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Rehabilitation of victims of natural disasters.

Hurricane Agnes Hurricane Agnes was the first tropical storm and first hurricane of the 1972 Atlantic hurricane season. A rare June hurricane, it made landfall on Florida before moving northeastward and ravaging the Mid-Atlantic region as a tropical storm.  in June of 1992 swept through the southern and eastern coasts of the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. , leaving 117 deaths and more than 15,000 injuries across five states (Arnold, 1988). These consequences are in addition to the three billion dollars in property damage, and many victims homeless and unemployed. In April, 1974, Xenia, Ohio Xenia (pronounced Zeen-yuh) is a city in the U.S. state of Ohio and the county seat of Greene CountyGR6. The municipality is located in southwestern Ohio near Dayton.  was devastated dev·as·tate  
tr.v. dev·as·tat·ed, dev·as·tat·ing, dev·as·tates
1. To lay waste; destroy.

2. To overwhelm; confound; stun: was devastated by the rude remark.
 by a tornado in which 30 persons died and more than 1,000 injured. Damage was estimated at 100 million dollars (Arnold, 1988). In Colombia, South American in 1985, the town of Armero was in the path of a volcano which killed 25,000, injured thousands more, and left 60,000 homeless (Arnold, 1988). These natural disasters, along with floods, earthquakes, and fires create conditions in which hundreds of thousands of persons become victims each year. Between 15 and 20 percent of the persons studied after natural disasters were reported to have symptoms of posttraumatic stress disorder Posttraumatic stress disorder

An anxiety disorder in some individuals who have experienced an event that poses a direct threat to the individual's or another person's life.
 (Steinglass and Gerrity, 1990). Only in last 20 years have mental health professionals been involved in the provision of services in the wake of natural disasters. Prior to that time, disaster research focused on housing problems and community organization.

The field of rehabilitation has not yet come to grips with the persons who have chronic disorders after trauma. Virtually the entire body of empirical literature on the trauma associated with disasters comes from the fields of social work and psychology. But it seems vital that the field of rehabilitation become aware of chronic posttraumatic stress disorders for three reasons. First, many rehabilitation counselors are becoming increasingly employed in sectors which are not traditionally the turf of rehabilitation counselors. Tangentially tan·gen·tial   also tan·gen·tal
1. Of, relating to, or moving along or in the direction of a tangent.

2. Merely touching or slightly connected.

, rehabilitation counselors are becoming more concerned with issues such as quality of life, and we are aware that psychosocial adjustment is of vital importance to persons whose life quality has deteriorated. Second, disabilities among disaster victims are common. Heart attacks as well as physical injury related to disasters can lead to permanent disability conditions which require assistance in order for the victim to return to work. Third, rehabilitation counselors will encounter more persons with traumatic stress Traumatic stress is recognized by the Diagnostic and Statistical Manual of Mental Disorders [1] as an acute emotional condition associated with reactive anxiety.  disorders as a result of the inclusion of these disorders in the American Psychiatric Association's Diagnostic and Statistical Manuals (III and IV).

Posttraumatic posttraumatic /posttrau·mat·ic/ (post?traw-mat´ik) occurring as a result of or after injury.

Following or resulting from injury or trauma.
 stress often has deleterious effects not only in a person's social and personal life, but in his or her vocational life as well. The most serious deficit associated with Post-Traumatic Stress Disorder post-traumatic stress disorder (PTSD), mental disorder that follows an occurrence of extreme psychological stress, such as that encountered in war or resulting from violence, childhood abuse, sexual abuse, or serious accident.  (PTSD PTSD posttraumatic stress disorder.

posttraumatic stress disorder

Post-traumatic stress disorder (PTSD) 
) is that of coping with The Coping With series of books is a series of books aimed at 11-16 year olds, written by Peter Corey and published by Scholastic Hippo. The first book, Coping with Parents, was released in 1989, and the series continued until the last book, Coping with Cash  stressors, especially those which have some similarity, to the initial traumatic event A traumatic event is an event that is or may be a cause of trauma. The term may refer to one of the followiong:
  • Traumatic event (physical), an event associated with a physical trauma
  • Traumatic event (psychological), an event associated with a psychological trauma
. As persons become identified who have PTSD as a result of natural disasters, these persons may be referred to public and private rehabilitation services. However, these service providers must know something about the disorder in order to provide appropriate rehabilitation services.

Natural disasters are crises, and a crisis is a time-limited period of psychological disequilibrium disequilibrium /dis·equi·lib·ri·um/ (dis-e?kwi-lib´re-um) dysequilibrium.

linkage disequilibrium
 in victims, precipitated by a sudden and significant change in individual life situations (Cohen cohen
 or kohen

(Hebrew: “priest”) Jewish priest descended from Zadok (a descendant of Aaron), priest at the First Temple of Jerusalem. The biblical priesthood was hereditary and male.
 & Ahearn, 1980). That life situation change can be represented by loss of home, which Laube & Murphy (1985) note leads to feeling of insecurity and vulnerability in the loss of privacy and treasured possessions. These persons are thrown into situations where they must lodge themselves in temporary shelters, without restrooms or cooking arrangements, and with poor sleeping conditions. The loss of home can extend to loss of community and employment, with concomitant loss of support and income.

The injury and death associated with natural disasters makes an imprint on the person's mind, with that imprint taking the nature of guilt for not doing enough, or of fear and anxiety (Figley, 1985). Horowitz (1976) has pointed out that denial and anger are frequent concomitants of disasters. The denial is especially common where lost relatives are involved, and the anger seems to be directed towards public officials for not having prevented dislocation, for rescuers who did not react fast enough, or to insurance companies for not paying a claim.

Perry and Muschkatel (1984) reported that more than 90 percent of those exposed to disaster had an anxiety reaction within five hours. This anxiety manifested itself in repeated attacks of anxiety, anxiety-induced sleep disturbances, startle reactions, and fears of approaching and returning to the scene of the disaster (these authors called these symptoms the traumatic anxiety syndrome"). Wood and Bootzin, (1992) conducted a study involving victims of the 1989 San Francisco earthquake San Francisco earthquake

disaster claiming many lives and most of city (1906). [Am. Hist.: Jameson, 443–444]

See : Disaster
 and the frequency of nightmares following their experience. They compared subjects from San Francisco San Francisco (săn frănsĭs`kō), city (1990 pop. 723,959), coextensive with San Francisco co., W Calif., on the tip of a peninsula between the Pacific Ocean and San Francisco Bay, which are connected by the strait known as the Golden  that were directly involved in the earthquake to subjects in Arizona whose only exposure was through news coverage. They found that nightmares were most frequent among subjects close to the earthquake. During the three weeks following the disaster, 40% of the subjects in the San Francisco area reported having repeated nightmares about earthquakes, compared to only 5% of the Arizona subjects.

Some persons use substances to cope with the situation. Canino, Bird, Shrout, Rubio-Stipec, Broavo, Martinez, Sesman, and Guevara (1987) compared persons in Puerto Rico Puerto Rico (pwār`tō rē`kō), island (2005 est. pop. 3,917,000), 3,508 sq mi (9,086 sq km), West Indies, c.1,000 mi (1,610 km) SE of Miami, Fla.  who were involved in massive flooding with those in surrounding areas that were unexposed. The flood and torrential rains caused extensive damage and mudslides, leaving 180 dead and more than four thousand persons homeless. They found that alcohol and drug abuse rates increased in the affected population in the months following the disaster compared to those persons who were uninvolved un·in·volved  
Feeling or showing no interest or involvement; unconcerned: an uninvolved bystander.

Adj. 1.
 in the flooding.

Depression is an expected consequence in victims of disasters. Grieving takes place for loved ones loved ones nplseres mpl queridos

loved ones nplproches mpl et amis chers

loved ones love npl
 who perished, for ruined homes, possessions, and shattered dreams "Shattered Dreams" is a single by Russian pop star Sergey Lazarev.

This is his first solo thing outside Soviet zone and it was the first international single released in UK properly. This is also a cover of Johnny Hates Jazz and it is rearranged.
. Cohen and Ahearn (1980) described a bereavement Bereavement Definition

Bereavement refers to the period of mourning and grief following the death of a beloved person or animal. The English word bereavement
 syndrome, which has five forms. The first form is inhibited grief, in which intense denial is the main characteristic. This containment of feelings, or numbing, can be detrimental to the future well-being of the person. The second form is anger. This anger leads to lawsuits and other acting out episodes, and can delay the final resolution of the grieving process. The third form is extreme guilty preoccupation, the dominant characteristic of which is self-blame for loss of possession or life of loved ones. Laube and Murphy (1985) point out that this profound guilt can lead to a delusional system of major depression. The fourth form is chronic grief, in which the suffering continues unchanged for years, and which is manifested by daily gravesite grave·site  
A place used for graves or a grave.
 visits, crying at the reminder of loved ones, and so on. These symptoms can impair present and future relationships, as well as the capacity to function. The fifth form is depressive illness, in which the person has social isolation, loss of energy, hopelessness, and suicidal ideation suicidal ideation Suicidality Psychiatry Mental thoughts and images which hinge around committing suicide. See Suicide. . If the preceding psychological effects are not addressed, these persons are in danger of acquiring PTSD. Rehabilitation counselors should be able to recognize these effects in the persons they are helping. Table 1 below provides a listing of the psychological defenses common to trauma and disaster victims, and the specific signs and symptoms to watch for in each of these defenses.

Table 1
Significant symptomatology of victims of natural disasters

Defense         Specific signs

Shock           Confusion and psychological numbing

Fear and        Sleep disturbance (e.g. nightmares, insomnia)
Anxiety         Substance abuse
                Uncontrollable and distressing images of event
                Increased absenteeism at work
                Loss of ability for intimacy
                Loss of interest in interpersonal relations
                Hyperalertness, scanning, hypervigilance,
                Desire not to be left alone
                Hyperreeactivity to particular cues
                (e.g. storms)
                Physical changes: increased blood pressure,
                arthritis, ulcers, chest pains, headaches.
                Problems in performance at school, home,
                or work
                Loss of sense of security

Denial          Containment of feelings
                Unwillingness to talk about event
                Cheerful or audacious reaction to trauma

Mourning and    Frequent and endless gravesite visits
Depression      Crying at the reminder of loved ones
                Social isolation
                Loss of energy
                Suicidal ideation
                Memory or concentration problems

Guilt and       Depressed moods
shame           Extreme guilty preoccupation

Retaliation     Lawsuits and other acting out episodes
                Temper tantrums or argumentative style

Post Traumatic Stress Disorder Post traumatic stress disorder (PTSD)
A disorder that occurs among survivors of severe environmental stress such as a tornado, an airplane crash, or military combat. Symptoms include anxiety, insomnia, flashbacks, and nightmares.

According to according to
1. As stated or indicated by; on the authority of: according to historians.

2. In keeping with: according to instructions.

 Figley, disaster victims who have acquired PTSD have a variety of symptoms. Perhaps the central feature is the re-experiencing of trauma in the form of dreams and uncontrollable and emotionally distressing images of the event. This leads to psychological numbing Psychological numbness is a mental self-defense mechanism used to prevent psychological trauma, in which a mental entity chooses to ignore thoughts or emotions relating to a specific body of knowledge, emotions, or ideas. This is often induced by social conditioning. , and lost interest and involvement in interpersonal relationships and increased absenteeism in work. Other symptoms include memory and concentration problems, hyperalertness, depressive syndromes, survivor guilt Noun 1. survivor guilt - a deep feeling of guilt often experienced by those who have survived some catastrophe that took the lives of many others; derives in part from a feeling that they did not do enough to save the others who perished and in part from feelings of , loss of ability for intimacy, and avoidance of activities which remind the person of the traumatic event. Steinglass and Gerrity (1990) studied two communities which had natural disasters -- a tornado and a flood -- and found that the incidence of PTSD in the former was 21.0% and that of the flooded community, 14.5%.

Those factors which have been associated with persons who acquire PTSD, rather than those who do not, include the role of the victim, coping skills and support systems, degree of loss, previous experiences, pre-existing illness and emotional health, and age (Figley, 1985). Victims who took a more active role in the assistance of injured persons are more likely to develop PTSD than those who were passive (possibly because of perceived failure). Figley (1985) found that persons with healthy coping skills and strong support systems do better in overcoming the stress associated with natural disaster. Silver and Wortman (1980) report that persons who have positive social support following trauma have a greater chance of re-establishing psychological well-being psychological well-being Research A nebulous legislative term intended to ensure that certain categories of lab animals, especially primates, don't 'go nuts' as a result of experimental design or conditions . Victims need to vent their emotions, voice their fears, and brain storm to solve problems. Steinglass and Gerrity (1990) reported on the probability of losses and the development of PTSD. They found that the more losses a person suffers, the more PTSD characteristics they claimed to possess. Figley (1985) found that prior involvement in a natural disaster can be beneficial if the victim emerged from the previous situation healthy and learned from it. However, if the victim had not completely overcome the previous trauma, flashbacks and increased anxiety emerged. Nolen-Hoeksema and Morrow (1991) found that persons with a pre-existing impairment were more susceptible to PTSD due to the destruction of their resources and increased concerns about how they would visit their doctor, and where they would obtain their medicines. Finally, age and developmental level seems to be associated in the literature with onset of PTSD. Shore (1986) found that young children are extremely vulnerable, especially when separated from relatives. After the trauma, they may have temper tantrums, become increasingly anxious when left alone, have difficulty sleeping by themselves, and have a partial loss of toilet training toilet training
The process of training a child to use a toilet for defecation and urination.

Noun 1. toilet training - training a young child to use the toilet
. Figley(1985) found that school-aged children experienced decreased school performance due to confusion and loss of a sense of security. These feelings also lead to violent or argumentative Controversial; subject to argument.

Pleading in which a point relied upon is not set out, but merely implied, is often labeled argumentative. Pleading that contains arguments that should be saved for trial, in addition to allegations establishing a Cause of Action or

Herman (1982) points out that not only victims of disasters, but also emergency workers have symptoms of PTSD. These workers work long hours, have high blood pressure, arthritis, and ulcers as a result of elevated adrenaline levels and emotional withdrawal (Comfort, 1988). They repress re·press
1. To hold back by an act of volition.

2. To exclude something from the conscious mind.
 unpleasant memories, have guilt associated with causing unintentional harm, and are exposed to a variety of crisis situations. Comfort (1988) found that 86% of disaster workers experience some symptoms of PTSD within 24 hours after their emergency experiences, and that 20% will still possess symptoms one year later. Ten percent become profoundly distressed by the event and are unable to continue in their line of work. Mitchell and Bray (1990) report from their extensive research on stress disorders with emergency services emergency services Emergency care '…services …necessary to prevent death or serious impairment of health and, because of the danger to life or health, require the use of the most accessible hospital available and equipped to furnish those services'  personnel, that 4 to 10 percent of these will ultimately develop PTSD.

The role of the rehabilitation counselor

Rehabilitation counselors are members of a human-service-provision community in which they may provide a range of services, from counseling members of disaster-stricken communities, to case management and vocational rehabilitation Noun 1. vocational rehabilitation - providing training in a specific trade with the aim of gaining employment
rehabilitation - the restoration of someone to a useful place in society
 for those who are dislocated dis·lo·cate  
tr.v. dis·lo·cat·ed, dis·lo·cat·ing, dis·lo·cates
1. To put out of usual or proper place, position, or relationship.

 in work. In the counseling role, the theoretical approach which approximates acute disaster counseling is that of Crisis Intervention crisis intervention Psychiatry The counseling of a person suffering from a stressful life event–eg, AIDS, cancer, death, divorce, by providing mental and moral support. See Hotline.  Theory (Cohen & Ahearn, 1980). The main goal of this intervention is to help the person out of immediate psychological danger and to seek to avoid future long-term problems, by learning from their experience and developing skills to deal with future stress. Gist and Lubin (1989) propose that in this approach, victims are not viewed as suffering from an underlying disorder, but as experiencing a transition. In this way, victims are reassured that they are not mentally ill, that they are persons who are experiencing a normal reaction to abnormal circumstances. The counseling intervention should provide continuous support and comfort. It may also include encouraging persons who have experienced the death of a loved one to view the body since that allows the person an opportunity to say good-bye, which helps to preclude denial. Counseling also includes allowing the person to express their emotions. After this phase, the counselor needs to provide information about what they can expect in the recovery process, such as fears of natural phenomena (thunderstorms thunderstorms

a storm characterized by thunder and lightning caused by strong rising air currents; identified as agents of animal disease because of their involvement causing (1) spasmodic colic; (2) lightning strike; (3) injuries of cattle acquired in stampedes initiated by storms.
, heavy winds, and so on) and that these fears are normal. Counseling may include group therapy, where victims realize that they are not alone and that they can learn from others' coping techniques.

An intervention for emergency personnel has been described by Barnett-Queen and Bergmann (1989), Clark (1988), Comfort (1988), Mitchell (1983), and Mitchell and Bray (1990), which also has utility for victims, called the Critical Incident Stress Debriefing de·brief·ing  
1. The act or process of debriefing or of being debriefed.

2. The information imparted during the process of being debriefed.

Noun 1.
 (CISD CISD Conroe Independent School District (Texas)
CISD Critical Incident Stress Debrief(ing)
CISD Carthage Independent School District (Texas) 
). In this intervention, participants in a group are asked to set the scene by re-creating the situation and providing as many details as possible. Persons express the feelings and concerns that they possessed before, during, and after their involvement in the disaster. This allows them to vent feelings and realize that their emotions are also shared by others. Long-term destructive behaviors and problems are less likely with this intervention. CISD has been used in over 25 major disasters (Herman, 1982) including a 1984 tornado which leveled the town of Barneveld, Wisconsin Barneveld is a village in Iowa County, Wisconsin, United States. The population was 1,088 at the 2000 census. Geography
Barneveld is located at  (43.014223, -89.895551)GR1.
. Emergency workers have also used such techniques as taking 15 minute breaks every hour, and not working shifts of longer than twelve hours with at least seven hours between shifts. Changes in activity help emergency personnel avoid becoming overwhelmed with one type of job.

Victims of PTSD require longer-term intervention than in crisis-oriented therapy. Rehabilitation of persons with this disorder utilizes similar concepts such as empathy, trust, and didactic work in the recovery process, but allows greater amounts of time to work on issues one-by-one. As in CISD, reexperiencing the trauma is emphasized and necessary, along with an understanding by the person that their behaviors and emotions are tied to the trauma for which they are not responsible. Nevertheless, the person is counseled that they are now responsible for learning new ways of dealing with their trauma-induced deficits in coping.

Ochberg (1993) has some suggestions with regard to that counseling relationship. The first is the normalization In relational database management, a process that breaks down data into record groups for efficient processing. There are six stages. By the third stage (third normal form), data are identified only by the key field in their record.  principle. Here the counselor helps the person to understand that post traumatic stress disorder is a normal response to an abnormal event, or series of events. This reorientation Noun 1. reorientation - a fresh orientation; a changed set of attitudes and beliefs
orientation - an integrated set of attitudes and beliefs

2. reorientation - the act of changing the direction in which something is oriented
 (away from "I" am abnormal, replaced with the trauma as abnormal) helps the person to understand that he or she is going through a process of rebalancing Rebalancing

The process of realigning the weightings of one's portfolio of assets.

For example, if your portfolio's proportion of stock has grown too large for your intended assets weightings and risk tolerance, you might rebalance by selling some stock and putting
 and healing, and that this process will require his or her involvement and patience. The fact that many persons with post traumatic stress disorders have been improperly diagnosed and improperly treated subsequently simply has added layers to their problems.

Ochberg's (1993) second principle is that of collaboration. Persons suffering from post traumatic stress disorders often feel dehumanized (such as in victims of crime) or powerless. The therapeutic style which emphasizes collaboration (working on a problem together to find a solution) in which the counselor and the person are partners in a search. This principle creates the expectation that the person naturally is responsible for a way out, but that the person can rely on the continuing support, objective viewpoint, and encouragement of the counselor.

Ochberg's (1993) third principle is that of individual response to trauma. Humans are all unique, and each has his or her own response to a traumatic event. Logically, then, each person must find his or her own path out of the morass, and the counselor deeply respects this. This respectfulness, then, precludes ideological or stereotyped diagnoses, labels, and prescriptions which are found so frequently in popular psychology in this modem era. The person's path out of the morass, according to Ochberg (1993), is that of an appreciation and learning of coping responses, rather than traditional medical-model treatment. Thus, the appropriate therapy for PTSD is educational and social in nature, rather than traditionally psychotherapeutic. Viewing PTSD in this way, rehabilitation methods can be used to evaluate coping capability, and to begin the didactic and social process needed to help persons who are impaired by posttraumatic stress disorder.

The teaching phase of rehabilitation counseling rehabilitation counseling,
n counseling started in the United States in 1920 to assist individuals disabled by industrial accidents; originally included physical, psychologic, and occupational training; expanded over the next 70 years and laid the

In rehabilitation counseling, two phases are apparent: the relationship/exploration phase, and the teaching of new ways of adapting and living. Ochberg (1993) discusses four categories of techniques which are necessary to address when helping the person with post traumatic stress disorder: a) educational (sharing of books and articles); b) holistic health holistic health,
n a concept in which concern for health requires a perspective of the individual as an integrated system rather than as a collection of parts and functions.
 (dealing with physical activity, nutrition, spirituality, and humor); c) social support and integration (family and group therapy, self-help and support groups, the reduction of irrational fears, and the learning of new social skills); and d) therapeutic (working through grief, extinguishing the fear response, stress debriefing, hypnotherapy Hypnotherapy Definition

Hypnotherapy is the treatment of a variety of health conditions by hypnotism or by inducing prolonged sleep.

Pioneers in this field, such as James Braid and James Esdaile discovered that hypnosis could be used to
 and other psychotherapeutic methods such as role playing role playing,
n in behavioral medicine, learning exercise in which individuals assume characters different from their own. The individual may also be asked to simulate a particularly difficult situation and apply the characteristics that are common to his
, guided imagery Guided Imagery Definition

Guided imagery is the use of relaxation and mental visualization to improve mood and/or physical well-being.
, and so on). The rehabilitation counselor must know about these techniques and the importance of addressing each of the four categories. The counselor is directed to Ochberg (1993) for more information on each technique.

The vocational rehabilitation of persons with posttraumatic stress disorders is based on four elements: a) a complete work evaluation of the person; b) a gradualized return-to-work approach; and c) the Stress Inoculation inoculation, in medicine, introduction of a preparation into the tissues or fluids of the body for the purpose of preventing or curing certain diseases. The preparation is usually a weakened culture of the agent causing the disease, as in vaccination against  Technique of Donald Meichenbaum (1985). It is also based on the awareness that rehabilitation will also involve a team approach, since other persons will necessarily be involved in the person's life: employers, spouses and other family members, psychiatrists and psychologists, and other professionals.

A complete work evaluation attempts to preclude future occupational stressors as much as possible by attempting to identify the person's strengths, limitations, and preferences and taking these into account in the guidance of the person in his or her re-entry RE-ENTRY, estates. The resuming or retaking possession of land which the party lately had.
     2. Ground rent deeds and leases frequently contain a clause authorizing the landlord to reenter on the non-payment of rent, or the breach of some covenant, when the
 into employment. The need for this assessment is apparent from the already impaired coping abilities of the person with PTSD. When helping the person to make occupational choices, the issue of control in the occupation should be discussed. It is likely that the person with PTSD may have experienced frustration at the lack of his or her ability to control a situation of disaster, and his or her self-efficacy estimates may have diminished since that experience. Hence, occupations that require high levels of self-confidence, or occupations with considerable ambiguity, such as sales or management, should be considered with caution.

Insofar in·so·far  
To such an extent.

Adv. 1. insofar - to the degree or extent that; "insofar as it can be ascertained, the horse lung is comparable to that of man"; "so far as it is reasonably practical he should practice
 that work environments are critical, the rehabilitation counselor may provide an important service to the client by helping to assess a potential work environment. The work environment consists of three areas, all of which need to be analyzed: a) the cultural environment (rules, dress, attendance requirements, etc.); b) the physical environment (heat, light, humidity, cleanliness, etc); and c) the social environment (the attitude, values, interest of the company and of other people who work there, and the behavioral expression of others such as supervisors, co-workers, etc.).

Gradualized work should begin in as low-demand work-type situations as possible, and increase to the point at which the person seems to be able to function without symptoms, utilizing coping skills learned in therapy, such as relaxation, mental imagery, mental activity, and physical exercise. For example, volunteer work is a good place to start since the person can set their own hours and work at an activity which has reinforcement value for the person. The volunteer work may be replaced, or supplanted, at the appropriate time with part-time competitive work, taking into consideration the person's needs and abilities on the one hand, and the reinforcers in the work and demands of it on the other. As long as the rehabilitation team continues to meet with the person on a regular basis, the activity can become gradually increased until the person's coping capacity has been reached.

The guiding principle behind gradualized return to work is that of Meichenbaum's Stress Inoculation (1985). Here persons are provided with varying situations in which new coping skills, gained through cognitive-behavioral techniques (e.g. cognitive restructuring Cognitive restructuring
The process of replacing maladaptive thought patterns with constructive thoughts and beliefs.

Mentioned in: Cognitive-Behavioral Therapy

cognitive restructuring,
, relaxation, self-observation, self-monitoring), are applied. The situations are mildly stressful in the beginning, and increase in stress as the person successfully handles the milder stimuli. This program prepares persons for stressful situations, and helps convince them that they can indeed handle these situations through successful and reinforcing feedback (and hence is motivating). Stress-inoculation training (SIT) includes components of information-giving, discussion, cognitive restructuring, problem-solving, relaxation training relaxation training,
n method that teaches specific techniques for producing the relaxation response. See also relaxation response.

relaxation training,
, behavioral rehearsals, self-monitoring, self-instruction self-reinforcement, and modifying environmental situations. SIT has three phases: a) the conceptual phase, which involves analyzing and changing irrational beliefs; b) the skills-acquisition and rehearsal phase, which involves learning how to self-analyze beliefs and new coping skills which are incompatible with stress such as using imaging and relaxation; and c) the application and follow-through phase, in which debriefing and re-learning occur.


Rehabilitation counselors can expect to encounter more persons who acquire disabilities because of natural disasters. Some of these will have physical impairments such as heart attacks or permanent disability due to injury. Still others of these victims will suffer the effects of PTSD, the net result of which is to impair coping skills with other stressors, including those in jobs.

Rehabilitation counselors are finding themselves increasingly in non-traditional sectors, as noted by Lynch, Lynch and Beck (1992). Thus, with regard to natural disasters, rehabilitation counselors may find themselves utilizing counseling skills counseling skills,
n the acquired verbal and nonverbal skills that enhance communication by helping a medical professional to establish a good rapport with a patient or client.
 either in the acute stage of crisis intervention, or in the rehabilitation of the psychosocial and vocational sequelae sequelae Clinical medicine The consequences of a particular condition or therapeutic intervention  of chronic conditions. These counselors must therefore be aware of the full range of needs which victims of natural disasters may have, and have the skills necessary to help these victims resolve these needs. This may involve crisis counseling during the crisis stage, or long-term rehabilitation in the chronic disability stage of the victim's experience. As in other disability experiences, the counselor will encounter persons with anxiety, depression, grief, loss, cognitive or social dysfunction, and almost certainly coping deficits. Because of the latter, rehabilitation counseling in the victim with PTSD may be of a different quality, perhaps a more gradualized and longer term than in persons with other kinds of disabilities. And perhaps as research continues in the area of PTSD, we will learn that some of the problems that we have ascribed to other disabilities, such as the emotional lability lability /la·bil·i·ty/ (lah-bil´i-te)
1. the quality of being labile.

2. in psychiatry, emotional instability.


the quality of being labile.
 in brain injury, may overlap with the normal sequence of the traumatic event produced by the injury. In that event, it behooves us as professional rehabilitation counselors to educate ourselves in the social and personal costs of natural disasters, particularly those associated with PTSD.


Arnold. C. (1988). Coping with natural disasters. New York New York, state, United States
New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of
: Walker & Co.

Beck, R. & Fogarty, C. (1995). Vocational rehabilitation in post-traumatic stress disorders. In Beck, R. & Fogarty, C. Proceedings of Rehabilitation and Stress Disorders Conference, SIUC SIUC Southern Illinois University Carbondale , April 19 and 20 1995. Available from the Rehabilitation Institute, Southern Illinois University Southern Illinois University, main campus at Carbondale; state supported; coeducational; est. 1869, opened 1874 as a normal school, renamed 1947. It has a center for archaeological investigation and a fisheries research laboratory. There is also a campus at Edwardsville.  at Carbondale, Carbondale, IL 62901.

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Horowitz, M. (1976). Stress response syndromes. New York: Jason Aronson.

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Author:Franke, Diane I.
Publication:The Journal of Rehabilitation
Date:Oct 1, 1996
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