ROCKY MOUNTAIN REGION DISASTER MENTAL HEALTH NEWSLETTER
Learning From The Past and Planning For The Future
MENTAL HEALTH MOMENT
September 14, 2001
"Who are you?" said the Caterpillar...
"I...I hardly know, Sir, just at present," Alice replied rather shyly, "at least I know who I
was when I got up this morning, but I think I must have been changed several times since then."
- Lewis Carroll Alice's Adventures in Wonderland
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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:
larlion@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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IMPAIRMENTS TO COME FOR TEENS WHO ABUSE NICOTINE
Results of a study performed by a Penn State researcher
with adolescent rats suggests that teenagers who smoke
or abuse nicotine patches may be setting themselves up
for depression, anxiety, memory or attention problems
as adults. Laura C. Klein, assistant professor of
biobehavioral health, says the study showed a direct
relationship between adolescent nicotine exposure and
elevations in the adult rats' stress hormones. In
humans, these same hormones are associated with
increased risk for anxiety, depression and cognitive
impairments. The rat studies may offer a biochemical
explanation for the effects observed in the human
study. Klein reported her results in the August issue
of the journal, Experimental and Clinical
Psychopharmacology. The study is the first to involve
the use of adolescent rats to investigate the effects
of adolescent nicotine exposure on the likely effects
of consuming addictive drugs in adulthood. For the full
story by Barbara Hale, visit
http://www.psu.edu/ur/2001/nicotineteens.html
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PROGRESS IN EL SALVADOR
With 1.6 million people left homeless in the aftermath
of the El Salvador earthquakes in January and February
this year, the priority for both the government and aid
organisations has been to provide shelter for all as
soon as possible. A roof of some sort over their head
is essential for people to quickly pick up the threads
of their former lives.
But this was not going to be easy. The earthquakes had
killed 1,259 people, including 400 who were buried
under a massive landslide in the small village Santa
Tecla, on the outskirts of San Salvador. The thousands
of aftershocks didn't help either for those who were
left homeless and fearful for their lives. The
Salvadorean Red Cross, with support from the
International Federation and other members of the Red
Cross Red Crescent Movement, has worked hard to provide
basic necessities for thousands of people. They have
already helped more than 213,000 people by providing
them with food, clean water and health assistance.
More at: http://www.ifrc.org/Docs/News/01/081301/
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MENTAL HEALTH OUTREACH SERVICES FOLLOWING A DISASTER
Published research and reports from disaster mental health programs have demonstrated the
importance of active outreach to the affected population. Active outreach services are needed
based on the following:
* Most people do not see themselves as needing mental health services after a disaster. They
do not seek out such services. As a result, mental health staff must actively find and interact
with survivors in the community sites where they are living, working, and reconstructing their
lives.
* Everyone who sees a disaster is affected by it. This includes those people who are exposed
to it through extensive media coverage. Therefore, mental health education and intervention
must be provided to the community at large following a disaster.
TYPES OF OUTREACH
There are two types of "outreach": microlevel outreach to individuals or small groups, and
macrolevel outreach to the community at large.
Microlevel Outreach
Disaster mental health outreach activities which occur on a "micro" or individual level
entail a face-to-face contact, telephone, or written interaction between mental health
workers and specific individuals or small groups. Casefinding, letter writing, and door-to-door
visits to survivors are some examples. The major goal of microlevel outreach is to find and
make contact with survivors, assess their problems and needs, provide education about
resources and coping strategies, and link them with needed assistance.
Cohen and Ahearn (1980) list the following as microlevel outreach objectives for individual
survivors:
* Providing education and information about resources available to help 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 identify survivors who are in need of mental health intervention.
In these cases, outreach is a precursor to individual treatment. However, outreach to
individuals can be an effective, beneficial intervention in and of itself. Often, mental
health workers in disaster recovery programs are discouraged by the fact that large numbers
of "clients" do not materialize. They interpret this as meaning that their outreach activities
have not been successful. In fact, outreach has a far larger objective than "advertising"
services and bringing people in the clinic door for treatment. The educational aspect of
outreach can promote and enhance healthy adaptation and coping. By providing survivors with
anticipatory guidance about normal stress and grief reactions, stress management strategies,
and information about resources, such outreach may actually prevent a survivor from
needing mental health treatment.
Preventive outreach strategies may help reduce survivors' anxiety and diminish the number of
people needing clinical treatment. However, disaster mental health professionals should be
cautious not to "normalize" disaster stress reactions to the point of stigmatizing people
who do feel the need to seek mental health assistance. The goal is to reassure survivors
about the normalcy of common reactions. Simultaneously, educational interventions must
help people to feel comfortable in seeking assistance if their reactions seem intense, go
on for too long, or interfere with interpersonal relationships, work, or school.
Macrolevel Outreach
On a broader scale, the mental health professional reaches out through organizations or
the community at large. An example would be public education through the electronic or
print media. Some other macrolevel outreach approaches include environmental or social
action interventions aimed at organizational, community, or societal target points. Examples
include consultation, training, or advocacy. Such activities aim to influence policies,
procedures, legislation, organization of services, environmental factors, or community
attitudes and behavior that may impede the emotional recovery of disaster survivors.
Community organization is another macrolevel form of outreach. It seeks to bring together
community residents to deal with specific problems of recovery. It can increase a sense
of environmental mastery and help to establish or repair social bonds and support networks
among affected citizens.
SOME CHARACTERISTICS OF SUCCESSFUL OUTREACH PROGRAMS
Early Intervention and Visibility
Disaster survivors often view their experiences as intensely personal. They believe that their
ordeal is something that cannot be understood by someone who did not share the experience.
By arriving as early as possible in the disaster, mental health professionals see, hear,
and often feel very similar things to the survivors. A willingness by the mental health
workers to engage in whatever needs to be done (helping with cleanup, for example) contributes
to the early establishment of trust and credibility in the eyes of survivors.
Borrowing from Freud, Lindy and Grace (1986) describe a survivor network boundary that forms
after a disaster. This perimeter seeks to safeguard traumatized members from harm and to
promote psychic healing. They have called this barrier the trauma membrane. While the
membrane includes early permeability to people willing to help, it soon becomes tightly
sealed.Outsiders are allowed in only under certain circumstances. The concept of the trauma
membrane further reinforces the importance of early mental health involvement in response
activities. Acceptance must be attained before the membrane closes to "outsiders".
Deploying Appropriate Staff
Outreach workers have to be comfortable working in community based, nonclinical roles. They
must be able to adapt to changing situations, make independent decisions, and work without
close supervision (Peuler, 1988). They need to be action-oriented and willing to do whatever
needs to be done. Staff should be comfortable with being outside and in the elements.
Mental health workers must be comfortable and adept in striking up conversations with people
they have not met before, and have not come to them seeking help. It is helpful if the workers
live in the community, as they will have common knowledge, concerns, and topics of
conversation. Workers must enjoy people and not appear lacking in confidence.
It is helpful if workers wear comfortable clothes that blend into the community. In a farming
or ranching area, for example, boots and jeans might be the appropriate attire. Clothing
should be appropriate to the weather, to the hazards, and to the job to be done.
There are some advantages for outreach workers to be older. They have more life experience
to draw from, especially if they come from the community that was affected by the disaster.
Secondly, they are more frequently perceived as nonthreatening (DeWolfe, 1992). However, age
and gender should be appropriate to the group being served.
Workers should be comfortable and effective in making public presentations, as they will
often be called upon to give impromptu talks about the emotional impact of disasters. They
should have a thorough awareness of community resources, and must be knowledgeable about
the phases of disaster recovery. They should be culturally sensitive and appropriate in
their interventions. It is also important for them to have a thorough understanding of the
stress inherent in disaster work. They must also possess the knowledge and skills necessary
to recognize and manage that stress for themselves and with other workers.
Personnel who generally function well in outreach roles include crisis workers, psychiatric
emergency staff, case managers, mental health nurses, social workers, mental health counselors,
and psychologists.
Indigenous Workers
Professionals from within local community groups can be particularly effective as outreach
workers. Indigenous personnel are especially useful in providing services to distinct ethnic
and cultural groups. A thorough knowledge of the cultures, cultural values and cultural
practices is essential to providing appropriate interventions. In addition, when mental
health professionals have been unable to penetrate the trauma membrane, indigenous workers
from within the membrane can often be identified and trained to do outreach and education.
Paraprofessionals recruited and trained from within the local population can often
accomplish social support functions that outside workers cannot. They are often more
successful at establishing a peer relationship and understanding the survivors' style of
life (Reiff and Riessman, 1965). These peer counselors can play the role of a "friendly
neighbor" who listens and provides emotional support for people who would shun mental
health because of the associated stigma (Riessman, 1967; Solomon, 1986). In addition,
workers from the area will likely have an easier "in" with the community. With a rural
population, for example, a person familiar with farming or ranching, animals, orchards,
gardening, farm equipment, and the price of hay or manure will have some common topics
with which to begin a conversation (DeWolfe, 1992).
Trained indigenous staff are often uniquely able to develop effective case finding strategies.
They can recognize survivors' emotional and social needs, identify resources acceptable to
the population, and make effective referrals. Local workers can adeptly use their status
as a peer to transmit norms about help-seeking (Solomon, 1985). In other words, survivors
perceive that seeking help is acceptable and sanctioned by his/her own group members.
Workers indigenous to particular community groups can provide services within the context
of the values, norms, systems, and politics of their community group.
Using Social Network Analysis
Social network analysis examines the interrelationships of individuals and groups in a
community concerning exchange of resources, information, social obligations, economic
resources, and kinship ties. A thorough community needs and resource assessment should
be done, using social network analysis. This will identify problem areas and vulnerable,
high-risk groups. It can also lead to a directory of available and appropriate services
(Mathews and Fawcett, 1979).
For example, social network analysis may show that a neighborhood or social group attends
church frequently. In such a case, mental health staff could use the clergy, church social
groups, and church bulletins for distributing information about common reactions to disaster
and about mental health resources.
Using Community Caretakers and Neighborhood Leaders
In every community, there are informal leaders and "caretakers" who provide support,
assistance, or material goods to the community. They are often in jobs or positions
of social interchange that allow them to see a great deal of what goes on among community
residents. These individuals may include hairdressers, bartenders, merchants, mail delivery
persons, utility repair persons, contractors, etc. These important individuals can serve
as "key informants" to mental health staff, identifying people in need and areas of
community concern. In addition, they are major sources of information and referral for the
individuals in their social network. Providing information about formal resources to
informal caregivers has been found to increase the number of referrals these individuals
make to social service agencies (Lentz, 1976).
Mental health staff can enhance the effectiveness of informal caregivers and community
leaders. Training and consultation of community leaders can enhance their knowledge and
skills in providing support to their own community. It is useful to provide them with
consultation on the disaster related psychological and health problems they may see in
the community, as well as information about mental health and disaster resources. Mental
health staff can also give information about backup services for problems that are beyond
the helping capacity of the informal support system (Cohen and Sokolovsky, 1979).
Recognizing Phases of Recovery and Using Phase Appropriate Outreach Methods
Certain interventions do not work well during the early "heroic" and "honeymoon" phases,
when people are generally feeling energetic and optimistic. To ask people to talk about
their feelings if they are still denying the implications of their loss is probably ill
timed. A more phase-sensitive approach would be to help them with their immediate,
practical concerns. People will likely be more open to talking about their thoughts and
feelings a little later in the "disillusionment" phase. Then, much of the protective
"numbness" has worn off. People are anxious, sad, tired, irritable, frustrated, and
discouraged. A thorough understanding of the phases of disaster, as well as focused
attention to the phase that individual survivors are experiencing, is essential to
successful outreach.
Ethnic, Cultural and Linguistic Appropriateness
Services need to be provided in a manner relevant to the ethnicity, culture, and languages
of the people. Literacy in English and in the language of origin must be considered.
Specific outreach approaches must be tailored to people who do not read (public meetings,
radio programs in native languages, etc.). Different ethnic groups have varying beliefs
about asking for help, about whom they see as helpers, whether they trust government
programs, and so forth. Ideally, mental health outreach staff should be indigenous to
the ethnic group they are working with. At minimum, they should be well trained in
cultural values, practices, and beliefs of the group they are serving. They must work
through trusted community groups and individuals.
Identifying and Overcoming Barriers
Mental health professionals need to identify barriers to reaching the community. For
example, distance, transportation, bureaucratic procedures, or cultural insensitivities
may get in the way of mental health programs reaching the people, and may be in the way
of people seeking services. A technique that has been useful in many mental health
disaster recovery projects is to have staff brainstorm at the beginning of their project
about what barriers might interfere with carrying out the project objectives. Staff can
then also brainstorm about specific ways to overcome or eliminate the anticipated barriers.
By doing this at the front end of the project, staff can eliminate some obvious barriers
immediately. It also helps to establish a "can do" attitude among staff. While obstacles
will occur from time to time, the project staff will find ways to modify their approach
so that the program can succeed.
Utilizing Interventions Perceived as Nonthreatening and Nonstigmatizing
Mental health information, education, consultation, and even clinical interventions are
usually well-received when presented as "normal" events that are familiar and nonthreatening
to the community. Community meetings, presentations, training, discussion groups, written
materials such as brochures, and information in the media are examples.
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REFERENCES
Cohen, C.I. and Sokolovsky, J. (1979). Clinical use of network analysis for psychiatric and
aged populations. Community Mental Health Journal, 15 (3): 203-213.
Cohen, R.E. and Ahearn, F.L. (1980). Handbook for mental health care of disaster victims.
Baltimore: The Johns Hopkins University Press.
DeWolfe, D. (1992). A guide to door-to-door outreach. Final Report: Regular Services Grant,
Western Washington Floods. State of Washington Mental Health Division.
Garaventa, D., Martin, P., and Scremin, D. (1984). Surviving the flood: Implications for small
town disaster planning. Small Town, 14 (4): 11-18.
Leutz, W.N. (1976). The informal community caregiver: A link between the health care system
and local residents. American Journal of Orthopsychiatry, 46: 678-688.
Lindy, J.D. and Grace, M. (1986). The recovery environment: Continuing stressor versus a
healing psychological space. In Sowder, B.J. and Lystad, M. (Eds.), Disasters and Mental
Health: Contemporary Perspectives and Innovations in Services to Disaster Victims,
Washington, D.C.: American Psychiatric Press, Inc.
Mathews, R.M. and Fawcett, S.B. (1979). Community information systems: Analysis of an agency
referral program. Journal of Community Psychology, 7: 281-289.
Peuler, J. (1988). Community outreach after emergencies. In Lystad, M. (Ed.), Mental Health
Response to Mass Emergencies: Theory and Practice. New York: Brunner/Mazel, Inc.
Reiff, R. and Riessman, F. (1965). The indigenous paraprofessional. Community Mental Health
Journal. Monograph No. 1.
Riessman, F.A. (1967). Neighborhood-based mental health approach. In Cowen, E.L., Gardner,
E.A., and Zax, M. (Eds.) Emergent Approaches to Mental Health Problems. New York: Appleton-
Century-Crofts.
Solomon, S.D. (1985). Enhancing social support for disaster victims. In Sowder, B.J. (Ed.),
Disasters and Mental Health: Contemporary Perspectives. Rockville, MD: National Institute
of Mental Health.
Solomon, S.D. (1986). Mobilizing social support networks in times of disaster. In Figley, C.R.
(Ed.), Trauma and its Wake, Volume II: Traumatic Stress Theory, Research and Intervention.
New York: Brunner/Mazel.
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
