Rehabilitation of victims of natural disasters.
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, 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 disorders as a result of the inclusion of these disorders in the American Psychiatric Association's Diagnostic and Statistical Manuals (III and IV).
Posttraumatic 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 (PTSD) is that of coping with stressors, especially those which have some similarity, to the initial traumatic event. 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 in victims, precipitated by a sudden and significant change in individual life situations (Cohen & 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 and the frequency of nightmares following their experience. They compared subjects from San Francisco 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 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 in the flooding.
Depression is an expected consequence in victims of disasters. Grieving takes place for loved ones who perished, for ruined homes, possessions, and shattered dreams. Cohen and Ahearn (1980) described a 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 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. 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.
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, ticks 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 Hopelessness 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 (PTSD)
According to 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, 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, 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. 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. 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 behaviors.
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 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 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 for those who are dislocated in work. In the counseling role, the theoretical approach which approximates acute disaster counseling is that of Crisis Intervention 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, 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 (CISD). 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. 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 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 (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 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
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 (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 and other psychotherapeutic methods such as role playing, guided imagery, 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 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 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 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, 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, 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 either in the acute stage of crisis intervention, or in the rehabilitation of the psychosocial and vocational sequelae 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 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.
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|Author:||Franke, Diane I.|
|Publication:||The Journal of Rehabilitation|
|Date:||Oct 1, 1996|
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