Crisis Intervention Training for Disaster Workers E-Book

George W. Doherty

• Herausgeber: Modern History Press
• Kategorie: Geisteswissenschaft
• Sprache: Englisch
• Veröffentlichungsjahr: 2007

Seitenzahl: 479

Beschreibung

This book provides information about training for mental health professionals and first responders who work with victims of disaster related stress and trauma. It helps prepare them to relate with disaster victims and co-workers. Warning signs and symptoms are explored together with stages, strategies and interventions for recovery.
The book will introduce you to disasters, the community response, the roles of first responders, Disaster Mental Health Services and Critical Incident Stress Management (CISM) responders and teams. It provides a brief overview of these and their roles in responding to the needs of both victims and disaster workers. The role of CISM is presented and discussed both for disasters and other critical incidents. This includes discussion about war, terrorism and follow-up responses by mental health professionals. The book is designed to help readers identify appropriate methods for activating Disaster Mental Health Crisis Intervention Teams for disaster mental health services for victims, co-workers, and self.
The content includes general theory and models of Disaster Mental Health, CISM, crisis intervention techniques commonly used in these situations, supportive research, and practice of approaches used in responding to the victims, workers and communities affected by disasters, critical incidents and terrorism threats and events.
What People are Saying About Crisis Intervention Training for Disaster Workers
"Provides a breadth and depth of knowledge as well as practical tools for beginner to expert. Should be required reading for all disaster responders, and, especially, mental health professionals considering disaster work."
-Bruce L. Andrews, MS, LPC (ARC Disaster Mental Provider/Instructor)
"This text serves as a wonderful adjunct and lead into the discipline of CISM. It provides a brief survey of disaster mental health and disaster mental health services."
-Thomas Mitchell, LPC
Rocky Mountain Disaster Mental Health Institute Press
"Learning from the past and planning for the future"
PSY018000 Psychology : Mental Illness
EDU045000 Education : Counseling - Crisis Management
SOC040000 Social Science : Disasters & Disaster Relief

Leseprobe

Crisis Intervention TrainingFor Disaster Workers

An Introduction

GEORGE W. DOHERTY

Rocky Mountain

Disaster Mental Health Institute Press

Learning from the Past and Planning For the Future

Rocky Mountain DMH Institute Press is an Imprint of Loving Healing Press

Copyright© 2007 George W. Doherty and Rocky Mountain Region Disaster Mental Health Institute, Inc.

Use of material contained herein is authorized by the author for personal use and in courses of instruction provided that the material is used in full and this copyright statement is reproduced. Any other usage is prohibited without the express permission of the author. All rights reserved.

Rocky Mountain Disaster Mental Health Institute, Inc.

PO Box 786

Laramie, WY 82073-0786

http://www.rmrinstitute.org

email: [email protected]

Phone: [phone]

Library of Congress Cataloging-in-Publication Data

Doherty, George W. (George William)

  Crisis intervention training for disaster workers : an introduction / by George W. Doherty.

      p. cm.

  Includes bibliographical references and index.

  ISBN-13: 978-1-932690-42-2 (pbk. : alk. paper)

  ISBN-10: 1-932690-42-5 (pbk. : alk. paper)

  1. Crisis intervention (Mental health services)–Handbooks, manuals, etc. I. Title.

  RC480.6.D64 2007

  362.2’04251–dc22

2007028458

Rocky Mountain DMH Institute Press is an Imprint of:

Loving Healing Press5145 Pontiac TrailAnn Arbor, MI 48105 USAhttp://[email protected] Fax [phone]

Contents and Course Outline

Table of Figures

About the Cover – Medicine Bow Peak

Goals and Objectives

Objectives

Course Content

Chapter 1 – Introduction

Definitions

Chapter 2 – Fundamentals

Fundamentals of Victims’ Responses to Disasters

Loss, Mourning, and Grief

Stages of Grieving

Why Do Some People Reach A State Of Crisis?

Stages of Disaster Recovery

Symptoms of Psychological Trauma

Chapter 3 – Children and Disasters

Children's Reactions

Fears and Anxieties

Children with Special Needs

Providing Help for Children and Families

Telephone Crisis Service

Chapter 4 – Special Risk Groups

Middle-Age, Elderly, and Older Adults

Society and Culture

Other Special Risk Groups

Chapter 5 – Cultural Aspects of Disasters

Cross-Cultural Examples in Disasters

Cultural Approaches or Models

Children

Responders

Approaches

Chapter 6 – Crises in Rural Areas

Culture and Rurality

Some Cultural Considerations

Rural Problems

Children and School Counseling

Farm and Ranch Crises

Changing Roles

Different Approaches

Rural Trauma

Chapter 7 – Crises and Crisis Interventions

Dealing with Crises

Techniques

Psychological First Aid

Selecting and Training Disaster Mental Health Staff

Roles and Responsibilities of Mental Health Workers

Examples of Disaster-Related Emotional Problems

Intervention Strategies

Psychological Implications for Disaster Workers

Chapter 8 – Stress Management

Stress Responses

Coping With Stress – Guidelines for Responders

Interventions during a Disaster

Interventions Following a Disaster

Follow-up and Referral to Mental Health Resources

Psychological First Aid and Short Term Therapy

Traumatic Incident Reduction (TIR)

Eye Movement Desensitization Reprocessing (EMDR)

Chapter 9 – Coping and Resiliency

Recovery and Returning To Equilibrium

Where Do We Go From Here?

Chapter 10 – War

Fear and War

Children and War

Resiliency Following War

Chapter 11 – Terrorism and Terrorists

What Is Terrorism And Who Are The Terrorists?

Role of Psychology in Coping with Terrorism

Children's Responses to Terrorism

Militant Islam and Terrorism

Coping, Resiliency, and Recovery

Selected References

Websites

Appendix A – Disaster Scenario

Appendix B – Disaster Victims’ Needs Assessment

Appendix C – Course Test

About the Author

Index

Table of Figures

Fig. 2-1 Stages of Grieving (Kübler-Ross)

Fig. 2-2: Stages of Disaster Recovery

Fig. 2-3: BASIC ID explained

Fig. 3-1: Children's Reactions to Disaster

Fig. 5-1: Ethnic Group Factors

Fig. 5-2: Major Problem Areas of Psychiatric Consultancy in Planning Responses to Disasters

Fig. 7-1: The Six “Ts”

Fig. 7-2: Factors Affecting Severity of Responder Reactions

Fig. 7-3: Effects of Long Exposure to Stressors by Disaster Responders

Fig. 8-1: Suggestions to Help Responders Deal with Stress

About the Cover – Medicine Bow Peak

The Medicine Bow Mountains are a mountain range in the Rocky Mountains in southern Wyoming and in northern Colorado. From the northern end of the Front Range, the range extends north from Cameron Pass along the border between Larimer and Jackson counties in Colorado northward into south central Wyoming west of Laramie, in Albany and Carbon counties to the route of the Union Pacific Railroad. The highest peak in the range is Medicine Bow Peak (12,013 ft), located in the northern end of the range in southwestern Albany County, Wyoming. Much of the range is located within the Medicine Bow National Forest. The range runs northward from the Never Summer Mountains on the continental divide. On its eastern flank it is drained by the Laramie River, another tributary of the North Platte. In Wyoming this range is known as the Snowy Range.

United Airlines Flight 409 was a scheduled flight departing from Denver, Colorado to Salt Lake City, Utah on October 6, 1955. The DC-4 aircraft crashed into Medicine Bow Peak, near Centennial, Wyoming killing all 66 people on board (63 passengers, 3 crew members.) Passengers included members of the Mormon Tabernacle Choir, and military personnel. At the time, this was the worst crash in U.S. commercial aviation history.

Flight 409 left Denver, Colorado at 6:33 AM that morning, some 83 minutes after its scheduled departure time. The flight path 409 was expected to take was north of Laramie, Wyoming, then over the town of Rock River, Wyoming, and onward to Salt Lake City.

The plane did not report in over the town of Rock Springs at 8:11 AM as expected. With the plane's status unknown, the Civil Aeronautics Authority was notified of the missing craft. No radar was in place for civil aviation in this region in 1955. With no radar traces, manual searches were required to find the aircraft.

The Wyoming Air National Guard dispatched two planes, one of which found the aircraft's wreckage atop Medicine Bow Peak. The pilot of the search plane, Mel Conine, speculated that the plane may have been taking an unauthorized shortcut away from its specified flight plan in an effort to make up for its 83 minute delay out of Denver.

Recovery of passenger and crew remains were extremely difficult and took a full five days to complete. Small fragments of flight 409's airframe still exist on this mountaintop. Flight 409's crash, and other crashes which occurred shortly after convinced the U.S. Congress to improve airline safety procedures, and increase the use of radar for civil aviation.

Goals and Objectives

GOALS: This course will introduce you to disasters, the community response, the role of first responders, and the role of Disaster Mental Health Services and Critical Incident Stress management responders and teams. It will provide a brief overview of Disaster Mental Health Services and Critical Incident Stress Management and their roles in responding to the needs of both victims and disaster workers. The role of critical incident stress management will be presented and discussed both for disasters and for critical incidents. This includes discussion about war, terrorism and the follow-up responses by mental health professionals.

Objectives

Following completion of this course, you should be able to:

Describe what disasters are and how they affect people and their communities.Identify how the community, including voluntary and community organizations, government, business, and labor, work together to prepare for, respond to, and recover from disasters.Identify activities in preparing for, responding to, and recovering from disasters.Describe the mental health services provided to people affected by disaster.Identify how disaster mental health professionals provide these services.Describe the roles mental health professionals play in Disaster Services and Critical Incident Stress Management.Identify the skills and abilities you have that you would like to apply as a volunteer with Disaster Services and Critical Incident Stress Management as a team member.Define ‘crisis intervention” as it relates to disaster situations and critical incidents.Identify the stages of disaster recovery and problems associated with each stage.Identify the signs and symptoms of disaster induced stress and emotional trauma.Discuss and be able to recognize disaster's and critical incident's effects and impacts on victims and workers, including posttraumatic stress.Identify common strategies for coping with disaster and critical incident related stress.Demonstrate basic disaster mental health professional responses to disaster related crisis situations/scenarios.

Course Content

The content of this course includes general theory and models of Disaster Mental Health, Critical Incident Stress Management, crisis intervention techniques commonly used in these situations, supportive research, and practice of approaches used in responding to the victims, workers and communities affected by disasters, critical incidents and terrorism threats.

1Introduction

Working with survivors following the loss of loved ones, homes, property or community is one role of disaster mental health professionals. Besides meeting their basic physical needs, clients will need to understand the grieving process, which may extend for a prolonged period of time. Disaster mental health professionals also work with first responders and other responders to disasters and critical incidents. Their role here is to assist in keeping responders on the job and to help mitigate post-traumatic stress.

Throughout this course, you will learn why Critical Incident Stress Management, Defusing, Debriefing and other forms of crisis intervention have important roles in alleviating disaster induced stress and in preventing further psychological complications among victims and first responders.

Definitions

A crisis is defined in terms of an individual's response to a situation rather than in terms of the situation itself. The same situation may produce a crisis in one person, but not in another. A crisis exists when a person feels so threatened in a situation that he/she cannot cope with it. Their normal resources for dealing with an emergency break down and the individual becomes immobilized. Thus, a crisis exists IN a person. The individual may become confused and overwhelmed by the situation and unable to meet the demands placed upon him/her. It is therefore understandable that a disaster may produce a crisis reaction in an individual, whether they are a survivor or a responder.

A crisis may also be an important learning experience for an individual. Normal patterns of behavior have fallen apart, leaving defenses down. The individual is open and accepting of help in problem solving in order to restore his/her equilibrium. New coping skills and strategies may be developed to assist with this as well as future crises which may occur.

Following are some of the definitions of major techniques which are commonly used by disaster mental health professionals to assist responders and victims who may have experienced a disaster related crisis.

Crisis Intervention: Focuses on providing immediate emotional support (psychological first aid) at times when a person's own resources appear to have failed to adequately cope with a problem.

Critical Incident Stress: The reactions that occur during or immediately after the actual incident, disaster or stressor.

Defusing: An on-scene opportunity for responders involved in a stressful incident to vent their feelings, and institute coping strategies which can reduce stress while they are still working in the assignment setting.

Debriefing: An organized approach to supporting disaster responders who have been involved in emergency operations under conditions of extreme stress in order to assist in mitigating long-term emotional trauma. Usually done at the end of an assignment as part of exiting procedure to assist the responder in putting closure on the experience.

Critical Incident: Any situation faced by emergency responders or survivors that causes them to experience unusually strong emotional reactions which have the potential to interfere with their ability to function, either on the scene or later.

2Fundamentals

Fundamentals of Victims’ Responses to Disasters

In order to fully understand the necessity for and functions of a Crisis Intervention Team, it is important to have a basic understanding of the psychological factors which influence the emotional responses of disaster victims and responders. This section presents and discusses the basics of those factors and the resulting commonly observed responses of survivors and responders.

Loss, Mourning, and Grief

All survivors of disaster suffer loss. They suffer loss of safety and security, loss of property, loss of community, loss of status, loss of beauty, loss of health, or loss of a loved one. Following a disaster, all individuals begin a natural and normal recovery process through mourning and grief.

In our western culture, we put emphasis on life and youth. We often refuse to think about death. It is normal to be upset by a major loss—and then to suffer because of it. Bereavement is always deeply painful when the connection that has been broken is of any importance. The loss which is the reason for our mourning most often involves a person close to us. However, it can also be a familiar animal, an object to which we are very attached, or a value we have held dear. In mourning, the connection with what we have lost is more important than the nature of the lost object itself.

Grief is the process of working through all the thoughts, memories and emotions associated with that loss, until an acceptance is reached which allows the person to place the event in proper perspective. Theories of stages of grief resolution provide general guidelines about possible sequential steps a person may go through prior to reaching acceptance of the event. These stages include: Denial, Anger, Bargaining, Depression, and Acceptance (see Fig. 2-1). Whereas these theories provide general guidelines, each person must grieve according to his or her own values and time line. However, some persons will have trouble recovering emotionally and may not begin the process of mourning effectively. This may result in troubling and painful emotional side effects. Sometimes these side effects may not appear immediately. They may remain beneath the surface until another crisis brings the emotions out into the open. Hence, many individuals may be surprised by an increase in emotionality around the third month, sixth month, and one year anniversaries of the event. Crisis intervention can assist victims and facilitate their progress in proceeding through the predictable phases of mourning, thus avoiding surprise reactions or emotional paralysis later.

DenialAngerBargainingDepressionAcceptance

Fig. 2-1 Stages of Grieving (Kübler-Ross)

Grief is the process of working through all the thoughts, memories, and emotions associated with a loss, until an acceptance is reached that allows the person to place the event into the proper perspective. Some typical reactions to grief might include:

People who say they are drained of energy, purpose and faith. They feel like they are dead.Victims who insist they do not have time to work through the grief with “all the other things that have to be done”, and ignore their grief.People who insist they have “recovered” in only a few weeks after the disaster, and who are probably mistaking denial for recovery.Victims who focus only on the loss and are unable to take any action toward their own recovery.Each of these extreme emotional states is very common, very counterproductive, and requires active crisis intervention.

Stages of Grieving

Denial: At the news of a misfortune, tragedy or disaster, our first reaction is not to accept it, but to refuse it (“No, it's not true! No! It's not possible!”). The opposite would be abnormal. This is a sign that it is essential for our psychological organization to avoid pain without ignoring reality. This refusal is, at the same time, the beginning of an awareness of the horrible reality and is aimed at protecting us from the violence of the shock.

Anger: A feeling of anger is experienced at the fact of our powerlessness in the face of something imposed on us arbitrarily. This anger is inevitable and it must be permitted. It allows the expression of our helplessness at the situation. Therefore, it isn't surprising that survivors (and sometimes responders) take out their anger on the people around them (government and municipal officials, rescue personnel, insurance companies, their families and friends, etc.). Hence, there is the need to be able to verbalize and vent this anger in post-traumatic sessions with a counselor.

Depression: The path toward the acceptance of bereavement passes through the stage of depression. At the beginning of mourning, and for a long time after during this stage of depression, the lost being is omnipresent. Of course, he or she is lost to us in reality we agree and we are trying to accept it. However, inside, we reinforce our connection to him or her, because we no longer have it in objective reality. This process of intense re-appropriation allows us, at the same time, both to lessen our pain and to console ourselves in a way by means of the temporary survival of the loved being within us. At the same time, this movement enables the work of detachment to be carried out little by little.

Generally, slowly over time, these movements of detachment become less frequent, the pain subsides, the sadness lessens, the lost being seems less present and his or her importance tends to decrease. The end of mourning is approaching.

Acceptance: This stage is neither happy nor unhappy. Mourning leaves a scar as does any wound. But the self once again becomes free to live, love and create. One is surprised to find oneself looking toward the future, making plans. It is the end of mourning.

The normal process of mourning takes place over a period of several months.

Returning To Equilibrium

Mental health is described by Antoine Parot as “a psychic ability to function in a harmonious, agreeable, effective manner when circumstances allow, to cope flexibly with difficult situations and to reestablish one's dynamic equilibrium after a test.”

Every time a stressful event happens, there are certain recognized compensating factors which can help promote a return to equilibrium. These include:

Perception of the event by the individualThe situational reports which are availableMechanisms of adaptation

The presence or absence of such factors will make all the difference in one's return to a state of equilibrium. The strength or weakness of one or more of these factors may be directly related to the initiation or resolution of a crisis.

Why Do Some People Reach A State Of Crisis?

When stress originates externally, internal changes occur. This is why certain events can cause a strong emotional reaction in one person and leave another indifferent. There are a number of factors that contribute to how one reacts to an event. These include the following:

Perception of the event

When the event is perceived realistically: There is an awareness of the relationship between the event and the sensations of stress, which in itself will reduce the tension. It is likely that the state of stress will be resolved effectively.When the perception of the event is distorted: There is no awareness of the connection between the event and the feeling of stress. Any attempt to resolve the problem will be affected accordingly.Hypotheses to verify concerning the individual's perception of the event: What meaning does the event have in the person's eyes?How will it affect his/her future?Is he/she able to look at it realistically? Or does he/she misinterpret its meaning?

Support by the Natural Network

Support by the natural network means the support given by people in the individual's immediate circle who are accessible and who can be relied on to help at that time. In a stressful situation, the lack or inadequacy of resources can leave an individual in a vulnerable position conducive to a state of disequilibrium or crisis.

Mechanisms of Adaptation

These mechanisms reduce the tension and help promote adaptation to stressful situations. They can be activated consciously or unconsciously. Throughout life, individuals learn to use various methods to adapt to anxiety and reduce tension. These mechanisms aim at maintaining and protecting their equilibrium. When an event happens which causes stress, and the learned mechanisms of adaptation are not effective, the discomfort is experienced at a conscious level.

PhaseTime Frame of PhaseEmotionsBehaviorsMost Important ResourcesHeroicOccurs at time of impact and period immediately afterward.Altruism. All emotions are strong and direct at this time.Use of energy to save their own and others' lives and property.Family groups, neighbors, and emergency teams.HoneymoonFrom 1 week to 3 to 6 months after the disaster.Strong sense of having shared a catastrophe experience and lived through it. Expectations of great assistance from official and government resources.Victims clear out debris and wreckage buoyed by promises of great help in rebuilding their lives.Pre-existing community groups and emergent community groups which develop from specific needs caused by disaster.DisillusionmentLasts from 2 months to 1 or even 2 years.Strong sense of disappointment, anger, resentment and bitterness appear if there are delays, failures, or unfulfilled hopes or promises of aid.People concentrate on rebuilding their own lives and solving individual problems. The feeling of “shared community” is lost.Many outside agencies may now pull out. Indigenous community agencies may weaken. Alternative resources may need to be explored.ReconstructionLasts for several years following the disaster.Victims realize that they need to solve the problem of rebuilding their lives. Visible recovery efforts serve to reaffirm belief in themselves and the community. If recovery efforts are delayed, emotional problems which appear may be serious and intense.People have assumed the responsibility for their own recovery. New construction programs and plans reaffirm belief in capabilities and ability to recover.Community groups with a longterm investment in the community and its people become key elements in this phase.

Fig. 2-2: Stages of Disaster Recovery

Stages of Disaster Recovery

Just as there are stages of individual grieving, there are also stages of disaster in communities. The emotional responses of a community can be very closely tied together with emotional responses of individuals.

Heroic Stage

The Heroic Stage lasts from impact or pre-impact to approximately one week post impact (this will be longer with more severe widespread events. e.g., Hurricane Katrina). People respond to the demands of the situation by performing heroic acts to save lives and property. There is a sense of sharing with others who have been through the same experience. There is almost a feeling of “family”, even with strangers. There is immediate support from family members both in and out of the area and by agency and governmental disaster personnel promising assistance. Feelings of euphoria are common. There is strong media support for the plight of the victims and the needs of the community. Activity levels are high. However, efficiency levels are low. Pain and loss, including physical pain, may not be recognized.

The most important resources during the Heroic Stage are family, neighbors, and emergency service responders.

During the immediate post-impact phases, responders react and respond with high levels of energy, and seek information and facts. They develop and coordinate plans, equipment and staff resources. Following the impact, adrenaline levels are high. Responders continue to push themselves through the stress signals and past warnings.

Honeymoon Stage

The Honeymoon Stage follows the Heroic Stage and may last for several weeks following the disaster. In the early parts of this stage, many survivors, even those who have sustained major losses, are feeling a sense of well-being for having survived. Shelters may at first be seen as central meeting places to talk about shared experiences. They are also seen as being a safe place to stay until they can return to their homes. Supported and encouraged by the promises of assistance by disaster relief personnel from voluntary and federal agencies, survivors clear the dirt and debris from their homes in anticipation of the help they believe will restore their lives.

The community as a whole pulls together in initial clean-up and distribution of supplies. Church and civic groups become active in meeting the various needs of the community. “Super Volunteers“ who are not ready to deal with their own losses work from dawn until after dark helping their friends and neighbors get back on their feet. In the early parts of this stage, the community's expectations of the various volunteer and governmental agencies are extremely high. Their faith in those organizations’ ability to help them recover is frequently unrealistic.

Some of the common emotional reactions during this stage include: adrenaline rush, anxiety, anger and frustration, survival guilt, restlessness, workaholism, risk-taking behaviors and hyperactivity.

Disaster mental health professionals can assist during this stage by educating about common stress reactions and coping techniques, working with distressed clients, advocating for breaks and time off, defusing workers, team building, etc.

Disillusionment Stage

The greatest amount of frustration in the recovery process happens during the time it takes to process relief forms. The disaster event may be 3 or more weeks in the past before a disaster declaration is made. This time can be called a “Second Disaster“. It is usually the period when the greatest amount of stress is seen because continual stressors are added to those experienced in the initial event. Victims must be encouraged to ventilate their built-up emotional energy.

The disillusionment Stage lasts from one month to one or even two or more years. As the Honeymoon Stage passes into the Disillusionment Stage, the excitement of the media attention in the earlier stages begins to wane. Rather than feeling supported by the media, victims begin to feel that they are objects of insensitive curiosity. At the same time, they feel let down and isolated when the media no longer covers the story and moves on to other, fresher news. The departure of the media at the same time victims are beginning to dig out can be extremely upsetting.

Victims begin to ask for answers, especially if the disaster could have been avoided, or if negligence of a person or agency was involved. Community support at this stage can be extremely important in determining the course of recovery.

During this stage, disaster mental health professionals work with clients, offer debriefings, defusings, and other crisis interventions for staff, mediate problems between staff and supervisors or clients, advocate for time off, educate about methods to decrease stress, and assist with team building as centers begin to consolidate and/or close down.

Reconstruction Stage

The final stage is the Reconstruction Stage. Victims come to the realization that the rebuilding of homes and businesses is primarily their responsibility. The rebuilding of the community reaffirms the victims’ belief in themselves and the community. This stage may take from several years to the rest of their lives, depending on the amount of damage. If the rebuilding is delayed, the recovery process will also be delayed.

Many of the disaster related stress reactions will return when conditions are right for another disaster similar to the one the victims have experienced.

When the emergency response phase of the disaster is over, responders return to business as usual at their routine jobs. They may experience frustration and loss after the intensity of the emergency situation. Local staff may also be victims, thus facing job pressures, as well as feeling overwhelmed by needs to complete their own recovery, feelings of loss, depression, anger, etc. By providing crisis intervention following a disaster it is hoped that both responders and survivors can develop effective coping mechanisms that will assist them through the stages of recovery with less long term emotional impact.

Summary

This section has discussed how all disaster victims proceed through recognized stages of grieving, from denial to acceptance. Also, just as there are recognized stages of grieving, there are recognized stages of disaster and expected individual and community reactions during the different stages. By understanding these stages, it will help you to better understand how disaster victims and responders may react psychologically. As a result, you will be better able to meet the emotional needs that arise due to disaster.

Symptoms of Psychological Trauma

In a person's life when there occur events which threaten his/her biological, physical or social well-being, there is a resulting disequilibrium. When this well-being is threatened, people react with anxiety. When there are a particularly large number of painful or unpleasant stimuli like those associated with a disaster or tragedy, the individual requires a great capacity for adaptation. The mental health literature describes the stress following disaster and tragedy as a precise set of symptoms manifested after an extraordinary traumatic event.

Symptoms of disaster caused stress will vary greatly based on an individual's prior history of personal trauma, age and ethnic background. Some of the typical symptoms experienced by both victims and responders are briefly discussed below.

Individuals may have an exaggerated startle response or exhibit hyper-vigilance. This is frequently seen after earthquakes, where people are known to jump after loud or sudden noises, such as doors slamming or trucks rumbling by.They may experience phobias about weather conditions (e.g., responses to wind noises following a tornado or hurricane) or other reminders that the accident or situation could happen again.They may experience difficulty with memory or calculations.Suddenly, they cannot balance their checkbook, or remember simple tasks, appointments, or such things as their address or phone number when asked.They may exhibit anger or even rage over their lack of control over the occurrence and their impotence at preventing it and protecting their families.Many times this may be displaced towards those who are trying to help.

BASIC ID

Typical stress reactions to disaster trauma can be assessed by adapting the multi-modal behavioral approach initially outlined by Lazarus (1976, 1989, 2000). He used the acronym BASIC ID to identify areas of concern for assessment (see Fig. 2-3 on next 3 pages).

BASICIDBehavioralAffective/EmotionalSomaticInterpersonal SkillsCognitiveImageryDrugsBehavioral ResponsesHyper startle responseHyperactivityWorkaholismReckless, risk-taking behaviorsCarelessness in tasks, leading to an increase in injuriesExcessive use of sick leaveWorried, rigid look, nervous activityWithdrawal or social isolationInability to express self verbally or in writingDifficulty returning to normal activityAvoidance of places or activities that are reminders of the eventSexual problemsAffective/EmotionalInitial euphoria and reliefSurvival guiltAnxiety, fear, insecurityPervasive concern over well being of loved onesFeelings of helplessness, hopelessnessUncontrolled mood swings, periods of cryingApathy, isolation, detachmentShame or anger over vulnerabilityIrritability, restlessness, hyper-excitability, agitationAnger, rage, blame (often directed at those attempting to help)Frustration, cynicism, negativityDespair, grief, sadnessDepression and withdrawalSomaticVague body complaintsMuscle aches and painsFatigue or generalized weaknessSleep disturbancesIncreased or decreased heart rate or blood pressureFeeling of pounding heart or pulseIncrease in allergies, colds, flu, headachesTrouble breathing or “getting breath”Tightness in chest, throat or stomachSweatingFeelings of heaviness in arms or legsNumbness or tinglingChanges in appetite or weightNausea or GI upsetsTrembling, dizziness or faintingImagerySleep disturbancesNightmaresFlashbacks and recurrent dreams of eventIntrusive thoughts about eventRuminations about eventCognitiveInability to concentrateDifficulty with calculationsConfusion, slowness of thoughtImpaired decision makingAmnesiaPreoccupation with eventLoss of objectivityRigidityLoss of faithIncreased awareness of one's own and loved ones’ vulnerabilityRepetitive thoughts, memories, ruminations about eventLoss of judgmentInterpersonal SkillsIrritability and anger towards othersFamily and relationship problemsDisruption of work, school or social relationshipsDrugs/AlcoholIncreased use of alcoholIncreased use of drugs

Fig. 2-3: BASIC ID explained

3Children and Disasters

Children's Reactions

Children in crisis present a complex challenge. Children in various age groups have specific needs and respond differently to the same crisis event. A serious problem in working with children in crisis situations is that the responders tend to become emotionally involved with the children they are attempting to help. Emotional involvement frequently interferes with proper crisis management.

Reactions of children to a disaster can have both short term and long term effects. A child's view of his or her world as safe and predictable is temporarily lost. Most children have difficulty understanding the damage, injuries, or death that can result from an unexpected or uncontrollable event.

A basic principle in working with children who have experienced a disaster is relating to them as essentially normal children who have experienced a great deal of stress. Most of the problems that appear are likely to be directly related to the disaster and are transitory in nature. Relief from stress and the passage of time will help re-establish equilibrium and functioning for most children without outside help.

Children will often express anger and fear after a disaster. These will be evidenced through continuing anxieties about recurrence of the event, injury, death, or separation and loss. In dealing with children's fears and anxieties, it is best to accept them as being very real to the child. The reactions of the adults around them can also make a great deal of difference in their recovery from the shock of a disaster.

Preschool Children

Children's perceptions of a disaster are primarily determined by the reactions of their parents. Children of preschool age believe that their parents can protect them from all danger. They believe they cannot survive without them. They fear being injured, lost, or abandoned and these fears increase when they find themselves alone or among strangers.

Adults should be aware that the fertile imagination of preschool children makes them more fearful. Three levels of anxiety in pre-school children in a disaster can be identified:

Contagious Anxiety: This type of anxiety is transmitted by adults. It can be easily handled in difficult circumstances in a child who is not normally anxious by placing the child in calming surroundings.

True or Objective Anxiety:- This is related to the child's capacity for understanding the nature of the danger threatening him/her and his/her tendency to create fantasies based on concrete events. The child is really afraid because he/she does not know the causes and dangers felt to be threatening. For example, it is useless to try to convince a child that thunder and lightening present no danger if the child does not understand their causes.

One can respond to the objective fears of children of this age by taking into account their degree of maturity and type of imagination. Adults should help them live through the event and conquer their fears to help prevent the fears from persisting into adulthood.

Profound Anxiety: Different from fear, this involves separation anxiety. The child fears losing those close to him/her. Everything seems dangerous. Fear is omnipresent.

Generally, young children express themselves little verbally. It is their behavior that reveals their anxiety and fear.

The intensity and duration of a child's symptoms (Fig. 3-1) decrease more rapidly when his or her family or other significant adults are able to indicate that they understand his or her feelings. Children are most fearful when they do not understand what is going on around them. Every effort should be made to keep them accurately informed, thereby relieving their anxieties. Talking with children, providing simple accurate information about the disaster, and listening to what they have to say are probably the most important things we can do. Sharing the fact that adults were frightened too and that it is normal and natural to be afraid is also reassuring to a child. It is comforting to hear “fear is natural. Everybody is afraid at times.”

Sleep disturbances are very common for children following a disaster. Behavior is likely to take the form of resistance to bedtime, wakefulness, unwillingness to sleep in their own rooms or beds, refusal to sleep by themselves, desire to be in a parent's bed or to sleep with a light, and insistence that the parent stay in the room until they fall asleep. These behaviors are disruptive to a child's well being. They also increase stress for parents. Some of the more persistent bedtime problems, like night terrors, nightmares, and refusal to fall asleep may point to deep-seated fears and anxieties which may require professional intervention.

When talking with clients with children, it is helpful to explore the family's sleep arrangements. They may need to develop a familiar bedtime routine. This might include reinstating a specific time for going to bed. The family may find it helpful to plan calming, pre-bedtime activities to help reduce chaos in the evening. Developing a quiet recreation which includes the whole family as participants can also be helpful.

Crying, depression, withdrawal and isolationRegressive behaviors including thumb sucking, bedwetting, clinging behaviorsIncreased fighting, anger, ragesNightmares and sleep disturbances, including fear of sleeping alone, night terrors, fear of falling asleepNot wanting to attend school or other athletic or social eventsHeadaches, rashes, GI upsets, nauseaChanges in appetiteFears of future disastersFears about death, injury and lossSeparation anxiety or fearLoss of interest in school and routine activities s

Fig. 3-1: Children's Reactions to Disaster

Ages 6-12

The attitude of the family and the environment have great influence on the degree of anxiety experienced by the child and on what mechanisms the child uses in both the short and long term to cope with stressful situations or events.

The reaction may be immediate or delayed, brief or prolonged, intense or minimal. The child reacts with his/her present personality at a given level of biological and emotional development. The nature and intensity of the reaction will be determined by the child's temperament as well as past experiences. Faced with the same stressful situation, two children may react in entirely different ways. These reactions suggest the adaptations the child is making to assimilate, cope with, and “accept” the painful situation.

The reactions most often expressed will translate in various ways the child's anxiety and his/her defenses against it. These will vary with the age of the child. They include: fear, sleep disturbances, nightmares, loss of appetite, aggressiveness, anger, refusal to go to school, behavioral problems, lack of interest in school, inability to concentrate in school or at play. Sometimes these difficulties occur only in school. Sometimes they only occur at home with the child functioning adequately in the school environment.

An anxious child needs security and, above all, love. The role of the adult consists of helping the child psychologically and trying to understand him/her.

Children can be spared much anxiety if we try to imagine their reaction to the event. Seeing through the child's eyes helps the adult to prepare the child emotionally to face events calmly and confidently as they occur.

Reactions can be prevented or lessened by clarifying the situation through open communication about the traumatic event or situation by those close to the child.

Fears and Anxieties

Fear is a normal reaction to disaster, frequently expressed through continuing anxieties about recurrence of the disaster, injury, death, separation and loss. Because children's fears and anxieties after a disaster often seem strange and unconnected to anything specific in their lives, their relationship to the disaster may be difficult to determine. In dealing with children's fears and anxieties, it is generally best to accept them as being very real to the children. For example, children's fears of returning to the room or school they were in when the disaster struck should be accepted at face value. Treatment efforts should begin with talking about those experiences and reactions.

Before the family can help, however, the children's needs must be understood. This requires an understanding of the family's needs. Families have their own shared beliefs, values, fears and anxieties. Frequently, the children's malfunctioning is a mirror of something wrong in the family. Dissuading them of their fears will not prove effective if their families have the same fears and continue to reinforce them. A family interview should be conducted in which the interviewer can observe the relationship of the children and their families, conceptualize the dynamics of the child-family interactions, and involve the family in a self-help system.

The parents’ or adults’ reactions to the children make a great difference in their recovery. The intensity and duration of the children's symptoms decrease more rapidly when the families are able to indicate that they understand their feelings. When the children feel that their parents do not understand their fears, they feel ashamed, rejected, and unloved. Tolerance of temporary regressive behavior allows the children to re-develop anew those coping patterns which had been functioning before. Praise offered for positive behavior produces positive change. Routine rules need to be relaxed to allow time for regressive behaviors to run their course and the re-integration process to take place.

When the children show excessive clinging and unwillingness to let their parents out of their sight, they are actually expressing and handling their fears and anxieties of separation or loss most appropriately. They have detected the harmful effects of being separated from their parents and, in their clinging, are trying to prevent a possible recurrence. Generally, the children's fears dissolve when the threat of danger has dissipated and they feel secure once more under the parents’ protection.

Children are most fearful when they do not understand what is happening around them. Every effort should be made to keep them accurately informed, thereby alleviating their anxieties. Adults, frequently failing to realize the capacity of children to absorb factual information, do not share what they know, and children receive only partial or erroneous information. Children are developing storehouses of all kinds of information and respond to scientific facts and figures, new language, technical terms, and predictions. Following the 1971 earthquake, the children in Los Angeles were observed to become instant experts. The language used by them in a daycare setting was enriched by technical terms, such as Richter Scale, aftershock, temblor, etc. The children learned these new words from the media and incorporated them readily, using them in play and in talking with each other.

The family should make an effort to remain together as much as possible, for a disaster is a time when the children need their significant adults around them. In addition, the model the adults present at this time can be growth enhancing. For example, when the parents act with strength and calmness, maintaining control at the same time they share feelings of being afraid, they serve the purpose of letting the children see that it is possible to act courageously even in times of stress and fear.

Sleep Disturbances

Sleep disturbances are among the most common problems for children following a disaster. Their behavior is likely to take the form of resistance to bedtime, wakefulness, unwillingness to sleep in their own rooms or beds, refusal to sleep by themselves, desire to be in a parent's bed or to sleep with a light, insistence that the parent stay in the room until they fall asleep, and excessively early rising. Such behaviors are disruptive to a child's well-being. They also increase stress for the parents, who may themselves be experiencing some adult counterpart of their child's disturbed sleep behavior. More persistent bedtime problems, such as night terrors, nightmares, continued awakening at night, and refusal to fall asleep may point to deep-seated fears and anxieties which may require professional intervention.

It is helpful to explore the family's sleep arrangements. The family may need to develop a familiar bedtime routine, such as reinstating a specific time for going to bed. They may find it helpful to plan calming, pre-bedtime activities to reduce chaos in the evening. Teenagers may need to have special consideration for bedtime privacy. Developing a quiet recreation in which the total family participates is also helpful.

Other bedtime problems of children, such as refusing to go to their rooms or to sleep by themselves, frequent awakening at night, or nightmares can be met by greater understanding and flexibility on the part of the parents. The child may be allowed to sleep in the parents’ bedroom on a mattress or in a crib, or may be moved into another child's room. A time limit on how long the change will continue should be agreed upon by both parents and child, and it should be adhered to firmly. Some children are satisfied if the parents spend a little extra time in the bedroom with them. If they come out of bed at night, they should be returned to it gently, with the reassurance of a nearby adult presence. Having a night light or leaving the door ajar are both helpful. Getting angry, punishing, spanking, or shouting at the child rarely helps and more frequently makes the situation worse. Sometimes, it becomes clear that it is actually the parent who is fearful of leaving the child alone.

Parents from middle-class families have been educated to believe that allowing their child to sleep in the parents’ room has long-lasting deleterious effects on the child. Families accustomed to overcrowded and shared sleeping space have less trouble in allowing children to be close to them. Closeness between parents and children at bedtime reduces the children's and adults’ fears.

Providing families with information on how to handle bedtime fears can best be done in the family setting or with groups of families meeting together. The families feel reassured upon learning that what they are experiencing is a normal, natural response, and that time and comfort are great healers. Learning that the sleep disturbance behavior is a problem shared with other families is reassuring.

School Avoidance and School Phobias

It is important for children and teenagers to attend school since, for the most part, the school is the center of life with peers. The school becomes the major source of activity, guidance, direction, and structure for the child. When a child avoids school, it may generally be assumed that a serious problem exists. One of the reasons for not going to school may be fear of leaving the family and being separated from loved ones. The fear may actually be a reflection of the family's insecurity about the child's absence from the home. Some high achieving children may be afraid of failing and, once they have missed some time at school, may have concern about returning. The low performers may find that the chaos of disaster makes it even more difficult for them to concentrate. School authorities should be flexible in the ways they encourage children to attend school.

Programs designed for schools vary. Some projects involve teachers and school counselors, while others provide trained workers who have direct contact with the children and the teachers. In some instances, management within the school setting is advantageous. Troubled children can be identified by their behavior in both the classroom and on the playground. Some of the signs are fighting and crying in school for no apparent reason, increased motor activity, withdrawal, inattentiveness, marked drop in school performance, school phobia, rapid mood changes, incessant talking about the disaster, and marked sensitivity to weather changes. Puppetry and psychodrama conducted by a counselor or teacher in the classroom or in special groups are helpful in re-enacting the disaster. They may be followed by discussions and reports by the children of their own experiences in the event. Field trips to disaster sites may be arranged, and group meetings with students and parents may be held. Coloring books, word puzzles, connect-the-dot pictures, and arithmetic problems about the disaster build self-confidence. Class projects may be developed in which all the information about the disaster or a previous similar one is collected and made into a book with color drawings. Craft models or replications (such as dams, earthquake geology, volcanoes, rivers, etc.) may be built. Puppets may be made and used to re-enact the disaster.

Children can be encouraged to construct their own games as a way of mastering the feelings associated with the disaster. For example, children play tornado games in which they set up the rules by themselves. In one game, each child is designated as an object, such as a tree, house, car, etc., and one child is the tornado making a noise like a siren and running. The other children begin to run and knock each other over. The “tornado” leaves, and all the children get up and return to their normal activities. Another example has children building a dam in a gutter or ditch and filling it with water. One child then breaks the dam and allows the water to escape harmlessly down the street or into the ditch.

School rap groups are also particularly helpful. Administrative information meetings, teachers’ in-service meetings, and parent-teacher meetings can be used for public education. Newsletters and the school newspaper are useful in distributing information among the students. Chat rooms and web-sites on the internet can also be helpful.

Public involvement can be integrated through use of widespread associations, such as Camp Fire Girls, Cub Scouts, Brownies, 4-H, FFA, etc.

Loss, Death and Mourning

It is not unusual for a disaster, particularly a major disaster in which there has been loss of life, to trigger children's questions about death and dying. The fear of the loss of mother or father underlies many of the questions and symptoms a child may develop, such as sleeplessness, night terrors, clinging behavior and others. Often, when loss has occurred, the children's problems are overlooked. No one assists them in handling their reactions to the loss. When a mother or father dies, most children are fearful of what will happen to them if the remaining parent dies as well. Being told that adults will look after them is very reassuring. The children should be encouraged to voice their questions. The adults should be as honest as they can be with their answers. For example, questions about what happens to a person after death can be answered with the statement that the wisest men and women through the ages have tried to answer this question. However, there is no sure answer. Explanations dealing with heaven and hell, or afterlife, or the flat statement that after death there is nothing are confusing to a child.

It is not uncommon for children to make believe that the deceased parent is still alive. They may call the remaining parent or family a liar and deny their parent's death. Some children may go back and forth between believing and not believing that the parent has died and may ask such questions as “When is Daddy coming home from being dead?” or “I know Mommy's dead, but when is she going to make my supper?” Young children may not realize that there is no return from death—not even for a moment.

Many of the same issues that adults struggle with in coming to terms with death are also found in children's struggles. Magical thinking is more prevalent in childhood. Most children, when they are very young, believe that wishing for, or thinking about, something can make it happen. Children who have had angry thoughts or death wishes toward the parent (as most children have at one time or another) need to be reassured that these thoughts did not cause something to happen. Children may believe that fighting with a sibling can cause a parent's death and that ceasing to fight will prevent the other parent from dying. They need reassurance that the parent's or family member's death was not their fault, that it was caused by an accident or illness. It is comforting to be told that there are some things they cannot control, such as parents getting sick or having an accident or dying. These can be contrasted with things they can control, such as the games they play, whether or not they play fairly, whether or not they do their chores and homework.

Both the child and family may suffer loss of pets, property, valuables, and treasured sentimental objects. Such losses may have as much impact on them as the loss of a loved one. A mourning process can be anticipated. When family treasures or sentimental objects are still available, they can be helpful to the mourners. They often provide something tangible as a security object. Families in disaster frequently return to the ruins to retrieve what seem like valueless objects. This is understandable because mourning pertains to the loss of home and objects as well as to loss of loved ones.

Responders need to know that mourning has a purpose and that crying by both a child and an adult is helpful. A child needs to be aware that thoughts about the dead person are likely to come to mind over and over. Forgetting takes time and overt mourning helps them integrate the loss more quickly. The family that expresses concern and annoyance at a child who asks the same questions about death over and over again needs to understand that this is the child's way of adapting to the loss.

Suicidal Ideation

Threats or attempts to injure or kill oneself in latency-age children and younger are rare. However, they are not uncommon among adolescents. Any indication of suicidal feelings must be taken seriously. The most frequent motivation is loss of close family, a sweetheart, and of significant objects such as pets, instruments, or a car. Even loss of the opportunity to participate in team sports for the year may bring on serious depression.

Feelings of helplessness, hopelessness, and worthlessness are strong indicators of suicide potential, expressed verbally or nonverbally through behavioral signs—withdrawal, asocial behavior, loss of interest, apathy, and agitation; physical symptoms—sleep and appetite disturbance; and cognitive process changes—loss of alternatives, poor judgment, and reasoning ability. Evidence of caring and concern are the most immediate, effective elements of help which can be provided by all responders. Generally, however, any person with suicidal ideation should be referred to professional help.

Confusion

A trouble sign that requires immediate attention, confusion implies a deep-seated disturbance which also probably requires referral to a mental health professional. Confusion generally refers to a disorientation in which the young person has lost the ability to sort out incoming stimuli, whether sensory or cognitive. As a result he/she is overwhelmed by a profusion of feelings and thoughts. Associations with familiar objects may be distorted or disappear, regressive behavior may reappear, and feelings displayed may be inappropriate for the occasion. In extreme cases, immobilization or uncontrolled movement may occur. The mental health professional can begin the process of helping to reorient the children by talking to them calmly, by providing them with specific information, and by being caring and understanding.

Antisocial Behavior

Behavior problems—group delinquency, vandalism, stealing, and aggressiveness—have been reported in some communities following a disaster. These behaviors may be a reaction of an adolescent with low self-esteem to community disruption. A major problem for the adolescents is the boredom and isolation from peers which comes from disruption of their usual activities in school and on the playground. One way to counteract this is to involve adolescents and their peers, under adult direction, in clean-up activities which may be therapeutic to the teenagers and beneficial to the community. The adolescents also serve as an excellent resource for helping elderly people and babysitting for families.

It should be remembered, however, that young people of this age have difficulty expressing their fears and anxieties, lest they seem less competent to their peers and themselves. The use of peer rap groups, in which teens can talk about their disaster experiences and ventilate feelings, is helpful in relieving buried anxieties. A “natural” setting for these rap groups, such as school, work or task sites, or wherever teenagers congregate, is desirable. Training teenagers to lead their own rap groups should be considered. Boy Scout and Girl Scout leaders and teachers are natural leaders/trainers.

Children with Special Needs

Two groups of children with special needs are briefly discussed below: those with prior developmental or physical problems; and those who have been injured or become ill as a result of the disaster. Both require more intensive attention in a disaster than normal or less seriously affected children.

The Exceptional Children

Exceptional children are defined as those who have developmental disabilities or physical limitations, such as blindness, hearing impairment, orthopedic handicaps, mental retardation, cerebral palsy, etc. Exceptional children have special needs that require consideration when a disaster occurs. Disasters and their periods of disruption bring additional burdens upon the parents of exceptional children. These parents have problems just in coping with their children's needs on a day-to-day basis. The emotional needs of exceptional children are very likely to be exacerbated by a disaster of any magnitude.

Most exceptional children live in their own homes and receive assistance from community agencies. The agencies, part of the network of human services in the community, may need to be alerted to the special needs of the children in home settings. Exceptional children find it more difficult to function when their usual home environment is damaged or if they are moved to strange surroundings. Helping such children to understand what has occurred requires heightened sensitivity. Generally, it would be desirable to have professionals who normally are in contact with the children assist in providing help. The professionals are able to locate and identify the children in the community and determine what special services they need, such as schooling or medical care.