Social Work in Mental Health - Contexts and Theories for Practice. - Sage Publications - Page 248
DISASTER MANAGEMENT – A MENTAL HEALTH PERSPECTIVE
Mr.Brian D.A.Fernandes.; HR Consultant,
Mangalore, Karnataka, India. Email:
brian_daf@hotmail.com, Ph: +91 99865
58534.
Dr.Sebastin.K.V.; Associate Professor,
School of Social Work,Roshni Nilaya, Mangalore, Karnataka, India. Email: sebshaila@gmail.com, Ph: +91 94481 54901.
Abstract
This article titled Disaster Management - A Mental Health Perspective describes disasters, their phases, and
ill effects with special reference to Mental Health and the role of mental
health workers in alleviating, reducing and eliminating those ill effects.
The role of the mental health worker in restoring mental health
of the community post disaster, is based on the
three dimensions of Psycho social well being – physical, social ecology
and Human capital.
All disasters have impacts. Some of these impacts are visible
and measurable, while some others are invisible and immeasurable. The tangible
losses combined with the intangible effects, provide a fertile ground for
adverse psycho social and mental consequences.
The article draws a distinction between distress, which includes
under its umbrella, normal short term emotional reactions to the trauma and
disorders which are longer term psychological reactions to the disaster.
The Mental health worker begins with an interdisciplinary, Multi
sectoral, multi strategy plan that seeks to eliminate or reduce the
risk of psychosocial injury among the disaster afflicted, reduce distress and ensure
the psychosocial recovery of the population affected by the disaster after the
acute phase, among other objectives. The plan provides for three types of
interventions to achieve these objectives – General, Targeted and those aimed
at vulnerable groups among the afflicted population.
While general interventions such as , Psychological first aid,
Individual psycho education and
promotion of community resilience are sufficient
to deal with distress, Secondary assessments by, and referral to mental health
professionals, crisis intervention, grief support are targeted interventions
that deal with disorders. Interventions
for the psycho social well being of vulnerable groups like children, the
elderly, substance addicts and the disabled are also addressed.
Key Words: Disaster,
Mental Health and Psycho social support, Impact, Vulnerability
Introduction
A disaster is often
called a calamity, which is exactly what it is.
The word
Disaster comes from Middle French désastre, from Old Italian disastro, from the
Greek pejorative prefix dis-bad + asterstar.
The World Health
Organization defines it as ‘any occurrence causing damage, ecological
disruption, loss of human lives, deterioration of health and health services on
a scale sufficient to warrant any extraordinary intervention from outside the
affected community.’
Consequently a community afflicted by
disaster, needs and seeks external governmental and nongovernmental help to
sustain and overcome the effect of the trauma caused by the losses incurred,
both tangible and intangible.
The Disaster Management Act of 2005
of the Govt. of India, formulated in the wake of the deadly Tsunami of 2004,
clearly defines the term, in a very comprehensive manner as follows:
‘disaster’ means a catastrophe, mishap,
calamity or grave occurrence in any area, arising from natural or manmade
causes, or by accident or negligence which results in substantial loss of life
or human suffering or damage to, and destruction of, property, or damage to, or
degradation of, environment, and is of such a nature or magnitude as to be beyond
the coping capacity of the community of the affected area;’
In pursuance of the Act becoming
law, the Govt. of India set up the Disaster management Authority which is
concerned with guiding and coordinating a comprehensive disaster response in
India. This response methodology also ensures a coordinated approach to,
besides physical needs, the psycho social well being of the survivors of a
disaster and indeed it has the served the country well though a lot more needs
to be done in terms of preparedness.
A disaster is different from an Emergency in that, an emergency is a situation in which the community is capable of
coping. An emergency assumes that a
disaster can be prevented by preparedness of a defined degree. We must note
that this does not presuppose that individuals are individually capable of
coping. They may require assistance to overcome the stress that the imminent
occurrence of a particular situation.
Types of Disasters:
One of the
earliest recorded natural disasters was the volcanic eruption of Mt. Vesuvius
in 79 A.D. which destroyed the cities of Pompei and Herculaneum. Since then the
world has seen an increasing number and variety of disasters
“We
live in the midst of alarms; anxiety beclouds the future; we expect some new
disaster with each newspaper we read.”- Abraham Lincoln, 12 February 1809 - 15
April 1865.
Abraham
Lincoln said this on the 29th May, 1856 in a different context. However, 150
years on, these words haven’t lost their significance; the news channels are
full of a disaster a day always with heavy loss of life, limb, or sanity. No longer is a disaster married to nature, it
has new suitors in technology and man’s basal instincts Disasters are therefore
classified by their causative factors – Natural and Man Made. This
classification helps formulate a more targeted response for disaster management.
Natural Disasters
These
are primarily natural events that are related to the elements of nature –
Earth, Wind, Water and Fire and include Earthquakes, Floods, Cyclones,
Volcanoes and Forest Fires.
India
is prone to natural disasters. Its population of 120 Billion coupled with its
density compounds the impact. The India Disaster Report 2000 provides the
following statistics to reiterate that belief.
- 12% of its land vulnerable to floods
- 8% of its land vulnerable to cyclones
- 56% of its
land is vulnerable to earthquakes
- 26% of its
land vulnerable to droughts
Consequently the
losses too have some depressing statistics:
·
Over
27.55 million people have been affected by disasters
·
5536
people die annually due to disasters
·
2.36
million houses are damaged annually
·
Annual
economic loss is of the value of US$
1,88,393,0000
Some of the major natural Disasters
in India include, the Lattur Earthquake (1992), Orissa
Super Cyclone(1999), Gujarat Earthquake (2001) and Riots(2002), South
Indian Tsunami (2004) and the
Kashmir Earthquake (2005).
Man Made Disasters
These
disasters are caused by deliberate or accidental acts of omission or commission
on the part of man. Many of them can be contained
at the emergency level, and thus prevented – if sufficient precautionary
measures, are in place and due diligence in the discharge of duties assigned to
individuals is exercised. Man Made Disasters
include but not are limited to Nuclear Leaks, Chemical Leaks, Terrorism and riots,
Structural Collapses, Building Fires, and Wars.
Some of the major Man Made disasters
that have struck India in the Last century are the Venus
Circus fire tragedy, Bangalore(1981), Bhopal Gas tragedy (1984) are clear
cases then, for worry and action.
Stages of a Disaster:
A
disaster results in the destruction of life and property and passes through
five main phases from Pre-disaster to reconstruction. The devastation is not
over once the immediate event has passed; rather the ill effects linger on for
years thereafter. The 5 main stages are
described below
Pre-disaster or Warning / Threat stage: This is the stage just before the hazard
strikes. Education and awareness is carried out in this stage. If it is a slow
onset disaster then enough warning and awareness is given to the community on
the risks posed by the hazard, thus giving the community enough time to
prepare. If the onset is sudden, there is very little or no warning and the
impact is much greater.
During this phase, people feel vulnerable,
unsafe, and apprehensive. Others may believe they are invincible which could
turn a full circle if they are severely affected.
Heroic Stage:
This is the stage usually at the onset or impact
of disaster and immediately after the disaster. During this stage, most people are in a fight
or flight mode. At this stage many people in the community are strong and
focused, and use most of their energy in saving themselves as well as others.
There is a strong sense of sharing, people helping one another, and treating
even a stranger as “family”. However, pre existing schisms widen or new ones develop
once the immediate danger has passed.
Honeymoon:
The honeymoon stage follows immediately after
the heroic stage and may take several weeks. It is during this stage that there is cohesion
in the community, in the care centres, where the immediate needs of food and water
are being attended to. If expectations of care levels are not met by government
and aid agencies, the victims of disaster begin to get frustrated from the
congested living in care centres, and anger, restlessness, survival guilt, and
anxiety begins to set in. The honeymoon stage is thus a very critical stage for
the psycho social recovery of the affected community.
Disillusionment:
This stage is also termed the “second disaster”
stage in that people have now been in care centres for more than a month. They
find that their request for assistance to get their lives back to normal seems
to be taking forever by the authorities! It is also at this stage that many of
the relief agencies have left the scene. Frustration with the pace of rehabilitation
is often a catalyst for social problems and exacerbation of the Psychological
conditions that preceded the disaster. Coping mechanisms come under severe
strain and the social support systems are limited adding to the problem.
Reconstruction:
This stage lasts for several years following the
disaster. In this stage people have already assumed the responsibility of
recovery and work together to develop reconstruction plans and programs. Reconstruction and rebuilding may be going on
around them but the community has already returned to its normal routine; with
some adaptation. While social structures are progressively re-built and public
infrastructure is gradually restored, depending the availability of resources,
Individuals may continue to have lingering negative effects depending upon
their coping abilities and resources and will need continued support.
General effects of a disaster
Disasters, whether man made or natural,
affect everyone connected with them, albeit differently. The Impact is
pyramidical in its spread across the affected zone the broadest impact being on
the community in general and tapering
into individual victims problems generally related to their mental and
emotional well being post trauma.
The negative impact of a disaster varies
with proximity, vulnerability and responsibility of individuals / community to
the disaster. Proximity to the disaster
increases the damage to ordinary individuals and community. Those in the eye of
the storm suffer the greatest losses and are the hardest hit. Impact is also determined by a group’s,
family’s or individual’s vulnerability which is basically of three types – Physical:
Location, Structural Design, Infrastructure; Social: Poverty, Lack of
opportunity, lack of education; and
economic: Social Groups, Class differences and community capacity (Resources
and preparedness). The higher the
vulnerability, the greater the impact. Heads
of families, groups and communities along with rescue workers have a greater
responsibility in dealing with the aftermath of a disaster and therefore the
stress, both disaster related, and ongoing related to rescue and rehabilitation
efforts are that much greater.
However not all the impacts are visible
or noticeable, and generally fall in either of two categories – Tangible / intangible
based on their visibility.
ü
Tangible/Material Losses - (easy to see; value easily determined)
1.
People – lives, health, security,
living conditions
2.
Property – services, physical property
loss, loss of use
3.
Economy – loss of products and
production, income
4.
Environment – water, soil, air,
vegetation, wildlife,
ü
Intangible/Abstract Losses - (difficult to see; value difficult to
determine)
1.
Social structures – family and
community relationships
2.
Cultural practices – religious and
agricultural
3.
Cohesion – disruption of normal life
4.
Motivation – the will to recover;
coping mechanisms to deal with reaction to the event / loss of the tangible
All too often it is much easier to see
the physical consequences of a disaster – injuries, death, and displacement. In such cases the immediate and correct
response is to alleviate the pain and suffering and this is easily measured in
terms of shelter, food, medicine, water and other things alike. What is not so evident is the effect of the
intangible losses. These have a greater impact on the Psycho social well being of
Communities and individuals – the subject of this article.
A few factors determine a
community’s ability to cope and rebound from disasters. These include the familiarity with the event (has it happened before), its avoidability,
the suddenness of its onset, Intensity of impact, its duration, the degree of
control exercised over it and the availability of resources to rebuild – a prime example is Japan and Germany in the
aftermath of the second world war when both countries were devastated in
contrasting ways and the world community poured in resources, albeit with
ulterior motives, to help their communities cope. Similarly, Surat was rebuilt
in record time after the Gujarat earthquake of 2001 which cost 20000 lives and
is now a model for reconstruction, post disaster.
The Psycho Social effects of a Disaster
An individual’s
response to stress caused by disasters, is interplay of a variety of factors. It has been recognized
that most of the disaster-affected persons experience stress and emotional
reactions after a disaster as a 'normal response to an abnormal situation'.
While some of the survivors would be able to cope by themselves, a
significant proportion of them may not be able to do so effectively. In the
absence of appropriate and adequate support, these survivors experience
emotional distress and decline in social functioning there by requiring psycho social
support from Social Workers and Mental Health Professionals.
This is borne out by research carried
out to examine the impacts of a potential disaster by categorizing them into
two tracks. One focuses on economic analyses and attempts to estimate or
predict the potential property losses and dollar costs of a disaster in advance
(Garrett L, 2005; Karesh WB, Cook RA, 2005; Meltzer
MI et al, 1999; Mileti DS, 1999) by applying statistical methodology
with predefined probability distributions of the key input variables to
forecast the possible death toll, property damage, and dollar costs. The other
track examined the possible long-term psychological consequences of a disaster,
specifically PTSD, by conducting post disaster follow-up case analyses.
Researchers surveyed the disaster
affected population to examine their post-impact reactions, and then kept
tracking them for several years after the disaster in an attempt to understand
the factors related to increased or decreased risk for PTSD, which ideally
helps affected people recover from their disaster distress (Norris FH et al
2002b; Clark L, 2003; Johnson NR, 1987; Quarantelli EI, Dynes, RR, 1977; Udwin
O et al 2000; Ursano RJ et al 1996).
Researchers in the second track show
that a disaster can impair people’s physical bodies and minds, that people
exposed to the disaster often display different reaction and symptom levels
during or after the disaster, and that some people will be more affected than
others, depending on the nature of the event and the characteristics of the
persons who have experienced or witnessed it (Koopman C et al 1995). Whereas
some people experience significant subjective discomfort, others display
conspicuous impairment in their day-to-day functioning, such as sleeplessness,
and still others indicate clear impairment in one or more functional aspects,
such as work productivity or the ability to engage in and enjoy leisure
activities.
These common adverse reactions have
been classified according to their symptoms into five categories as below:
Common adverse reactions to
disasters:
Adverse reactions to a disaster are classified as
physical, emotional, cognitive, behavioral and spiritual (International Society
for Traumatic Stress Studies, 2005; Young, Ford, & Watson, 2007a). Most
people who experience these reactions will recover and return to previous
functioning within a short period of time and will not progress to a diagnosable
condition.
Physical: Muscle
tremors, fatigue, chills, sweating, nausea, shock symptoms, Gastro - intestinal
distress, dizziness, difficulty breathing, chest pain, headaches, elevated
blood pressure, a feeling of hollowness, weakness and sensitivity to noise.
Emotional: Impatience,
fear, anxiety, anger, irritability, numbness, loneliness, sadness, guilt, shame
and lack of enjoyment in everyday activities
Cognitive :Difficulty
concentrating or remembering things, confusion, limited attention span,
decreased ability to make decisions, decreased ability to solve problems,
calculation difficulties, recurring dreams or nightmares about the disaster,
mentally reconstructing the events surrounding the disaster in an effort to
make it come out differently and repeated thoughts or memories of the disaster
that are difficult to stop.
Behavioral :Overprotecting
self and family, isolating self from others, startling easily, sleeping
problems, avoiding activities that serve as a reminder of the disaster,
increased conflict with family members, keeping excessively busy to avoid
thinking about the disaster, tearfulness, crying for no apparent reason,
changes in appetite and increased alcohol and drug use.
Spiritual: Crisis of
faith, questioning basic religious beliefs (“Why did God let this happen?”) and
displaced anger toward authority figures.
Emotional reactions reported by the people are
normal responses to an abnormal event. It is estimated that nearly 90% of
survivors undergo these emotional reactions immediately after the disaster.
However, it reduces to 30% over a period of time with psychological reactions
to stress, leading to a change in behaviour, relationships and physical or
psycho social situations.
Continuation of the situation leads to an
abnormal pattern and long-term mental illness among the survivors, if not
attended to. Indian experience in Orissa super cyclone, Gujarat earthquake,
riots and tsunami has demonstrated that appropriate psycho-social intervention
during the rescue, relief, rehabilitation and rebuilding period significantly
decreases the distress and disability among survivors, leading to an overall
improvement in the quality of life. If unattended it could lead to the
following consequences.
Common Psycho-Social and Mental Health Consequences of Disasters
The Inter-Agency Standing Committee Guidelines
on Mental Health and Psycho-Social Support in Emergency Settings, Geneva,
(2007) identifies the following consequences of disaster
(A) Psycho-social consequences
1. Exacerbation of pre-existing (pre-disaster)
social problems (e.g. extreme poverty, belonging to a group that is
discriminated against or marginalized)
2. Disaster induced social problems (e.g. family
separation; disruption of social network; destruction of the community
structure; resources and trust; unemployment, homelessness, increased
gender-based violence)
3. Humanitarian aid induced social problems
(e.g. undermining of the community structure or traditional support mechanism).
(B) Mental health consequences
1. Exacerbation of pre-existing problems (e.g.
severe mental disorder; alcohol abuse)
2. Disaster induced problems (e.g. grief,
non-pathological distress, depression and anxiety disorders, like
post-traumatic stress disorder (PTSD);
3. Humanitarian aid related problems (e.g.
anxiety due to lack of information about food distribution).It should be noted
that mental health and psycho-social problems in disasters encompass far more
than the experience of PTSD.
There are characteristic
differences between natural and human-caused disasters and their impact on
survivors. Human-caused events often have a more devastating psychological
impact on a
community than natural disasters, although either type of disaster may create profound human and material
losses.
The emotional response to a disaster may vary
widely from individual to individual, population to population and community to
community (DeWolfe, 2000; Norris et al., 2002a; Ursano, McCaughey, &
Fullerton, 1994). Most of the frequently
observed adverse reactions to disaster are considered common or expected.
Fortunately, a robust display of resilience is also common and expectable among
individuals affected by disaster (American Psychological Association, 2006;
Bonanno, 2004; Neria, DiGrande, & Adams, 2011; Watson, Brymer, &
Bonanno, 2011).
While a display of resilience is common among
individuals affected by disaster, a significant minority of direct disaster
victims are at risk for a new or aggravated clinical disorder based on exposure
to certain risk factors. (Galea, 2005) These exposure-based risk factors have been identified as contributing to
the likelihood that an individual will experience long term psychological
complications.
These factors include the individual prima facie
being a danger to self or others, feeling or expressing extreme panic or fear,
feeling a direct threat to life of self and/or family member, seeing / hearing
of serious injuries to others including those closely connected, death or
disappearance of a relative especially a parent, child or
family member, death of a much loved pet, delayed evacuation from disaster
scene or being trapped in the disaster rubble / zone, a lost child or
separation from immediate family during the event, a disaster-related illness
or physical injury to self or family member, destruction of living quarters
rendering it unlivable, prior history of
mental health issues and a prior history of experiencing a disaster.
Psychiatric diagnoses associated with disaster
On an average, 30–40 percent of people who are
direct victims of the disaster experience one or more psychiatric disorders
after the event, such as PTSD, depression and anxiety (Galea, Nandi, &
Vlahov, 2005; Bonanno et al., 2010; DiGrande et al., 2011).
For populations affected by lower-intensity
disasters, research suggests that 5–10 percent of people in the
community-at-large and 10–20 percent of responders will experience a disorder.
Some of the more common Psychiatric Disorders as distinct from adverse emotional
reactions requiring psycho social support are noted below:
Acute Stress disorder - Some stress symptoms
may occur almost immediately after a disaster. This occurrence can be a
predictor of later development of Post Traumatic Stress Disorder (PTSD)
PTSD - PTSD is the most commonly studied diagnosis
associated with disaster (North, 2007). However, it should not be considered a
“normal” response to traumatic events and disasters. . PTSD is characterized by re-experiencing of
the traumatic event, avoidance, numbing and hyper arousal. Symptoms need to be
present for at least one month and cause clinically significant distress or
impairment in functioning to fulfill criteria for PTSD.
Major depression - Risk of major depression after a disaster is
also one of the more significant concerns (Nandi et al.,2009). Depression is the second most commonly
observed psychiatric disorder in survivors of disasters followed by various
problems with anxiety (Norris, Friedman, Watson, Byrne,
Diaz, & Kaniasty, 2002). Co-morbidity with PTSD is common. Individuals who have suffered
significant personal losses or injuries are especially likely to develop a
depressive disorder.
Substance abuse disorders - Whereas there is some association between
experiencing a disaster and an increase in substance abuse, this appears more
likely to be due to continuation, exacerbation or recurrence of preexisting substance
use difficulties rather than new diagnoses as a result of the disaster (North
et al., 2010).
Generalized anxiety disorder - Distress
and anxiety are common reactions to disaster, but some may linger and become
sufficiently ingrained to warrant a diagnosis of generalized anxiety disorder
(Ghafoori et al., 2009).
Brief psychotic disorder - Disaster
survivors may experience disruptions in their ability to distinguish between
what is real and not real. However, these situations are relatively uncommon
(Katz et al., 2002).
It is also important to note that many
survivors of massive disasters report other problems that may not be captured
by traditional diagnostic categories. Sleep problems, worry, maladaptive
substance use, and interpersonal conflict commonly occur after disasters.
Although these may not be diagnosed as mental conditions, they can nonetheless
contribute to very persistent social problems affecting individuals, families
and communities.
The
role of the Mental Health worker
The
mental health professional has a definite and important role to play at three
levels – Psychological First Aid (PFA), Mental Health Supervisor and Leader in
disaster management from the Honey moon stage to the reconstruction stage.
His
role begins with the formulation of an action plan for mental health care and
psychosocial support in emergencies. The objective of the plan should be to introduce and develop the
mental health and psycho social component of health care during emergencies, as
well as to offer an appropriate response to the mental and psycho social needs
of the affected population.
Primary goals that are implicit in
the plan, include elimination of the
risk of psycho social injury and problems among the disaster affected
population, prevention, treatment and
rehabilitation of the mental disorders occurring as a direct consequence of the
disaster, and the reduction of mental
and emotional distress among the population. A secondary goal would be to
prevent psycho social injury to the mental health workers working among the
affected.
The Plan should be based on an Inter
disciplinary strategy, bolstered by social participation and ensure that human
wellness is dealt with holistically, rather than mental health in
isolation. It should be incremental
based on vulnerability and risk, and keep in mind sensitivities related to
human rights, ethnic, linguistic and cultural differences and gender equity.
Ultimately it should be flexible and be able to adapt quickly to changing local
circumstances
Possible
components of this plan include first response actions, training of staff,
damage assessment methodologies, specialized psychiatric care options, health
and psycho education programmes, communication modules and methodologies, and
an agency coordination and community organization system and a resource
documentation / outcome recording protocol.
Intervention Strategies
Psycho
Social Intervention strategies are guided by a three dimensional approach to psychosocial
well being in Disaster Management: These dimensions are Human Capacity, Social Ecology and Cultural Capacity.
Human Capacity - Human Capacity is primarily constituted by
the health (physical and mental), knowledge and skills of an individual. In
these terms, improving physical and mental health, or education and training in
support of increased knowledge, enhances human capacity and psycho-social
well-being.
Social Ecology -
Social Ecology includes social relations within families, peer groups,
religious and cultural institutions, links with civic and political
authorities. It also includes changes in power relations between ethnic groups
and shifts in gender relations etc. (all of these may be referred to as the
'social capital' of the community). It is a well established that disasters and
the effects on social dimensions are widely accepted as contributing factors to
psycho-social well-being. There is strong empirical evidence linking mental
health outcomes to the presence of effective social engagement, including wider
cultural and pragmatic concerns.
Cultural Capital –
This dimension essentially comprises of values, beliefs and practices of the
community. Disasters, irrespective of their nature, can threaten cultural
traditions and erode the values and beliefs due to devastation and trauma.
Intervention strategies based on the above three
dimensions are of three types – General, Targeted and for Vulnerable
populations:
1. General Interventions
Psychological
First Aid - (PFA) is the approach recommended
by many international expert groups, including WHO, the Sphere Project which
was established in 1997 (a voluntary project established by global humanitarian
agencies), and the Inter-Agency Standing Committee on Mental Health and
Psychosocial Support, to support people affected by crisis events. PFA is an evidence-informed intervention that
addresses the practical psychosocial needs of individuals, families, and
communities in the immediate aftermath of a disaster.
In the early post-disaster phase,
PFA facilitates recovery in affected individuals across all age groups by
reducing the initial distress caused by traumatic events, helping them to meet
their basic needs and connect with social supports and services, providing
information, and fostering short- and long-term adaptive functioning and
coping.
PFA is based on the assumption that all
people have innate coping abilities and the capacity to recover from
distressing events, especially if they are able to restore basic needs and have
access to support as needed. Current PFA models are designed for delivery by a
range of people—health or mental health personnel, disaster response workers,
lay volunteers—who can offer early assistance to affected children, families,
and adults.
The ‘Psychological first aid pocket
guide’, excerpted from the WHO Psychological first aid guide for fieldworkers (2011)
indicates that the main principles to be followed by PFA’s are required to provide practical care and
support which does not intrude, Assess needs and concerns of the affected
population, Help people to address basic needs (for example, food and
water, information), Actively listen to and engage with people, without
pressuring them to talk or being judgmental, provide emotional and intellectual
comfort and reassurance, helping them to weather the storm, provide information
on services and social support, and help them connect to and avail of them and
prevent further harm as far as possible.
Good communication skills are key to
offering PFA effectively and respectfully to people in distress. Guidance on
active listening, empathy, and socio-cultural considerations in communication
are described in most PFA resources. Effective communication is based on an
understanding of the cultural and social norms of the people being helped, and
how to speak and behave in ways that are respectful and appropriate.
As a Mental Health Worker, reactions
must not be judged and labeled; rather they may be observed and categorized
under the three headings below for deciding and targeting interventions:
·
The expected/usual psychological
reactions to a disaster;
·
Exaggerated, prolonged unusual or
severe reactions to a disaster;
·
Reactions that put the individual or other
members of the community at risk. Among the group of individuals with this type
of reaction there are likely to be persons who have had previous mental health
problems, as well as persons who have had no prior history of mental illness.
Based on this assessment, interventions can be decided.
If the Mental Health Worker comes
across the last two behaviors he must take recourse to secondary referrals to
professionals for advice as discussed in the next section.
Individual Psycho Education:
Reactions to disaster stress vary widely. One
individual may become extremely task oriented and appear to be coping very
well. Another may become disoriented or distracted.
Mental Health Workers need to help individuals
understand when their reactions are due to the expected stresses of the
disaster. Reassuring both survivors and rehabilitation workers that they are
functioning as well as can be expected given the circumstances will promote
their resilience and lead to more adaptive coping strategies. If the person’s
response is within the range of typical reactions to disaster, they may be
provided educational brochures and an opportunity to discuss their reactions with
the mental health worker. At this stage, the afflicted should be provided with
and understanding of his reaction, and additional methods of coping, If the
person is not calmed or reassured by the interaction, secondary assessment and further intervention
strategies, such as crisis intervention or a referral to a mental health
professional may be considered.
Promotion
of Community Resilience:
It is well known that resilient communities can
better sustain and support the recovery of individual. Communities vary in
size, pace, composition of residents, income levels, services rendered, types
of agencies providing services to the population and level of cohesiveness,
among other things. All of these variables can influence a community’s response
to a disaster. In addition, there are
some common phases through which a community passes after a disaster.
Initially, there may be a suppression of any community conflict as disparate
groups pull together to respond to the common ‘enemy.’ However, shortly after
the disaster has ended, and the ‘honeymoon’ period—with the abundance of
emergency relief efforts—is over, social class differences and other
preexisting issues will return and may be exacerbated. As relief efforts and
resources come into the area and are mobilized, prior loyalties and divisions
will reemerge. Family, level of community integration, type of disaster and
community’s emergency response system, History of prior disasters and the
availability of community mental health resources can all provide challenges to
the community’s resilience.
Community resilience can be promoted by,
community psycho education on the lines of individual psycho education, Public
messaging and contact over social networks and media, Public consultation,
training volunteers to spread the right messages and partnering with
educational institutions, Nongovernmental and governmental social service
agencies for spreading awareness.
Targeted interventions:
Reactions to disaster stress vary across the affected population. As discussed in the previous section (General
Interventions – Psychological First Aid), some individuals, may exhibit
exaggerated, prolonged, unusual or
severe reactions to a disaster; or exhibit reactions that put the individual or
other members of the community at risk. Among the group of individuals with
this type of reaction there are likely to be persons who have had previous
mental health problems, as well as persons who have had no prior history of
mental illness. Based on this assessment, additional interventions targeted to
specific clients may be necessary as follows:
Referrals to Mental health
Professionals for a Secondary Assessment / Treatment
Some reactions, in the aftermath of
a disaster are a cause for concern when it comes to the well-being of
individuals who display them and signal a need for appropriate evaluation and
psychiatric interventions. These reactions include the inability to look after
his/her own basic needs, the inability to look after young children he/she is
responsible for, delusions, hallucinations, suicidal thoughts, homicidal
thoughts, prolonged and excessive mind altering substance use, including
alcohol, and / or Violent and aggressive behavior.
These clients exhibit a risk of long-term
psychological consequences and a secondary assessment by mental health
professional needs to be done to determine the most appropriate type of
intervention. The client’s current level of distress and impairment within the
disaster setting (which may be quite different than usual functioning) should
also be assessed.
Based on his assessments, the mental health
worker must arrange for referrals for further assessment / support by a mental
health professional. However, this should
be with the consent of the client (generally, unless undergoing a psychotic
episode) and after undertaking an assessment of the client’s resilience
factors, including current availability of a social support network as availability
of a social support system is a key factor tied to the impact of risk on
resilience (Norris et al., 2008; Ozer et al.,
2003; Brewin et al.,2010) There is accumulating evidence that for individuals
at risk, prompt secondary assessment, referral and linkage to certain evidenced-based
interventions may result in improved outcomes (Roberts et al., 2010; Bryant,
Moulds, and Nixon 2003; DHHS 2008; Brewin et al., 2010).
Crisis Intervention:
The purpose of crisis intervention is to offer
short-term help to people experiencing a crisis during and after a disaster.
Crisis intervention may prevent the development of a serious and long-term disability.
As laid down in the Red
Cross Crisis Intervention Methodology (Hand Book Oct 2012), crisis intervention,
is time-limited (two to three contacts); is focused on problems of daily living
(immediate reactions to the disaster situation rather than intra-psychic
conflict); is oriented to the here and now (alleviating distress and enabling
clients to regain equilibrium); Includes a high level of activity by the mental
health worker (engaging with the client to identify immediate tasks for
completion); uses concrete tasks as a primary tactic of change efforts (the
task development process involves clients in achieving a new state of
equilibrium); is more directive than approaches than those in non-disaster
mental health work.
Grief Support:
In a disaster response, there may be a number of clients
that experience the sudden and traumatic loss of loved ones. For some, this will
entail an experience of traumatic grief. Grief support is the provision of a
compassionate presence and emotional support to individuals affected by deaths
or serious injuries due to a disaster. Intervention should be supportive and
appropriate to the specific situation.
The Core components of grief support by a mental
health worker are, the provision of a compassionate presence, assisting with
practical needs, connecting affected
individuals to support systems, helping
him realize, recognize and utilize his
internal strengths and coping skills, problem solving, helping deal with
the family communications, and guidance in handling the children in the family.
Dealing with vulnerable populations
Children:
After disasters, children are considered among
the highest risk groups for mental health difficulties. The child’s direct
exposure to the disaster and related stressors influences his or her level of
risk (Norris et al., 2002a). Other factors that determine the level of impact
on children include how well the parents are coping and prior history of
traumatic experience or mental health difficulties. A number of disaster
specific features, including levels of death, injury and destruction in the
community and interruption in vital lifelines serving families (e.g.,
continuity of school attendance) are also significant (Norris et al., 2002a).
For many children, depending on the factors above, distress will be
short-lived.
When considering how to best help children after
a disaster, there are four key assumptions - Children must be viewed from a
developmental perspective, The family system is the primary source of support;
it is important to build on family resilience and support parental coping, Multiple
child-serving systems can support children and families and influence
children's responses and after disasters, there is a continuum of risk to
resilience for children; it is important to quickly identify high-risk children
for secondary assessment and, if indicated, evidence-based treatment.
The Mental health worker together with parents
(if available) or foster parents / closet kin, must encourage the children to
talk and listen to their concerns, calmly provide factual information about the
disaster and plans for insuring their ongoing safety and Involve the children
in updating their family disaster plan and disaster supplies kit and practicing
it in role plays wherever and whenever possible, involve the children by giving
them specific tasks to let them know they can help restore family and community
life, Spend extra time with them and move to quickly re-establish daily
routines for work, school, play, meals, and rest.
The
Elderly:
Elderly individuals have unique needs after a
disaster because their health and functional status may delay their response.
The term ‘elderly’ refers to an older adult population suffering from the
effects of physical, mental and sensory deterioration due to age and chronic diseases
(Inderscience Publishers, 2009). This population might be severely affected in
their ability to recognize and respond to a disaster. Factors such as declining
health and increased chronic diseases; limitations in sight, hearing and
mobility; limited access to health care resources; low economic status; and
restricted social networks increase the risk a person faces in a disaster
(Inderscience Publishers, 2009). The elderly may lack the social supports
needed during a disaster because of the loss of loved ones or separations from
spouses or partners, children and others who are often their caregivers
(American Counseling Association, 2009). The
cumulative effect of multiple losses and the devaluation of the elderly in some
cultures may compound these losses.
The elderly generally need from a mental health
worker, reassurance of safety by providing strong and persistent verbal
reassurance (Oriol, 1999); accommodations for
sight, hearing, cognition and mobility; respect with dignity; recognition of
the strengths and abilities of older individuals; Understanding of the person’s
reluctance to seek help, particularly mental health assistance (Oriol, 1999).
It may be noted that this group may often suffer
from Dementia / Alzheimer’s, Delirium or Depression and may require special
care in these circumstances.
People
with pre-existing psychiatric disorders:
Individuals with psychiatric disorders in
disasters have the same basic needs as compared to other individuals affected
by the disaster. However, they are at greater risk for post-disaster stress
reactions than the disaster community at-large.
Some specific risk factors associated with mental
illness include deficits in communication, social and coping skills, isolation
from sources of positive social supports such as family, caregivers and support
services workers, lack of a perceived social support system, disruption of
familiar routine, Previous history of trauma (e.g., child abuse, sexual abuse,
domestic violence, etc.), need for adherence to a medication regimen to address
psychiatric symptoms.
Some symptoms may surface (e.g., confusion,
anxiety, grief, sadness that is normal / expected reactions to the disaster
rather than symptoms of pre - existing psychiatric disorders. These reactions
may include disorientation, fear and exacerbation of symptoms, including
anxiety and obsessive-compulsive symptoms and suspiciousness of relief staff
and yet they may not disclose a prior psychiatric history, making
identification of the same difficult.
Adaptive communication, reassurance of safety,
provision of basic amenities, and provision of regular medication are methods that
need to be adopted by mental health Workers to alleviate the tribulations of
this vulnerable group.
People with substance related disorders:
Many people may use alcohol and other drugs as a
negative coping mechanism during the aftermath of a disaster to avoid or
overcome certain emotions such as anxiety, fear, depression, hopelessness,
shame and guilt.
There are two substance-related disorders that may
be encountered in people affected by disaster: substance abuse and substance
dependence. Both substance abuse and dependence involve psychoactive substances
including alcohol, illicit drugs, prescription medicines, over-the-counter
medicines, dietary supplements and herbal and botanical medicines. Psychoactive
substances bring about physiological, emotional or behavioral changes.
If the substance changes the way the individual
acts, feels or thinks, it could lead to a pattern of substance abuse that
results in at least one of four consequences: 1) failure to fulfill role
obligations, 2) substance use placing the person in danger (e.g., driving under
the influence), 3) legal consequences or 4) interpersonal or social problems
(Center for Substance Abuse Treatment 2007).
Individuals with substance abuse disorders often
have co-occurring mental illness that may be exacerbated by a disaster. A
disaster may put people who actively abuse substances or are in the beginning
stages of recovery from substance abuse at risk for withdrawal symptoms.
Help of mental health / de addiction
professionals must be sought immediately to manage this group of people and /
or initiate withdrawal therapy.
People with Disabilities:
According to the Americans with Disabilities Act
of 1990, an individual with a disability is a person who ‘Has a physical or
mental impairment that substantially limits one or more major life activities; Has
a record of such impairment; or Is regarded as having such impairment.’
Disabilities refer to individual functioning,
including physical, sensory, cognitive and intellectual impairment in addition
to various types of chronic disease.
They are a vulnerable group and their
vulnerability increases dramatically post disaster. A person with a disability may need adaptations such as alternative
methods of communication or transportation to evacuate a disaster.
This vulnerable group can best be served by the
PFA / Mental health worker if he, verbally reassures the individual and their
caregivers of their safety, advocates for reasonable accommodations for sight,
hearing, cognition and mobility as well as invisible disabling conditions, recognizes
the strengths and abilities of people with disabilities, respects the
individual’s dignity and worth, when it is necessary to help a person relocate
following a disaster, pay attention to a suitable relocation of the person with
a disability in a supportive environment that most closely matches his or her needs
and level of independence and assist the individual in accessing needed medical
and financial assistance.
Conclusion:
Psycho social wellness is now recognized as an important element of
Disaster management effectiveness.
While emotional reactions in a disaster are normal and expected, their
ebb into the normal, will depend a lot on restoring social structures,
maintaining cultural practices, rejuvenating cohesion among various groups and
supporting psychological recovery through various support mechanisms. Mental
health workers need to keep these factors in mind in their rehabilitation work
and create access to as many forms of social support as is possible, especially
for the vulnerable sections of the afflicted population.
Despite recovery, and intense rehabilitation efforts, ongoing
stressors always remain and are a cause for worry as they could trigger
negative psychological reactions in individuals. Mental health workers must
work hard to monitor those, and minimize them as much as possible.
Individual and Community resilience is promoted by Psycho education,
which will help the community recognize its responses to the trauma, deal with
them and overcome lingering negative effects or seek help to resolve issues
that may crop up during the reconstruction and rehabilitation phase. Religious
symbols, and a resurgence of faith teaching combined with philosophical perspectives enable the individual to make sense
of disaster experiences.
In addition, a community needs resources to rebuild its
institutions and infrastructure. Here not only are monetary resources required,
leadership too needs to be bolstered and a mental health worker has a big role
to play in developing avenues for education, employment and infrastructure building.
All of these together with the appropriate targeted
interventions will go a long way in promoting the psycho social well being of
individuals and communities post disaster.
e committee constituted to look into the matter to submit its report within a week and would write to the UPSC to postpone the exam, pending the recommendations of the committee. In the meanwhile however the UPSC has started issuing hall tickets and this has enraged the protesting aspirants no end. The protests have now turned violent. Certainly the issue could have been handled with more finesse.
Secondly, Civil Service aspirants come from all the states, not just Hindi speaking states. All states have their own medium of instruction and many students study in their state’s official language even at the college level. The common language therefore is English. It is also language of International diplomacy and administration. Since the civil services aspirants are from all over the country, the options cannot be restricted to Hindi and English and therefore having it exclusively in English would not in my opinion be discriminatory.
2011 international dollars, converted using purchasing power parity rates.
Life expectancy in India is the lowest in the region (66.4 years)
It’s not just young women that are at the receiving end of this heinous crime, women past their prime and children, even infants are not immune to it. Often we wonder, what was the motivation, what was the need, what was the temptation, and basically, what the heck, why did he do it, what got into him. Actually nothing “went into him”. It’s what came out as we will see later in this article.
The Psychology of Rape:
Groth and Burgess of Boston College wrote that the medical evidence justifies their position that rape should be considered a sexual deviation. Their research suggested that the rapist is driven by psychological deviations, which express themselves in sexual aggression.
Bystander or witness behavior ranges from the noble (intervention) to the shameful (purposeful ignoring) to the misguided (failing to intervene because the situation is not correctly perceived). It rarely involves the positive group dynamic.
There is no leader of opposition designated as yet and the NDA is reluctant to grant that status to the leader of the single largest party in the Lok Sabha, the Congress, as the rules stipulate that the party (not the formation) concerned must have a minimum of 10 percent of the seats of the Lok Sabha in its kitty. Viz. 55 while currently it has 10 short of that magic figure. The Congress is pressing for the same through back channels on the basis that it is the single largest party and also heads the largest opposition formation, though it has yet to make a formal demand in this regard. Reports say that it is also considering moving the judiciary on the matter for an interpretation of the rule that the NDA is quoting to deny them the privilege. The outcome of this wrangling is still not clear. In fact, the speaker steered clear of all questions on the issue of granting leader of opposition status to the Congress, saying the meeting she had convened was to discuss the business before the house. This indicates reluctance on the part of the government to give in to the Congress demand.
Parliamentary Affairs Minister Venkaiah Naidu said the government is ready for a discussion on any issue and appealed to the opposition to "cooperate" to ensure that the decorum and dignity of parliament is maintained and the house business was carried out smoothly. The government also intends to bring bills to replace the Telecom Regulatory Authority of India or TRAI (Amendment) Ordinance, 2014 and the Ordinance with respect to Polavaram project under Andhra Pradesh Reorganization (Amendment) Ordinance, 2014.
The Rail budget will be contentious. Tempers have already risen due to the sudden pre budget railway freight rate and passenger fare hikes. The former is likely to impact inflation and take prices to a new high.
The stock market and inflation, both are booming. External CAD is down, but then it was down before the election results were announced. The Fiscal and revenue deficits remain a challenge as does liquidity in the economy, a key input for growth, but also a key driver of inflation. Hoarding is rampant in anticipation of a failing and delayed monsoon and the Middle East is fighting itself, leading to rising fuel prices. Domestic consumption is also a concern
announcement of tax incentives for industry. As a prelude to the Budget, the government has already extended the excise duty concessions for automobile and consumer durable sectors till December. Gold Import duties and relief to farmers to help them tide over the impact of a deficient and delayed monsoon are also on the agenda of the finance minister. 
As I grew older I realized that this yearning, this desire for more, was restricted to the pleasurable and not the painful. Natural I guess, we are born to avoid pain and grab whatever is pleasurable and forbidden by God, nature or fellow human beings – remember the story of Adam and Eve? Adam and Eve were allowed to roam free in the garden of Eden, but forbidden to eat the fruit of the garden. They plucked and ate an apple, and the rest is history.
The irony – it figured in a debate that was a political, economic and sociological hot potato. By the end of the debate and vote in the Rajya Sabha, I was convinced that FDI in retail is the way forward… but for all the wrong reasons. After six Lays packets, I was feeling as prosperous as the potato farmer, albeit for different reasons.