Crisis counseling An intervention technique that restores survivors' capacity to cope and handle stressful situations and provides assistance for reordering and reorganizing their world; education and interpretation of the overwhelming feelings produced by post-disaster stresses are available to help restore a sense of capability and hopefulness.
• Providing education and information about resources available to help survivors reorganize their lives.
• Helping with identification of ambivalent feelings, acknowledging needs, asking for help, and accepting support.
• Helping with prioritizing needs, obtaining resources, and increasing individual capacity to cope with specific priorities identified.
• Providing opportunities to become engaged and affiliated.
• Providing a structured method of perceiving specific problems, self-observations, behavior, and powerful emotions through help in understanding, defining, and ordering events in the larger world.
Outreach to individuals may initiate the linkage to mental health intervention. In such situations, outreach can be followed by crisis counseling.
The goal of post-disaster psychological intervention is to alleviate a survivor's emotional distress and/or cognitive disorganization and to suggest corrective action and offer appropriate information. The crisis worker can help survivors interpret their overwhelming emotions, understand the reactive nature of feelings, and recover a sense of capability and hopefulness.
Specific elements of post-disaster crisis counseling and outreach are:
• Reorientation and adaptation to a social transition period;
• Appraisal of the support network;
• Determination of thoughts, emotions, levels of anxiety, depressive reactions, fear, anger.
During the first phase of the post-disaster experience, the primary effort is the outreach process. This "first aid" technique helps survivors get reoriented and adapted to their new transitory reality. Outreach is the crucial first step in beginning to resolve a survivor's sense of being overwhelmed by the events of the disaster.
While disaster survivors need help with reality testing to determine what has happened, what is happening, and what will happen in the future, care should be taken not to interfere with the psychological defense mechanisms used by the survivor. These defense mechanisms, which give the survivor a personal sense of remaining in control, include denial of the extent of an injury, loss, or trauma, and a sense of vagueness concerning the catastrophic event.
Further, although expressions of empathy are helpful, care must be exercised not to reinforce or reward the victim role. The healthier parts of the survivor's personality must be encouraged and mobilized to enhance the ability to "hold on" for the present.
An appraisal of the survivor's emotional reactions needs to be done to determine what assistance is appropriate in the situation and appraise levels of anxiety, depression, fear, and anger. All support system resources should be mobilized. The responsibilities of daily living can be apportioned to family members.
Crisis workers themselves should seek to strike a balance between rest and work. They should also build networks to enhance their own support systems in order to prevent "burn out." Crisis personnel should always work to facilitate the expression and understanding of painful emotions that are part of all phases of recovery.
The setting where survivors are physically located is an important variable that will affect the choice of psychological interventions. The turnover of large numbers of survivors in the shelter and the small number of trained crisis personnel make it important for crisis workers to realize the impact of their interaction. This transitory situation must, therefore, mold the type of intervention that is used.
GOALS AND OBJECTIVES OF CRISIS COUNSELING
To foster mastery of coping behavior, the mental health worker should promote action directed toward the "unknown" generated by change in the survivor's environment. Appropriate action includes helping survivors follow temporary shelter procedures, await news of post-disaster events, or deal with the lack of information on the whereabouts of other family members.
In addition, the crisis worker can provide guidance concerning the survivor's immediate focus of attention. Communication of reasons for hope is crucial, as is conveying an attitude of concern and confidence about the probability of an eventual successful outcome.
Specific objectives of crisis intervention include the following:
• To identify problems generated by the disaster and the difficulties posed by the need for change.
Helping survivors adjust to the possibility that they may not be able to return home and may have to stay in an emergency shelter for an extended period.
• To list alternatives and strategies for action.
Explaining to survivors that a list of options for obtaining resources and handling living situations will be provided in the next few days.
• To build a decision-making model and develop steps for implementing it.
Choosing an individual to assist the survivors on a permanent basis or introducing a team of workers that is available to them.
• To operationalize alternatives.
Explaining and "walking through" the many operations of the shelter with the survivors.
• To take steps toward dealing with survivors' problems and get feedback on outcome and results.
Talking to survivors about the problems to be addressed when they move out of the shelter and asking for reactions.
Assessing the mental health needs of survivors in a post-disaster setting can be a delicate matter. The environment is murky, time is short, and the standard methods are not available. In this confusing setting, crisis workers need to determine the mental/emotional condition of survivors and decide how that condition will affect their abilities to deal with solving immediate problems and deciding whether to refer them for professional help.
To provide support for necessary decision-making, the worker should follow guidelines to determine the appropriate type and level of activity that the survivors can perform. Furthermore, interventions must be planned in terms of immediacy versus delay and should take into account the emotional state of survivors and the staffing conditions in the emergency setting.
To measure the level of function, the crisis worker must investigate the following risk factors to ascertain the indications of emotional reactions:
• Psychosocial maturity or immaturity of the survivor's personality;
• Role of stress in social expectations of performance, as judged by survivors and others living with them, within or outside the temporary setting;
• Continued environmental stress, both in social and physical conditions, including interventions such as surgery, relocation, lack of privacy;
• Accidental crisis events occurring in the survivor's life, either before or after the disaster, that affect them or their loved ones.
PRINCIPLES OF CRISIS INTERVENTION
There is a need to prepare the survivor for post-disaster crisis counseling and intervention. The mental health worker plans for crisis intervention by obtaining the information needed to plan the intervention, establishing competence and credibility, describing the psychosocial intervention plan, and eliciting the survivor's cooperation with the plan.
The counselor must discern the survivor's attitudes and expectations about the intervention and then move forward to a collaborative decision. From this awareness, the crisis worker arrives at a tentative formulation of the problem and/or plan of action.
Crisis workers should be familiar with a wide variety of approaches and should select the combination that best fits the characteristics of the problem. The objectives are to alleviate emotional distress and/or cognitive disorganization and to offer the survivor information and suggestions for corrective action.
Survivors are potentially capable of handling their own problems after being helped to recognize barriers to solutions or redirect their behavior toward exploring new solutions. Transposed dependence may initially occur so that survivors can "borrow" confidence from the crisis workers. Advice should generally be given with caution, although survivors should be informed about relevant matters on which they are uninformed or misinformed in order to enhance the problem-solving.
Communication in the initial interview may be difficult due to distorted ways of communicating stemming from high anxiety and cognitive disorganization. Often survivors are also defensive and guarded. Success in communicating freely with survivors depends on a general ability to win their trust and confidence.
Survivors need help in resolving the present crisis produced by the disaster. Discussion of the "here and now" establishes a relationship, facilitates feedback and options in solving problems, and helps survivors analyze realistic ways of moving toward the solution of problems.
Some exploration of past methods of problem-solving will aid the counselor in understanding how survivors handle the present situation. Meaning and symbolism, including psychophysiological responses to present events, are largely determined by past experiences. Therefore, a partial review of the past may help understand how survivors perceive the problems they face and what they consider acceptable options in terms of their own value systems. Interpretation that enables survivors to see the linkages between feelings or behaviors may be therapeutic, as it will allow survivors to make sense of feelings that are not clear, and it can enhance a sense of mastery and control by putting feelings in perspective.
Reinforcing positive activities and reminding survivors of their skills and strengths in handling problems is critical. It is important to focus on personal skills that are working well rather than focusing only on weaknesses or pathological aspects of the survivor's problem-solving.
The purpose of intervention is to bring about a change in the survivor's problem-solving capabilities, which have been weakened by the disaster conditions. Specifically, survivors experience the following psychological states:
• Feelings of diminished self-confidence and inability to remember past successes in overcoming traumatic episodes. Survivors are overwhelmed by the external circumstances in the post-disaster environment and by their own confusing feelings and thoughts in reaction to a new, unfamiliar, and uncomfortable world.
• Belief that failure will be the outcome of all their traumatic and crisis experiences. This, in turn, strengthens feelings of guilt and shame as part of adaptive regression.
• Feelings of resentment because others on whom they counted for help seem unable or unwilling to provide the needed help. The reactive behavior of these other people, who include multidisciplinary crisis personnel, may be to express irritation because crisis workers often feel that survivors should show gratitude, not feelings of entitlement. The crisis worker's own fatigue and frustration adds to this, often creating a vicious circle between survivors, families, and crisis personnel.
• Increased dependency on others causes a lack of feedback that exacerbates the survivor's low self-esteem. This creates further distance between the survivor and potential support systems.
• Loss of faith in group values and in former beliefs or peers that had, in the past, given the survivors a sense of security and significance in the world. Survivors need help in reestablishing and reordering this faith.
The main objective of crisis intervention is to help survivors develop an internal sense of order and perspective, so that they will be able to organize their own environments as they are helped to process the painful and powerful emotions accompanying the post-disaster events. Another objective is to help survivors reach out, acquire, and build upon resources from recovery agencies so that they gain help in reordering their world and develop a sense of comfort, security, and self-esteem.
TYPES OF INTERVENTION ACCORDING TO POST-DISASTER PHASES
First Phase: Triage and Outreach Activities
The primary objective in the first phase is to lessen stress and offer support. Psychological emergencies require immediate, rapid evaluation of the survivor's behavior. A minimum of data will be available for making decisions, and both time and human energy will be limited. The skill and knowledge required to treat multiple problems may seem overwhelming.
The emergency situation not only requires that the crisis worker play a new role, but also demands types of intervention that can be classified under the concept of outreach.
Disaster triage and outreach are the procedures used by team members and other crisis workers to assess behavior, gage the degree and level of crisis, and supply guidance, resources, and information. This knowledge is provided to the assisting team so that disaster aid planning can alleviate the immediate situation and the psychosociological reactions of the survivors by assisting them in venting feelings, sharing experiences, and receiving support.
Immediately following the disaster, survivors may temporarily become emotionally disorganized. Cognitive disorganization will affect attention and focus, level of interest and involvement, ability to stop ruminating about the catastrophe, learning capacity to absorb information given by crisis personnel, and recall of skills available to solve problems. The therapeutic objective should be to help survivors minimize the effects of the disorganization and reinforce their cognitive mastery. Procedures must be implemented to increase competence and maintain awareness by allowing survivors to tell their stories and obtain validation for their suffering.
The following areas of outreach are useful in dealing with cognitive disorganization:
• Assisting the survivors by reinforcing their knowledge of their new social world, such as demonstrating time-space scheduling and recognizing practical daily living arrangements.
• Strengthening conscious awareness of the appropriateness of social reactions and informing them of normal post-trauma reactions. Many survivors believe they are "going crazy" because they notice changes in their social behavior and they therefore need reassurance.
• Helping survivors identify realistic causal relationships between events and reactions and discussing them individually or in groups.
In dealing with emotional disorganization, the crisis worker should be able to rapidly gage the type and quality of the predominant effects through social interactions with survivors. The major effects seen in the initial phase include sadness, fear, and anger, which are manifested in many forms and with a wide range of intensity. Some expressions are pronounced, while some are subdued or defensive, such as feigned composure, calm, or passive dependence.
During the triage and outreach stage, the worker should not tamper with these sets of behavior. They offer a means of psychological first-level healing that keeps the personality functioning during the acute phase. Although these behaviors cover up emotions, the worker should not encourage expression of guarded emotions until the place and time are appropriate and the worker can stay with the survivor through the process of recuperating some emotional stability.
Intervention objectives for survivors in the shelter include helping them achieve physical comfort, increased cognitive organization, and a sense of emotional control. These approaches will help diminish survivors' sense of helplessness, indecisive or regressive behavior, and belief that they lack coping skills. In addition, these approaches help increase competency, self-esteem, flexibility to consider alternative solutions, and ability to handle the confusion and mixed communications that are characteristic of this first phase of disaster assistance.
As the days go by, crisis workers must sort out priorities for action, such as helping survivors with a sense of orientation, reinforcing reality testing, and developing support systems. De facto support systems must also be developed within the group of survivors in shelters.
In addition, the wide array of available resources must be organized to meet the specific needs of survivors, whether physical or psychological. Crisis personnel can mobilize appropriate help by observing the way survivors behave or approach them. This requires a special type of technique that allows the crisis worker to elicit directly and personally from the survivors their perceived immediate needs. The worker can then collaborate with other emergency personnel in mobilizing resources so that the survivors feel assisted, rather than helpless, hopeless, or destitute.
Second Phase and Third Phase
As survivors are relocated from emergency shelters to temporary housing and back to their reconstructed homes, a new stage of bereavement and crisis emerges. This necessitates a broader repertoire of mental health intervention activities, including crisis counseling with the objective of achieving crisis resolution and assisting with depression reactions that emerge in response to the "second disaster."
Therapeutic activities can help achieve some of the following objectives in assisting survivors:
• Providing education and information about the help available;
• Helping to identifying ambivalent feelings about acknowledging needs and asking for and accepting worker support;
• Helping survivors interact on a cognitive level, assigning priorities to needs, accepting advice on how to obtain information, and increasing the capacity to cope with the dislocation of their lives.
• Providing a structured method of perceiving problems, self-observations, behavior patterns, and powerful emotions through help in understanding, defining, and ordering events in the new environment.
Once these objectives have been met, each categorical problem can be singled out and suggestions can be made for its management. At the same time, several areas of cognitive, emotional, behavioral, and social reality are put into perspective as a first step toward understanding what is happening.
All these activities are preparatory for further work. If the survivors need and accept the offer from the crisis worker, they are led naturally into accepted methods of crisis counseling and therapy for several weeks. If necessary, they are referred to another mental health group.
Families report a reemergence of memories of their emotions with the return of the date of the disaster. Generally the media reinforce these memories by publishing pictures of the event. The range of distress can go from reliving the trauma to evoking unfinished mourning. For survivors who have experienced significant losses mourning is still in progress one year later. For other survivors dealing with the abnormal situation following the disaster, the anniversary can also provide an opportunity for further healing.
PREVENTIVE PLANNING FOR ANNIVERSARY REACTIONS
Crisis counselors should expect and be ready for a resurgence of calls asking for help to obtain further counseling. For many survivors, all that will be needed is phone counseling and reassurance that their emotions are healthy reactions. Others will need more extensive assistance and referral.
At the time of the one-year anniversary of the disaster, the workers themselves will already have returned home, or will be preparing to do so, and they may therefore have some difficulty in separating their own feelings from the survivors' reactions. Workers will need support from senior staff and trainers.
In keeping with the guidelines presented above, mental health intervention programs can be organized along two major lines of assistance activity. The first is direct, face-to-face intervention with families that were housed in emergency shelters during the acute stage of the emergency. Guided by their knowledge of the time phases and the sequential manifestation of crisis phenomenology, the workers can identify and organize a number of approaches to help families through the anniversary phases of crisis, coping, and adaptation. The second line of activity focuses on the community as families relocate to temporary or permanent housing, which may mean a complete change of neighborhood or human support networks. This is accompanied by changing phases of crisis resolution and will necessitate different crisis counseling procedures, as well as both individual and community support organizations.
The objective of mental health assistance during the anniversary period is effective use of interventions that will assist families in (1) handling the stressful situation and (2) further strengthening their coping capacity.
Crisis counselors should consult with child welfare agencies so that they can anticipate difficulties around the anniversary date, which will help prevent problems and offer broad-based opportunities to assist families and children who have been traumatized by a disaster. School personnel are also important collaborators to help children resolve any long-term problems linked to the disaster.
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