This section deals with the function and role shift of the mental health worker. It is essential to clarify the role of the mental health worker in providing technical expertise alongside multidisciplinary post-disaster emergency relief agency staff. That role comprises both subjective and objective aspects and is not well-defined at this time. To be more specific, mental health workers are just beginning to be incorporated into the long-standing, well-organized governmental and Red Cross programs. These programs have developed roles, functions, skills, responsibilities, and clear guidelines for dealing with individuals who are disaster survivors, not patients. To enter this field, mental health workers must shift their usual mode of work and theoretical focus to a new system of guidelines; at the same time, they must develop knowledge, skills, and attitudes for working with individuals who are traumatized but not mentally ill.
The knowledge and skills needed at each stage of a disaster change. In the immediate response phase the demands on the worker are quantitatively and qualitatively different than those in the long-term recovery phase. The nature and pace of the work change continually as a result of (1) the sequences of emotions and coping processes, (2) the rate of recovery in the community as it reorganizes post-disaster, and (3) changes in the organization of disaster agency systems and mass care shelters, Red Cross centers, and FEMA disaster application centers, which change over time in the intensity of the services and characteristics of the assistance provided. The demands for action and assistance gradually lessen in intensity and become more protracted. This slower-paced problem-solving requires more patience and perseverance on the part of workers and brings them fewer narcissistic/altruistic rewards.
The initial expectations of mental health workers participating in post-disaster situations, both of themselves and of others, can lead to discomfort and confusion regarding their role. These workers need to learn to feel comfortable performing new roles and outreach functions, such as going into homes or sitting down for a cup of coffee at the kitchen table as they obtain information on how survivors are coping with the aftermath of the disaster. Many aspects of post-disaster work incorporate non-traditional assistance roles, including helping survivors to find lost pets or obtaining phone numbers of insurance adjusters, plumbers, or roofers.
Although mental health workers are sincere in their desire to assist survivors, they are still not sure of their own and others' expectations about their activities. As they are trained, they should be better prepared to adjust to the unfamiliar situations that may occur in post-disaster emergency work and develop methods of dealing with the reality of making rapid use of information that is difficult to access and only minimally available. Experience will help them to shift their learned attitudes so that they will become comfortable and flexible in collaborating with other disaster aid professionals. When mental health workers interact with colleagues from the Red Cross, FEMA, Civil Defense, and local law enforcement and rescue agencies, they will invariably encounter problems such as confidentiality of material, shared responsibility for mutual tasks, and the need to respect other value systems and communication styles. Mental health workers may find themselves in conflict with long-standing traditions that guide the behavior of other disaster/emergency program workers. Often, the authority to make broad decisions rests with the lead government post-disaster agency. Some of these decisions may, at times, be made without consultation or consideration of the mental health implications for survivors. Such events have produced problems for mental health workers in their attempts to collaborate and cooperate within multidisciplinary teams.
Professional status and behavior norms, which form a value system and psychological school of thought within a specific cultural group, are coupled with differing methods of working among many mental health workers in post-disaster settings. Professional boundaries in a clinical setting not only define the structure and responsibilities of clinical services in the traditional programs from where many of the team members are recruited, but they also define the domain of the workers. A very different situation exists in a post-disaster response setting, where enormous demands are placed on mental health workers as they attempt to respond to the needs of the community, and this domain has no recognizable boundaries to guide community agencies. The worker must set limits and boundaries and prioritize requirements and resources as it becomes painfully clear that all the needs encountered cannot be met. In such outreach situations, the worker will have to grapple with the conflicting roles of "active outreach mobilizer" versus "passive-receptive counselor/ therapist," which is the role that many workers will have played in the past. As these role configurations develop, mental health workers must consider the continuously shifting context in which the survivors find themselves as they react to abrupt relocation, differing shelter arrangements, and daily announcements of new directives from governmental authorities and slow-evolving assistance programs.
SKILLS OF POST-DISASTER WORKERS
Disaster mental health workers need to adapt their previous skills to be able to help survivors realize and cope with the fact that their world has changed. To do that, survivors will need to act and make decisions to solve problems day after day. By assisting survivors emotionally and providing support and guidance, the worker legitimizes the healthy aspects of the survivors' coping capacity. This means that survivors are seen as capable individuals who will be able to reorganize their lives if they are assisted with sensitivity, knowledge, and respect.
Workers must have a clear focus in their interventions and appreciate the boundaries between post-disaster crisis counseling, mental health treatment, and advocacy. As defined by the Center for Mental Health Services, an agency of the U.S. Department of Health and Human Services, the aim of crisis counseling is to assist individuals in coping with the psychological aftermath of the disaster in order to mitigate additional stress or psychological harm and promote the development of understanding and coping strategies which the individual may be able to call upon in the future. In contrast, mental health treatment implies the existence of a diagnostic syndrome listed in the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association. The method and duration of treatment may vary in length and modality, including medication and hospitalization. Advocacy implies a confrontational role vis-a-vis the agencies that provide services after a disaster. It aims to obtain services for survivors. Although helping survivors obtain resources is a goal, representing the survivor in an interview or resolving disputes between agencies and survivors is beyond the scope of the crisis counseling program.
Teams should include members who have skills in helping children, the elderly, and those with chronic physical or mental illness. Although all members should be trained as generalists in order to ensure a common base of knowledge, specialized skills will be necessary to address the needs of different population groups. This will necessitate further specialized training to prepare workers for these tasks. Populations with special needs are discussed in Chapter 5 of this manual.
ATTITUDES OF POST-DISASTER WORKERS
Among the attitudes that will enable workers to provide more effective assistance to survivors are the following:
• Belief that survivors are reacting normally to very abnormal situations. Their responses are, in most cases, expressions of their attempts to cope.
• Willingness to reach out to survivors - outreach is an integral part of all efforts to find, make contact with, and assist survivors.
• Ability to avoid creating dependence on the worker and comfortable acceptance of the possibility of rejection or skepticism by the survivor.
• Willingness to accept that survivors may not consider themselves in need of mental health services and for this reason may not seek out such services.
• Ability to feel comfortable helping a survivor with practical concrete assistance to obtain resources.
• Ability to adapt the worker's usual behavior to the cultural values and beliefs of the survivor, paying attention to small details of social, traditional, or religious practice.
• Capacity to set aside usual methods of classifying emotions and behaviors according to clinical categories or mental health labels.
• Ability to resist the impulse to promise to supply all the needs of survivors, which would necessitate more resources and for a longer duration than feasible through the recovery program.
• Capacity to assist survivors in understanding the scope and limits of the post-disaster counseling program while acknowledging their impatience or anger with the slow pace of bureaucracy.
• Ability to refrain from identifying with the survivor's emotions so as not to lose objectivity and unwittingly adversely affect the survivor's perceptions of the reality stemming from the trauma.
• Ability not to lose focus or the ability to respond appropriately in an ever-changing, confused, and painful environment and take action to solve problems.
• Capacity to deal with rapid changes, edicts imposed by official governmental representatives, unclear lines of authority, and shifting agency structures.
• Realistic expectations, recognizing that individuals representing other agencies - such as FEMA, the Red Cross, the Civil Defense, the housing authority - have different goals, guidelines, approaches, and mandates.
• Acknowledgement of the need for rest and self-care.
POST-DISASTER CRISIS INTERVENTION BY THE MENTAL HEALTH COUNSELOR
The variations, complexity, and severity of crisis reactions encountered by post-disaster counselors present a challenge for the development of intervention approaches.
The following example illustrates the multilevel activities carried out to assist a family and highlights the shining role of the post-disaster mental health worker:
A husband, 49, wife, 47, and five children had recently immigrated to the United States from Honduras when a tornado damaged their home. The woman contacted the crisis team located in a church near the disaster site to ask for help to find out "if she was crazy." She met with the crisis counselor and reported that her feelings and behavior were changing. She had heard from neighbors that behavior changes were to be expected after the trauma of a tornado. In spite of this knowledge, she thought that her experiences went beyond the normal "post-traumatic reaction." She described feelings of depression, crying spells, and inability to make up her mind about household routines. She had no interest in anything, and found it difficult to manage her children. Her drinking, normally limited to social situations, had increased, and her friends had expressed concern about it.
The family's home had been damaged, but they had already received monetary assistance from government agencies, and workers were ready to begin repairs. Although the response to this component of the upheaval was proceeding in a satisfactory manner, the family was still experiencing serious troubles. Most of the wife's complaints and expressions of difficulties centered around her husband, who suffered from multiple sclerosis that resulted in difficulty of movement and mood swings. Despite his disability, the husband wanted to control all aspects of the home's repair and the distribution of the funds received from government agencies. The woman felt her husband's attitude was adding to the complications associated with the repairs and wanted him to live with relatives while the workers were in the house. Her marital situation, already shaky, had worsened and she felt trapped. While previously she had been able to function with strong, realistic defenses and with support from her friends and relatives; she now felt that everything was falling apart because her nearest family members had also suffered in the disaster and had been forced to move to other parts of the state.
The crisis intervention counselor interviewed the husband, the couple, and the entire family to assess their psychological condition and hear their perceptions of the family's problems. The counselor was able to ascertain that the wife was using excessive control to deal with her feelings about the trauma, felt responsible for the family, and was unable to relinquish responsibility for the complex array of activities needed to deal with the bureaucracy of the disaster assistance agencies. Her inability to cope effectively with the reality of her life and process the emotions resulting from the tornado and its effects had precipitated a crisis.
The counselor also learned that the family's cultural traditions regarded the husband as the head and controlling force in the family - a role he did not want to relinquish. The counselor, sensitive to this traditional value system, helped the wife reassess and reevaluate her situation, showing her how the mix of traumatic events, traditional values, and her need for extended family ties were exacerbating the post-disaster crisis resolution process. By enabling the wife to experience relief through verbal expression of her feelings, and then guiding her into collaboration with her husband, rather than attempting to control his dealings with the repair workers, the counselor helped her gain control of her emotions. The counselor also helped the woman to recognize her own internal feelings.
As the woman became aware of her increased efficiency, she began to feel more positive about her family. The counselor supported her in the difficult situation and commended her for the way in which she had managed the bureaucratic requirements necessary to get her home repaired, despite her unfamiliarity with the procedures.
Like many disaster survivors, this family needed more than basic assistance. They were grappling with many problems before the tornado struck; the disaster unleashed latent problems in family relations that were aggravated by the unresolved family crisis. The crisis counselor needed to identify the boundaries of post-disaster crisis assistance and then put the family in contact with a community agency that could provide additional resources to help them resolve the chronic marital problems.
Such an example highlights the types of crisis counseling for victims after the basic, concrete post-disaster assistance is rendered to normalize living conditions.