ROCKY MOUNTAIN REGION DISASTER MENTAL HEALTH NEWSLETTER
Learning From The Past and Planning For The Future
MENTAL HEALTH MOMENT
November 2, 2001
"Experience is not what happens to a man. It's what a man does with what happens to him."
- Aldous Huxley
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Network for parents investigating child anxiety
http://www.childanxiety.net
Edited by Donna Pincus, PhD, of Boston University, the Child Anxiety Network uses
nonspecialist language to aim worried parents in the most effective direction through
free information. In addition to explaining and answering common questions about
anxiety, fears and phobias in children, the site offers resources for parents such as
books and toys, a directory of specialists in child anxiety and even a quarterly
newsletter. Professionals can visit as well and gain resources. The network is "dedicated
to helping parents, teachers and professionals who have an interest in learning more
about childhood anxiety disorders," says the site's webmaster, John Otis, PhD, a
research psychologist in Connecticut.
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CRITICAL INCIDENT STRESS WORKSHOP sponsored by The University of Wyoming Counseling Center
and The Rocky Mountain Region Disaster Mental Health Institute will be held in Laramie, WY
on November 16, 17, 2001. There will be two workshops. One will be in Basic Critical Incident
Stress Management (CISM) on 11/16-11/17 and will be a certification course taught by
International Critical Incident Stress Foundation (ICISF) certified trainers. The Advanced
Issues in Critical Incident Stress Debriefing will be taught by U.S. Navy Psychologist
CDR Bryce Lefever, PhD, ABPP. Enrollment in both workshops is limited. There is an early bird
registration period. If you wish to receive a printed brochure, please email:
GeorgeDoherty@callatherapist.com with your name and mailing address.
Online Brochure can be accessed at: https://www.angelfire.com/biz3/news/cismuw.html
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INTERACTIVE VIDEO VISITS OFFER COST-EFFECTIVEWAY FOR NURSES TO AID PATIENTS AT HOME
A Penn State-led study has shown that substituting interactive video sessions for up to
half of a visiting nurse's in-home meetings with post-surgical or chronically ill patients
can be a cost-effective way to provide care.
The study is the first to identify the specific costs associated with the new technology
and to show that while the new approach imposes additional initial expenses for care
delivery, it contributes substantial savings without compromising quality. It is also the
first comprehensive study to link patient outcomes with the use of telehomecare.
Dr. Kathryn Dansky, associate professor of health policy and administration, who led
the study, says "Video visits are not a complete substitute for in-home nursing care.
You are always going to need home visits because patients benefit from the personal
touch."
However, the team found that over a typical 60 days of care, savings of $300 per
patient could be achieved by substituting video visits for seven in-home visits and
$700 per patient was saved if half of the visits were made via advanced communication
technology.
"As the number of nursing visits increase, you can substitute more and more video
visits if the purpose is to monitor the patient's health status," Dansky adds. "Substituting
an equal number of video and home visits can produce a major difference in the cost
of the care."
The sources of savings include less travel time and travel costs, fewer travel accidents,
less car theft and the ability to see more patients in the same amount of time.
The researchers published their results in the current (fall) issue of the Telemedicine
Journal and e-Health. The authors are Dansky, Dr. Liisa Palmer, who earned her
doctorate in health policy and administration at Penn State, Dr. Dennis Shea, professor
of health policy and administration, and Dr. Kathryn H. Bowles, assistant professor of
nursing at the University of Pennsylvania.
Skilled nursing care in the home requires a registered nurse to drive to the patient's
residence, conduct examinations and assessments, provide patient care and education,
and then drive to the next patient's house. The process is time-consuming, dangerous
at times for the nurse and expensive.
To see if new technology could help both patients and nurses without incurring
additional costs, the Penn State researchers initiated a 24-month evaluation of the
use of telecommunications as a supplement to skilled nursing visits for people with
diabetes. Called the TeleHomecare Project, the effort was a partnership of Penn State,
American Telecare Inc., and the Visiting Nurses Association of Greater Philadelphia (VNAGP),
a large, urban, home health agency.
A group of 171 diabetic patients discharged from the hospital and referred to the VNAGP
participated in the study. Half of them were randomly assigned to receive a patient
telecommunication station in their homes while the remaining patients received
traditional in-home nursing visits. The patient station included a computer and
monitor equipped with two-way voice capability and a video camera. A blood pressure
cuff and stethoscope were also attached to the computer.
Using the patient station, which works over ordinary phone lines, the patient could see
and talk with the nurses. The system also allowed the nurses to see and hear the
patients and to take temperature and blood pressure measurements, listen to heart
and lung sounds and discuss diet and blood sugar results.
Patients who used the telecommunications system scored higher on positive outcomes
of treatment, had fewer re-hospitalizations and fewer visits to hospital emergency rooms.
Dansky notes that, in general, the patients liked working with the telecommunications
equipment. The stations gave patients a sense of security because they could keep in
touch with their nurse at all times. Some patients even prepared for the video visits by
fixing their hair and dressing up. Far from frivolous, such interest in self-care is an
important indicator of vitality and personal responsibility.
The nurses, too, responded favorably to the technology although three generations
of telehomecare machines were introduced and tested during the study period.
Dansky notes that the nurses found ingenious ways to deal with equipment failures.
For example, if a patient didn't respond, they'd hold up a sign that said, "Nod your
head if you can see and not hear me."
The nurses also used laundry baskets to take the equipment into homes so that
thieves wouldn't see what they were doing. There were no thefts during the project
and no break-ins despite the fact that some patient's homes were located in crime-
ridden areas of the city.
Dansky sees many possibilities for broader application of the telecommunications
systems. She is currently working with Sun HomeHealth to study whether the systems
can aid nurses in helping patients manage their medications especially when there
is a danger of drug interactions. She also sees the possibility of physical therapists
using the system to supervise family members or aides who are helping patients
exercise in the home. Dieticians could also use the system to supervise meal
planning and preparation. Contact: Barbara Hale bah@psu.edu
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RETURNING TO DYNAMIC EQUILIBRIUM
On September 11, our country underwent one of the most widely viewed traumatic events in
our history. People who were directly affected include the victims, the families of the victims,
the immediate and continuing responders (firemen, police, emergency services, Red Cross
teams, medical and psychological trauma teams, etc.), and anyone who witnessed the event
unfold on the live television broadcasts. For perhaps the first time ever in history, a highly
traumatic event was witnessed first-hand by hundreds of millions of people. The long-term
effects of this event on people's lives has yet to be determined. However, it can be expected
that a significant number of people (adults and children) will experience emotional upsets,
somatic disturbances, sleep disturbances including nightmares and of disturbing intrusive
thoughts, depression, anxiety (including panic attacks, phobic reactions and generalized
anxiety), and other stress-related reactions. Persons with certain pre-existing conditions
(e.g. post-traumatic stress related problems and PTSD) can be expected to experience
different levels of responses that will likely cause a re-occurrence of their original emotional,
somatic, cognitive and physical responses. Some of these responses may be transient; others
may be more chronic or ongoing. In all cases, these responses are a normal reaction to an
abnormal event. And, in this case in particular, the event is even more the cause of such
reactions because it was man-made and deliberate and, potentially, avoidable.
A flood, tornado, hurricane or earthquake can cause widespread death and destruction, but
is a result of nature and is something that is unavoidable. Attribution for its impact is directed
toward nature, God, fate, etc. In any case, its causes are out of the control of people (Taylor,
2001).
A terrorist act or other man-made mass casualty event cannot be attributed to nature, God,
fate, etc. It is a deliberate act of destruction caused by people with intent to target other
people and is, potentially perceived as being avoidable. The feelings of hopelessness,
helplessness, and loss of control by survivors are mixed with feelings of anger, revenge,
and retribution towards those responsible. Again, in both natural and man-made disasters,
the feelings are normal responses to very abnormal events.
LOSS, MOURNING, AND GRIEF
ALL survivors (including ones who view the events on TV) 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 a lot of 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 attached, or a value or freedom 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. 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 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 (an example in the current crisis might be someone who was exposed to or
involved in the Oklahoma City bombing or the first WTC bombing in 1993). 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. Some typical reactions 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 states is very common, very counterproductive, and requires active
crisis intervention.
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 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 reappropriation allows
us, at the same time, both to lessen our pain and to console ourself 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, in small steps, 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 generally 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 re-establish 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 individual
* the situational reports which are available
* mechanisms 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.
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.
WHY DO SOME PEOPLE REACH A STATE OF CRISIS WHILE OTHERS DO NOT?
Perception Of The Event
When the event is perceived realistically:
There is an awareness of the relationship between the event and the sensation 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.
STAGES OF DISASTER
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. 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
workers. During the immediate post-impact phases, workers 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. Workers continue to push themselves
through and past the stress signals and 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. It is 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' abilities 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 and defusings
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, workers 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, et. By providing crisis
intervention and following a disaster it is hoped that both workers and survivors can develop effective
coping mechanisms that will assist them through the stages of recovery with less long term emotional
impact.
SUMMARY
This discussion has looked at how all disaster victims proceed through recognized stages of grieving,
from denial to acceptance. Just as there are recognized stages of grieving, there are also recognized
stages of disaster and expected individual and community reactions during the different stages. By
understanding these stages, it helps to understand how disaster victims and workers may react
psychologically. As a result, it helps us be better able to meet the emotional needs that arise due to
disaster.
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REFERENCES
De Girolamo, G. (1993). International perspectives on the treatment and prevention of posttraumatic
stress disorder. In J.P. Wilson and B. Raphael (Eds.). International handbook of traumatic stress
syndromes. The Plenum series on stress and coping. (pp. 935-946). New York: Plenum Press.
De la Fuente, R. (1990). The mental health consequences of the 1985 earthquake in Mexico.
International Journal of Mental Health, 19, 21-19.
Delamater, A. & Applegate, E.B. (1999). Child development and post-traumatic stress disorder
after hurricane exposure. TRAUMATOLOGYe http://www.fsu.edu/~trauma/a3v5i3.html
Vol. 5, Issue 3, Retrieved May 1999.
Doherty, G.W. (1999). Cross-cultural counseling in disaster settings. Australasian Journal of
Disaster and Trauma Studies, Volume 1999-2.
http://www.massey.ac.nz/~trauma/issues/1999-2/doherty.htm
Retrieved 9/9/99.
Taylor, A.J.W. & Frazer, A.G. (1982). The stress of post-disaster body handling and victim
identification work. Journal of Human Stress, 8, 4, 4-12.
Taylor, A.J.W. (1987). A taxonomy of disasters and their victims. Journal of Psychosomatic
Research, 31, 4, 535-544.
Taylor, A.J.W. (1989). Disasters and disaster stress. New York: AMS Press.
Taylor, A.J.W. (1990). Apattern of disasters and victims. Disasters: The Journal of Disaster
Studies & Management, 14, 4, 291-300.
Taylor, A.J.W. (1998). Observations from a cyclone stress/trauma assignment in the Cook Islands.
TRAUMATOLOGYe, 4:1, Article 3 http://www.fsu.edu/~trauma/art3v4i1.html
Retrieved May 1, 1999.
Taylor, A.J.W. (1999). Value conflict arising from a disaster. Australasian Journal of Disaster
and Trauma Studies, Vol 1999-2. http://www.massey.ac.nz/~trauma/issues/1999-2/taylor.htm
Retrieved February 2000.
Taylor, A.J.W. (2000). Tragedy and trauma in Tuvalu. Australasian Journal of Disaster and
Trauma Studies, Vol 2000-2. http://www.massey.ac.nz/~trauma/issues/2000-2/taylor.htm
Retrieved October 2000.
Journal: TRAUMATOLOGYe http://www.fsu.edu/~trauma Vol 5 Issues 2 & 3.
To search for books on disasters and disaster mental health topics and purchase them online,
go to the following url: https://www.angelfire.com/biz/odochartaigh/searchbooks.html
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Contact your local Mental Health Center or
check the yellow pages for counselors, psychologists,
therapists, and other Mental health Professionals in
your area for further information.
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George W. Doherty
O'Dochartaigh Associates
Box 786
Laramie, WY 82073-0786
MENTAL HEALTH MOMENT Online: https://www.angelfire.com/biz3/news
