Crisis A crucial period or turning point in a person's life that has both physical and emotional consequences. A crisis is a time-limited period of psychological disequilibrium, precipitated by a sudden and significant change in an individual's life situation. This change results in demand for internal adjustments and the use of external adaptation mechanisms that are temporarily beyond the individual's capacity.
The crisis model has considerable significance for post-disaster workers. The model conveys an understanding that certain life events produce a loss of habitual modes of behavior due to the personal turmoil, tension, and emotional upset that accompany stress response. The model also identifies crucial periods when an individual is faced with ongoing decisions that have long-term implications for subsequent life styles and levels of adjustment.
Individuals will give different meaning to an event depending on:
• their perception of what has occurred;
• their past experience with hazardous events; and
• their success or lack of success in managing its impact.
Consequently, a crisis will differ depending upon the people or society involved. Some groups will define a certain event as producing crisis, while others will not.
The final phase of crisis involves finding appropriate defenses and ways to master painful feelings during a period of turmoil. This process of reconstitution involves marshaling personal and social resources in the search for equilibrium and effective functioning. Individual activation of the skills that are necessary to cope emerge during this final phase.
In coping with a crisis, an individual may attempt to:
• change, reduce, or modify a problem;
• devalue an event by seeking satisfaction elsewhere; or
• become resigned to what has happened and then attempt to manage the resulting stress.
The individual in crisis may be seen as affected by an interplay of dynamic changes, which, in turn, are continuously influenced by natural, biopsychic mechanisms designed to bring about a state of balance and personal equilibrium. There are both inputs and outputs of energy and information into the system.
The essential point of crisis is that the intensity of the energy exceeds the capacity of the organism to adjust and adapt. The individual is overwhelmed and the system goes into a state of disturbed biologic rhythms and temporary disorganization.
The severe fluctuation of an individual in the face of a crisis event is associated with the disorganization of psychological and somatic systems. The consequences of this fluctuation include severe personal tension and stress. The imbalance may be induced by such events as the death of a loved one, loss of income or property, illness, relocation, or other important personal factors.
As a secondary consequence, changes in role patterns and in usual or expected behaviors often produce problems in interpersonal relationships. As these changes occur, the individual tends to develop new patterns and behaviors to manage stress and therefore diminish discomfort and pain.
The stress response is likely to produce a pathological outcome if it is severe and/or prolonged. If the combination of events that encompass the experience of the disaster are prolonged or severe, the survivor may develop problematic psychological or behavioral mechanisms to cope with the situation.
Crisis theory is based on the following assumptions:
Disasters are stressors that produce an impact on survivors, resulting in a crisis situation that affects biological, psychological, social, and behavior systems.
Integration and synthesis of complex phenomenology data allows the development of a comprehensive formulation that conceptualizes the situation of the survivor at a specific point in time after the disaster. This clarifies the situation for the post-disaster worker and makes it possible to develop a psychological intervention.
At the moment of impact, a survivor's behavior will depend on prior life factors and the survivor's interpretation and definition of the threatening event.
To understand the individual in stress, it is necessary to look specifically at the chief complaints and the presenting problems of the survivor, the relationship of those presenting problems to precipitating factors, and a description of relevant prior life events as part of the assessment and indications for crisis intervention.
The initial impact of a stressor may produce a level of stress stimulated by:
• type and duration of the disaster;
• degree of loss;
• survivor's role, coping skills, and support systems; and
• survivor's perception and interpretation of the catastrophe.
These reactions represent different stages of the crisis resolution process and follow several developmental phases. These disaster-produced reactions may also be influenced by other random environmental events of a traumatizing nature, such as failure of bureaucratic reconstructive efforts and other disappointments, which have been called the "second disaster."
ORGANIZING PRINCIPLES FOR UNDERSTANDING CRISIS
Survivors whose lives have suddenly been disrupted by a disaster, and who may also be receiving help to heal physical traumas, must develop a coping behavior. Psychological observation and interviewing techniques can be used to understand this set of behaviors and to evaluate the degree of distress in order to offer assistance and support.
Through observation and interviewing, the disaster worker can identify the following:
• Individual personality traits;
• Type of historical events that have influenced the individual's level of development;
• Survivor's usual coping mechanisms and available methods to deal with the crisis when confronted with physical and psychological trauma;
• History of the disaster and how it physically impacted and personally affected the individual.
• The survivor's reactive behavior and personality skills for adapting to the new post-disaster situation.
• Social and post-disaster support system available to the survivor and use of those resources to support healing and recovery.
• Level of support of the medical/social matrix as measured by the degree of community organization versus the disorganization of both the official emergency unit and the disaster assistance agencies.
• The social balance between the availability of support systems resources and the intensity of the stressors, adding further difficulties in obtaining adequate medical and psychological aid.
All of these variables influence the balance between adaptive and non-adaptive behavior and may heighten the vulnerability of survivors and their specific needs before psychological equilibrium can be regained. They will determine the interactive set of responses that influence the course of crisis resolution as they interact with the disaster conditions.
Survivors first call on their own personality skills to adapt. If they are unable to deal with the multiple events occasioned by the catastrophe, they next try to access sources of support in an effort to gain assistance from emergency personnel. If these resources are unavailable or inadequate to meet the life event demands produced by the disaster, the survivors may turn to their culturally provided beliefs, values, and symbols. In post-disaster behavior, many survivors take advantage of all available resources simultaneously and in a complementary manner.
As hours go by in the aftermath of a disaster, some survivors are not able to cope with their problems and continue to express anxiety, apathy, anger, nightmares, insomnia, and difficulty in interpersonal relationships. At some point in the survivor's crisis resolution behavior, the worker will encounter a juncture that will lead either to a healthy or a pathological endpoint. The crisis worker needs to acquire the skills and the knowledge to assess the situation and bring to bear therapeutic intervention procedures that will support and guide the survivors toward achieving the best potential outcome in the situation. This objective necessitates planning logistics and training crisis counseling personnel.
Crisis personnel may also be exposed to post-disaster stress and express emotional problems in the aftermath of a disaster. Relatives of survivors, medical professionals, and disaster relief workers are all vulnerable to the consequences of post-disaster stress. Crisis workers may expect emotional problems from the impact of a natural catastrophe, including reactions such as fear, shock, psychic numbing, anxiety, depression and psychosomatic complaints.
It has been recognized that several stages of crisis resolution occur following a disaster. These stages overlap, and survivors may go back and forth with no clear distinction between stages. This emotional vacillation is a normal reaction in survivors experiencing stress responses, and their emotional state may fluctuate for some time.
In the early period, the survivor may deny the reality of the situation or the physical impact of the trauma. A survivor may verbalize acceptance of what has happened or even admit being grateful that it was not worse. This lack of emotional reaction to the reality of discomfort or change signals a need to defend him/herself from fully registering the consequences of the trauma. The level of accommodation to all the manipulations necessary for medical intervention may vary from mild complaints to exaggerated complaints to feigned unconcern.
As the survivor allows the reality of the new situation to sink in, a new set of symptoms may appear:
• Episodes of strong emotional reaction that will overwhelm the denial defense;
• Restlessness, anxiety, extreme talkativeness or reluctance to talk, passive resistance to medical advice, sudden brief episodes of irritation or signs of frustration;
• A helpless, indecisive reaction to orders;
• Evidence of psychic disorganization, with the passage of time and according to the degree of somatic trauma,;
• Episodes of fear, mood swings without crying episodes, and resentment of minor demands made by the emergency professionals.
An important type of behavior described as "survivor's guilt" needs to be monitored. This behavior is defined as the ambivalent feelings of being happy to be alive, while at the same time feeling guilty about being alive when others have died or suffered worse injuries. This behavior can be antecedent to feelings of depression or paranoid ideation, and it can be the precursor of paranoid clinical depression.
Post-traumatic stress disorder
Psychic trauma is a process initiated by a catastrophic event that confronts an individual and presents an acute, overwhelming threat to survival. When the event occurs, the central nervous system loses the capacity to control the disorganizing effects of the experience and a state of disequilibrium ensues. The event propels the individual into a traumatic state lasting for as long as the brain systems need to return to an organized state. The individual has a need to make sense of the new world view - that is, the why and how of the event that has occurred and what it means.
A person's genetic, constitutional, and personality make-up, state of mind when the event occurred, psychological level of development, existing support systems, as well as the content, intensity, and duration of the event, all contribute to the severity of the traumatic effect.
The central feature of post-traumatic stress disorder is the development of characteristic symptoms after experiencing a psychologically traumatic event, or events outside what is usually considered the normal range of human experience.
The characteristic symptoms include:
• Reliving the traumatic event;
• Numbing of responsiveness to, or involvement with, the external world.
• Autonomic, dysphoric, or cognitive symptoms.
The reactions to and consequences of the disaster effects can produce varied behavioral and emotional expressions, including the following:
• The survivor may have obsessive repeated memories of the event and become preoccupied with them. These memories may appear in dreams or nightmares.
• The survivor may also have periods of feeling distant or detached. This detachment may intermittently disturb social relationships.
• The survivor may experience symptoms of autonomic arousal and increased sensitivity to strong noises or unfamiliar situations that recur many months following the psychic trauma of the disaster.
• The survivors may complain of impaired memory and difficulty in carrying out usual daily tasks.
These subtle changes in personality and sense of social effectiveness are difficult to differentiate from the preexisting emotional characteristics of the individual or the acute response to the impact of the disaster. Nevertheless, these changes in functioning should all be considered by the crisis worker in the diagnostic evaluation of the quality of the stress response, the level of psychic trauma, and the psychological sequelae of crisis resolution. If the worker notices that there is no change in the severity of behavior dysfunction after one or two months, he/she should ask for a consultation or referral to a mental health clinic.