is sharing facts and collectively creating a picture of what happened. “Tell us who you are and what happened from your perspective. Who would like to start?” Include everyone’s account of what happened to them (although, again, participants can pass if they choose to). Refrain from focusing on psychological reactions at this point. If participants begin to talk about their reactions, gently steer them back to the “facts.” With relief workers, the starting point may be to ask about what their role was in the relief effort, how long they have been on the job, and whether there were any troubling situations.
Phase 3: Reactions: In this phase, a shared inventory of thoughts and feelings is developed. Participants learn that others share their symptoms, which lessens feelings of isolation and shame. They also learn that thoughts and feelings are related, and that changes in understanding can lead to changes in feelings.
(a) Go around the room and ask about people’s cognitive reactions at the time of the incident. “What were your first thoughts? What did you think next?” “What did you do then?” Then turn to reactions in the aftermath of the events. “What did you think when the event was over?”
(b) Now shift to reports of feelings, rather than thoughts. Ask participants to describe their feelings, linking them to their thoughts and appraisals of the situation. “How did you feel then?” “What was the worst thing about the experience for you?” “What aspect of the events caused/causes you the most pain?” Ask about the reactions of the participants’ family and other significant people in their lives. Look for any feelings that family members or other significant people didn’t understand what had happened to them or that family members increased their anxiety by the way they expressed concern. Ask about subsequent reactions (e.g., “that night” or “the next day ”). Ask about both physical reactions and emotional symptoms.
Emotional expressions at this stage (and possibly at others) are to be expected. This should be accepted, but contained. If a participant is unable to contain his or her feelings to a degree that it becomes hard for the group to continue, he or she should be asked to leave the room (accompanied by the co-leader of the group) until they can compose themselves. The expectation should be that they will return within a few minutes.
(c) Continue to explore the sequence of thoughts and feelings in the days or weeks following the event, moving into the present.
(d) Now begin to shift back from emotions. Explore coping strategies. “How did you deal with it? How are you dealing with it?” “What do you usually do when you feel this way?” “What has helped you at other times to cope with problems?” “What could you do to help yourself next time you feel this way?” “Were there any positive aspects of the experience?” (With relief workers, helping identify positive or hopeful memories is especially important, since it may help them return to their relief work).
Phase 4: Education: In this phase, the focus shifts more formally to education, although educational interventions may be made throughout the process.
(a) Summarize the session, bringing together the narratives and the responses (thoughts, actions, feelings).
(b) Warn participants that their symptoms may not subside instantly and that new symptoms may appear. Recognize the potential for some difficult times. Hold out the expectation that this will be for a limited time, however. Be realistic, though: it can take months or even a year or more for symptoms to subside. At the same time, teach participants that symptoms are not universal and that a lack of symptoms is just as “normal” as symptoms.
(c) Teach techniques of stress management (e.g., relaxation exercises). Emphasize the importance of getting rest, having a good diet, getting exercise. Encourage talking with others. Encourage identifying concrete steps they need to pursue.
(d) Identify those who need immediate help (e.g., desensitization of phobic symptoms). Arrange for follow-up or referral.
(e) Give information on sources of further help. Distribute and pamphlets or leaflets available on responses to disasters.
(f) Arrange for follow-up.
Phase 5: Follow-up: Two or more weeks later, follow up, either by a formal questionnaire or by a brief interview. Track recovery or lack of it. Identify what has been helpful. Identify problems needing further attention.
Variations and adaptations:
1. With disaster relief workers (assuming that they are not themselves primary victims of the disaster), debriefing is a response not to their experience of the disaster itself but to the stresses and strains of relief work. It may be useful to carry out a debriefing session periodically (e.g., once a week or even more often). In any event, a session should be scheduled before relief workers from outside the disaster community return home to their “everyday” lives.
An end-of-service debriefing session should focus on issues such as:
2. Debriefing can be conducted with a variety of audiences and under a variety of constraints.
3. Debriefing can be adapted to various cultural situations. For instance, groups formed in response to a volcanic eruption in the Philippines replaced the training in relaxation exercises with prayer as part of the sessions. Other traditional healing rituals could be incorporated in a similar fashion.
Stress Reduction Techniques
What They Are: Technique for helping individuals reduce stress and anxiety
People It Is Aimed At: Relief workers, victims
When to Use it: At times of stress or on regular basis
Disasters produce a great amount of stress and anxiety, both immediately and over the weeks and months that follow. A variety of techniques may be useful in reducing stress and anxiety.
Rest and recreation: Both brief periods of rest in the course of the day’s activities and adequate sleep are important, both for relief workers and survivors. Understandably, the emergency created by a disaster may interfere with these in the first hours or days after the disaster. As soon as the most urgent, life-and-death rescue needs are met, however encourage relief workers to permit themselves to take a break or a short nap and ensure that adequate facilities are available for these. Encourage those supervising relief efforts to schedule relief workers shifts so as to ensure that the workers get adequate sleep. Recreational activities, ranging from card games to watching television to participating in games may be helpful, both for adults (relief workers and primary disaster victims) and for children and adolescents. In part, these serve as a diversion, preventing “ruminating” about the disaster. They also help restore a sense of normalcy and control over one’s life.
Ventilation: Allowing relief workers and survivors to talk about their experiences and feelings in both informal and formal settings relieves stress. Repetitive restatements or rumination, however, do not relieve stress and may promote depression, however, and should be discouraged. Divert the discussion on to other topics, provide diversions, or use other approaches to promoting relaxation.
Exercise: Physical activity helps dissipate stress. Provide opportunities for relief workers and primary disaster victims (e.g., in a shelter) to get exercise: taking a walk, jogging, engaging in a group exercise “class,” engaging in an athletic event, dancing.
Relaxation exercises: Several types of relaxation exercise can easily be adapted for use in disaster settings to help clients reduce anxiety and stress. These include breathing exercises, visualization exercises, muscle relaxation exercises, and combinations of these.
First, the counselor leads an individual or a small group of individuals through these exercises. If the victims have tape cassette players available, it may be helpful to record a relaxation exercise for each client to listen to and engage in on his or her own. Individuals can also be taught how to use the procedures on their own without an auxiliary tape.
Relaxation procedures can be used on an “as needed” basis (i.e., at a time when the relief worker or survivor is feeling “stressed out”), either on their own or with the help of the counselor. A regularly scheduled relaxation event, whether consisting of relaxation exercises, prayer, stretching exercises, or other techniques, may be offered at a consistent time once or twice a day. Many people also find that following the relaxation procedure on their own two or three times a day on a routine basis increases their ability to deal with stress throughout the day.
After learning a full relaxation exercise, a shortened form can be developed. Such brief forms are especially useful for using “as needed.”
For a person to be willing to allow themselves to relax by following the directions of another person (the disaster counselor) requires some trust. Teaching relaxation exercises should be delayed until the counselor and the client have created a trusting relationship. This is especially true of disaster survivors who have developed post traumatic stress disorder. Others, who are very anxious or very depressed, may find relaxation exercises problematic. Relaxation exercises should be approached with caution with such clients. If the client begins to become agitated, stop the exercise.
Contraindications to the use of relaxation exercises
Relaxation exercises are not for everyone. They should be used with extreme caution or not at all in the following circumstances:
Also note that visualization exercises can inadvertently re-trigger traumatic experiences (e.g., using a walk through the woods as a "pleasant" image with a refugee who escaped through the woods). Similarly, breathing exercises may be frightening to those who have been buried under rubble.
Sample scripts for several types of relaxation exercise can be found in Appendix B.
What They Are: Techniques which do not require the ability to explicitly label
People It Is Aimed At: Children; adults who have trouble responding to
questions or describing feelings in verbal form
When To Use It: Several days to a year or more after the disaster
It is difficult for children to discuss their emotional problems. Their verbal abilities are relatively undeveloped and they lack facility at labeling their emotions. This is especially the case for children below the age of eleven or so, but even older children and adolescents, and not a few adults, may have difficulty or inhibitions about explicitly talking about their feelings. In these settings, techniques that permit expression and exploration of feelings in non-verbal form (e.g., play, art, dance, games) or in forms that, although they use words, do not require the person to explicitly identify and label emotional states (e.g., writing poetry, role playing, puppet play) are useful. These techniques can be collectively labeled “expressive techniques.”
Underlying these techniques is the notion that play, artistic creation, and similar activities are systems of communication and interpersonal interaction. Through play and similar activities, the child reveals meaningful information about his or her emotional problems, inner thought processes and states, desires, and anxieties.
As with conventional verbal techniques, the goals of expressive techniques include ventilation of feelings, creating a new narrative about terrifying events, regaining a sense of control and mastery, working through grief, finding and feeling support from peers, and normalizing unexpected and unfamiliar reactions. They also help establish a trusting relationship between the child and the counselor.
Expressive techniques are commonly used with children up to the age of eleven or so, and with children as young as two to four. They can be used with people of any age, however, In what follows, the word “child” will be used to indicate the person with whom the technique is used, with the understanding that the “child” may, in fact, be an adolescent or adult.
Expressive techniques can be used with a single child, but are also easily adapted for groups (either ad hoc or a school class). In some cases, children experience a disaster but the parents do not experience it directly. This would be the case, for example, if there were an explosion or other violent incident at a school. In these circumstances, although parents might benefit from group debriefing sessions, the children might be treated in their classes. If, however, the child’s parents were themselves also primary victims of the disaster or if the child is especially distressed, it may be helpful to involve the whole family unit together. A mix of expressive and verbal techniques might then be used.
Expressive techniques involve an active role for the counselor. They do not just consist in letting the child play. Undirected play may be diverting and healing for the child. However, monotonous, repetitive, ritualized play by an isolated child is a sign of trauma. It does not release the child from distress. In expressive therapy, the counselor participates; limits (emphasizes rules, encourages frustration tolerance, prevents overt aggression against others); interprets (“I wonder if you felt like your doll when….”).
Just as with other techniques, the user of expressive techniques should be sensitive to the stage of response to the disaster. Immediately after the disaster, play may help children acknowledge and ventilate their feelings. This helps reduce anxiety and provides an opportunity to provide the children with accurate information and to screen for those in severe distress. Lack of expression of intense emotion at this time is not necessarily a sign of severe disturbance, requiring treatment, however. The child who has lost a parent in a disaster, for instance, may be in a state of shock and denial for a week or two after the event and may not be fully able to communicate intensively about it for several weeks beyond that. Providing repeated opportunities for the child to express him or herself, when ready, is appropriate. More extensive intervention must wait until the child is able to handle it.
Expressive therapy may, initially, at least, be either “directive” or “non-directive.” In non-directive play, the child’s free activity (e.g., with puppets, dolls, or art materials) is observed. The counselor gently interacts with the child, entering the child’s fantasy world but in doing so, seeking to help the child explore feelings and thoughts.
In directive or pre-arranged play, the child is asked to re-enact some part of his or her experience. This might take the form of a re-enactment with dolls or puppets, or it might take the form of drawing or modeling with clay. An alternative form, especially with older children, might involve the child writing poems or stories that draw on his or her experience. The goal is to help the child eventually replay the experience with a different ending or in a fashion in which the child is exhibiting mastery.
The school may be an appropriate place for some expressive techniques (e.g., story writing, role playing). In addition, the teacher can teach children about the responses to be expected after a disaster, allow for the ventilation of feelings, teach coping skills and problem-solving techniques (through role playing, games, “complete-this-story” techniques), reassure. Aside from specific activities engaged in at school, merely going to school regularly has a healing effect. School provides structure and normalcy. Just as disaster workers benefit from the expectation that, after a crisis, they should get help but then return to their job promptly, so children benefit from the clear expectation that they will return to school promptly after a disaster. If extended shelter stays or stays in refugee camps are necessary and children cannot return to their regular school, it is important to create an ad hoc school. Teachers can receive brief training as disaster counselors with a special emphasis on work with children in their schools, using expressive techniques. In some settings, children in mid-adolescence have also been trained as peer counselors.
Some expressive techniques
Free drawing, painting, modeling in clay
Drawing “a person” or drawing “your family”
“Squiggles”: Each takes a turn making a picture from the other’s “squiggles”
and then makes up a story about it
Drawings, maps, clay models of disaster scene
Creating a group or community mural
Human or animal dolls (commercial or homemade or paper dolls)
Other “props” – toy soldiers, trucks, etc.
Free interactions with puppets
Re-enactments of experiences (in disaster or elsewhere); role playing
Child tells story, adult re-tells it with a “healthier” ending/solution/attribution
Making books of stories and poems and drawings
Role playing; re-enactments of actual experiences in the disaster; role playing
of coping strategies
Mock escapes from the disaster
Oral histories: adults tell stories about the history of the community (to adults and
Event and emotion diaries
Visualization, with a “magic word” to trigger the relaxed state produced
Exercise; active games; races
Neck and back massage
Appendix A: Assessment Instruments
I. The Self Reporting Questionnaire (SRQ)
The Self Reporting Questionnaire (SRQ) is a measure of general psychological distress developed by the World Health Organization and intended for use with adults and older adolescents (ages 15 up). If the person completing the questionnaire does not have at least five years of schooling, the questions should be read to them. This is permissible in any case.
Interpretation: No universally applicable cut off score can be used under all circumstances. In most settings, however, five to seven positive responses on items 1-20 (the “neurotic” symptoms) indicate the presence of significant psychological distress. Item 21 addresses drinking behavior, a problem in its own right and potentially a signal of distress. A single response to any of items 22-24 (the “psychotic” symptoms”) indicates serious symptoms and need for help. Items 25-29 refer to common symptoms of post traumatic stress disorder. A single response to any of these items warrants follow-up.
Translations: Translations of the SRQ into Arabic, French, Hindi, Portuguese, Somali, and Spanish are available upon request, together with further information, from the World Health Organization (see footnote 4). The SRQ has been translated into a number of other languages, including Afrikans, Bahasa Malaysia, Bengali, Filipino, Italian, Kiswahili, Njanja Lusaka, Shona, Siswati, and South Sotho. References to studies using these translations, as well as additional information about the SRQ can be found in A User’s Guide to the Self Reporting Questionnaire (see footnote 4).
Self Reporting Questionnaire
Name: ___________________________________ Date: _____________
Instructions: Please read these instructions completely before you fill in the questionnaire. The following questions are related to certain pains and problems that may have bothered you in the last 30 days. If you think the question applies to you and you had the described problem in the last 30 days, put a mark on the line under YES. On the other hand, if the question does not apply to you and you did not have the problem in the last 30 days, put a mark on the line under NO. If you are unsure how to answer a question, please give the best answer you can. We would like to reassure you that the answers you provide here are confidential.
____ ____ 1. Do you often have headaches?
____ ____ 2. Is your appetite poor?
____ ____ 3. Do you sleep badly?
____ ____ 4. Are you easily frightened?
____ ____ 5. Do you feel nervous, tense, or worried?
____ ____ 6. Do your hands shake?
____ ____ 7. Is your digestion poor?
____ ____ 8. Do you have trouble thinking clearly?
____ ____ 9. Do you feel unhappy?
____ ____ 10. Do you cry more than usual?
____ ____ 11. Do you find it difficult to enjoy your daily activities?
____ ____ 12. Do you find it difficult to make a decision?
____ ____ 13. Is your daily work suffering?
____ ____ 14. Are you unable to play a useful part in life?
____ ____ 15. Have you lost interest in things?
Go on to the next page
____ ____ 16. Do you feel that you are a worthless person?
____ ____ 17. Has the thought of ending your life been in your mind?
____ ____ 18. Do you feel tired all the time?
____ ____ 19. Do you have uncomfortable feelings in your stomach?
____ ____ 20. Are you easily tired?
____ ____ 21. Do you drink alcohol more than usual?
____ ____ 22. Do you feel that somebody has been trying to harm you in some way?
____ ____ 23. Have you noticed any interference or anything else unusual with your
____ ____ 24. Do you ever hear voices without knowing where they come from or
which other people cannot hear?
____ ____ 25. Do you have distressing dreams about the disaster or are their times when
it seems like you are re-living your experiences in the disaster?
____ ____ 26. Do you avoid activities, places, people, or thoughts that remind you of the
____ ____ 27. Do you seem less interested than you used to be in your usual activities
____ ____ 28. Do you feel very upset when you are in a situation that reminds you of the
disaster or when you think about the disaster?
____ ____ 29. Are you having trouble experiencing or expressing your feelings?
II.The Pediatric Symptom Checklist (PSC)
The Pediatric Symptom Checklist (PSC) is a measure of distress in children, aged four to sixteen. There are two versions.
Interpretation of the PSC-P:
Part I: For four and five year old children, a score of 24 or higher suggests moderate to severe distress. For children aged six to sixteen, a score of 28 or higher suggests significant distress. These cut-off scores should be regarded as approximate. There is no universally applicable cut off score that can be used under all circumstances. In some situations, use of a slightly lower cut off may be justified.
Part II: No norms are available. Based on the content of the items, in the context of a post-disaster evaluation, a score of 4 or more suggests the need for further evaluation of the child.
Interpretation of the PSC-Y:
Part I: A score of 30 or higher suggests moderate to severe psychosocial distress. This cut-off score should be regarded as approximate. There is no universally applicable cut off score that can be used under all circumstances. In some situations, use of a slightly lower cut off may be justified.
Part II: No norms are available. Based on the content of the items, a score of 2 or more on items 36-38, which suggest psychotic experiences, or a score of 4 or more on items 40-43, which reflect post traumatic responses, suggest the need for further evaluation of the child.
Translations: The PSC-P has been translated into a number of languages, including Spanish, Chinese, Swahili, Khmer, and Haitian Creole. For further information on these, see the references at the PSC website, http://healthcare.partners.org/psc, which also contains additional details on this measure.
Pediatric Symptom Checklist- Parent Report Form (PSC-P)
Child’s Name: ______________________________________________________
Your Name: ____________________________________ Date: ____________
Instructions: Please mark under the heading that best describes this child.
Never Sometimes Often
1. Complains of aches and pains………………………... _____ _____ _____
2. Spends more time alone……………………………… _____ _____ _____
3. Tires easily, has little energy………………………… _____ _____ _____
4. Fidgety, unable to sit still……………………………. _____ _____ _____
5. Has trouble with teacher……………………………... _____ _____ _____
6. Less interested in school…………………………….. _____ _____ _____
7. Acts as if driven by a motor…………………………. _____ _____ _____
8. Daydreams too much………………………………… _____ _____ _____
9. Distracted easily……………………………………… _____ _____ _____
10. Is afraid of new situations…………………………… _____ _____ _____
11. Feels sad, unhappy…………………………………… _____ _____ _____
12. Is irritable, angry…………………………………….. _____ _____ _____
13. Feels hopeless……………………………………….. _____ _____ _____
14. Has trouble concentrating…………………………… _____ _____ _____
15. Less interested in friends……………………………. _____ _____ _____
16. Fights with other children…………………………… _____ _____ _____
17. Absent from school………………………………….. _____ _____ _____
18. School grades dropping……………………………… _____ _____ _____
19. Is down on him or herself…………………………… _____ _____ _____
20. Visits the doctor with doctor finding nothing wrong… _____ _____ _____
21. Has trouble sleeping…………………………………. _____ _____ _____
22. Worries a lot…………………………………………. _____ _____ _____
23. Wants to be with you more than before……………… _____ _____ _____
24. Feels he or she is bad………………………………… _____ _____ _____
25. Takes unnecessary risks……………………………... _____ _____ _____
26. Gets hurt frequently………………………………….. _____ _____ _____
27. Seems to be having less fun…………………………. _____ _____ _____
28. Acts younger than children his or her age…………… _____ _____ _____ 29. Does not listen to rules…………………………. _____ _____ _____
30. Does not show feelings………………………………. _____ _____ _____
Go on to next page
Never Sometimes Often
31. Does not understand other people’s feelings………… _____ _____ _____
32. Teases others………………………………………… _____ _____ _____
33. Blames others for his or her troubles………………… _____ _____ _____
34. Takes things that do not belong to him or her……….. _____ _____ _____
35. Refuses to share……………………………………... _____ _____ _____
36. Gets nervous or scared or upset for no reason……… _____ _____ _____
37. Thinks a lot about bad things that have happened….. _____ _____ _____
38. Does special things so nothing bad will happen……. _____ _____ _____
39. Has bad dreams or nightmares……………………… _____ _____ _____
40. Says scary thoughts just pop into his or her head ….. _____ _____ _____
41. Fears certain animals or situations or places……….. _____ _____ _____
42. Brags or boasts a lot………………………………… _____ _____ _____
43. Wets bed at night…………………………………… _____ _____ _____
44. Gets jumpy at loud noises, startles easily…………… _____ _____ _____
45. Repeats certain acts over and over………………….. _____ _____ _____
Part I Total: ________
Part II Total: ________
Pediatric Symptom Checklist - Youth Report (PSC-Y)
Name: ____________________________________________ Date: ___________
Instructions: Please place a mark under the heading that best fits you:
Never Sometimes Often
Go on to next page
21. I have trouble sleeping..............................……………. _____ _____ _____ 22. I worry a lot.........................................………………… _____ _____ _____
23. I want to be with parent more than before.........……..... _____ _____ _____
24. I feel that I am bad...............................………………. _____ _____ _____
25 I get hurt frequently...............................………………. _____ _____ _____
27. I seem to be having less fun.........................…………... _____ _____ _____
28. I act younger than my age.............………..…………... _____ _____ _____
29. I do not listen to rules...........................…………...…. _____ _____ _____
30. I do not show feelings................................………….. _____ _____ _____
31. I do not understand other people's feelings.........…….... _____ _____ _____
32. I tease others....................................…………………... _____ _____ _____
33. I blame others for my troubles...................………….... _____ _____ _____
34. I take things that do not belong to me..............………... _____ _____ _____
35. I refuse to share....................................……………….. _____ _____ _____
36. I feel that somebody has been trying to harm me…….. _____ _____ _____
37. I notice interference or something else unusual…….. _____ _____ _____
with my thinking
38. I hear voices without knowing where they come ….… _____ _____ _____
from or which other people cannot hear
40. I have distressing dreams about my experiences ……… _____ _____ _____
or times when it seems like I am re-living my
41. I avoid activities, places, people, or thoughts that …….. _____ _____ _____
me of the disaster
42. I seem less interested than I used to be in my ……… _____ _____ _____
usual activities and friends?
43. I feel very upset when I am in a situation that reminds.. _____ _____ _____
me of the disaster or when I think about the disaster
Total Items 1-35 __________
Total Items 36-38 __________ Total Items 39-43 __________
The Relief Worker Burnout Questionnaire is intended to help detect burn out among relief workers. Even relief workers not showing signs of acute distress (e.g., as indicated by a high score on the Self Reporting Questionnaire) may develop burnout, with loss of efficiency and potential long term consequences.
Interpretation: No formal norms are available for this measure. Based on the content of the items, a score of 0 – 15 suggests the worker is probably coping adequately with the stress of his or her work. A score of 16-25 suggests the worker is suffering from work stress and would be wise to take preventive action. A score of 26-35 suggests possible burn out. A score above 35 indicates probable burnout.
Relief Worker Burn Out Questionnaire
Name: ____________________________________________ Date: _________
Instructions: Rate each of the following items in terms of how much the symptom was true of you in the last month.
0 = Never
1 = Occasionally (less than one time per week)
2 = Somewhat often (one or two times a week)
3 = Frequently (three or four times a week)
4 = Almost always (almost every day)
____ 1. Do you tire easily? Do you feel fatigued a lot of the time, even
when you have gotten enough sleep?
____ 2. Are people annoying you by their demands and stories about
their daily activities? Do minor inconveniences make you irritable or
____ 3. Do you feel increasingly critical, cynical, and disenchanted?
___ 4. Are you affected by sadness you can’t explain? Are you crying
more than usual?
____ 5. Are you forgetting appointments, deadlines, personal possessions?
Have you become absent-minded?
____ 6. Are you seeing close friends and family members less frequently?
Do you find yourself wanting to be alone and avoiding even your close
____ 7. Does doing even routine things seem like an effort?
____ 8. Are you suffering from physical complaints such as stomachaches,
headaches, lingering colds, general aches and pains?
____ 9. Do you feel confused or disoriented when the activity of the day stops?
____ 10. Have you lost interest in activities that you previously were interested
in or even enjoyed?
____ 11. Do you have little enthusiasm for your work? Do you feel negative, futile, or
depressed about your work?
____ 12. Are you less efficient than you think you should be?
____ 13. Are you eating more or less, smoking more cigarettes, are using more alcohol
or drugs to cope with your work?
_______ TOTAL SCORE (Add up scores for items 1 – 13)
Appendix B: Relaxation Scripts
I. Guided Relaxation Exercise
[The following is a script for a relaxation exercise combining breathing and muscle relaxation. It should be read to the client in a calm, slow voice, allowing time for the client to take and hold breaths, to let out their breath slowly, and to first tighten, then relax their muscles slowly, as indicated in the script.]
Close your eyes and put yourself in a comfortable position. If you need to, you can make adjustments now or as we go along. Quiet moves will not disturb your relaxation.
Help your body begin to relax by taking some slow, deep breaths. Take a deep breath now. Hold your breath and count silently to three, or five, or ten. Take the amount of time holding your breath that feels good to you. Then let your breath out in an easy, soothing way. Breathe in again and hold it a few seconds… and, when you are ready, again let it out. As you let your breath out, imagine breathing out the tension in your body, out through your nose and mouth, breathing out the tension as you breath out. Do it yet again, breathing in slowly… holding it… and out.
I will now going to teach you an easy method of relaxation. *Make a tight fist with both hands… very tight … so tight you can feel the tension in your forearms. Now, let go suddenly … Notice the feeling of relaxation flowing up your arms… Make a fist with both hands again… and suddenly let go. Again, notice the feeling of relaxation in your arms.… Let your mind move this feeling of muscle relaxation up your arms… through your shoulders…into your chest… into your stomach… into your hips. Continue to focus on this feeling of relaxation, moving it into your upper legs… through your knees… into your lower legs… your ankles and feet… Now let this feeling of comfortable relaxation move from your shoulders into your neck… into your jaw and forehead and scalp…Take a deep breath, and as you exhale, you can become even more deeply relaxed… You can deepen your relaxation by practicing this again. [Go back to the place above marked by the asterisk (*) and repeat this section a second time].
However you feel right now is just fine. As you become even more relaxed and comfortable, each time you breath out you can continue to drift even deeper into a state of comfort… safe and serene … When you relax, as you are now, you can think more clearly or simply allow yourself to enjoy feelings of comfort, serenity, and quiet. As a result of this relaxation, you can look forward to feeling more alert and energetic later on… You can enjoy a greater feeling of personal confidence and control over how you feel, how you think, and what you believe. You can feel more calm, more comfortable, more at ease, and more in control of what’s important to you….
When you’re ready, you can open your eyes, You can feel alert, or calm, or have whatever feelings are meaningful to you at this time. As you open your eyes, you may want to stretch and flex gently, as though you are waking from a wonderful nap.
II. Brief Muscle Relaxation Exercise
[The following is a breathing and muscle relaxation exercise for achieving relaxation rapidly. It should not be used until the client is able to use the longer version (above) effectively. As with the lengthier script, it should be read in a slow, calm voice, allowing the client time to carry out the directions.]
Take two or three deep breaths. Each time, hold your breath for a few seconds, then let it out slowly, concentrating on the feeling of the air leaving your body… Now tighten both fists, and tighten your forearms and biceps… Hold the tension for five or six seconds…Now relax the muscles. When you relax the tension, do it suddenly, as if you are turning off a light....Concentrate on the feelings of relaxation in your arms for 15 or 20 seconds…Now tense the muscles of your face and tense your jaw… Hold it for five or six seconds… now relax and concentrate on the relaxation for fifteen or twenty seconds…Now arch your back and press out your stomach as you take a deep breath… Hold it… and relax….Now tense your thighs and calves and buttocks…Hold…and now relax. Concentrate on the feelings of relaxation throughout your body, breathing slowly and deeply.
III. Guided Visualization Exercise (Example)
What follows is intended purely as an example, not as a script. Visualization exercises are based on identifying a setting that the particular client finds relaxing. It may be a particular place to sit in a forest, a walk by the ocean, watching the sun set and the night come on from in front of your house, or some other scene. What is important is that the client identify a place where he or she feels safe and relaxed. In the example below, it is walking on a path through the woods. Again, read it to the client in a slow, calm voice.
Put yourself in a comfortable position. Close your eyes. Check whether or not your body feels well supported and ready to become more comfortable. You can help your body begin to relax by taking in an easy deep breath, holding it for a few moments and then exhaling in a soothing, calming manner. Take in a deep breath now. Hold your breath and count silently to three, or five, or ten. Take the amount of time holding your breath that feels good to you. Then let your breath out in an easy, soothing exhalation. Breathe in again and hold it a few seconds… and, when you are ready, again let it out. As you let your breath out, imagine the tension in your body being breathed out with your breath, out through your nose and mouth, breathing out the tension as you breath out. Do it yet again, breathing in slowly… holding it… and out.
Now you can go to your safe place. Imagine yourself going to the woods that you love… You walk slowly across a field, toward the line of trees… As you get closer, you can hear the wind rustling in the leaves. You see the green leaves against the blue sky, and you can see the tops of the trees swaying, in an ever-changing pattern as the breeze moves them… You come to the edge of the woods. As you enter the woods, the air gets cooler, and the fragrance of the leaves on the forest floor greets you. Along the path, the light is bright in some places, dappled in others…The air is fresh, and the breeze cools your arms and face. The leaves rustle under your feet. The smell and the sounds and the leaves rustling make you feel happy and comfortable… At the side of the path, a patch of green moss looks soft and cool ...You stop for a moment, and concentrate on the songs of the birds, and the sounds of small animals scampering through the leaves… In the distance, a dove coos… As you walk, you feel more and more relaxed and comfortable…You see a small stream, the water meandering slowly, a leaf floating slowly down the stream. Beside the stream is a patch of soft grass, and you sit on the grass, watching the leaf float down the stream, hearing the water gurgling over the pebbles. The sun flashes on the water, making jewel-like sparkles. You listen to the breeze in the leaves, the birds singing, the water gurgling… As you sit and watch the sparkling water and listening to the gentle sounds of the birds and the leaves in the breeze and breathing the cool fresh air, your body becomes more and more relaxed… Now you stand up and slowly stretch, stretching every muscle of your body … and slowly, slowly, you retrace your path. You walk along the path, searching with your eyes for small flowers in the underbrush, recognizing a familiar bush. You pass the mossy bank and soon, the edge of the forest nears. As you leave the forest, the sun shines brightly, warming your skin, and you feel safe and rested and relaxed….
Appendix C: Leaflets and Handouts
I. Children and Disasters
II. Coping With Disaster
III. Coping With Disaster: A Guide
for Relief Workers
Children and Disasters
disaster is frightening for everyone. For a child, it can be especially frightening.
Children have not yet learned a wide range of techniques for controlling fear. Even more than for adults, a disaster threatens a child’s sense of control over his or her life.
Children experience the effects of disaster triply.
ost children respond sensibly and appropriately to disaster, especially if they experience the protection, support, and stability of their parents and other trusted adults. However, like adults, they may respond to disaster with a wide range of symptoms.
Some Responses of Children to Disasters
ometimes it is hard for parents and teachers to recognize children’s reactions to a disaster. We all want everything to be “all right” for our children, and we come up with all kinds of explanations to explain their conduct: We call it “willful” or believe that “he (or she) will get over it.” The child, in turn, may feel ignored or misunderstood or not nurtured. In the short run, feeling insecure, the child may inhibit expression of his or her own feelings, or may “misbehave” even more, to get attention and nurture. In the long term, letting the child’s feelings remain unappreciated can have negative long term consequences for the child’s development.
What You Can Do To Help Your Child
q Talk with your child about his or her feelings, without passing judgment. Allow the child to cry or be sad. Don’t expect him or her to “be tough.” Talk about your own feelings, as well. Encourage your child to draw pictures about the disaster or write stories or poems about the disaster. This will help you understand how he or she views what happened.
q Provide your child with factual information about what happened and what is (or will happen). Use simple, direct language your child can understand. Shielding a child from unpleasant information usually leads to more difficulty in the future. Correct any misunderstandings your child may have (such as that the disaster was, in some way, his or her fault).
q Reassure your child that he or she and you are safe. Hold and touch and be affectionate with your child. Spend extra time with your child, especially at bedtime. Many children are calmed by gentle back and neck massages.
q If your child returns to babyish behaviors, such as bedwetting or thumb sucking, initially try to be accepting. These are signs the child needs comforting and reassurance. Do not shame the child (e.g., by calling him or her a “baby”). Resume normal expectations only gradually.
q Children are especially vulnerable to feeling abandoned when they are separated from their parents. Avoid “protecting” your children by sending them away from the scene of the disaster if this will separate them from their loved ones.
q Children benefit from routine and structure. Initially, you may want to relax the usual rules, but maintain family structure and responsibilities. Return the child to school as soon as feasible after the disaster and expect regular attendance.
Coping With Disaster
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isasters affect people in many ways. The physical effects – loss of loved ones, pain or physical disability, damage to or destruction of homes and property and cherished belongings – are usually obvious. Short-term emotional effects, such as fear, acute anxiety, feelings of emotional numbness, or grief, are very common.
Some Initial Responses to Disaster
or most victims of disasters, these responses fade with time, but there may be longer-term emotional effects that do not fade. The emotional effects of a disaster may show up immediately or may appear months later. They may be obviously related to the disaster or their origin may go unrecognized.
Later Responses to Disaster
What You Can Do
q Recognize your own feelings. Strong feelings after a disaster are almost universal. It is not “abnormal” or “crazy” to have strong feelings and unanticipated reactions.
q Be tolerant of other people’s reactions – their irritability and short tempers. Disasters are a time of stress for everyone.
q Talk to others about your feelings. Talking helps relieve stress and helps you realize that your feelings are shared by other victims. You are not alone.
q Take care of yourself: Get enough rest. Eat properly. Take time off to do something you enjoy. Get as much physical activity as possible, such as running or walking.
q Learn relaxation exercises and use them regularly.
q Seek out and share accurate information about assistance being offered and possible resources, but do not spread rumors: Check out information about which you have doubts.
q Do not allow yourself to become inactive or completely dependent on others. Get involved in making decisions that affect you. Try to solve your own problems.
q Get back to work and resume your normal family role and functions as soon as possible.
q Do not allow yourself to become isolated from others. Participate in community responses to the disaster. Accept help from others, and offer help to others.
Coping With Disaster
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A Guide for Relief Workers
s a disaster relief worker, whether you are involved in rescue efforts immediately following the disaster and those involved in longer-term relief work, you carry out your work under difficult conditions. You may yourself be a direct victim of the disaster, and have to deal with your own losses and your own grief. You may be exposed to grisly experiences and you are certainly exposed to the powerful emotions and harrowing tales of other victims. Your tasks may be physically difficult, exhausting, or dangerous, and your work may leave little time for sleep or adequate rest. You may feel frustrated by bureaucracy or by the sense that, no matter how much you do, it isn’t enough. And you are exposed to the anger and apparent lack of gratitude of some victims.
t is extremely common for disaster relief workers to experience a range of powerful emotions and reactions. For instance, you may have unexpected feelings of anger, rage, despair, powerlessness, guilt, terror, or longing for a safe haven. These feelings may distress you or make you feel that there is “something wrong” with you. Your sense of humor may be stretched beyond its limits and your toleration for others’ failings becomes limited. Your religious faith may be thrown into doubt. The anger of other relief workers or victims may seem like a personal attack rather than a response to exhaustion.
fter a period of time on the job, many relief workers experience “burn-out.” You may feel excessively tired (even if you have gotten enough sleep), have trouble concentrating, or have a variety of physical symptoms such as headaches, gastrointestinal disturbances, and sleep difficulties. This can lead to neglecting your own safety and physical needs or to cynicism, mistrust of co-workers or supervisors, and inefficiency. You may find yourself smoking too much, drinking too much coffee, or drinking too much.
isaster workers face additional stress when they complete their tasks and return home, to their “regular” life. Your experience has been very different from your normal routine, while your family’s routine has gone on with little change. Your family members may make demands on you for attention and for help, while you still need time to recover your balance. You may expect an unambivalent welcome, while they may be feeling some anger at your having been gone. You may feel that they can not understand what you’ve been through and that their experiences while you were gone were shallow or meaningless. The crises of ordinary life may seem trivial to you, important to your family. You may see or hear things at home that will remind you of your experiences in relief work, which may trigger an unexpectedly strong emotional reaction. And you may find yourself wishing, at times, for the excitement and camaraderie of the relief operation. All of these stresses can produce marital and parent-child conflict.
What You Can Do
At the Disaster Site
q Recognize, understand, and appreciate your own feelings. It is not “abnormal” or “crazy” to have strong feelings and reactions to the experiences you are having.
q Be tolerant of the reactions of other relief workers and victims – their irritability and short tempers. Disasters are a time of stress for everyone.
q Talk to other relief workers about your feelings. Talking helps relieve stress and helps you realize that others share your feelings. Not coincidentally, it helps others recognize the same thing. You are not alone.
q Take care of yourself. Taking care of yourself is not a diversion from the “more important” tasks of relief work. It is necessary to enable you to keep doing your job. Get as much sleep as you can. Take rest breaks. Eat properly. Avoid drinking large amounts of caffeine or alcohol. Take time off to do something you enjoy. Get as much physical activity as possible, such as running or walking or engaging in sports. Keep a journal. Learn relaxation exercises and use them regularly.
q If an incident occurs that has really shaken you (whether a job-related incident or a conflict with another relief worker or a victim), take a short break. Use a relaxation exercise. Talk to someone (a disaster counselor if one is available). But don’t allow yourself to ruminate about what happened. Get back to work within a few minutes.
q Take part in regular “debriefing” sessions offered by the disaster counselors at the site of the disaster. This is especially important before you return home to your “regular” life.
When You Return Home
q Give yourself a few days to make the transition. Help your family understand you need some time to yourself before beginning a full schedule of normal activities.
q Be tolerant of what others at home want to share. What has happened to them is important to them, just as your experiences were important to you.
q Anticipate mood swings and strong emotional reactions. Expect that your family’s responses to you may not be what you expected or think you “deserve.” Be aware that you may have unexpected reactions to sounds, sights, or people that remind you of experiences at the disaster site. Prepare others for this and be realistic yourself.
Appendix D: Further Resources
Aptekar, L. (1994). Environmental disasters in global perspective. New York: G.K. Hall.
American Academy of Child and Adolescent Psychiatry (1998). Practice parameters for the assessment and treatment of children and adolescents with posttraumatic stress disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 37:10 (supplement).
Danieli, Y., Rodley, N.S., & Weisaeth, L. (Editors). (1996). International responses to traumatic stress. Amityville, NY: Baywood.
Enarson, E., & Morrow, B.H. (Editors) (1996). The gendered terrain of disaster through women’s eyes. Westport, CT: Greenwood Publishing Company.
Everly, G.S., & Lating, J.M. (Editors). (1995). Psychotraumatology: Key papers and core concepts on post traumatic stress. New York and London: Routledge.
Foa, E.B., & Meadows, E.A. (1997). Psychosocial treatments for posttraumatic stress disorder: A critical review. Annual Reviews of Psychology, 48, 449-480.
Foeken, I. (1999). Confusing realities and lessons learned in wartime: Supporting women’s projects in the former Yugoslavia. Women and Therapy 22 (1), 91-106.
Hodgkinson, P.E., & Stewart, M. (1998). Coping with catastrophe: A handbook of post-disaster psychosocial aftercare (2nd Edition). London: Routledge.
International Federation of Red Cross and Red Crescent Societies (annual). World Disaster Report. London: Oxford University Press.
Ladrido-Ignacio, L., & Perlas, A.P. (1995). From victims to survivors: Psychosocial intervention in disaster management in the Philippines. International Journal of Mental Health, 24, 3-51.
Lima, B.R., & Gittelman, M. (Eds.). (1990). Coping with Disasters: The Mental Health Component. International Journal of Mental Health, 19, No. 1 and 2 (whole issue)
Marsella, A.J., Friedman, M.J., Gerrity, E.T., & Scurfield, R.M. (1996). Ethnocultural aspects of posttraumatic stress disorder. Washington, D.C.: American Psychological Association.
Middleton, N., & O’Keefe, P. (1998). Disaster and development: The politics of humanitarian aid. London: Pluto Press.
Miller, K. Manual for “Planning to Grow” Program. Program for Prevention Research, Arizona State University, Tempe, Arizona, U.S.A. (on program carried out with children in Guatemala)
Raphael, B. (1986) When disaster strikes: How individuals and communities cope with catastrophe. New York: Basic Books.
Roberts, A.R. (Editor). (1990). Crisis intervention handbook. Belmont, CA: Wadsworth
World Health Organization, (1996). Mental health of Refugees.
Walker, B. (Ed.) (1995). Women and Emergencies. Oxford: Oxfam.
Young, B.H., Ford, J.D., Ruzek, J.I., Friedman, M.J., & Gusman, F.D. (1998). Disaster mental health services: A guidebook for clinicians and administrators. White River Junction, VT: National Center for PTSD. (Also available on-line at http://www.ncptsd.org ).
David Baldwin’s Trauma Pages, http://www.trauma-pages.com
National Center for PTSD, http://www.dartmouth.ed/dms/ptsd
Disaster Mental Health Institute, http://www.ncptsd.org
International Society for Traumatic Stress Studies (ISTSS). http://www.istss.org
National Hazard Center, http://www.colorado.edu/hazards/
PILOTS database, http://ncptsd.org/research/pilots/index.html
International Federation of Red Cross and Red Crescent Societies, 17, Chemin des Crets, PO Box 372, 1211 Geneva 19, Switzerland. Tel: (41)(22) 730-4222. Internet: http://www.ifrc.org.
UNICEF, 3 UN Plaza, New York, NY 10017, USA. Internet http://www.unicef.org
World Health Organization the Division of Mental Health, World Health Organization, CH-1211 Geneva 27, Switzerland. Internet http://www.who.org
John H. Ehrenreich, Ph.D. is a clinical psychologist. He is Professor of Psychology and Director of the Center for Psychology and Society at the State University of New York, College at Old Westbury, NY. He is the author or co-author of The American Health Empire: Power, Profits, and Politics (1971), The Cultural Crisis of Modern Medicine (1978), and The Altruistic Imagination: A History of Social Work and Social Policy in the United States (1985) as well as numerous articles on personality theory and on psychological assessment in professional journals.
Sharon McQuaide, M.S.W., Ph.D. is a clinical social worker. She was formerly Chief Clinical Social Worker and Director of Social Work Education in the Outpatient Mental Health Clinic at Danbury (Connecticut) Hospital. She has taught at Fordham University Graduate School of Social Service and Smith College School for Social Work. She has written extensively in professional journals on issues of assessment and psychotherapeutic treatment.
The Center for Psychology and Society (CEPAS) at the State University of New York, College at Old Westbury is a center initiated by the Psychology Department at the College at Old Westbury to sponsor research, education, and action at the interface between psychology and its allied sciences and society.
 The brief accounts of the Ecuador and Bhopal disasters are drawn from articles by L.K. Comfort and by R.S. Murthy in the International Journal of Mental Health, 1990. The account of the Manila disaster is from the New York Times, July 18, 2000.
 Susto is prevalent among some Latinos in the United States and among people in Mexico, Central America, and South America. Typical symptoms include appetite disturbances, inadequate or excessive sleep, troubled sleep or dreams, feelings of sadness, lack of motivation, feelings of low self-worth, and somatic symptoms. Ataques de nervios is recognized among many Latin American, Latin Mediterranean, and Caribbean Latinos. Commonly reported symptoms include uncontrollable shouting, attacks of crying, trembling, heat in the chest rising into the head, verbal and physical aggression, a sense of being out of control, and sometimes dissociative experiences, seizure-like or fainting episodes, and suicidal gestures. Amok is recognized in Malaysia and, under varying names, in the Philippines, Puerto Rico, and elsewhere. It is described as a dissociative episode characterized by a period of brooding followed by an outburst of violent, aggressive, or homicidal behavior directed at people and objects, ending with exhaustion. Dhat is a term used in India to describe a syndrome of severe anxiety, headaches and body aches, loss of appetite, hypochondriacal concerns associated with the discharge of semen, and feelings of weakness and exhaustion. Latah, found under various names in the South Pacific and Southeast Asia, involves hypersensitivity to sudden fright, often with an apparently senseless and automatic repetition of the words or actions of others and dissociative or trance-like behavior. Khoucheraug , found in Cambodia, includes excessive worry and rumination over past events.
 The CISD model of intervention was originally proposed by J. Mitchell in the Journal of Emergency Medical Services, 1983.
 The SRQ was developed by the World Health Organization. For additional details on its development and use and a bibliography, see the WHO document, A Users’ Guide to the Self Reporting Questionnaire (document WHO/MNH/PSF/94.8), available from the Division of Mental Health, World Health Organization, CH-1211 Geneva 27, Switzerland. I have added items 25-29 to explicitly address post traumatic symptoms.
 The PSC was developed by Michael Jellinek, J. Michael Murphy, and associates. A detailed discussion and bibliography can be found at their website, http://healthcare.partners.org/psc. I have added “Part II,” which addresses some common responses to disasters more specifically.