Stress Management in Disasters -

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i n D i s a s t e r s by Cyralene P. Bryce Pan American Health Organization S t r e s s M a n a g e m e n t by Cyralene P. Bryce STRESS MANAGEMENT i n D i s a s t e r s Emergency Preparedness and Disaster Relief Coordination Program Pan American Health Organization Regional Office of the World Health Organization Washington, D.C. 2001 ii This workbook was developed by Dr. Cyralene P. Bryce for the Stress Management in Disasters in the Caribbean (SMID) course. It is intended to be used in conjunction with the Insights into the Concept of Stress workbook. It is not intended to be a complete text on the sub- ject of stress. The compilation of this book benefitted from the input of too many persons for them to be mentioned individually. We would, however, like to express our deepest gratitude to everyone for their invaluable contributions and criticisms. PAHO Library Cataloguing-in-Publication Pan American Health Organization Stress Management in Disasters Washington, D.C.: PAHO, ©2001, —134 p.— ISBN 92 75 12358 6 I. Title II. Pan American Health Organization 1. PSYCHOLOGICAL STRESS 2. PSYCHOTHERAPY GROUP 3. DISASTER EMERGENCIES 4. CARIBBEAN REGION 5. HEALTH EDUCATION 6. MANUALS LV HV547.P187 2001 © 2001 by the Pan American Health Organization Printed in Washington, D.C., U.S.A. A publication of the Program on Emergency Preparedness and Disaster Relief, Pan American Health Organization, Regional Office of the World Health Organization (PAHO/WHO). The views expressed, the recommendations formulated, and the designations employed in this publication do not necessarily reflect the current policies or opinions of the Pan American Health Organization or of its Member States. The Pan American Health Organization welcomes requests for permission to repro- duce or translate, in part or in full this publication. Application and inquiries should be addressed to the Emergency Preparedness and Disaster Relief Coordination Program, Pan American Health Organization, 525 Twenty-third Street, N.W., Washington, D.C. 20037, U.S.A.; fax (202) 775-4578; e-mail: [email protected]. The production of this publication has been made possible with the support of the Canadian International Development Agency (IHA/CIDA), the Office of Foreign Disaster Assistance of the U.S. Agency for International Development (OFDA/USAID), and the Department for International Development of the United Kingdom (DFID). iii “When things go wrong and they sometimes will, just pick up the pieces and keep moving, never stand still.” –CPB M O T T O : Take control and move on. “ You need to be at peace with yourself before you can be at peace with others.” –CPB v C O N T E N T S Course Objectives vi Preface vii Section 1: Overview of Disasters 1 Section 2: Psychological Responses to Traumatic Stressors 21 Section 3: An Overview of SMID 43 Section 4: A Basic Introduction to Counseling and Crisis Intervention 59 Section 5: Therapeutic Groups 77 Section 6: Demobilizations and Defusings 85 Section 7: Debriefings 95 Section 8: The SMID Team 111 Appendix 1: Score Interpretations 127 Appendix 2: Quiz Answers 128 References 129 Page vi C O U R S E O B J E C T I V E S 1. Define a disaster. 2. Understand the characteristics of disasters. 3. Appreciate the possible impact of a disaster. 4. Describe the psychological profile of the emergency response worker. 5. List the possible occupational stressors encountered by emergency response personnel. 6. Outline the psychological syndromes associated with traumatic stressors. 7. Recognize the common signs and symptoms of post-traumatic stress syn- dromes. 8. Understand the principles of preventing and managing critical incident stress. 9. Outline the components of the SMID program. 10. Demonstrate crisis intervention and counseling skills in simulated exercises. 11. Demonstrate defusing and debriefing skills in simulated exercises. 12. Be able to plan and implement a SMID program in an organization or in the wider community. vii P R E F A C E It is universally accepted that optimum levels of stress can act as a creative, motiva- tional force that can drive people to achieve incredible feats (eustress). Chronic or traumatic stress (distress) on the other hand, is potentially very destructive and can deprive people of physical and mental health, and at times even of life itself. Emergency response personnel are unique in that they dedicate their time and energy in assisting persons during stressful times of their lives, for example, after disasters such as hurricanes, volcanic eruptions, earthquakes, etc. By doing this however, they are themselves repeatedly exposed to very stressful situations. Even though their training pre- pares them to deal with such situations, the reality is that they have a higher than normal risk for developing post-traumatic stress syndromes, including post-traumatic stress disorder (PTSD). Hence, it must be deduced that the repeated exposure of emergency response per- sonnel to critical incident stress does have a potentially deleterious effect on their well-being. It has also been found that the psychological well-being of emergency response personnel dealing with emergency situations can greatly affect the overall outcome of such situations, including the prognosis of the primary victims of the event. Despite all of this having been well documented and the repeated exposure of the Caribbean and Latin America to natural disasters, the vast majority of countries do not have a comprehensive stress management program in place to preserve the psychological well- being of their emergency response and disaster workers. The Program on Emergency Preparedness and Disaster Relief of the Pan American Health Organization, Regional Office for the Americas of the World Health Organization, took the initiative of bringing resource persons from throughout the region together in late 1998 to develop the Stress Management in Disasters in the Caribbean (SMID) Program. The SMID Program is a comprehensive, peer-driven, multi-component stress man- agement program which is administered on a volunteer basis and was designed to prevent and to mitigate the psychological dysfunction which exposure to traumatic situations like disasters may cause in emergency response personnel. The program is based on the princi- ples of crisis intervention and critical incident stress management and it is not intended to take the place of professional therapy. Instead, it seeks to provide persons with the knowl- edge and skills to better understand, recognize and manage their emotional responses to traumatic situations. While the SMID Program was developed with emergency response per- sonnel and disaster workers as its primary target group, the principles of the program, with appropriate modification, can be readily extended for use in the broader community, includ- ing with children and adolescents, to prevent and mitigate traumatic stress. This workbook, Stress Management in Disasters and the companion workbook Insights into the Concept of Stress were designed to provide the basic training material for persons who will be providing such a service. 1 SECTION 1: OVERVIEW OF DISASTERS What is a disaster? In this workbook, a disaster will be defined as a serious disruption of the functioning of a society, causing widespread human, material or environmental losses which exceed the ability of the affected society to cope using only its own resources (WHO, 1972). The typical result is significant disruption of normal living patterns, economic activ- ity and communication systems. Extraordinary needs for shelter, food, clothing, medical assistance and other essential care services may follow. What is a mass casualty incident? A mass casualty incident is any incident where the resulting number of casualties exceed the resources of the emergency services to manage them and hence the actual num- ber of persons affected will vary from situation to situation. A mass casualty incident may also qualify as a disaster and produce a scene of carnage so devastating that no description can adequately convey what it was like to have witnessed it. Most persons exposed to such a mass casualty incident experience some psychological dysfunction and a high percentage of such persons need help in coping. What are the characteristics of disasters? 1. Type of event 2. Familiarity of population with the hazard 3. Predictability of event 4. Avoidability of hazards 5. Suddenness of onset 6. Intensity of the impact 7. Severity of the consequences 8. Duration 9. Course 10. Threat of recurrence The period during which the disaster event occurs. CONSOLIDATION PHASE: The period during which the disaster is known to be threatening. WARNING PHASE: The period when a disaster is imminent and warnings have been announced. The period immediately following a disaster when individuals are taking stock of the situation. The period during which people rebuild their lives and try to bring something positive out of the ruins. CONSOLIDATION PHASE: REBUILDING PHASE: PRE-IMPACT PHASE IMPACT PHASE POST-DISASTER PRE!IMPACT PHASE Stress Management in Disasters 2 What are the phases of a disaster? The duration of each of these phases is dependent on the type of disaster, its severity, the pre-disaster standard of socioeconomic development and level of preparedness, the availablity of resources to rebuild and the stress tolerance of those affected. 3 SECTION 1: OVERVIEW OF DISASTERS What are some of the possible consequences of disasters? " • Injury • Suffering • Disease • Starvation • Death Morbidity & Mortality # • Damage • Destruction • Pollution • Economic loss • Resource depletion Material Losses $ Social Disruption % • Helplessness • Hopelessness • Grief • Guilt • Stress Psychological Distress • Disruption of normal activities • Homelessness • Unemployment • Antisocial behavior • Civil unrest What factors determine the stressfulness of a disaster? Features of the disaster: • Familiarity with the event, • Avoidability of the event, • Suddenness of its onset, • Intensity of its impact, • Course and duration of the event, • Degree to which it could be controlled. Community or societal factors: • The pre-existing level of resources, • The community’s level of preparedness, • The community’s past experiences with such an event, • Extent and nature of the damage done, • Consequent social and/or political unrest, • Availability of resources to rebuild. Characteristics of the individual involved: • Previous experiences with similar events, • Potential and actual losses, • Physical or psychological closeness with the event, • Level of background stress in one’s life, • Effectiveness of one’s coping mechanisms, • Nature and extent of available social support. Stress Management in Disasters 4 5 SECTION 1: OVERVIEW OF DISASTERS The realities of disasters Although almost every segment of a population will be touched by a disaster, the poor (especially women, chil- dren and the elderly) are much more vulnerable to its devas- tating consequences. Poverty usually implies sub-standard housing in areas most naturally prone to catastrophes, overcrowding, poor levels of sanitation, a shortage of basic medical services, inadequate levels of preparedness and a lack of resources with which to rebuild. The key to preventing epidemics after a disaster is to improve sanitary conditions and educate the public. When healthy persons die in a disaster, their bodies can be left in the open for up to three days. Admittedly, this will lower the morale of survivors, cause odors and attract flies, but will not cause the transmission of disease. Hence, one needs to deal with the injured first and bury the dead after. Even though isolated cases of antisocial behavior do occur, studies have consistently shown that disaster situations bring out the best in people. The majority of persons affected by a disaster tend to respond spontaneously and generously to help each other. Disasters have a way of accentuating social inequality. Disasters do not invariably bring out the worst in human behavior. Epidemics and plagues are not inevitable after every disaster. PAHO/WHO PAHO/WHO PAHO/WHO Stress Management in Disasters 6 Each disaster has its own unique effects on food supply. For example, floods may destroy crops and food stores while earthquakes hamper the distribution of such sup- plies. Relief agencies are now more cognizant of the fact that excessive food donations can result in a dependence syn- drome. Consequently, they are more careful to also invest in long-term solutions to food-shortages by donating agricul- tural supplies such as seeds and tools to ensure a new crop and to help rebuild the local economy. Persons at risk and those rendered homeless by dis- aster situations are usually taken in by relatives and friends with livable dwellings long before shelters can be mobilized to house them. Those with damaged dwellings tend to prefer assis- tance in salvaging such dwellings to render them habitable, over relocation to emergency shelters. “Tent cities” should only be established as a last resort. Instead, many donor agencies are now opting to use the funds that would normally have been spent on tents to purchase building materials, tools, etc., for the affected coun- try. This not only allows affected persons to rebuild but it also serves to stimulate the affected country’s economy. It is a myth that populations affected by disasters are too shocked and helpless to take responsibility for their own survival. For example, one of the realities of any disaster is that local people come to the assistance of those who have been affected. Foreign volunteers possessing skills already available locally serve only to deplete already scarce resources. Assisting people to rebuild while they remain within their neigh- borhood and close to their neigh- bors is economically and emo- tionally cheaper than relocation to temporary settlements. Only foreign volunteers who possess the specific skills required by the affected territories should go there after a disaster. Disasters do not invariably result in food shortages. PAHO/WHO PAHO/WHO PAHO/WHO 7 SECTION 1: OVERVIEW OF DISASTERS It is imperative that post-disaster assistance to af- fected communities be governed by the confirmed needs of such communities. Every gift to a disaster-affected community has a cost to the recipient country, whether it is the cost of receiving it and transporting it or the cost of its disposal if it proves to be inappropriate. Disaster affected countries tend to deplete the majori- ty of their resources in the immediate post-impact phase of a disaster. Hence, their major needs for external assistance should be geared towards the restoration of normal housing, primary health care services, water systems, waste disposal systems and income-generating employment. Consequently, effective post-disaster relief programs are those which take into consideration the fact that interna- tional interest wanes as needs and shortages become more pressing. After a disaster, international organizations providing assistance to affected communities need to work closely with local agencies and members of the community to ensure effec- tive and efficient operations. Local expertise needs to be uti- lized wherever possible. After a disaster, international assistance needs to be tailored to the needs of the affected community. Cash is the most flexible donation. International assistance which does not complement the national effort can result in chaos. PAHO/WHO PAHO/WHO Stress Management in Disasters 8 After a disaster has struck, things do not return to normal in a few weeks. In fact, the economic, psychosocial and environmental consequences may become long-term dis- asters in their own right and their effects may last for years. “Years have now passed but it seems like yesterday. I feel lost and empty. I can’t get rid of the horrifying memories and the vivid images that remain in my mind. These memories, some of which are very patchy indeed, seem to haunt me all the time and I become very distressed whenever anything - a sound, a smell or a sight - remind me of my ordeal.” The effects of a disaster are long-last- ing and do not just fade away within a few weeks like international interest usually does. The psychological consequences of dis- asters tend to be far more pervasive and long-lasting than their physical ones. PAHO/WHO PAHO/WHO

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