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As hurricanes batter the coast, rivers flood, forest fires rage, tornadoes swirl,
tsunami fears abound and terrorism thrives, www.psychceu.com is pleased to announce
a new course:

A Field Guide to Disaster Mental Health: The Very Big Wave and the Mean Old Storm After the tsunami Photograph by Kate Amatruda by Katie Amatruda, PsyD, MFT, CST-T, BCETS

This course meets the qualifications for 10 hours of continuing education

This course qualifies for 4 non-contact training hours for the Association for Play Therapy (Provider # 02-711)

CA BBS, FL, NAADAC, NBCC, TX SBEPC, TXBSWE

 

Sri Lanka Sari after the Tsunami 
Photograph by Kate Amatruda

 

How this course is organized Each section begins, where applicable, with a recounting of an example from Hurricane Katrina, followed by an example from the Tsunami in Sri Lanka, so students will see the similarities and differences between domestic and international disaster mental health work.

 

Disaster Mental Health is not the same as having a clinical practice.

Different skills and a different mind set are necessary to succeed.

At the most basic level, you are going to the clients, they are not coming to you. You will not be sitting in an office, having people line up to see you. Why? People don't like the concept of mental health! By and large, they have survived the disaster due to their resiliency, luck, or any number of factors. For a disaster survivor to admit that she or he 'needs help' rarely happens.

Disaster mental health can feel very chaotic if you are used to a practice in which clients come at appointed times to your office, sit down and talk for 50 minutes, and leave. You may be on your feet for 12 hours at a time. (There were days at when I was in Houston doing disaster mental health for Hurricane Katrina when I started work at 8:00 am and finished at 2:00am.  That is an 18 hour day!)

You need to be flexible and personable. The blank slate of doing psychotherapy, of processing transference and projections, does not work in a disaster.

 

Astrodome - Photograph by Chris Lewis

Welcome to Chaos!

Deciding To Volunteer

A disaster comes, and your adrenaline level spikes up. Can you go? Can your family, your patients, your work, spare you?

"[The force] is an energy field created by all living things. It surrounds us, penetrates us, it binds the galaxy together...I feel a great disturbance in the Force. As if millions of voices suddenly cried out in terror, and were suddenly silenced." —Obi-Wan Kenobi, Star Wars IV

For me, the question is answered by my reaction to seeing the disaster unfold. If, while plugged into CNN, I can not stop the tears from flowing, and I have a feeling that I HAVE to go, that my soul demands that I be there, then the decision is made. I go.

 

Know about the Disaster

It is  important to know as much about the disaster as you can. This helps prepare you for what you might experience. It also gives you information that the survivors, without electricity or access to media, may not know. You also can tell the survivors that you saw their struggle on TV, and are amazed at what they have been through. Do not, however, say that you know what they have been through, because you don't! If you are a survivor of the same disaster, be very careful if you decide to volunteer. Make sure your family is safe, and take care of yourself! You may be traumatized yourself.

Hurricane Katrina


The National Oceanic and Atmospheric Administration called Katrina
"the most destructive hurricane to ever strike the U.S." Then along came Rita, then Wilma...

Hurricane Katrina Timeline

August 28
• 7 a.m.: Hurricane Katrina intensifies to Category 5, the worst and highest category on the Saffir-Simpson scale.
• 10 a.m.: As Katrina hits 175 mph winds, New Orleans Mayor Ray Nagin orders mandatory evacuations as the storm seems to beat a direct path to the city.
• During the day, Bush declares a state of emergency in Mississippi and orders federal assistance. The National Hurricane Center says low-lying areas along the Gulf Coast could expect storm surges of up to 25 feet as the storm, with top sustained winds of 160 mph, hits early the next day.
August 29
• 4 a.m.: Hurricane Katrina is downgraded to a strong Category 4 storm.
• 7 a.m.: Katrina makes landfall on the Louisiana coast between Grand Isle and the mouth of the Mississippi River.
• 11a.m. Katrina makes another landfall near the Louisiana-Mississippi state line with 125 mph winds. The storm's daylong rampage claims lives and ravages property in Louisiana, Mississippi and Alabama, where coastal areas remained under several feet of water.
• Two major flood-control levees are breached, and the National Weather Service reports "total structural failure" in parts of New Orleans. A section of the roof of the Louisiana Superdome, where 10,000 people are taking refuge, opens. Many are feared dead in flooded neighborhoods still under as much as 20 feet of water.
• In Mississippi, dozens are dead and Gov. Haley Barbour describes "catastrophic damage" along the coast. More than 1.3 million homes and businesses in Louisiana, Mississippi and Alabama were without electricity, according to utility companies.
August 30
• New Orleans is left with no power, no drinking water, dwindling food supplies, widespread looting, fires -- and steadily rising waters from major levee breaches. Efforts to limit the flooding are unsuccessful and force authorities to try evacuating the thousands of people at city shelters.
• The U.S. military starts to move ships and helicopters to the region at the request of the Federal Emergency Management Agency.
August 31
• The entire region is declared a public health emergency amid fears of diseases that could spread because of the contaminated, stagnant water.
• Evacuations from the Louisiana Superdome to the Houston Astrodome begin. About 20,000 people are expected to be transferred from New Orleans to Houston.
• When asked about the number of dead, New Orleans Mayor Ray Nagin replies, "Minimum, hundreds. Most likely, thousands."
September 1
• In flooded New Orleans, stranded people remain in buildings, on roofs, in the backs of trucks or gathered in large groups on higher ground.
• Violence disrupts relief efforts as authorities rescue trapped residents and try to evacuate thousands of others living among corpses and human waste. Those stranded express growing frustration with the disorder evident on the streets, raising questions about the coordination and timeliness of relief efforts.
September 2
• Tired and angry people stranded at the convention center in New Orleans welcome a supply convoy carrying food, water and medicine.
• The U.S. Army Corps of Engineers estimate it will take 36 to 80 days to drain the city.
• Texas officials say nearly 154,000 evacuees have arrived there.

• Members of the Congressional Black Caucus criticize the pace of relief efforts, saying response was slow because those most affected are poor. (Watch: Rep. Elijah Cummings -- 5:50)
September 3
• Officials in New Orleans clear tens of thousands of evacuees from the Louisiana Superdome and Ernest Morial Convention Center , where they were living under squalid conditions with little food or water.
September 4
• Water and air rescue efforts continue in New Orleans; the U.S. Coast Guard said it has rescued more than 17,000 people, almost twice as many as it had saved in the previous 50 years combined, but that thousands of people remain stranded . Helicopters drop emergency food and water to people awaiting rescue.
• New Orleans Mayor Ray Nagin announces plans to move traumatized police and firefighters out of the city so they can receive medical and psychological treatment. Police officials said two officers committed suicide.
September 5
• The U.S. Army Corps of Engineers finishes patching a levee breach on the 17th Street Canal in New Orleans and begins pumping water out of the city's streets. A corps spokesman said it will take nearly three months before some neighborhoods are drained.
• Officials encourage residents remaining in New Orleans to evacuate. Deputy Police Chief Warren Riley said that "there is no reason -- no jobs, no food -- no reason for them to stay."
• Body recovery teams conduct house-to-house searches for human remains in New Orleans , while helicopters continue search-and-rescue operations for survivors. The U.S. Coast Guard said that it has rescued more than 22,000 people.
September 6
• Public health officials report "minor outbreaks" of diarrhea diseases in children evacuated from the flood zone. The Centers for Disease Control says five people have died from infection with Vibrio vulnificus, a form of the bacteria that causes cholera. An official in the New Orleans mayor's office says the standing floodwater is contaminated with E. coli bacteria.
• New Orleans Mayor Nagin orders police and law enforcement officials to remove everyone from the city who is not involved in recovery efforts. The order authorizes state and local police, firefighters, National Guard troops and other military forces "to compel the evacuation of all persons from the City of New Orleans, regardless of whether such persons are on private property or do not desire to leave."
• Several fires burn near downtown New Orleans. Several buildings in the city's Garden District are destroyed. New Orleans Fire Chief Charles Parent said crews often are unable to respond to fires until they are well developed because there is no working 911 system for reporting the blazes.
• The House Government Reform Committee announces it will begin hearings next week to investigate the local, state and federal response to Hurricane Katrina and its aftermath.
September 7
• More than 30 bodies are found at St. Rita's Nursing Home in St. Bernard Parish, an area east and southeast of New Orleans that was especially hard-hit by Katrina and the flooding that followed.
• Officials from the Centers for Disease Control and Prevention and Environmental Protection Agency encourage people to have as little contact as possible with contaminated floodwater. Preliminary tests show levels of dangerous bacteria at 10 times the acceptable level, the highest the test could measure. High levels of lead also were detected.

September 8
• Recovery teams remove 14 bodies from flooded Methodist Hospital in eastern New Orleans. A spokesman says the bodies are of people who died before the hospital could be evacuated.
• In a joint news conference, Red Cross and Louisiana state officials say that the state asked the Red Cross to delay bringing relief supplies into New Orleans, and that by Saturday, September 3, the mass evacuation of the city's shelters made that effort unnecessary.
September 11
• Firefighters in New Orleans, including some from New York who came to assist in recovery efforts, pause to mark the fourth anniversary of the September 11 attacks. A makeshift memorial in the city's Algiers section commemorates the 343 New York firefighters killed in the terror attacks.

September 12
• Federal Emergency Management Agency director Michael Brown announces his resignation after facing criticism over his handling of Hurricane Katrina and its aftermath. David Paulison, a 30-year fire and rescue veteran, is named interim director.
• President Bush tours New Orleans, getting his first ground-level look at the flood-ravaged city. "The rescue efforts were comprehensive, and the recovery will be comprehensive," Bush says.
• As pumps work 24/7 to drain floodwaters from New Orleans and crews race to restore more pumps to full operation, 40 percent of the city remains under water, down from 80 percent in the days after the levees broke.
• A CNN/USA Today/Gallup poll reveals deep divisions on how white and black Americans view the federal government's response to the storm, with blacks far more likely than whites to see race as a factor and to blame President Bush for the fact that many residents were trapped in the city.

Timeline compiled from cnn.com and other Internet sources. Images may be subject to copyright.

Desperate A young girl from Tulsa, Oklahoma, wrote a song two years ago and kept it, never finding the right place to use it until now. Her father attended one of the services at Keesler Air Force Base. This slide show combines pictures and the song into a PowerPoint presentation by Chaplain Captain Ann Luna, currently stationed at Keesler AFB.

 

Photographs from "Desperate" by Chaplain Captain Ann Luna, Keesler AFB.

Helping Children and Adolescents Cope with Violence and Disasters Trauma-What Is It? How Children and Adolescents React to Trauma Helping the Child or Adolescent Trauma Survivor Post-Traumatic Stress Disorder Treatment of PTSD What Are Scientists Learning About Trauma in Children and Adolescents? References Helping young people avoid or overcome emotional problems in the wake of violence or disaster is one of the most important challenges a parent, teacher, or mental health professional can face. The National Institute of Mental Health and other Federal agencies are working to address the issue of assisting children and adolescents who have been victims of or witnesses to violent and/or catastrophic events. The purpose of this fact sheet is to tell what is known about the impact of violence and disasters on children and adolescents and suggest steps to minimize long-term emotional harm. In the aftermath of the terrorist attacks on New York City and Washington, D.C., both adults and children are struggling with the emotional impact of such large-scale damage and losses of life. Other major acts of violence that have been felt across the country include the 1995 bombing of the Alfred P. Murrah Federal Building in Oklahoma City and the 1999 shootings at Columbine High School in Littleton, Colorado. While these disastrous events have caught the Nation's attention, they are only a fraction of the many tragic episodes that affect children's lives. Each year many children and adolescents sustain injuries from violence, lose friends or family members, or are adversely affected by witnessing a violent or catastrophic event. Each situation is unique, whether it centers upon a plane crash where many people are killed, automobile accidents involving friends or family members, or natural disasters such as the Northridge, California Earthquake (1994) or Hurricane Floyd (1999) where deaths occur and homes are lost-but these events have similarities as well, and cause similar reactions in children. Even in the course of everyday life, exposure to violence in the home or on the streets can lead to emotional harm. Research has shown that both adults and children who experience catastrophic events show a wide range of reactions.1,2 Some suffer only worries and bad memories that fade with emotional support and the passage of time. Others are more deeply affected and experience long-term problems. Research on post-traumatic stress disorder (PTSD) shows that some soldiers, survivors of criminal victimization, torture and other violence, and survivors of natural and man-made catastrophes suffer long-term effects from their experiences. Children who have witnessed violence in their families, schools, or communities are also vulnerable to serious long-term problems. Their emotional reactions, including fear, depression, withdrawal or anger, can occur immediately or some time after the tragic event. Youngsters who have experienced a catastrophic event often need support from parents and teachers to avoid long-term emotional harm. Most will recover in a short time, but the few who develop PTSD or other persistent problems need treatment. About NIMH Visit the following link for more information about NIMH. TRAUMA-WHAT IS IT? "Trauma" has both a medical and a psychiatric definition. Medically, "trauma" refers to a serious or critical bodily injury, wound, or shock. This definition is often associated with trauma medicine practiced in emergency rooms and represents a popular view of the term. Psychiatrically, "trauma" has assumed a different meaning and refers to an experience that is emotionally painful, distressful, or shocking, which often results in lasting mental and physical effects. Psychiatric trauma, or emotional harm, is essentially a normal response to an extreme event. It involves the creation of emotional memories about the distressful event that are stored in structures deep within the brain. In general, it is believed that the more direct the exposure to the traumatic event, the higher the risk for emotional harm.3 Thus in a school shooting, for example, the student who is injured probably will be most severely affected emotionally; and the the student who sees a classmate shot, even killed, is likely to be more emotionally affected than the student who was in another part of the school when the violence occurred. But even second-hand exposure to violence can be traumatic. For this reason, all children and adolescents exposed to violence or a disaster, even if only through graphic media reports, should be watched for signs of emotional distress. HOW CHILDREN AND ADOLESCENTS REACT TO TRAUMA Reactions to trauma may appear immediately after the traumatic event or days and even weeks later. Loss of trust in adults and fear of the event occurring again are responses seen in many children and adolescents who have been exposed to traumatic events. Other reactions vary according to age:4-7 For children 5 years of age and younger, typical reactions can include a fear of being separated from the parent, crying, whimpering, screaming, immobility and/or aimless motion, trembling, frightened facial expressions and excessive clinging. Parents may also notice children returning to behaviors exhibited at earlier ages (these are called regressive behaviors), such as thumb-sucking, bedwetting, and fear of darkness. Children in this age bracket tend to be strongly affected by the parents' reactions to the traumatic event. Children 6 to 11 years old may show extreme withdrawal, disruptive behavior, and/or inability to pay attention. Regressive behaviors, nightmares, sleep problems, irrational fears, irritability, refusal to attend school, outbursts of anger and fighting are also common in traumatized children of this age. Also the child may complain of stomachaches or other bodily symptoms that have no medical basis. Schoolwork often suffers. Depression, anxiety, feelings of guilt and emotional numbing or "flatness" are often present as well. Adolescents 12 to 17 years old may exhibit responses similar to those of adults, including flashbacks, nightmares, emotional numbing, avoidance of any reminders of the traumatic event, depression, substance abuse, problems with peers, and anti-social behavior. Also common are withdrawal and isolation, physical complaints, suicidal thoughts, school avoidance, academic decline, sleep disturbances, and confusion. The adolescent may feel extreme guilt over his or her failure to prevent injury or loss of life, and may harbor revenge fantasies that interfere with recovery from the trauma. Some youngsters are more vulnerable to trauma than others, for reasons scientists don't fully understand. It has been shown that the impact of a traumatic event is likely to be greatest in the child or adolescent who previously has been the victim of child abuse or some other form of trauma, or who already had a mental health problem.8-11 And the youngster who lacks family support is more at risk for a poor recovery.12 HELPING THE CHILD OR ADOLESCENT TRAUMA SURVIVOR Early intervention to help children and adolescents who have suffered trauma from violence or a disaster is critical. Parents, teachers and mental health professionals can do a great deal to help these youngsters recover. Help should begin at the scene of the traumatic event. According to the National Center for Post-Traumatic Stress Disorder of the Department of Veterans Affairs, workers in charge of a disaster scene should: Find ways to protect children from further harm and from further exposure to traumatic stimuli. If possible, create a safe haven for them. Protect children from onlookers and the media covering the story. When possible, direct children who are able to walk away from the site of violence or destruction, away from severely injured survivors, and away from continuing danger. Kind but firm direction is needed. Identify children in acute distress and stay with them until initial stabilization occurs. Acute distress includes panic (marked by trembling, agitation, rambling speech, becoming mute, or erratic behavior) and intense grief (signs include loud crying, rage, or immobility). Use a supportive and compassionate verbal or non-verbal exchange (such as a hug, if appropriate) with the child to help him or her feel safe. However brief the exchange, or however temporary, such reassurances are important to children. After violence or a disaster occurs, the family is the first-line resource for helping. Among the things that parents and other caring adults can do are: Explain the episode of violence or disaster as well as you are able. Encourage the children to express their feelings and listen without passing judgment. Help younger children learn to use words that express their feelings. However, do not force discussion of the traumatic event. Let children and adolescents know that it is normal to feel upset after something bad happens. Allow time for the youngsters to experience and talk about their feelings. At home, however, a gradual return to routine can be reassuring to the child. If your children are fearful, reassure them that you love them and will take care of them. Stay together as a family as much as possible. If behavior at bedtime is a problem, give the child extra time and reassurance. Let him or her sleep with a light on or in your room for a limited time if necessary. Reassure children and adolescents that the traumatic event was not their fault. Do not criticize regressive behavior or shame the child with words like "babyish." Allow children to cry or be sad. Don't expect them to be brave or tough. Encourage children and adolescents to feel in control. Let them make some decisions about meals, what to wear, etc. Take care of yourself so you can take care of the children. When violence or disaster affects a whole school or community, teachers and school administrators can play a major role in the healing process. Some of the things educators can do are: If possible, give yourself a bit of time to come to terms with the event before you attempt to reassure the children. This may not be possible in the case of a violent episode that occurs at school, but sometimes in a natural disaster there will be several days before schools reopen and teachers can take the time to prepare themselves emotionally. Don't try to rush back to ordinary school routines too soon. Give the children or adolescents time to talk over the traumatic event and express their feelings about it. Respect the preferences of children who do not want to participate in class discussions about the traumatic event. Do not force discussion or repeatedly bring up the catastrophic event; doing so may re-traumatize children. Hold in-school sessions with entire classes, with smaller groups of students, or with individual students. These sessions can be very useful in letting students know that their fears and concerns are normal reactions. Many counties and school districts have teams that will go into schools to hold such sessions after a disaster or episode of violence. Involve mental health professionals in these activities if possible. Offer art and play therapy for young children in school. Be sensitive to cultural differences among the children. In some cultures, for example, it is not acceptable to express negative emotions. Also, the child who is reluctant to make eye contact with a teacher may not be depressed, but may simply be exhibiting behavior appropriate to his or her culture. Encourage children to develop coping and problem-solving skills and age-appropriate methods for managing anxiety. Hold meetings for parents to discuss the traumatic event, their children's response to it, and how they and you can help. Involve mental health professionals in these meetings if possible. Most children and adolescents, if given support such as that described above, will recover almost completely from the fear and anxiety caused by a traumatic experience within a few weeks. However, some children and adolescents will need more help perhaps over a longer period of time in order to heal. Grief over the loss of a loved one, teacher, friend, or pet may take months to resolve, and may be reawakened by reminders such as media reports or the anniversary of the death. In the immediate aftermath of a traumatic event, and in the weeks following, it is important to identify the youngsters who are in need of more intensive support and therapy because of profound grief or some other extreme emotion. Children and adolescents who may require the help of a mental health professional include those who show avoidance behavior, such as resisting or refusing to go places that remind them of the place where the traumatic event occurred, and emotional numbing, a diminished emotional response or lack of feeling toward the event. Youngsters who have more common reactions including re-experiencing the trauma, or reliving it in the form of nightmares and disturbing recollections during the day, and hyperarousal, including sleep disturbances and a tendency to be easily startled, may respond well to supportive reassurance from parents and teachers. POST-TRAUMATIC STRESS DISORDER As mentioned earlier, some children and adolescents will have prolonged problems after a traumatic event. These potentially chronic conditions include depression and prolonged grief. Another serious and potentially long-lasting problem is post-traumatic stress disorder (PTSD). This condition is diagnosed when the following symptoms have been present for longer than one month: Re-experiencing the event through play or in trauma-specific nightmares or flashbacks, or distress over events that resemble or symbolize the trauma. Routine avoidance of reminders of the event or a general lack of responsiveness (e.g., diminished interests or a sense of having a foreshortened future). Increased sleep disturbances, irritability, poor concentration, startle reaction and regressive behavior. Rates of PTSD identified in child and adult survivors of violence and disasters vary widely. For example, estimates range from 2 percent after a natural disaster (tornado), 28 percent after an episode of terrorism (mass shooting), and 29 percent after a plane crash.13 The disorder may arise weeks or months after the traumatic event. PTSD may resolve without treatment, but some form of therapy by a mental health professional is often required in order for healing to occur. Fortunately, it is more common for traumatized individuals to have some of the symptoms of PTSD than to develop the full-blown disorder.14 As noted above, people differ in their vulnerability to PTSD, and the source of this difference is not known in its entirety. Researchers have identified factors that interact to influence vulnerability to developing PTSD. These factors include: characteristics of the trauma exposure itself (e.g., proximity to trauma, severity, and duration), characteristics of the individual (e.g., prior trauma exposures, family history/prior psychiatric illness, gender-women are at greatest risk for many of the most common assaultive traumas), and post-trauma factors (e.g., availability of social support, emergence of avoidance/numbing, hyperarousal and re-experiencing symptoms). Research has shown that PTSD clearly alters a number of fundamental brain mechanisms. Abnormal levels of brain chemicals that affect coping behavior, learning, and memory have been detected among people with the disorder. In addition, recent imaging studies have discovered altered metabolism and blood flow in the brain as well as structural brain changes in people with PTSD.15-19 TREATMENT OF PTSD People with PTSD are treated with specialized forms of psychotherapy and sometimes with medications or a combination of the two. One of the forms of psychotherapy shown to be effective is cognitive behavioral therapy, or CBT. In CBT, the patient is taught methods of overcoming anxiety or depression and modifying undesirable behaviors such as avoidance of reminders of the traumatic event. The therapist helps the patient examine and re-evaluate beliefs that are interfering with healing, such as the belief that the traumatic event will happen again. Children who undergo CBT are taught to avoid "catastrophizing." For example, they are reassured that dark clouds do not necessarily mean another hurricane, that the fact that someone is angry doesn't necessarily mean that another shooting is imminent, etc. Play therapy and art therapy also can help younger children to remember the traumatic event safely and express their feelings about it. Other forms of psychotherapy that have been found to help persons with PTSD include group and exposure therapy. A reasonable period of time for treatment of PTSD is 6 to 12 weeks with occasional follow-up sessions, but treatment may be longer depending on a patient's particular circumstances. Research has shown that support from family and friends can be an important part of recovery. There has been a good deal of research on the use of medications for adults with PTSD, including research on the formation of emotionally charged memories and medications that may help block the development of symptoms.20-22 Medications appear to be useful in reducing overwhelming symptoms of arousal (such as sleep disturbances and an exaggerated startle reflex), intrusive thoughts, and avoidance; reducing accompanying conditions such as depression and panic; and improving impulse control and related behavioral problems. Research is just beginning on the use of medications to treat PTSD in children and adolescents. There is accumulating empirical evidence that trauma/grief-focused psychotherapy and selected pharmacologic interventions can be effective in alleviating PTSD symptoms and in addressing co-occurring depression.23-26 However, more medication treatment research is needed. A mental health professional with special expertise in the area of child and adolescent trauma is the best person to help a youngster with PTSD. Organizations on the accompanying resource list may help you to find such a specialist in your geographical area. WHAT ARE SCIENTISTS LEARNING ABOUT TRAUMA IN CHILDREN AND ADOLESCENTS? The National Institute of Mental Health (NIMH), a part of the Federal Government's National Institutes of Health, supports research on the brain and a wide range of mental disorders, including PTSD and related conditions. The Department of Veterans Affairs also conducts research in this area with adults and their family members. Recent research findings include: Some studies show that counseling children very soon after a catastrophic event may reduce some of the symptoms of PTSD. A study of trauma/grief-focused psychotherapy among early adolescents exposed to an earthquake found that brief psychotherapy was effective in alleviating PTSD symptoms and preventing the worsening of co-occurring depression.27 Parents' responses to a violent event or disaster strongly influence their children's ability to recover. This is particularly true for mothers of young children. If the mother is depressed or highly anxious, she may need to get emotional support or counseling in order to be able to help her child.28-30 Either being exposed to violence within the home for an extended period of time or exposure to a one-time event like an attack by a dog can cause PTSD in a child. Community violence can have a profound effect on teachers as well as students. One study of Head Start teachers who lived through the 1992 Los Angeles riots showed that 7 percent had severe post-traumatic stress symptoms, and 29 percent had moderate symptoms. Children also were acutely affected by the violence and anxiety around them. They were more aggressive and noisy and less likely to be obedient or get along with each other.31 Research has demonstrated that PTSD after exposure to a variety of traumatic events (family violence, child abuse, disasters, and community violence) is often accompanied by depression.3,32-35 Depression must be treated along with PTSD, and early treatment is best. Inner-city children experience the greatest exposure to violence. A study of young adolescent boys from inner-city Chicago showed that 68 percent had seen someone beaten up and 22.5 percent had seen someone shot or killed. Youngsters who had been exposed to community violence were more likely to exhibit aggressive behavior or depression within the following year.36,37 NIMH-supported scientists are continuing to conduct research into the impact of violence and disaster on children and adolescents. For example, one study will follow 6,000 Chicago children from 80 different neighborhoods over a period of several years.38 It will examine the emotional, social, and academic effects of exposure to violence. In some of the children, the researchers will look at the role of stress hormones in a child or adolescent's response to traumatic experiences. Another study will deal specifically with the victims of school violence, attempting to determine what places children at risk for victimization at school and what factors protect them.39 It is particularly important to conduct research to discover which individual, family, school and community interventions work best for children and adolescents exposed to violence or disaster, and to find out whether a well-intended but ill-designed intervention could set the youngsters back by keeping the trauma alive in their minds. Through research, NIMH hopes to gain knowledge to lessen the suffering that violence and disasters impose on children and adolescents and their families. The General Public can obtain publications about PTSD and other anxiety disorders by calling NIMH's toll-free information service, 1-888-ANXIETY, or calling the Institute's public inquiries office at (301) 443-4513. Information is also available online from NIMH's website: http://www.nimh.nih.gov/healthinformation/anxietymenu.cfm. The accompanying resource list indicates agencies or organizations that may have additional information about helping children and adolescents cope with violence and disasters. Reporters interested in PTSD and other anxiety disorders may contact the NIMH press office at (301) 443-4536. Center for Mental Health Services (CMHS) CMHS is a component of the Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services. The Federal Emergency Management Agency, working with the Center for Mental Health Services' Emergency Services and Disaster Relief Branch (ESDRB), provides funding support for mental health services following a disaster. The Crisis Counseling Assistance and Training Program is implemented at the request of a state or territory when a "Major Disaster" has been declared by the President. Funding for the Crisis Counseling Program (CCP) is not automatic. Funding is provided if the need is beyond the means of state and local providers. Legislative authority is based on the Robert T. Stafford Disaster Assistance Act, Section 416 (Public Law 100-707). There are three components to the CCP program: Immediate Services, Regular Services, and Training and Preparedness. The 60-day Immediate Services Program (ISP) provides services from the date of the incident. The Regular Services Program (RSP) follows the ISP when there is a proven need and provides services for up to 9 months. A week-long training program is completed each year for state mental health authorities to assist in planning for mental health response to disasters. For more information about the CCP program, call the Emergency Services and Disaster Relief Branch, CMHS, at (301) 443-4735. For More Information Anxiety Disorders Information and Organizations from NLM's MedlinePlus (en Espanol) REFERENCES 1Yehuda R, McFarlane AC, Shalev AY. Predicting the development of posttraumatic stress disorder from the acute response to a traumatic event. Biological Psychiatry, 1998; 44(12): 1305-13. 2Smith EM, North CS. Posttraumatic stress disorder in natural disasters and technological accidents. In: Wilson JP, Raphael B, eds. International handbook of traumatic stress syndromes. New York: Plenum Press, 1993; 405-19. 3March JS, Amaya-Jackson L, Terry R, Costanzo P. Posttraumatic symptomatology in children and adolescents after an industrial fire. Journal of the American Academy of Child and Adolescent Psychiatry, 1997; 36(8): 1080-8. 4Osofsky JD. The effects of exposure to violence on young children. American Psychologist, 1995; 50(9): 782-8. 5Pynoos RS, Steinberg AM, Goenjian AK. Traumatic stress in childhood and adolescence: recent developments and current controversies. In: Van der Kolk BA, McFarlane AC, Weisaeth L, eds. Traumatic stress: the effects of overwhelming experience on mind, body, and society. New York: Guilford Press, 1996; 331-58. 6Marans S, Adelman A. Experiencing violence in a developmental context. In: Osofsky JD, et al., eds. Children in a violent society. New York: Guilford Press, 1997; 202-22. 7Vogel JM, Vernberg EM. Psychological responses of children to natural and human-made disasters: I. Children's psychological responses to disasters. Journal of Clinical Child Psychology, 1993; 22(4): 464-84. 8Garbarino J, Kostelny K, Dubrow N. What children can tell us about living in danger. American Psychologist, 1991; 46(4): 376-83. 9Duncan RD, Saunders BE, Kilpatrick DG, Hanson RF, Resnick HS. Childhood physical assault as a risk factor for PTSD, depression, and substance abuse: findings from a national survey. American Journal of Orthopsychiatry, 1996; 66(3): 437-48. 10Boney-McCoy S, Finkelhor D. Prior victimization: a risk factor for child sexual abuse and for PTSD-related symptomatology among sexually abused youth. Child Abuse and Neglect, 1995; 19(12): 1401-21. 11Roth SH, Newman E, Pelcovitz D, Van der Kolk BA, Mandel FS. Complex PTSD in victims exposed to sexual and physical abuse: results from the DSM-IV Field Trial for Posttraumatic Stress Disorder. Journal of Traumatic Stress, 1997; 10(4): 539-55. 12Morrison JA. Protective factors associated with children's emotional responses to chronic community violence exposure. Trauma, Violence, and Abuse: A Review Journal, 2000; 1(4); 299-320. 13Smith EM, North CS, Spitznagel EL. Post-traumatic stress in survivors of three disasters. Journal of Social Behavior and Personality, 1993; 8(5): 353-68. 14Breslau N, Kessler RC, Chilcoat HD, Schultz LR, Davis GC, Andreski P. Trauma and posttraumatic stress disorder in the community: the 1996 Detroit Area Survey of Trauma. Archives of General Psychiatry, 1998; 55(7): 626-32. 15Bremner JD, Randall P, Scott TM, Bronen RA, Seibyl JP, Southwick SM, Delaney RC, McCarthy G, Charney DS, Innis RB. MRI-based measurement of hippocampal volume in combat-related posttraumatic stress disorder. American Journal of Psychiatry, 1995; 152(7): 973-81. 16Stein MB, Hanna C, Koverola C, Torchia M, McClarty B. Structural brain changes in PTSD: does trauma alter neuroanatomy? In: Yehuda R, McFarlane AC, eds. Psychobiology of posttraumatic stress disorder. Annals of the New York Academy of Sciences, vol. 821. New York: The New York Academy of Sciences, 1997; 76-82. 17Rauch SL, Shin LM. Functional neuroimaging studies in posttraumatic stress disorder. In: Yehuda R, McFarlane AC, eds. Psychobiology of posttraumatic stress disorder. Annals of the New York Academy of Sciences, vol. 821. New York: The New York Academy of Sciences, 1997; 83-98. 18De Bellis MD, Baum AS, Birmaher B, Keshavan MS, Eccard CH, Boring AM, Jenkins FJ, Ryan ND. Developmental traumatology part I: biological stress systems. Biological Psychiatry, 1999; 45(10): 1259-70. 19De Bellis MD, Keshavan MS, Clark DB, Casey BJ, Giedd JN, Boring AM, Frustaci K, Ryan ND. Developmental traumatology part II: brain development. Biological Psychiatry, 1999; 45(10): 1271-84. 20Golier JA, Yehuda R. Neuroendocrine activity and memory-related impairments in posttraumatic stress disorder. Development and Psychopathology, 1998; 10(4): 857-69. 21Cahill L. The neurobiology of emotionally influenced memory: implications for understanding traumatic memory. In: Yehuda R, McFarlane AC, eds. Psychobiology of posttraumatic stress disorder. Annals of the New York Academy of Sciences, vol. 821. New York: The New York Academy of Sciences, 1997; 238-46. 22Gold PE, McCarty RC. Stress regulation of memory processes: role of peripheral catecholamines and glucose. In: Friedman MJ, Charney DS, Deutch AY, eds. Neurobiological and clinical consequences of stress: from normal adaptation to post-traumatic stress disorder. Philadelphia: Lippincott-Raven, 1995; 151-62. 23Yule W, Canterbury R. The treatment of post traumatic stress disorder in children and adolescents. International Review of Psychiatry, 1994; 6(2-3): 141-51. 24Goenjian AK, Karayan I, Pynoos RS, Minassian D, Najarian LM, Steinberg AM, Fairbanks LA. Outcome of psychotherapy among early adolescents after trauma. American Journal of Psychiatry, 1997; 154(4): 536-42. 25March JS, Amaya-Jackson L, Pynoos RS. Pediatric posttraumatic stress disorder. In: Weiner JM, ed. Textbook of child and adolescent psychiatry, 2nd edition. Washington, DC: American Psychiatric Press, 1997; 507-24. 26Murphy L, Pynoos RS, James CB. The trauma/grief-focused group psychotherapy module of an elementary school-based violence prevention/intervention program. In: Osofsky JD, et al., eds. Children in a violent society. New York: Guilford Press, 1997; 223-55. 27Goenjian AK, Karayan I, Pynoos RS, Minassian D, Najarian LM, Steinberg AM, Fairbanks LA. Outcome of psychotherapy among early adolescents after trauma. American Journal of Psychiatry, 1997; 154(4): 536-42. 28Deblinger E, Steer RA, Lippmann J. Maternal factors associated with sexually abused children's psychosocial adjustment. Child Maltreatment, 1999; 4(1): 13-20. 29Bromet EJ, Goldgaber D, Carlson G, Panina N, Golovakha E, Gluzman SF, Gilbert T, Gluzman D, Lyubsky S, Schwartz JE. Children's well-being 11 years after the Chernobyl catastrophe. Archives of General Psychiatry, 2000; 57(6): 563-71. 30McFarlane AC. Family functioning and overprotection following a natural disaster: the longitudinal effects of post-traumatic morbidity. Australian and New Zealand Journal of Psychiatry, 1987; 21(2): 210-8. 31Stuber ML, Nader KO, Pynoos RS. The violence of despair: consultation to a HeadStart program following the Los Angeles uprising of 1992. Community Mental Health Journal, 1997; 33(3): 235-41. 32Pfefferbaum B, Nawaz S, Kearns LJ. Posttraumatic stress disorder in children: implications for assessment, prevention, and referral in primary care. Journal of the Oklahoma State Medical Association, 1999; 92(7): 309-15. 33Lipschitz DS, Winegar RK, Hartnick E, Foote B, Southwick SM. Posttraumatic stress disorder in hospitalized adolescents: psychiatric comorbidity and clinical correlates. Journal of the American Academy of Child and Adolescent Psychiatry, 1999; 38(4): 385-92. 34McCloskey LA, Walker M. Posttraumatic stress in children exposed to family violence and single-event trauma. Journal of the American Academy of Child and Adolescent Psychiatry, 1999; 20(1): 108-15. 35Ackerman PT, Newton JEO, McPherson WB, Jones JG, Dykman RA. Prevalence of posttraumatic stress disorder and other psychiatric diagnoses in three groups of abused children (sexual, physical, and both). Child Abuse and Neglect, 1998; 22(8): 759-74. 36Bell CC, Jenkins EJ. Community violence and children on Chicago's Southside. Psychiatry, 1993; 56(1): 46-54. 37Bell CC, Jenkins EJ. Traumatic stress and children. Journal of Health Care for the Poor and Underserved, 1991; 2(1): 175-88. 38Earls FJ. Child exposure to violence and PTSD across urban settings. NIMH Grant No. 5R01-MH56241-05. In progress. 39Richards MH. Risky context and exposure to violence in urban youth. NIMH Grant No. 5R01-MH57938-02. In progress. NIH Publication No. 01-3518 NIMH publications are in the public domain and may be reproduced or copied without the permission from the National Institute of Mental Health (NIMH).

Sri Lanka

Sri Lanka Children
Photograph by Kate Amatruda

I look on the map and see that Sri Lanka is a teardrop off the coast of India.

It is the eyes that haunt me; the eyes of the father whose daughter was ripped out of his arms, the eyes of the grandmother who saw her children and grandchildren swept away. A generation lost in a heartbeat. I see shock on the faces of the survivors, and am reminded yet again of how everything can change in an instant. Whether it is an earthquake, a Tsunami, a tornado, or planes hitting towers, life is so fragile. Everything can be gone in the blink of an eye; we are so little, nature and war are so big. Yet we have this illusion, at least in the West, that we are in control. So I look, and look again, compelled to try to discern how people do it. How do you go on when your village, your home, your family, is destroyed? I see the faces of those who I met in the refugee camps, and it is the eyes that capture me. And it is the eyes of the children that haunt me, and make me unable to sleep through the night.

The number of people believed killed in December's Tsunami disaster rose to 285,993 on Saturday, February 12, 2005. Every day the death toll rises. The number of children orphaned is still unknown. Sri Lanka's death toll now stands at 43,832. (Reuters)

The earthquake hit on Sunday, December 26, 2004 at 7:58:53 AM = local time at epicenter
For us in California, it was on Christmas afternoon,
Saturday, December 25, 2004 at 04:58:53 PM (PST)
Location 3.307° N 95.947° E
Depth 30 km (18.6 miles) set by location program
Region OFF THE WEST COAST OF NORTHERN SUMATRA.
It was a 9.0 earthquake, the fourth biggest since 1900.

(This should be animated to show the Tsunami. If it is not, try passing your mouse over the map.
If it does not animate, the non-animated map below shows the course of the Tsunami.)

I am remembering the Northern California Loma Prieta earthquake in 1989. The Indian Rim "Boxing Day" 9.0 earthquake makes our 6.9 magnitude pale in comparison, as each Richter logarithmically increases the size on an earthquake, yet the Loma Prieta was strong enough to break the Bay Bridge.   Scientists from Pasadena explain, "It has since been shown to be proportional to the energy released in the earthquake but the energy goes up with magnitude faster than the ground velocity, by a factor of 32. Thus, a magnitude 6 earthquake has 32 times more energy than a magnitude 5 and almost 1,000 times more energy than a magnitude 4 earthquake."

I received an e-mail from the Association for Play Therapy calling for a team of volunteers "to participate in a US delegation to Sri Lanka to provide play activities (but not psychotherapy) to children in orphanages and community centers."

I quickly faxed and mailed off my application, hoping to be selected. I was so honored when when Dr. Janine Shelby, the Association for Play Therapy Foundation President, and a brilliant clinician, called to invite me to join the project.  I learned later that only 14 play therapists from across the country have been selected to go. We will be working with OperationUSA, an NGO that was the co-recipient of the 1997 Nobel Peace Prize for its work banning land mines. Their mission is based upon Mahatma Gandhi's belief that
" You must be the change you wish to see in the world"

After the initial elation, panic sets in. What am I going to do there? I don't speak the language, nor know the culture. I madly research techniques for working with children after a disaster, and find very little. There is a need for Dr. Shelby's project, which will be to bring specific cognitive-behavioral protocols, in the form of games, to the field.

I find that the Save the Children guidelines are:

 

Before you read any further - Are you prepared for a disaster?

 

There is much information available on how to prepare for a disaster; the following is from The Department of Homeland Security:

When preparing for a possible emergency situation, it's best to think first about the basics of survival: fresh water, food, clean air and warmth.
Recommended Items to Include in a Basic Emergency Supply Kit:
Water, one gallon of water per person per day for at least three days, for drinking and sanitation
Food, at least a three-day supply of non-perishable food
Battery-powered or hand crank radio and a NOAA Weather Radio with tone alert and extra batteries for both
Flashlight and extra batteries
First aid kit
Whistle to signal for help
Dust mask, to help filter contaminated air and plastic sheeting and duct tape to shelter-in-place
Moist towelettes, garbage bags and plastic ties for personal sanitation
Wrench or pliers to turn off utilities
Can opener for food (if kit contains canned food)
Local maps
Additional Items to Consider Adding to an Emergency Supply Kit:
Prescription medications and glasses
Infant formula and diapers
Pet food and extra water for your pet
Important family documents such as copies of insurance policies, identification and bank account records in a waterproof, portable container
Cash or traveler's checks and change
Emergency reference material such as a first aid book or information from www.ready.gov
Sleeping bag or warm blanket for each person. Consider additional bedding if you live in a cold-weather climate.
Complete change of clothing including a long sleeved shirt, long pants and sturdy shoes. Consider additional clothing if you live in a cold-weather climate.
Household chlorine bleach and medicine dropper – When diluted nine parts water to one part bleach, bleach can be used as a disinfectant. Or in an emergency, you can use it to treat water by using 16 drops of regular household liquid bleach per gallon of water. Do not use scented, color safe or bleaches with added cleaners.
Fire Extinguisher
Matches in a waterproof container
Feminine supplies and personal hygiene items
Mess kits, paper cups, plates and plastic utensils, paper towels
Paper and pencil
Books, games, puzzles or other activities for children
http://www.ready.gov/america/getakit/index.html

Please go RIGHT NOW to FEMA's Disaster Supplies Checklists. Print them out...please!

Preparing your family for disasters After a disaster, you and your family should be prepared to be on your own for at least three days. Emergency response teams may be overwhelmed and may not be able to provide immediate care to all who need it. Here are steps you can take now to help your family through any disaster. Things you can do to protect your family Choose a place for your family to meet after a disaster in case you are apart when a disaster happens. Choose a person outside the immediate area to contact if family members are separated. Your contact person should live far enough away that they are not involved in the same emergency. Know how you can contact your children at their school or daycare and when and where you can pick them up after a disaster. Designate others to pick up your child should you be unable to pick them up. Keep your child’s emergency release card up to date. Put together an emergency supply kit for your home and workplace. If your child’s school or daycare stores personal emergency kits, make one for your child to keep there. Know the locations of the nearest fire and police stations. Learn your community’s warning signals, what they sound like, and what you should do when you hear them. Learn first aid and CPR. Learn how to shut off your water, gas, and electricity. Know where to find shutoff valves and switches. Keep a small amount of cash available. If the power is out, ATM machines will not operate. If you have a family member who does not speak English, prepare an emergency card written in English indicating that person’s name, address, and any special needs such as medication or allergies. Tell that person to keep the card with them at all times. Conduct earthquake and fire drills once every six months. Make copies of your vital records and store them in a safe deposit box in another city or state. Make sure your originals are stored safely. Take photos and videotapes of your home and your valuables and keep them in your safe deposit box. Make sure family members know all the possible ways to exit your home. Keep all exits clear. Make sure all family members know about your plan. Give emergency information to babysitters or other care-givers. Things you can do to protect your pets: Store enough food and water to last at least three days for each pet. Prepare an emergency kit for your pet. The kit should include: an unbreakable dish, medications and instructions, a leash or pet carrier, and your pet’s veterinary records. Consider having a permanent microchip implanted in your pet; this ID cannot be lost or removed. See your veterinarian for more information. Make arrangements for your pets if you must evacuate after a disaster. Remember, pets are not allowed in shelters. Leave your pets in a secure place with ample water and food. If possible, return daily to check on your pets until you can return to your home permanently. Source: Washington State Department of Health: This document was produced in cooperation with the Emergency Management Division of the Washington State Military Department and is in the public domain.

 

 

Things to think about:

1. How will you communicate in an emergency?

2. Where will you meet family members?

3. Can you access your disaster supplies kit?

4. What is the school emergency plan of any school-age children you may have?

5. Does your workplace have an emergency plan?

6. Do you have a way to get information?

7. Consider taking a first aid or CPR course if you have not done so  (These courses may be required before you are deployed on a disaster.)

8. If you have animals, what is the plan for their care? (Many shelters will not allow animals.)

9. If you or someone is your family has special needs, be aware that evacuation and meeting needs in a shelter or during a disaster may be complex.

10. Are you prepared to be self-reliant for at least 72 hours, with no water, power, communication, public utilities, emergency services, etc.?

 

As we learned in the aftermath of Hurricane Katrina, and after the terrorist attack on September 11, 2001:

• There may be deaths, injuries, and significant damage to buildings and the infrastructure.  In England, Bob Brotchie, a paramedic and clinical team leader for an ambulance service, after years of trying to reach relatives of people he was treating, came up with the idea that cell users should put the acronym ICE -- "in case of emergency" -- before the names of the people they want to designate as next of kin in their cell address book, creating entries such as "ICE -- Dad" or "ICE -- Alison."
• Heavy law enforcement involvement may or may not be present: The WTC attack prompted a huge response of police, FBI, firefighters, etc., while in New Orleans the rescuers were not evident.
• Health and mental health resources may be overwhelmed.
• Anxiety, strong public fear and international implications and consequences can continue for a prolonged period; there may be intense media coverage,.
• Schools , businesses and public services may be closed, and you may be trapped, unable to leave.
• In the aftermath, people may have to evacuate an area, avoiding unsafe roads .
• Clean-up may take many months or years.

Evacuation
If you are asked to evacuate, please keep in mind Denial may rear its head. During Hurricane Emily, I was in the Outer Banks with a baby, and kept thinking, "No, this hurricane won't hit..I will stay." The idea of driving for hours to a safe place, and going to a shelter or trying to find a hotel, was daunting. We did leave, and the house we had been staying in was severely damaged - windows blown out, roof damaged.

If you chose to stay, the police will come and visit, and ask you for the names of your next of kin. They will take out a Sharpie pen and ask you to write your name and social security number of your arms.

If you do evacuate:

What should I take with me?
License or Identification card with photo
Your medications, extra eye glasses, hearing aids and other essential items
A flashlights with batteries, if you don't already have one in your car
A battery-operated portable radio, if you don't have a car radio
Water or other beverages to drink on your trip
Non-perishable foods to eat on your trip
Spare clothes and shoes
Soap, shampoo, and other toiletries
Important papers, including deeds and wills
Contact numbers of friends, family members, physicians, and your insurance agent
Money, checks, travelers' checks or credit cards
An inventory of your personal belongings and any photographs or videotapes of your possessions
If I plan on going to a public shelter, what additional items should I take?
Public shelters are austere facilities that provide temporary housing for evacuees. Most shelters do not have beds or cots, so you will probably be sleeping on the floor. So pack as if you were going camping. Bring:
Sleeping pads or air mattresses
Blankets or a sleeping bag for each person
Robe & shower shoes
Books, cards, games and QUIET toys for children
What should I NOT take to a public shelter?
Alcoholic beverages, weapons, and drugs are not allowed in public shelters.
http://www.txdps.state.tx.us/dem/documents/Hurricane%20Evacuation%20QA.doc.

 

These are the Shelter-in-place instructions for Contra Costa County in the event of a chemical emergency:

KNOW HOW TO Shelter-In-Place In the event of a chemical release, safety sirens in Contra Costa County’s industrial corridor will sound to alert the public. If you hear the sirens, or are told by emergency authorities to shelter-in place, take these actions: Go inside (take pets with you) Close and lock all windows and doors (locking provides a tighter seal) Turn off all ventilation systems such as heating or air conditioning Close all fireplace dampers. If there are gaps in windows or doors, seal with tape or damp towels. Tune to KCBS 740 AM on the radio for more information. How long will the sirens sound? The sirens will sound initially for about three minutes. They will continue to be re-sounded periodically if the event continues. Shelter-in-place alerts are also broadcast over weather radios in Contra Costa County, and the County operates a phone ringdown system that is activated for shelter-in-place alerts. What should businesses do during a shelter-in-place event? Shelter employees and customers in place, following the same steps as for a home. Close doors and windows, shut down heating and air conditioning systems, seal gaps and do not call 9-1-1 unless there is a medical emergency. Where can people get information in languages other than English when the sirens sound? Tune to CCTV, the County’s TV station (check local cable listings for channel in your area). CCTV is connected to the CWS, so shelter-in-place information in English, Spanish and Tagalog will automatically scroll if there is an alert. How will I know when the event is over? County authorities will announce the “All Clear” via the news media. CAER recommends tuning an AM radio to KCBS 740. People with Internet access can subscribe at www.incident.com for free alerts and all-clear announcements via e-mail sent by the State Office of Emergency Services. The safety sirens will not be sounded for the All Clear. Are the sirens tested? The sirens are tested on the first Wednesday of each month at 11:00 a.m. Instead of three minutes, they are sounded for only about one minute during the test. If you hear the safety sirens at any other time, you should shelter-in-place. CCC CAER Group, Inc. www.cococaer.org CCommunity AAwareness and EEmergency RResponse Agencies·Communities·Industries Working together for a safe and informed public. For more information, call toll-free (888) 972-2237

A FEDERAL EMPLOYEE’S EMERGENCY GUIDE UNITED STATES OFFICE OF PERSONNEL MANAGEMENT BIOLOGICAL THREATS A biological attack is the deliberate release of germs or related substances. To affect individuals adversely, these substances must usually be inhaled, be ingested, or enter through cuts in the skin. Some biological agents such as smallpox can be spread from person to person while others like anthrax do not cause contagious diseases. Different than a conventional explosive or attack, biological attacks may not be immediately evident. Some of the normal indicators of this type of attack would be an increase in the number of illnesses reported by local health care workers or a large number of dead or sick animals throughout your area. These attacks are normally discovered by emergency response personnel in reaction to the indicators listed above. What Should You Do? In the event that you witness a suspicious attack using an unknown substance, there are a number of things you can do to protect yourself and your family. First, leave the immediate area as quickly as possible and protect yourself by finding something to place over your nose and mouth. Any layered material like a tshirt, handkerchief, or towel may help prevent particles of the substance from entering your respiratory system. If you have a long-sleeved shirt or jacket, they would be useful in covering exposed skin. They may also prevent bacteria from entering cuts you may have. If you are indoors and the suspected attack takes place outdoors, remain inside unless told otherwise by authorities. Report the attack to emergency personnel. You can also take precautionary measures such as keeping shots up-to-date and making sure you practice good personal hygiene. A healthy body will be able to better fight any potential contamination by biological agents. In the event that anyone around you becomes ill, do not automatically assume that it is from the suspected attack as many of the symptoms from these attacks resemble common illnesses. Seek the medical advice of your physician. Create a Personal Safety Kit There are some items which employees may wish to assemble in a personal safety kit that is stored at their work space. These could be used in the event of an attack or other emergency. Items that may be appropriate for these kits include–additional dosages of any medication that an employee requires, bottled water, long sleeved shirt or jacket, and emergency contact numbers. You may also think about adding such small items as snack food, an extra pair of glasses or other “comfort” items you think are necessary. CHEMICAL THREATS Chemical attacks differ from biological attacks in that a toxic gas or liquid is used to contaminate people or the environment. The prevalent symptoms you would experience from a chemical attack are tightness in the chest, difficulty breathing, blurred vision, stinging of the eyes, or loss of coordination. What Should You Do? If you witness a suspected chemical attack outdoors, move away from the area as quickly as possible. If you cannot leave the area, try to get inside, away from direct exposure and follow your instructions to shelter-in-place. If you are inside and an attack occurs in your building, try to leave the area if possible. If not, move to a safe location in the building and shelter-in-place. If you suffer any of the symptoms mentioned above try to remove any clothing you can and wash your body with water or soap and water if available. Do not scrub the area, as this may wash the chemical into the skin. Seek medical assistance as soon as possible. If you see someone experiencing these symptoms, keep them away from others as much as possible, and try to keep them comfortable. While extensive decontamination requiring disrobing is a possibility, this will normally only occur if you become a casualty of the agent or are evacuated and require medical treatment in a “clean” medical facility. This procedure may be required to prevent the spread of contamination. NUCLEAR EXPLOSIONS AND RADIOLOGICAL CONTAMINATION A nuclear blast consists of tremendous thermal (heat), light, and blast energy. The blast can spread radioactive waste capable of contaminating the air and surrounding landscape. While this type of attack is less likely than a biological or chemical attack, the remote possibility of its occurrence means you should be prepared. What Should You Do? If a nuclear explosion occurs, immediately drop and stay down until any blast wave passes over you and it is safe to get up. Debris can often cause injuries from a nuclear explosion so it is often safer to remain down until debris stops falling. Do not look at the blast. When it is safe to do so, seek shelter inside a building or basement. Since dirt or earth is one of the best forms of protection from radiation, put as much shelter between you and the potential contamination as possible. If it is safe to leave without going in the direction from which the blast came, you should decide whether to leave the area to minimize the amount of time you spend exposed to radiological contamination. You should always try to place as much shielding and distance between yourself and the contamination as possible and limit the amount of your exposure by leaving laterally or upwind from the area when it is safe to do so. Dirty Bombs Dirty bombs are regular explosives that have been combined with either radiation causing material or chemical weapons. While most news reports talk about radiological dirty bombs, chemical agents may be used as well. Blasts from these types of weapons normally look more like a regular explosion, and the contamination spread is not often immediately noticeable. While this type of attack normally spreads contamination over a more localized area, you should be prepared to follow many of the same procedures as listed above. After experiencing any of these types of attacks, tune to your local channels for information and instructions. Emergency responders are trained and equipped to evaluate and react to threats rising from these incidents. After a nuclear blast, you may be unable to get a signal from radio or television stations for a period of time. This is expected; so be persistent. While radioactive, biological, and chemical weapons do pose a threat, they are attacks that you, and your family or fellow employees can survive if you keep a cool head and follow the instructions given by your local responders. ACKNOWLEDGMENTS United States Office of Personnel Management www.opm.gov

Pandemic Flu Planning Checklist for Individuals and Families You can prepare for an influenza pandemic now. You should know both the magnitude of what can happen during a pandemic outbreak and what actions you can take to help lessen the impact of an influenza pandemic on you and your family. This checklist will help you gather the information and resources you may need in case of a flu pandemic. To plan for a pandemic: Store a two week supply of water and food. During a pandemic, if you cannot get to a store, or if stores are out of supplies, it will be important for you to have extra supplies on hand. This can be useful in other types of emergencies, such as power outages and disasters. Periodically check your regular prescription drugs to ensure a continuous supply in your home. Have any nonprescription drugs and other health supplies on hand, including pain relievers, stomach remedies, cough and cold medicines, fluids with electrolytes, and vitamins. Talk with family members and loved ones about how they would be cared for if they got sick, or what will be needed to care for them in your home. Volunteer with local groups to prepare and assist with emergency response. Get involved in your community as it works to prepare for an influenza pandemic. To limit the spread of germs and prevent infection: Teach your children to wash hands frequently with soap and water, and model the correct behavior. Teach your children to cover coughs and sneezes with tissues, and be sure to model that behavior. Teach your children to stay away from others as much as possible if they are sick. Stay home from work and school if sick. Items to have on hand for an extended stay at home: Examples of food and non-perishables Examples of medical, health, and emergency supplies Ready-to-eat canned meats, fish, fruits, vegetables, beans, and soups Prescribed medical supplies such as glucose and blood-pressure monitoring equipment Protein or fruit bars Soap and water, or alcohol-based (60-95%) hand wash Dry cereal or granola Medicines for fever, such as acetaminophen or ibuprofen Peanut butter or nuts Thermometer Dried fruit Anti-diarrheal medication Crackers Vitamins Canned juices Fluids with electrolytes Bottled water Cleansing agent/soap Canned or jarred baby food and formula Flashlight Pet food Batteries Other non-perishable items Portable radio Manual can opener Garbage bags Tissues, toilet paper, disposable diapers The Centers for Disease Control and Prevention (CDC) hotline, 1-800-CDC-INFO (1-800-232-4636), is available in English and Spanish, 24 hours a day, 7 days a week. TTY: 1-888-232-6348. Questions can be e-mailed to cdcinfo@cdc.gov. Links to state departments of public health can be found at http://www.cdc.gov/other.htm#states. U.S. Department of Health and Human Services January 2006 http://www.pandemicflu.gov/planguide/checklist.html En Español: http://www.pandemicflu.gov/espanol/planguide/checklistsp.html

Bad disaster humor:

Bird flu hits trailer park in Florida

A note on television watching

It is very compelling to watch TV as disasters unfold. In some ways, this is an attempt to master the emotional impact of what has occurred; to try to comprehend the incomprehensible. It is however, deeply unsettling to children to see the same images broadcast again and again. After the Loma Prieta Earthquake, every child I saw recreated the "breaking of the bridge" in his/her play therapy session. yet no child saw the bridge, nor did they have any family members who were on or near the bridge at the time of its collapse. It was the repeated viewing of the images on television that seared this into their psyches. The same occurred with September 11; the image of the World Trade Center on fire was seem again and again; the drawing you see was done by a girl in a play therapy session in California, who had no firsthand knowledge of the WTC or the attack, yet her drawing clearly communicates her distress.

 

A fireball explodes from the impact of a jet airliner against one of the World Trade Center towers on Tuesday, Sept. 11, 2001, in New York. (c) AP/WWP - Carmen Taylor at http://usinfo.state.gov

 

Basic First Aid - Please take a CPR or First Aid course if you have not done so recently! It is a great feeling to know that there are concrete, tangible steps you can take to save a life.

For more information about the specific effects of chemical or biological agents, please visit:

Centers for Disease Control and Prevention: www.bt.cdc.gov

U.S. Department of Energy: www.energy.gov

U.S. Department of Health and Human Services: www.hhs.gov

Federal Emergency Management Agency: www.fema.gov

Environmental Protection Agency: www.epa.gov/swercepp

 

In a major disaster, it might be several days before vital services are restored. Earthquakes, fires, severe storms, power outages, and acts of terrorism are just some of the potential emergencies we may encounter.
Imagine that you have no electricity, no gas, no water and no telephone service. Imagine that all the businesses are closed and you are without any kind of emergency services. What will you do until help arrives?

Food
When a disaster occurs, you might not have access to food, water and electricity for days, or even weeks.
Store enough emergency food to provide for your family for at least 3 days.
Food Tips:
* Avoid foods that require a lot of water, refrigeration or cooking.
* Choose foods your family will eat.
* Don’t forget a manual can opener and utensils.
Recommended Foods Include:
* Ready-to-eat canned meats, fruits and vegetables
* Canned juices, milk and soup.
* High-energy foods, such as peanut butter, jelly, crackers, granola bars and trail mix.
* Comfort foods, such as hard candy, sweetened cereals, candy bars and cookies.
* Dried foods (select carefully as some have a high salt content).
* Instant meals that don’t require cooking or water.

Water
In a disaster, water supplies may be cut off or contaminated.
Store enough water for everyone in your family to last for at least 3 days. More is better.
* Store a gallon of water per person per day.
* Seal water containers tightly in a clean food-grade plastic container, label them with a date, and store in a cool, dark place.
* Rotate water supplies every 6 months.
* Keep a small bottle of unscented liquid bleach to purify water.
If you have concerns about your water safety do one of the following:
* Boil water for at least five minutes, let cool, then drink or use to prepare food.
* Add 8 drops of unscented liquid bleach to each gallon of water. Shake or stir, then let stand 30 minutes.
A slight chlorine taste and smell is normal.
If you run out of stored drinking water, strain & treat water from your water heater.
To strain, pour it through a clean cloth or layers of paper towels. Treat, following the directions above.

Go Bag
A go-bag is for use in the event of an evacuation. Be sure that your bag is easy to carry and that it has an ID tag.
Prepare one for each family member. Keep a go-bag at home, at work and in your vehicle.
Include the following:
* Some water, food, and manual can opener
* Flashlight
* Radio – battery operated
* Batteries
* Whistle
* Pocket Knife
* Personal medications and prescriptions
* Extra keys to your house and vehicle
* Basic First Aid kit and instructions
* Walking shoes, warm clothes, a hat, and rain gear
* Extra prescription eye glasses, hearing aid or other vital personal items
* Toilet paper, plastic bags and other hygiene supplies
* Dust mask
* Paper, pens and tape for leaving messages
* Cash
* Copies of insurance and identification cards
* Any special-need items for children and seniors or people with disabilities. Don’t forget pet supplies.
(source: http://www.72hours.org/)

Download the pdf  "How would you survive for 72 hours?" 

 

 

 

Sri Lanka Temple
Photograph by Kate Amatruda

 

Getting the Call
Preparing to Go
The Journey

Arrival - the Beginnings of Chaos
On Site Training
Hurry up and Wait
Your Assignment - It's Not about you
The Work
Time to Go Home
Re-entry into your Life
Integration

 

Getting the Call

In order to go, you may have to call to a disaster hotline and tell them your availability, starting and ending dates. While most deployments are three weeks, mental health workers, due to the increased stresses of our positions, usually have a two week deployment. Sometimes it is possible to go for a shorter time.

You may get a phone call or e-mail giving you the details of your deployment; I received my e-mail to go to Hurricane Katrina at 2:00 a.m. on a Wednesday night; my flight left at 6:00 a.m. on Friday.

This is the e-mail I got (with numbers xxxxed out):

Preparing to Go

Katrina

Ok! The deployment notification has arrived!  I gulp!  Then run to the bathroom. (This is rather crude, but I want to be as honest as I can here, to help prepare you. This is when I need the immodium! I always use more anti-diarrheal medicine before the plane touched the ground than at the actual disaster site!)

I take a deep breath, and re-read the Hardship Codes for Hurricane Katrina/Louisiana

* C-1 Water Disruption
* C-2 Power Outage
* C-3 Limited Food Availability
* C-4 Extreme Heat/Humidity
* C-6 Housing Shortage
* C-7 Working Conditions
* C-8 Limited Health Care Access
* C-9 Extreme Emotional Stress
* C-10 Travel Conditions
* C-11 Transportation Limitations
* C-12 Air Quality
* C-13 Lifting Limitation

Am I up for this?

I print out the e-mail, grab a pen and paper, and call the DR Info Line: 1.888.xxx.xxxx. I put DR 009 when the prompt asks, and my DSHR ID. (Already my brain is swimming with numbers and abbreviations!  DR is Disaster Response, DSHR is Disaster Services Human Resources, DRO is Disaster Relief Operation. I have been recruited in the MHS (Mental Health Services.)

The DR Info phone line tells me that my assignment, 009, is in Houston. Houston is the wonderful city which opened its doors to tens of thousands of people displaced by Hurricane Katrina, in particular those who had been at the Superdome and New Orleans Convention Center.  Shelters were opened at the Astrodome and the adjacent Reliant Arena and Reliant Center exhibition hall, as well as the downtown George R. Brown Convention Center, housing 24,950 people.

The phone recording gives my phone numbers of the DRO in Houston, as well as an after hours emergency number. I listen to instructions on where to go when I arrive in Houston. If I arrive in the day, I am to go to the disaster relief headquarters in Houston; after hours I am to go to a hotel, and then get to headquarters first thing in the morning. they also tell me to call the DR Info phone line when I arrive in Houston, as instructions may change (and they do!)

Sri Lanka

Preparing to go to Sri Lanka is completely different. In addition to my own anxiety, I begin to realize how little I know. I don’t know yet which area I will be assigned to, the southern part of the island, which is primarily Buddhist, or the northern and eastern parts, which are Hindu and Muslim. Interventions will differ depending on which religion is dominant. For example, because Buddhists believe that if you focus on negative emotions such as anger, revenge, and fear, you can become these things, it would not be appropriate to do play interventions that focus on loss and anger.) Along the same lines, we were asked to leave religious symbols or messages (jewelry, T-shirts) at home.

We have to learn enough about the culture(s) on the island to know what is appropriate, so that we don’t provide interventions that are inappropriate or inconsistent for the culture.

We were asked to respond positively to any questions about our reaction to Sri Lanka; this turned out to be easy. We fell in love with the people – their spirit; their resilience; their generosity in the midst of death and devastation was truly touching. Less easy was the mandate to not speak critically of government policies – either theirs or ours.

We can not hold political discussions (e.g., do not discuss Bush, the war, politics, or religion). When we are there, we represent Operation USA, which is a nonpartisan organization.
We have to only speak positively about our host’s culture, which proves to be a challenge when we are stationed in the rebel territory, amidst the Tamil minority. It felt in some ways like having to defend segregation while working with African Americans in the 1950s. We learned to employ the neutral therapeutic “hmmm…” of neither agreeing nor disagreeing; of not having to defend policies that felt unfair, nor doing anything that could jeopardize Operation USA’s ability to be invited back to provide aid and assistance.

As much of what we do will need translation, we need to remember to speak clearly, and avoid slang, and to use short sentences. Metaphors can be problematic as they are often culturally bound. We also have to be sensitive to any water metaphors; to say that one is “drowning in tears’ or ‘grief comes like waves’ would be very insensitive post-tsunami.

We were reminded not to litter or spit out gum (In Singapore, this is punishable with a fine; not imprisonment nor public caning.) Actually, you cannot chew gum in Singapore unless you have a doctor's note, and you cannot buy it anywhere, so if you need to chew gum for your ears during a flight, make sure you bring enough with you, as you will not be able to buy any in the airport.

As there is tremendous curiosity about caning in Singapore, we went to Wikipedia.org  to find out more:

Caning in the city-state of Singapore is used as a form of corporal punishment for criminal offences.
More than one thousand convicted criminals are caned in Singapore each year for both violent and non-violent offences such as vandalism, overstaying one's visa or illegal immigration.
Current caning procedures are carried out not in the public's view, with the subject to be caned strapped to a metal frame with the buttocks exposed. The bamboo cane has been soaked in water overnight to prevent the cane from splitting and to maximize inflicted pain. Parts of the prisoner's body are padded to prevent accidental damaging of the kidneys, but the procedure can still leave permanent scars on the subject.
The subject may be caned if he is male, is below the age of fifty, and is certified medically fit by a medical doctor.
Crimes which may result in caning include:
Misuse of drugs: three to six strokes. Repeat offenders: six to twelve strokes
Illegal entry into Singapore: At least three strokes
Unlawful overstay in Singapore for over ninety days: At least three strokes
Unlawful possession or conveyance of any arms or ammunition: At least six strokes
Piracy: At least twelve strokes
Dealing with dangerous fireworks: Up to six strokes
Using a corrosive or explosive substance or offensive weapon: At least six strokes
Males engaging in prostitution trading activities
Obstructing engine or carriages or endangering safety of passengers
For the complete list, please go to (http://en.wikipedia.org/wiki/Caning_in_Singapore_)

 

Generally, if you are respectful of the people and the environment wherever you go, you will not find yourself in trouble.

In Sri Lanka , we were told to eat and shake hands with people using only our right hands.

We were told to expect many questions, even from strangers (e.g., where are you going? where are you from? I was surprised how frequently the children wanted to know what my religion was).

In disaster work, it helps to match match body language, tone, volume, and eye contact of the host culture. this is true, I believe of all mental health interventions, as it establishes a cellular rapport, but it particularly important when people are extremely stressed, and when there are cultural differences. We want to impart on a non-verbal basis that we are here for you, we are not a threat, and we are trying, at the most basic level of our consciousness, the cellular, to show up and empathize.

Matching body language, tone, volume, and eye contact of the host culture is a concept called 'mirroring', Recent research has pinpointed parts of the brain called "mirror neurons".

“With knowledge of these neurons, you have the basis for understanding a host of very enigmatic aspects of the human mind: "mind reading" empathy, imitation learning, and even the evolution of language. Anytime you watch someone else doing something (or even starting to do something), the corresponding mirror neuron might fire in your brain, thereby allowing you to "read" and understand another's intentions, and thus to develop a sophisticated "theory of other minds." . (MIRROR NEURONS and imitation learning as the driving force behind "the great leap forward" in human evolution By V.S. Ramachandran http://www.edge.org/3rd_culture/ramachandran/ramachandran_p2.html)

" It seems we're wired to see other people as similar to us, rather than different."
Vittorio Gallese University of Parma

"Mirror neurons are a type of brain cell that respond equally when we perform an action and when we witness someone else perform the same action. They were first discovered in the early 1990s, when a team of Italian researchers found individual neurons in the brains of macaque monkeys that fired both when the monkeys grabbed an object and also when the monkeys watched another primate grab the same object."Winerman, L.,, The mind's mirror: A new type of neuron--called a mirror neuron--could help explain how we learn through mimicry and why we empathize with others. APA Monitor, Volume 36, No. 9 October 2005

http://www.apa.org/monitor/oct05/mirror.html

We began to receive a series of e-mails for the Sri Lanka trip, with increasingly specific instructions:

Brave Team Members,
I would like to say thanks and congratulations to all of you! While what will surely be quite an adventure. We plan to have some team meetings and intervention review in Singapore.
We arrive in Sri Lanka late Sunday night, and will have a cultural/political background orientation conducted by Operation USA on Monday morning. After that meeting, we will register with the embassy, and the teams will separate into 5 and 3 person groups for the rest of the trip.
Health precautions: Even if you have done nothing else, you still have time to acquire a Malaria prophylaxis, tetanus shot, and flu shot. Malaria can be transmitted through mosquitoes, so repellant will also be very useful in this aspect. As with most third world countries, scented shampoos and lotions are NOT the best idea, as they tend to attract bugs/mosquitoes.

Later, we received this e-mail:

Both teams:
Thanks to everyone for your patience over the weekend. Now prepare to be bombarded with too much information at once. We have spent the last three days in meetings and preparations for the teams to leave.
From our meeting with OP USA:
• Each team will be separated into two “sub-teams” on Monday and for the rest of their respective trips. Five people will be traveling to Batticaloa immediately after the political/cultural meeting on Monday. This is probably an 8 hour drive all the way across the island to the most effected area. This part of the team will be spending each day in a different area near Batticaloa. The remaining three people will make several trips south to other villages. One of them is Galle.
• Final words on what to wear: Everyone is expected to wear long pants. Jeans are just a bad idea, it will be very hot and humid. Women will be expected to wear their hair up or back. Absolutely no form fitting shirts. No shirts cut below the neck line. Most of the places we’ll be going are extremely conservative. You may wear any footwear you want, including sandals.
• Americans have a high sensitivity to personal space. This concept is all but disregarded where we are going.
From our meeting with Janine and other info from APT:
• We will be adhering to a very specific intervention protocol. Janine will be emailing the outline that we will be using in our trainings in Singapore. This will give you an idea of what kind of interventions will be used. These interventions have been reviewed by Operation USA to help ensure cultural appropriateness and feasibility.
I am extremely optimistic about the work we will be doing, and can’t wait to work with you in Sri Lanka. This is such a groundbreaking opportunity, the first of it’s kind for the APT to form such a task force. There is a lot more information to be disseminated, and I'm sure many of you have remaining questions. Many of these will be covered at the meetings that we have scheduled in Singapore and Colombo. We have a long flight to cover this as well. Thanks for your attention.

_________________________________________________________________

To further prepare, especially emotionally, I go to the Center for Disease Control, the National Center for Post Traumatic Stress Disorder, and the  National Center for Child Traumatic Stress. The following articles are in the public domain.

Disaster Rescue and Response Workers

A National Center for PTSD Fact Sheet

by Bruce H. Young, L.C.S.W., Julian D. Ford, Ph.D. and Patricia J. Watson, Ph.D.

The terrorist attacks on New York and Washington are, together, the greatest man-made disaster in America since the Civil War. Lessons learned from natural and human-caused disasters can help us understand the unique stressors faced by rescue workers such as police and firefighters, National Guard members, emergency medical technicians, and volunteers. Past experience may also help us recognize how these stressors may affect response workers. Rescue workers face the danger of death or physical injury, the potential loss of their coworkers and friends, and devastating effects on their communities. In addition to physical danger, rescue workers are at risk for behavioral and emotional readjustment problems.

What psychological problems can result from disaster experiences?

The psychological problems that may result from disaster experiences include:

• Emotional reactions: temporary (i.e., for several days or a couple of weeks) feelings of shock, fear, grief, anger, resentment, guilt, shame, helplessness, hopelessness, or emotional numbness (difficulty feeling love and intimacy or difficulty taking interest and pleasure in day-to-day activities)
• Cognitive reactions: confusion, disorientation, indecisiveness, worry, shortened attention span, difficulty concentrating, memory loss, unwanted memories, self-blame
• Physical reactions: tension, fatigue, edginess, difficulty sleeping, bodily aches or pain, startling easily, racing heartbeat, nausea, change in appetite, change in sex drive
• Interpersonal reactions in relationships at school, work, in friendships, in marriage, or as a parent: distrust; irritability; conflict; withdrawal; isolation; feeling rejected or abandoned; being distant, judgmental, or over-controlling

What severe stress symptoms can result from disasters?

Most disaster rescue workers only experience mild, normal stress reactions, and disaster experiences may even promote personal growth and strengthen relationships. However, as many as one out of every three rescue workers experience some or all of the following severe stress symptoms, which may lead to lasting Posttraumatic Stress Disorder (PTSD), anxiety disorders, or depression:

• Dissociation (feeling completely unreal or outside yourself, like in a dream; having "blank" periods of time you cannot remember)
• Intrusive reexperiencing (terrifying memories, nightmares, or flashbacks)
• Extreme attempts to avoid disturbing memories (such as through substance use)
• Extreme emotional numbing (completely unable to feel emotion, as if empty)
• Hyper-arousal (panic attacks, rage, extreme irritability, intense agitation)
• Severe anxiety (paralyzing worry, extreme helplessness, compulsions or obsessions)
• Severe depression (complete loss of hope, self-worth, motivation, or purpose in life)

Who is at greatest risk for severe stress symptoms?

Rescue workers who directly experience or witness any of the following during or after the disaster are at greatest risk for severe stress symptoms and lasting readjustment problems:

• Life threatening danger or physical harm (especially to children)
• Exposure to gruesome death, bodily injury, or dead or maimed bodies
• Extreme environmental or human violence or destruction
• Loss of home, valued possessions, neighborhood, or community
• Loss of communication with or support from close relations
• Intense emotional demands (such as searching for possibly dying survivors or interacting with bereaved family members)
• Extreme fatigue, weather exposure, hunger, or sleep deprivation
• Extended exposure to danger, loss, emotional/physical strain
• Exposure to toxic contamination (such as gas or fumes, chemicals, radioactivity)

Studies also show that some individuals are at a higher than typical risk for severe stress symptoms and lasting PTSD if they have a history of:

• Exposure to other traumas (such as severe accidents, abuse, assault, combat, rescue work)
• Chronic medical illness or psychological disorders
• Chronic poverty, homelessness, unemployment, or discrimination
• Recent or subsequent major life stressors or emotional strain (such as single parenting)

Disaster stress may revive memories of prior trauma and may intensify preexisting social, economic, spiritual, psychological, or medical problems.

How can you manage stress during a disaster operation?

Here are some ways to manage stress during a disaster operation:

Develop a "buddy" system with a coworker.

Encourage and support your coworkers.

Take care of yourself physically by exercising regularly and eating small quantities of food frequently.

Take a break when you feel your stamina, coordination, or tolerance for irritation diminishing.

Stay in touch with family and friends.

Defuse briefly whenever you experience troubling incidents and after each work shift.

How can you manage stress after the disaster?

After the disaster:

• Attend a debriefing if one is offered, or try to get one organized 2 to 5 days after leaving the scene.
• Talk about feelings as they arise, and be a good listener to your coworkers.
• Don't take anger too personally - it's often an expression of frustration, guilt, or worry.
• Give your coworkers recognition and appreciation for a job well done.
• Eat well and try to get adequate sleep in the days following the event.
• Maintain as normal a routine as possible, but take several days to "decompress" gradually.

How can you manage stress after returning home?

After returning home:

• Catch up on your rest (this may take several days).
• Slow down - get back to a normal pace in your daily life.
• Understand that it's perfectly normal to want to talk about the disaster and equally normal not to want to talk about it; but remember that those who haven't been through it might not be interested in hearing all about it -they might find it frightening or simply be satisfied that you returned safely.
• Expect disappointment, frustration, and conflict -sometimes coming home doesn't live up to what you imagined it would be -but keep recalling what's really important in your life and relationships so that small stressors don't lead to major conflicts.
• Don't be surprised if you experience mood swings; they will diminish with time.
• Don't overwhelm children with your experiences; be sure to talk about what happened in their lives while you were gone.
• If talking doesn't feel natural, other forms of expression or stress relief such as journal writing, hobbies, and exercise are recommended.

Taking each day one at a time is essential in disaster's wake. Each day provides a new opportunity to FILL-UP:

* Focus Inwardly on what's most important to you and your family today;

* Look and Listen to learn what you and your significant others are experiencing, so you'll remember what is important and let go of what's not;

* Understand Personally what these experiences mean to you, so that you will feel able to go on with your life and even grow personally.

______________________________________________________________________________

Sri Lanka Shelter
Photograph by Kate Amatruda

Psychological Impact of the Tsunami Across the Indian Rim

National Child Traumatic Stress Network
www.NCTSNet.org

The massively destructive Tsunami that struck across the Indian Rim caused extensive loss of life and injury as well as devastation to property and community resources. The combination of life-threatening personal experiences, loss of loved ones and property, massive disruption of routines and expectations of daily life, pervasive post-disaster adversities, and enormous economic impact on families and entire nations pose an extreme psychological challenge to the recovery of children and families in the affected areas. This brief information sheet provides an overview of expected psychological and physical responses among survivors. The key concepts include:

o Reactions to Danger
o Posttraumatic Stress Reactions
o Grief Reactions o Traumatic Grief o Depression
o Physical Symptoms o Trauma and Loss Reminders
o Post-disaster Adversity/Disruption

Appreciating the psychological implications of such an overwhelming event on the lives of the survivors plays a crucial role in considering specific efforts that will be of greatest help to the affected communities. The following issues may be helpful to consider in efforts to respond to disaster victims:

Reactions to Danger

It is important to recognize the difference between a sense of danger and reactions to traumatic events. Danger refers to the sense that events or activities have the potential to cause harm. In the wake of the recent disaster, people and communities have greater appreciation for the enormous danger of a Tsunami and the need for an effective early warning system. There are likely to be widespread fears of recurrence that are increased by misinformation and rumors. Danger always increases the need and desire to be close to others, making separation from family members and friends more difficult.

Posttraumatic Stress Reactions

These reactions are common, understandable, and expectable, but are nevertheless serious and can lead to many difficulties in daily life. There are three types of posttraumatic stress reactions. Intrusive Reactions are ways the traumatic experience comes back to mind.

These include:

o recurrent upsetting thoughts or images that occur while awake or dreaming
o strong emotional or physical reactions to reminders of the Tsunami
o feelings and behavior as if something as terrible as the Tsunami is happening again

Avoidance and Withdrawal Reactions include:
o avoiding talking, thinking, or having feelings about the Tsunami
o avoiding places and people connected to the event
o feeling emotionally numb, detached or estranged from others o losing interest in usually pleasurable activities

Physical Arousal Reactions are physical changes that make the body react as if danger is still present.

These include:
o constantly being “on the lookout” for danger
o being startled easily or being jumpy or nervous
o feeling ongoing irritability or having outbursts of anger
o having difficulty falling or staying asleep or having restless, easily disturbed sleep
o having difficulty concentrating or paying attention

Children may show some of these reactions through their play or drawing. They may have bad dreams that are not specific to the Tsunami. In addition to increased irritability, children may also have physical complaints (headaches, stomachaches, vague aches and pains). Sometimes these are difficult to distinguish from true medical concerns.

Grief Reactions

Those who survived the Tsunami have suffered many types of losses – including loss of loved ones, home, possessions, and community. Loss may lead to:

o feelings of sadness and anger
o guilt or regret over the loss
o missing or longing for the deceased
o dreams of seeing the person again

These grief reactions are normal, vary from person to person, and can last for many years after the loss. There is no single “correct” course of grieving. Personal, family, religious and cultural factors affect the course of grief. Although grief reactions may be painful to experience, especially at first, they are healthy reactions and reflect the ongoing significance of the loss. Over time, grief reactions tend to include more pleasant thoughts and activities, such as positive reminiscing or finding positive ways to memorialize or remember a loved one. One of the many untoward results of the Tsunami is that some family members’ bodies have not been found. This, unfortunately, has prevented the normal use of religious, and cultural burial and mourning rituals, and has put the experience of grief on hold. Whereas trauma is more restricted to personal experience of the Tsunami, loss and grief extend well beyond the impacted areas, indeed across the world.

Traumatic Grief

People who have suffered the traumatic loss of a loved one often find grieving more difficult. Their minds stay on the circumstances of the death, including preoccupations with how the loss could have been prevented, what the last moments were like, and issues of accountability. These reactions include:
o intrusive, disturbing images of the manner of death that interfere with positive remembering and reminiscing
o delay in the onset of healthy grief reactions
o retreat from close relationships with family and friends, and avoidance of usual activities because they are reminders of the traumatic loss

Traumatic grief changes the course of mourning, putting individuals on a different time course than is usually expected by other family members, religious rituals, and cultural norms that offer support and comfort.

Depression

Over time, the risk of depression after the Tsunami is an additional major concern. Depression is associated with prolonged grief and strongly related to the accumulation of post-Tsunami adversities. Symptoms include:
o persistent depressed or irritable mood
o loss of appetite
o sleep disturbance, often early morning awakening
o greatly diminished interest or pleasure in life activities
o fatigue or loss of energy
o feelings of worthlessness or guilt
o feelings of hopelessness, and sometimes thoughts about suicide

Demoralization is a common response to acutely unfulfilled expectations about improvement in post-disaster adversities, and resignation to adverse changes in life circumstances.

Physical Symptoms Survivors of the Tsunami may experience physical symptoms, even in the absence of any underlying physical injury or illness. These symptoms include:
o headaches, dizziness
o stomachaches, muscle aches
o rapid heart beating
o tightness in the chest
o loss of appetite
o bowel problems

In particular, near-drowning experiences can lead to panic reactions, especially in response to reminders. Panic often is expressed by cardiac, respiratory, and other physical symptoms. More general anxiety reactions are also to be expected. Physical symptoms often accompany posttraumatic grief and depressive reactions. More generally, they may signal elevated levels of life stress.

Trauma and Loss Reminders

Posttraumatic stress reactions are often evoked by trauma reminders. Many people continue to encounter places, people, sights, sounds, smells, and inner feelings that remind them of the Tsunami experience. The ocean has become a powerful reminder. Additionally, the tide simply going out or even the wave in a bathtub while bathing a child can act as a disturbing reminder. Because the Tsunami was accompanied by a loud roar and the crashing of waves, loud noises can be strong reminders. Reminders can happen unexpectedly, and it can take quite a while to calm down afterward. Adults and children are often not aware that they are responding to a reminder, and the reason for their change in mood or behavior may go unrecognized. The day of the week, the time of day, and the anniversary date are common reminders. Television and radio news coverage can easily serve as unwelcome reminders. It is particularly difficult when family members have been together during a traumatic experience, because afterward they can serve as trauma reminders to each other, leading to unrecognized disturbances in family relationships.

Grief reactions are often evoked by loss reminders. Those who have lost loved ones continue to encounter situations and circumstances that remind them of the absence of their loved one. These reminders can bring on feelings of sadness, emptiness in the survivor's life, and missing or longing for the loved one's presence.

There are several types of loss reminders: Empty situations occur when one would be used to being with a loved one and they are no longer there, for example at the dinner table, during activities usually done together, and on special occasions, like birthdays and holidays. Children, adolescents, and adults also are reminded by the everyday changes in their lives, especially hardships that result from the loss. Examples include temporary or changed caretakers, decreases in family income, depression and grief reactions in other family members, disruptions in family functioning, increased family responsibilities, lost opportunities (for example, sports, education, and other activities), and the loss of a sense of protection and security.

Post-disaster Adversities/Disruption

Successfully addressing the multitude of post-disaster adversities not only saves lives, protects health, and restores community function, but constitutes an important mental health intervention. Contending with adversities such as lack of shelter, food and other resources, and disruption of daily routines can significantly deplete coping and emotional resources and, in turn, interfere with recovery from posttraumatic stress, traumatic grief, and depressive reactions. Post-disaster medical treatment and ongoing physical rehabilitation can be another source of post-disaster stress. New or additional traumatic experiences and losses after the initial experience are known to exacerbate distress and interfere with recovery. Likewise, distress associated with prior traumatic experiences or losses can be renewed by the experience of the Tsunami.

Children’s recovery is put in jeopardy without proper caretaking, reunification with family members, and restoration of normal daily routines – for example, schooling. Some adversities require large-scale responses, while others can be addressed, in part, by personal and family problem solving.

What Are the Consequences of These Reactions?

Post-disaster reactions can be extremely distressing and may significantly interfere with daily activities. For adults, posttraumatic stress, grief, and depressive reactions can impair effective decision-making, so vital in adapting to the recovery environment. They also compromise parenting. For children and adolescents, intrusive images and reactivity to reminders can seriously interfere with learning and school performance. Worries and fears may make it difficult for young children to return to school or to venture any distance from parents or caregivers.

Avoidance of reminders can lead adolescents to place restrictions on important activities, relationships, interests and plans for the future. Irritability can interfere with getting along with family members and friends. Trauma-related sleep disturbance is often overlooked, but can be especially persistent and affect daytime functioning. Adolescents and adults may respond to a sense of emotional numbness or estrangement by using alcohol or drugs. They may engage in reckless behavior. Adolescents may become inconsistent in their behavior, as they respond to reminders with withdrawal and avoidance or overly aggressive behavior. Over time, there may be increases in marital discord and domestic violence.

Depressive reactions can become quite serious, leading to a major decline in school or occupational performance and learning, social isolation, loss of interest in normal activities, self-medication with alcohol or drugs, acting-out behavior to try to mask the depression, and, most seriously, attempts at suicide.

Traumatic grief can lead to the inability to mourn, reminisce and remember, fear a similar fate or the sudden loss of other loved ones, and to difficulties in establishing or maintaining new relationships. Adolescents may respond to traumatic losses by trying to become too self-sufficient and independent from parents and other adults, or by becoming more dependent and taking less initiative.

Coping after Disaster

In addition to meeting peoples basic needs for food, water, shelter, clothing and medicine, there are several ways to enhance people’s coping. Physical: Stress can be reduced with proper nutrition, exercise and sleep. People may need to be reminded that they should take care of themselves physically to be of help to families and communities. Emotional: People need to be reminded that their emotional reactions are normal and expected, and will decrease over time. However, if their reactions are too extreme or do not diminish over time, there are professionals who can be of help. Social: Communication with, and support from, family members, friends, religious institutions and the community are very helpful in coping after a disaster. People should be encouraged to communicate with others, and to seek and use this support where available.

Daily Routines: For children especially, it is important to restore normal routines, including mealtimes, bedtime) as much as possible. Children feel more safe and secure with structure and routine. Meeting basic survival needs, restoring a sense of safety and security, and providing opportunities for normal development within the social, family and community context are important steps to the recovery of children and adolescents.

source: http://www.nctsnet.org/nccts/asset.do?id=603
This project was funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), US Department of Health and Human Services (HHS). The views, policies, and opinions expressed are those of the authors and do not necessarily reflect those of SAMHSA or HHS.

 

What do you pack to go to a disaster?

We received this e-mail from Joseph Wehrman, one of our Sri Lanka team members:

 

What to do before you go to a disaster

There are many professional and personal things to take care of before you leave. Professional: o Contact your back-up colleague(s) to see if they can cover your practice while you are gone. o Notify your clients to let them know when you plan to return, and who is covering your practice while you are gone (All my clients know that I do emergency mental health, so when a disaster strikes, they know that I might be going away. We spend time in sessions processing what that evokes for them.) o Change your message on your answering machine. o Make a plan to notify clients if there is an emergency (We should all have a list of current clients, their phone numbers, and a professional will to dispose of and distribute confidential material in the event of our deaths anyway. Do we? NO...so at least leave a sealed envelope with current client names and phone numbers, with instructions on who should open it to contact your clients if you are delayed, injured, or worse...) o Decide if you want to bring a list of client phone numbers with you, in case your return is delayed and you want to contact them yourself. o Do not give clients a way to contact you in an emergency. They should go through the person who is covering your practice. If you can not bear to be out of contact with your clients during your deployment, please re-think if you should go. You will be stressed and exhausted doing disaster mental health, and it is often difficult to find a working phone. o Be prepared for your clients to express anger at you, and to feel abandoned. They may feel that you are awful for going, not the generous, compassionate volunteer that you are. o If appropriate, call the local newspaper to tell them of your deployment, ending with a plea to donate to the group that is sponsoring you. Personal o Make sure your family feels loved by you. Take time to really explain to them why you are going. o Make sure you feel loved and supported by your family. o Tell your friends that you are going, and why. o If you have children, notify the school, teacher, bus driver, and community about your trip. My son Colety is 13, so I send out an e-mail to his teacher and the parents of his friends: Dear all, Thank you again for your support! I will be deployed by as a Disaster Mental Health Services volunteer on Thursday, September 8 for up to two weeks and just received an e-mail stating I am going to the Houston Astrodome. Please keep your hearts and homes open for Colety - in addition to my going to the Astrodome, he is getting braces today! Roy and Colety are very very supportive of my going to help out, and they both wish they could come. (Colety is also very excited about getting braces.) I am hoping that some of you will allow Colety to come home with your child after school. Roy takes the Vanpool to his work at UC Berkeley, and is back in Novato around 6:00. What I am hoping is that for this week (Thursday and Friday) and all of next week, Colety can go home after school with one of your children, and do LOTS of homework (ha ha!!! we've been struggling with that one for years!) or just play, until Roy can pick him up around 6:00. If you can help out, please e-mail or call me today (Wednesday) because I am leaving at 5:30 am tomorrow. I am excited and terrified - my heart has been breaking, watching the suffering of the people as I watch CNN. The Astrodome is perhaps now the 'emotional ground zero' of the evacuees - these people have lost their homes, their jobs, sometimes their families and friends. Their sense of safety was further compromised in New Orleans, at the Superdome, when the roof was destroyed, rain poured in, assaults and rapes occurred, and there was no power or water. All the best (and please wish me luck!!) Kate

 

 

 

The Journey

Usually, by the time I get on the plane, I am so exhausted from the adrenaline rush of getting ready that I just fall asleep! If you are awake, it is nice to hook up with fellow disaster workers on the plane, if possible. You can share your excitement and fears, and compete on who had the least time to get ready.

When I went to Sri Lanka, I was part of a group, so we meet at LAX to begin the arduous journey to Sri Lanka. We were able to sit together, and played 'musical chairs', switching seats to get to know each other, and grabbing sleep when we could.

We had received this e-mail from our leader, David, prior to departure:

I thought you would be interested to know:

LA to Tokyo is 11h 40m long. One hour layover in Tokyo, we will get off the plane, walk around, re-charge mp3 players, get back on.

Tokyo to Singapore is 7h 30m long.

Singapore to Colombo 3h 35m.

Yes, that's 22 hours and 45 minutes in airplanes before we have any interaction with children. Are we there yet? Maybe we can play with kids on the plane.

 

Being deployed with the other groups may be more independent. You call the travel bureau, and book your own flight. I wore my identifying jacket on the plane, so was easily identifiable. There were people on the flight who were also going to DR 009, and we were able to meet and share a cab to disaster headquarters.

Arrival - the Beginnings of Chaos

Be prepared for chaos! You are going to an area that has suffered a massive disaster.

Expect the unexpected.

Be flexible.

Follow directions, even if they don't seem to make a lot a sense.

Be compassionate.

Be prepared to hurry up and wait.

Be very very patient.

Bring a good book to read while you are waiting, with your baggage, in hot crowded hallway, with hundreds of other volunteers.

Make sure the people checking you in know that you are with disaster mental health, and have a copy of your license readily available.

Do not be a prima donna - this is not about you!

Drink lots of water!

On Site Training

Chances are you will receive very little on-site training; perhaps just an orientation to the current disaster (how many evacuees there are; where they are housed), basic health (use Purell, whether or not the water is Ok to drink, etc.) and safety information (travel in pairs). Much of what is covered is logistics; transportation to and from the shelter, phone numbers, etc.

 

In Sri Lanka, we were fortunate to have training specific to the culture as well as the protocols we were going to do with the children. We reviewed the principles of Psychological First Aid, after physical safety was assured, that food and shelter needs were met, that the interventions would focus on building strength and resilience in the children who survived the tsunami. We were taught to assess coping skills, knowing that the people would be in "Immediate postdisaster phase: recoil and rescue"and the "recovery" phase. They were no longer in the acute aftermath of the tsunami; enough time had passed to employ slightly different tools to assist in psychological recovery.

 

Phases of Traumatic Stress Reactions in a Disaster
A National Center for PTSD Fact Sheet
Disasters and terrorist attacks are often widespread with many people who directly experience the event and many more who may witness or be indirectly impacted. Many people may encounter behavioral and emotional readjustment problems. Many posttraumatic stress symptoms are normal responses to overwhelming stressors. Exposure to these overwhelming stressors may change our assumptions about life and create distress, but the intensity of this distress will subside with time. Experts agree that the amount of time it takes people to recover depends both on what happened to them and on what meaning they give to those events.
Terroristic acts may result in a whole society questioning the fundamental view of the world as a predictable, just, and meaningful place to live. This questioning is amplified by the fact that organized violence is intentional; it often has a political agenda; and it is meant to create terror, destroy, and hurt. Studies have shown that deliberate violence creates longer lasting mental-health effects than natural disasters or accidents. The consequences for individuals and the community are long lasting and survivors often feel that injustice has been done to them. This can lead to anger, frustration, helplessness, fear, and a desire for revenge. Reestablishing meaningful patterns of interactions in the community after a trauma may facilitate reconstruction of a sense of meaning and purpose. Prior research into terroristic events and disasters has shown that reactions to these events may be categorized into different phases.
Impact phase
Most people respond appropriately during the impact of a disaster and react to protect their own lives and the lives of others. This is a natural and basic reaction. A range of such behaviors can occur, and these may also need to be dealt with and understood in the postdisaster period. After the fact, people may judge their actions during the disaster as not having fulfilled their own or others' expectations of themselves.
During the impact phase, some people respond in a way that is disorganized and stunned, and they may not be able to respond appropriately to protect themselves. Such disorganized or apathetic behavior may be transient or may extend into the postdisaster period, so that people may be found wandering helpless in the devastation afterwards. These reactions may reflect cognitive distortions in response to the severe disaster stressors and may for some indicate a level of dissociation.
Several stressors may occur during impact, which may subsequently have consequences for the person:
* Threat to life and encounter with death
* Feelings of helplessness and powerlessness
* Loss (e.g., loved ones, home, possessions)
* Dislocation (i.e., separation from loved ones, home, familiar settings, neighborhood, community)
* Feeling responsible (e.g., feeling as though could have done more)
* Inescapable horror (e.g., being trapped or tortured)
* Human malevolence (It is particularly difficult to cope with a disaster if it is seen as the result of deliberate human actions.)
Immediate postdisaster phase: recoil and rescue
This is the phase where there is recoil from the impact and the initial rescue activities commence. Initial mental-health effects may appear (e.g., people show confusion, are stunned, or demonstrate high anxiety levels). Emotional reactions will be variable and depend on the individual's perceptions and experience of the different stressor elements noted earlier. Necessary activities of the rescue phase may delay these reactions, and they may appear more as the recovery processes get under way. Reactions may include:
* Numbness
* Denial or shock
* Flashbacks and nightmares
* Grief reactions to loss
* Anger
* Despair
* Sadness
* Hopelessness
Conversely, relief and survival may lead to feelings of elation, which may be difficult to accept in the face of the destruction the disaster has wrought.
Recovery phase
The recovery phase is the prolonged period of adjustment or return to equilibrium that the community and individuals must go through. It commences as rescue is completed and individuals and communities face the task of bringing their lives and activities back to normal. Much will depend on the extent of devastation and destruction that has occurred as well as injuries and lives lost (Raphael, 1993).
This period may be associated with a honeymoon phase deriving from the altruistic and therapeutic community response immediately following the disaster. A disillusionment phase may soon follow when the disaster is no longer on the front pages of newspapers, organized support starts to be withdrawn, and the realities of losses, bureaucratic constraints, and the changes wrought by the disaster must be faced and resolved (Raphael, 1986).
During the stage of acute danger the priority for all is basic safety and survival. Once this is relatively secured, other needs emerge that are both existential and psychological. And once manifest, these needs are typically left frustrated and unfulfilled for a prolonged period of time. Many times, through the media, retribution, or continued violence, the community in question is exposed to further traumatic events.
It is particularly important to remember that emotional needs may be very significant, especially for those who have been severely affected. They may only start to appear during this phase. People may also be hesitant to express distress, concern, or dissatisfaction, feeling they should be grateful for the aid given or because they have suffered less than others have. It should be noted that sometimes emotional reactions may present as physical health symptoms, such as sleep disturbance, indigestion, and fatigue, or they may present as social effects such as relationship or work difficulties.
Excerpted from Raphael, Disaster Mental Health Response Handbook, NSW Health, 2000
Copies available from:
The NSW Institute of Psychiatry
Telephone: (02) 9840 3833
Fax: (02) 9840 3838
Email: inspsy@magna.com.au
Website: www.nswiop.nsw.edu.au

 

Treating Survivors in the Acute Aftermath of Traumatic Events
A National Center for PTSD Fact Sheet
Excerpted with permission, from a chapter written by Arieh Y. Shalev, M.D., Department of Psychiatry, Hadassah University Hospital, Jerusalem to appear in R. Yehuda (Ed.), Treating Trauma Survivors with PTSD: Bridging the Gap Between Intervention Research and Practice. Washington, DC: American Psychiatric Press.

Shalev writes:

A stable narrative of the traumatic events and of one's own responses is formed and consolidated during the short period that follows trauma and shapes how the event will be remembered. Memories of a traumatic event can be influenced by social appraisals of behaviors during or following the event (e.g., shameful, virtuous, dishonorable, heroic, cowardly, etc.). Extreme social labels are often counter-productive because they make it harder for survivors to process the complexities and ambiguity of their own experience.

Phases of coping with traumatic stress
Responses in the days that follow trauma are characterized by being under stress, use of extreme defenses, (such as over control of emotions or dissociation), and a focus on physical and emotional survival.
A later period of reappraisal and reevaluation has the main psychological task of assimilation of events and their consequences. This period is characterized by intrusive recollections of the traumatic event.
Both periods can be physically and psychologically demanding.
Coping styles vary from action prone to reflective and analytical, from emotionally expressive to reticent. Clinically, response style is not as ultimately important as the degree to which coping efforts are successful as defined by the survivor's ability to:
* Continue task-oriented activity
* Regulate emotion
* Sustain positive self value
* Maintain and enjoy rewarding interpersonal contacts

Indicators of effective coping include: a low degree of distress (though this should not be confused with numbing or blunted affect); intrusive recollections that lead a survivor to recruit sympathy and help; upon repetition, the trauma narrative becomes richer, includes other elements, and takes on a reflective tone (e.g., "When I think about it now, I could have done worse."); nightmares change from mere repetition of the event to more remote renditions.

Indicators of more pathological responses include: continuous distress without periods of relative calm or rest; severe dissociation symptoms that continue following a return to safety; intense intrusive recollections that are fearfully avoided, experienced as a torment, or seriously interfere with sleep; extreme social withdrawal; the inability to think about rather than just emotionally experience the trauma.

Evolution of symptoms over time.
This includes the quality, intensity, and development of early responses. Assess content and structure of trauma narrative as it evolves (including concrete descriptions, subjective appraisals, emotional responses) without pointing out inconsistencies or making interpretations. Notice whether narrative becomes richer, includes more elements, takes on a reflective tone.
* Coping efficacy: degree to which symptoms are tolerated by survivor or interfere with functioning.
Can the survivor continue task-oriented activity? How well organized, goal directed, and effective is such activity? Is the survivor overwhelmed by strong emotions most of the time? Can emotions be modulated when such modulation is required? Is the survivor inappropriately blaming himself or herself? Does the survivor generalize such accusations to his or her personality or self? How isolated, alienated, or withdrawn is the survivor? Does he seek the company of others or avoid it?
* Availability of healing resources.
Includes access to social support, nature of societal response.
Interventions
General principles
* Help providers must be tolerant of symptomatic behavior, strong emotions.
* Help providers must respect the survivor's ability to self-regulate and monitor his or her environment.
* Help providers must break the wall of mental isolation that can follow trauma exposure and must maintain continuity of care so that survivors do not begin to feel betrayed and re-isolate.
* Help providers must provide care that is tailored to the needs, capacities, and desires of survivors.
* The survivor must be able to properly utilize and enjoy what is offered. Stress responses may reduce such capacity.
Generic goals of early interventions
* To reduce psychobiological distress and the effects of secondary stressors.
* To treat specific symptoms when they interfere with normal healing processes.
* To assist the normal healing process by supporting the survivor and helpers, by seeing that such helpers are available, that families are evacuated together, etc.
* To follow progress by continued assessment of global coping efficacy.
Interventions in the different phases of the acute response
Peri-traumatic period
* Protect from further exposure to stress, contain the immediate physiological and psychological responses, and increase controllability of the event and of subsequent rescue efforts.
* Be aware of and responsive to survivor's comfort and dignity (e.g., by covering his or her body, avoiding intrusive looks of others and of the media).
* Reorient survivor within the rescuing environment, identify self and role.
* Continuously inform survivors about steps to be taken (e.g., evacuation to a hospital), medication given (e.g., morphine), and other information.
* Provide genuine information (including admitting lack of information) but avoid breaking bad news if possible.
* Maintain human contact with survivors throughout rescue efforts.
* Bring in natural helpers (e.g., relatives, friends) and support them with advice and information.
* If survivors have difficulty expressing their experience verbally, use other bodily and emotional channels are open for communication. E.g., comforting touch (with respect for gender and social boundaries), physical comforts (warmth, hot showers, clean clothes), favorite music, foods, books, movies.
* Whenever possible, reconnect or evacuate survivors with their family and friends.
Addressing Early Responses
Early post-trauma interventions should aim to facilitate psychological recovery and disable progressive sensitization.
* Encourage survivors to verbalize and share their individual story with others.
While telling the story is stressful and rarely without strong emotion, it also creates an emotional bond that reduces the survivor's isolation.
* Expect oscillation between periods of extreme anguish and relative rest.
* Encourage grieving for losses and re-adaptation (new learning about self /others).
* Encourage survivors to express painful emotions (verbally, through art, music).
* Attempt to interrupt continuous distress.
* Encourage survivors to be with others.
* Encourage increased thinking about the trauma (rather just experiencing).
* Allow for specific recovery styles to develop in individuals and families (one may talk and another may be silent).
* Assess the strengths and the weakness of the survivor's immediate supporters.
* Explain meaning of symptoms and recovery process to survivors and their helpers.
Treating Emergent or Unremitting Symptoms Upon Return to Normal Activities
* Survivors may become more symptomatic as they prepare to leave the hospital.
* Phobic responses, major depression, and acute PTSD may become evident because they start to interfere with normal tasks.
* If there are new or unremitting symptoms 4 or more weeks after return to a safe environment, survivor may require professional care.
Specific techniques
Crisis interventions and stress management
* These interventions attempt to stop the vicious circle of catastrophic appraisal and extreme distress, address survivors' perception that their reaction is abnormal or that they have totally lost their inner strength, move subjects from a stage of disarray to a stage of effective coping.
* Excessive distress is thought to impair effective problem solving, and coping.
* Steps of crisis interventions include 1. Appraising with the individual what specific elements in a given situation create intolerable distress. 2. Recognizing, legitimizing, and challenging the perceived totality of the situation. 3. Addressing efforts already made to solve the salient problem. 4. Assessing other ways of problem-solving, other resources, alternative plans of action (such as effective help-seeking, postponing efforts to find a solution, and focusing on alternative goals).

http://www.katrinaskidsproject.org/
Photograph by Janine Schueppert

Hurry up and Wait
Your Assignment - It's Not about you

Please do whatever task you are assigned!  It may not be what you want to do, and your leader may have much less experience than you do, but now is the time to pitch in and support the work of your team and the entire project. Giving out water to people in line may not seem to be the best use of your education, training, and experience, but if that is your assignment, say "yes" and do it with good grace. You might be surprised to learn how effective you can be, just by being present.

 

"A gathering cloud looms over the patchwork landscape of psychotherapy: the growing certainty that, despite decades of divergent rectification and elaboration, therapeutic techniques per se have nothing to do with results….Strip away a therapist’s orientation, the journals he reads, the books on his shelves, the meetings he attends – the cognitive framework his rational mind demands – and what is left to define the psychotherapy he conducts?

Himself. The person of the therapist is the converting catalyst, not his order or credo, not his spatial location in the room, not his exquisitely chosen words nor denominational silences. So long as the rules of a therapeutic system do not hinder limbic transmission – a critical caveat – they remain inconsequential, neocortical distractions. The dispensable trappings of dogma may determine what a therapist thinks he is doing, what he talks about when he talks about therapy, but the agent of change is who he is…. "
(A General Theory of Love by Thomas Lewis, M.D., Richard Lannon, M.D., and Earl Amini, M.D. Vintage Books, 2001., p. 186-187)

 

It is important to FOLLOW THE PROTOCOLS of the group that has sent you to the disaster. This means, even if you are the most skilled EMDR practitioner in the world, if the group with which you are working does not allow EMDR as a treatment, that you can not do it.  This can be very frustrating, especially if you have experience with a specific technique. 

Beware of the 'lone wolf'' syndrome. Being a 'lone wolf'' can be a very good trait, particularly if you are in a private practice. The positive pole of the 'lone wolf' 'archetype is independence, and saying '"no" to collective values. It does not, however, translate well to disaster mental health. When there are thousands of evacuees, and hundreds of disaster volunteers, there is no tolerance for those who go off on their own. Please remember, "It's not about you"!

The negative pole of the archetype is discussed by Tim Herlocker, special agent-in-charge of intelligence for the counterterrorism division of the FBI's New York office. ''The lone wolf, when influenced by day-to-day events, is harder to stop, harder to know about, much more difficult to defend against.'' (http://www.officer.com/article/article.jsp?siteSection=8&id=25303)

At the Katrina relief effort, some disaster mental health workers were sent home for going to the Astrodome without permission. Be a team player (a concept remarkably alien to many of us in the mental health field.)

The Work

Stealth Mental Health

Photograph by Chris Lewis

What if you got all ready,
studied your materials on disaster mental health and psychological first aid,
and no one came?

Many people still avoid mental health services, feeling there is a stigma attached to needing help. In a way this makes sense. If they have survived the disaster, they have a certain amount of resilience. They have made really good decisions, or they would not be alive.  So the most effective mental health help often comes subtly, in the form of 'smoozing', or chatting. You will not have an office nor office hours. People will not come and sit down with you at a pre-appointed time for a 50 minute session. Instead, mental health help is given on the fly, while you are passing out water in a line to hot and cranky survivors. It may be holding a wet toddler when his mother fills out forms for disaster aid. It might be that you are walking through a shelter and collapse next to an elderly woman who is also resting her feet.

So what do you do? One technique is to start chatting about something inconsequential, such as, "Can you believe the lines here?" Get people talking about how they are doing, matching body language and the pace of their speech. People in the Astrodome, from the deep south, tended to speak much more slowly than I did. I had to learn to say "Y' all" instead you of "you guys" (How are y' all doing today? Do y' all want more water?")  and to respect local customs, such as waiting for the eldest family member, often the great-grandmother, to speak first. I had to sloooooooooow down my speech. I would gently join a family group, sometimes engaging a baby first. People everywhere like it when you say how beautiful their children are, so that is another way to join a system.

After you have established rapport, then you can check in with how they are doing. People will often want to tell their story of survival if you give then the opportunity to do so. I like to do a full circle, so to speak, asking them how they are now, then, if they want to tell it, listening to their story. I try to end with how they survived, reinforcing the strength and resilience they demonstrated in getting themselves to a safe place. It is not considered wise, in disaster mental health, to lead a person into speaking about their trauma. Rather, lend a receptive ear if, and only if, they wish to speak about what happened to them. If they do, do not leave them hanging; instead, bring the circle back to where they are right now;  the full circle.

The line at St. Agnes Baptist Church was truly staggering. It was a hot and very humid Houston day. The local police stopped allowing people in when there were 8000 people there, and the line snaked all around the building. People were waiting to meet with FEMA and disaster workers to get some assistance. Many had been in line since before dawn.  When I walked in, wearing my identifying vest, I was bombarded with questions, most of which I did not know how to answer. As I made my way to the headquarters set up for volunteers, I saw two policemen holding a crying toddler. He looked about one and half years old. I pulled my puppet out of my pocket and tried to engage the child, while the police were talking about how they had found the boy wandering quite far away, near a dangerous intersection.

They asked if I could help, and with relief put the very wet, very sad boy in my arms while they went on to other duties.  I tried to soothe the boy, to find out his name, but he was beyond talking. Holding him, I started to walk by the long line, hoping someone would recognize him.  I did not want to broadcast 'lost child' for two reasons; the first being my fear that he would end up with someone who was not his relative ( spending time in Southeast Asia, after the Tsunami, I realized how real child trafficking is) and, secondly, there were too many lost and missing children from the hurricane. I did not want to re-traumatize anyone whose child was lost by shouting out "lost child".

Holding this sweet crying boy, I walked down the line of people. A very old woman, using a walker, came up to me and demanded, "What are you doing with my great grandbaby?"  I watched the boy closely, and it appeared that he recognized the woman. I explained where he had been found, and that we were looking for his family. The woman said we should wait where we were, and that the rest of the family would appear. Soon enough, a slightly younger old woman came up and confronted me in the same way, asking " "What are you doing with my grandbaby?" Finally, a frantic looking younger woman came up, holding out her arms to the boy. "What are you doing with my baby?" she asked.

The boy buried his face in his mother's neck and sobbed. She explained how he had let go of her hand when they were coming to get benefits, and that she had been frantically been looking for him ever since. They all began to complain about FEMA, and how long the line was. I agreed with them about the heat of the day and the long wait, and soon they were all speaking at once, telling me of their harrowing escape from New Orleans, and their worry about the relatives left behind. They told me that there were 13 of them staying in one room in a relative's apartment. They were hoping that FEMA could offer them a larger place. I said I hoped so too, but did not know what FEMA was giving to people. (Be prepared to say, "I don't know" a lot. It is better to not know then to give out information that later is proven to be false, or that has changed.) The family thanked me, and laughed at the giant wet spot on my smock, noting that the boy did indeed need a new diaper.  I was able to escort the great grandmother to the front of the line, where chairs were set up for those who could not stand for hours in line.

Later in the day, still working the line, I  saw a man in a dark blue long sleeved FEMA uniform standing forlornly by a garbage can. He was very flushed. I brought him over a bottle of water  and asked him if he would come stand in the shade with me. He refused, saying, "I can't abandon my post, M' am."  I looked at his post; an overflowing garbage can, with no people around. I knew that stealth was called for, so I asked him to come stand in the shade with me. "I am very hot", I told him, "and if you are with me, no one will come up to me and ask for help. All I need is a few minutes to regroup."

He graciously agreed, and I become his new "post".  As he guarded me in the shade, I asked him what it was like to be part of FEMA (which was taking a lot of flack for having botched the whole New Orleans rescue). He said he was not part of FEMA, but a New York City fireman who had offered to go on a 30 day deployment with FEMA. I asked him how he was doing, as today was the fourth anniversary of September 11. "Well, M' am. It is hard. I am finding it hard to concentrate here. I keep thinking of my brother firemen who died at the Twin Towers..." He spoke on and on, while 'protecting me' from being bothered. Someone came up to ask a question, and he waved them away. He got us both sandwiches from the Salvation Army truck, all in the service of taking care of me, all the while talking about how he was doing.

***********

Please visit CamboKids to see an innovative play project in Cambodia.

CamboKids - Randjana Buddhi Pabodhana Mita

Existential Activities	Construction & Deconstruction	Cultural Identity
Sand	Wooden Blocks (big size)	Statues
Clay	Puzzles	Singing
Water	Empty Cans	Music
Swings	Cement blocks & Bricks	Costumes
Tree	Wooden blocks (small size)	Traditional games
Dance		Storytelling
Gymnastics		Lawyers
Running		Reading
		Interview
		Video
		Museum
		Khmer Traditional Graphic Arts
Aggression	Relaxation
Fighting	Meditation
Tyres	Chanting
Cushions	Drawing
Tubes	Origami
Ropes	Palm Leave Arts
Baskets

 

Disaster Handouts and Manuals

Psychological First Aid

Field Operations Guide
Terrorism and Disaster Branch
National Child Traumatic Stress Network and National Center for PTSD

This Psychological First Aid Field Operations Guide has been under development by the Terrorism Disaster Branch of the National Child Traumatic Stress Network and the National Center for PTSD. Although not a final document, the present version is being released to meet the need for guidelines and strategies for early assistance to so many affected by Hurricane Katrina. Members of the National Child Traumatic Stress Network and the National Center for PTSD, as well as other individuals involved in coordinating and participating in disaster response, have contributed to the current document.

The principal authors (in alphabetical order) included: Melissa Brymer, Chris Layne, Robert Pynoos, Josef Ruzek, Alan Steinberg, Eric Vernberg, and Patricia Watson.

In the interests of training as many clinicians as possible, the principal authors of the Psychological First Aid Field Operations Guide have generously allowed us the use of their materials on our website.

(You will need Adobe Acrobat to open these files. Please go here for the free plug-in if you do not have access it on your computer ,but check first, by trying to open one of the files, as you may already have it on your computer).

The following is from http://www.ncptsd.va.gov

NEW: Psychological First Aid Manual (PDF)

The Psychological First Aid Field Operations Guide was created by the Terrorism Disaster Branch of the National Child Traumatic Stress Network and the National Center for PTSD as well as others involved in disaster response. Production of this information was supported by SAMHSA.

It is an evidence-informed modular approach for assisting people in the immediate aftermath of disaster and terrorism: to reduce initial distress, and to foster short and long-term adaptive functioning. It is for use by mental health specialists including first responders, incident command systems, primary and emergency health care providers, school crisis response teams, faith-based organizations, disaster relief organizations, Community Emergency Response Teams, Medical Reserve Corps, and the Citizens Corps in diverse settings.

It is an evidence-informed modular approach for assisting people in the immediate aftermath of disaster and terrorism: to reduce initial distress, and to foster short and long-term adaptive functioning. It is for use by mental health specialists including first responders, incident command systems, primary and emergency health care providers, school crisis response teams, faith-based organizations, disaster relief organizations, Community Emergency Response Teams, Medical Reserve Corps, and the Citizens Corps in diverse settings.

Self Care for Providers (PDF)

Connecting with Others: Seeking Support (PDF)

Connecting with Others: Giving Support (PDF)

When Terrible Things Happen (PDF)

Tips for Helping Pre-School Children After a Disaster (PDF)

Tips for Helping School-Age Children After a Disaster (PDF)

Tips for Helping Adolescents After a Disaster (PDF)

Tips for Relaxation (PDF)

Alcohol Medication and Drug Use After a Disaster (PDF)

NEW: Provider Handouts

To assist medical providers in the wake of this terrible disaster with the lack of communication capabilities, the National Center for PTSD has developed some brief handouts to assist doctors and other medical personnel who are less qualified in disaster response. These fact sheets are single page, two-sided for ease of reference and use. The first three PDFs compliment one another and are intended to be used as a set.

Mental Health Reactions After Disaster: A Fact Sheet for Providers (PDF)
Covers information about normal stress responses to a disaster as well as more severe reactions and risk factors.

Psychosocial Treatment of Disaster Related Mental Health Problems: A Fact Sheet for Providers (PDF)
Recommended interventions including normalizing and support strategies, a review of plosive and maladaptive coping actions, and brief information on treatments for more severe stress reactions.

Pharmacological Treatment of Acute Stress Reactions and PTSD: A Fact Sheet for Providers (PDF)
Information about about who should be provided with pharmacological treatment, when treatment should begin, and what it includes.

Assessing and Responding to Suicidal Intent: A Fact Sheet for Providers (PDF)
Includes important questions for medical professional to ask, guidance on how to handle suicidal intent, and provides resources for more information.

NEW: Survivor Handout

Because of the magnitude of this disaster, most individuals will experience some type of stress reaction. This sheet is provided as a handout for survivors of the disaster and their families

Reactions to a Major Disaster: A Fact Sheet for Survivors and their Families (PDF)
Provides information about normal stress reactions, other mental health problems that commonly occur following a disaster, and explains the recovery process.

Other Helpful Handouts

NEW: USUHS
Uniformed Services University of the Health Sciences provides additional hurricane disaster resources. Below is a list of fact sheets for RESCUE and RECOVERY WORKERS as well as other helpful fact sheets.

The Health Consequences of Disasters and Evacuation: What Patients Need to Know to Prepare (PDF)

Family Planning for Disasters: How to Plan for and Protect Your Family's Health (PDF)

Psychological First Aid: Helping Victims in the Immediate Aftermath of Disaster (PDF)

How you can Support Well-Being in Disaster Victims (PDF)

Sustaining Effectiveness in First Responders (PDF)

Evacuees and Refugees Mental Health and Care (PDF)

Psychosocial Concerns after Hurricane Katrina: Tips for Medical Care Providers (PDF)

NEW: Disaster Counseling Tips (SAMHSA)
This page provides tips on how to establish rapport with and actively listen to survivors, examples of appropriate things to say and not to say, and how to interact with disaster victims. Click here to see other publications on disaster by SAMSHA.

Project Liberty
Here you can find educational pamphlets in a variety of languages created following the 9/11 disaster.

International Society of Traumatic Stress Studies(ISTSS)
This Web site also provides important information regarding disaster recovery.

The information on this Web site is presented for educational purposes only. It is not a substitute for informed medical advice or training. Do not use this information to diagnose or treat a mental health problem without consulting a qualified health or mental health care provider.

All information contained on these pages is in the public domain unless explicit notice is given to the contrary, and may be copied and distributed without restriction.

 

http://www.katrinaskidsproject.org/
Photograph by Janine Schueppert

(Text as written) I feel bad sleeping in New Orleans because I dream about the hurricane everytime I go to sleep."
(person says)... Help!!! Help!!! Stop Katrina... Helpppppp!!! I need help to leave New Orleans. Pleaseeee!!!"
" Hurricane Katrina did all of this water. The lil boy need help because he is by his self."
" But now I and safe in Texas I am not in New Orleans I am very happy."

 

                     

 

                

http://www.katrinaskidsproject.org/
Photographs by Janine Schueppert

 

A.A. in the Astrodome
Photograph by Chris Lewis

 

 

Houston, TX., September 2, 2005 -- A volunteer comforts a survivor from hurricane Katrina in the Houston Astrodome. Approximately 18,000 people are temporarily housed in the shelter at the Astrodome and Reliant center. The City of New Orleans is being evacuated following hurricane Katrina and rising flood waters. FEMA photo/Andrea Booher

 

International Psychological First Aid - Sri Lanka

The Sri Lanka Team -A humanitarian mission sponsored by the Association for Play Therapy and OperationUSA
clockwise: Kate, Joe, Prabha, Jodi, Sharolyn, David, Valerie, Janine and Maria

(Note: Much of this is written in present tense, as it derives from a journal I wrote in Sri Lanka. All photographs by Kate Amatruda, unless otherwise indicated.)

Today is my flight, and at 4:00 a.m., I am still awake. The alarm is set for 5:00 a.m. to begin the journey. Yet here I am, packing and racing around, fueled by adrenaline, anxiety and pressure to get everything into one small bag. I am shocked by my lack of preparation; why am I just now starting to pack? It was hard, I had only known for a week and one half that I was going to Sri Lanka, and only found out yesterday I will be in the group going to Batticaloa, affectionately known as “Batti”. I hear many jokes from my son Colety that “Mom is going Batty!”, which feels very true at the moment. We are allowed two bags, up to 70 lbs each, so my husband Roy and son Colety packed the big suitcase with things for the children: stickers, paper, letters and drawings from children here, zillions of children’s band-aids, scissors, paper punches and balloons. 69 pounds, all donated. Colety handed me a roll of money; between bake sales and spare change jars, the Novato Charter School had collected $200 for the children of Sri Lanka.

 

7:09 am
Now the journey really begins. I missed the Airporter bus, so Roy had to race me to the Larkspur terminal to catch another bus. Kate Chaos! I do get a little tired of my frenzy at times, wishing for some of Roy's composure and serenity. Finally, I am on the Airporter bus, heading to SFO. From there, I catch a plane to LA, switch airlines and terminals, meet with the group, and then we fly to Colombo, via Tokyo and Singapore.

Our team met in boarding area of Singapore Airlines, we range in age from 26 (our leader, David) to the geriatric one among us; me, age 50. We bring a wide range of experience to the project. We will find out more of what we will be doing in Singapore; there will be training. The interventions are specific, and directive. We cannot bring anything aquatic, including in the stickers. I would like to know more about this; it seems a paradox to be directive, but avoid talking about the thing that caused the trauma. Kind of the "you-know-who" Lord Voldemort thing in Harry Potter.

 

The flights are endless. We left LA at 1:00 pm, went to Tokyo for a refueling. In Tokyo, even though the layover was less than an hour, everyone had to get off the plane, exit, go through security again, wait in a long line, and get back on the plane. All the people I encounter on the plane, in the airports, even at the security screening areas are so touched that I am going to Sri Lanka, that they thank me. I accept their gratitude, knowing it is soul food that will sustain me during the hard times.

The LA to Tokyo flight was 11h 40m long. Tokyo to Singapore is 7h 30m long. Singapore to Colombo 3h 35m. 22 hours and 45 minutes in airplanes! Are we there yet?

Back on the plane, seven+ more hours in the air until Singapore. I am getting a bit squirrelly. It would be nice to go outside, breathe fresh air. In Singapore, we stagger out of the airport, having been stamped through immigration and through the “nothing to declare” line in customs. We get off the plane, into the night, and realize we have no way of getting to the hotel. David arranges for a van, and we get to the hotel at 3:00 a.m., but which day I have no idea.

Sunday
Hotel, shower, sleep. In the morning, David tells us “The Protocol”, a series of exercises and games to play with children. Designed by Janine Shelby and her team to help children master trauma, they are cognitive behavioral, with specific objectives and techniques. Each game has the objective, such as to:

*Normalize reactions ("Yes, you are having a 'normal' reaction to an 'abnormal' situation; whatever you are experiencing; sleep difficulties, crying, anger, etc. is OK and normal."   In my work in the States, this is the  stage when I usually reassure a person that they are NOT crazy, but in Sri Lanka I don't know the cultural context for craziness.  In local trauma work, I have had families write notecards stating "This is a 'normal' reaction to an 'abnormal' situation" and post them all over their homes.)
*Assess current coping mechanisms (and reinforce healthy ones)
*Assess and modify misattributions and cognitive distortions (such as if the child feels that he or she did something to cause the Tsunami, or they could have stopped it, or saved someone's life. This step is important, given the relatively short time after a trauma there is for a 'narrative' to develop.)
*Decrease hyperarousal and panic symptoms (We hear that at one camp, people feared that another Tsunami was coming, and panicked. Some children were hurt in the stampede.)
*Increase self-soothing and self-comforting behaviors(breathe! breathe! children may want to eat comfort foods, which can be difficult to acquire or prepare in a shelter or camp.)
*Identify and change intrusive re-experiencing, such as flashbacks (In the States,  I have found it helpful for children to yell out "STOP!" to intrusive memories, or to imagine pushing them away, or even writing the memory on a paper and burning it. I am not sure what will work in Sri Lanka.)
*Decrease isolation and withdrawal and reinforce the ability to seek helpful social support (ask for a hug, find someone to talk to, tell an adult what you are feeling)
*Decrease regressive behaviors and increase resilience by focusing on strengths and resources (I think of this as "The Little Engine that Could" coping mechanism, in which the little train overcomes obstacles by repeating ""I think I can, I think I can".)
*Identify loss reminders (water images, perhaps the aquatic stickers?) and trauma triggers (such as loud noises, big waves, whatever the individual was doing at the time at the disaster)
*Finally, to leave the child with a sense of hope.

I am worried that our attempts to help will come to nothing; that we are offering a band-aid for a gaping wound. A disaster that has killed so many cannot be quickly overcome, particularly after so much war trauma. The Tsunami is a holocaust that will affect Sri Lanka, the Indian Rim nations, and the world for generations. And no technique will work if the hierarchy of needs is not met; if the child is still in danger, hungry, or without shelter. The first step in trauma work is to establish that the danger is over, that the child is safe now.

Why do we go to play, and teach play techniques, in a cataclysm? As we get closer to Sri Lanka, my mind struggles to hold the number who died. September 11 was about 3000, the Tsunami was around 150,000 when I left.  By the time I returned home the death toll was 285,000; the count rises each day. I think we go to play with children because play is the first language, before children can verbalize, they play. Play allows for the expression and healing of trauma. And we go because we, as humans, want to do something for other humans who are suffering.

We get to Colombo, where there is a strong military presence. The Army is everywhere, running checkpoints and randomly pulling over cars. We are pulled over and the soldiers shine a flashlight into the car, mostly focusing on Valerie. She is scared, keeps asking, “Should I open the door?” Everyone yells out, “No! No!” Later we find out we were stopped because some of the women in our group have short hair.  The women fighters of the Liberation Tigers of Tamil Eelam (LTTE), or Tamil Tigers, are the only women in this country to have short hair.  We get to the hotel very late, it is 3:00 a.m. I am still awake, wondering what is to come.

Monday
The next day is Monday, and we have another meeting, this time with Nimmi Gowrinathan, an OperationUSA worker, a Tamil woman who grew up in Los Angeles, and is getting a Ph.D. in Political Science from UCLA.  Nimmi orients us to the political and social structure of the country. We learn about the years of warfare, the riots, the discrimination that the Tamil have felt at the hands of the Singhalese. (For more on this conflict, please go to: Sri Lanka: Ethnic Conflict & Civil War.)

There is now a cease-fire in the war. We learn that three days after we left Batticaloa that Kousalyan, the head of the Liberation Tigers' political division for the Batticaloa-Amparai district, was killed in an ambush on the highway to Batticaloa Monday night February 7 around 7:45. Three people who were traveling with him were killed and four were injured. [source: TamilNet, February 07, 2005 16:08 GMT]

I wonder how this will affect the survivors of the Tsunami...how can they begin to feel safe if the war comes again? I cannot help but feel we left just in time, and, after viewing the devastation wrought by nature, I would like to bring the leaders of every country to view it, to tell them to stop all wars.  To help rebuild the planet. To stop senseless killing.  To use resources to end human suffering, not to increase it. (Of course, I do keep all these sentiments to myself. One of the requirements of disaster response is to be non-political, non-denominational and nondiscriminatory. We offer aid by need, not religion, ethnicity, political affiliation, etc.)  

We have two teams, one headed to the South, the area that is primarily Buddhist and Singhalese. My team's destination is Batticaloa, ground zero of the Tsunami, and the place where there have been the least services provided. The East is primarily Tamil, with the major religions being Hindu and Muslim. There also seem to be pockets of Christianity throughout the country, and the Eastern team will be staying at an orphanage started by Christian Missionaries.

We learn about the social customs; that women tie their hair up or back at all times, that dress is modest, with most of the body covered. Women and girls wear earrings, and we hear tales that if a woman has a hole in her ear, without an earring in it, that the Sri Lankan women will come up and try to put an earring in the piercing. Irreverently we joke that is a way to get more earrings. The henna paintings on hands, toe rings and lovely sandals make sense if a woman's body is mostly covered; for where else can she show her beauty?

To Batticaloa is a long drive, at least 8 hours through the center of the island. The roads are winding, the countryside incredibly beautiful. We see elephants and monkeys, and go by some huge statutes of the Buddha, towering over the town and countryside.

We are almost there when our driver, Ravi, pulls over. The van has a flat tire. We stand around swatting at mosquitoes until Nimmi’s father, Roger, suggests that we put mosquito repellant. We find later that the mosquitoes are very resilient in Sri Lanka, finding the tiniest area of skin not covered with DEET. Poor Valerie awakens one morning with swollen eyelids; it had not occurred to her to put the repellant on her eyelids. “DEET UP” becomes a clarion call of the group, morning and evening.

We drive further, and are ‘almost there’ when the lights go out on the van. This is very dangerous, as the road is narrow and the people drive like maniacs. (It doesn't help my sense of mastery that Sri Lanka has right hand drive; I keep being surprised by trucks and busses roaring toward us on the right.) I feel as if I am in one of my son’s video games, in which driving on a road means taking your life into your hands. We find out later that traffic fatalities are the leading cause of death in Sri Lanka, followed by snakebites. We scrounge around in our luggage and find flashlights, and Nimmi hold a flashlight through the windshield as Ravi drives. We are grateful for Ravi’s driving skills, as in the morning we see that he has successfully navigated between the sea on one side and the sewer trench on the other. There are cows and goats to be avoided as well; somehow, Ravi got us safely to the orphanage. Later we draft Ravi into our team to work with the children; he knows how to play cricket!

We finally find our destination, St, John’s, an “American Ceylon” mission that is an orphanage and school for children whose families have died in the war. The children run out to greet Nimmi, who has visited before.   Jeff Greenwald   wrote in his Field Journals: A Journey Through the East January 19, 2005:
"At the St. John’s Tsunami Relief and Rehabilitation Center in Batticaloa, an Episcopal Reverend known as “Father J” (short for Keynesian) is spearheading a multi-level effort that includes orphanages, feeding centers, vocational training, and emergency relief supplies. (The popular Reverend was already immersed in refugee work, providing for families displaced by the civil war, when the Tsunami struck. Trained at the Hebrew University in Jerusalem, Father J’s commitment to spiritual integration is immediately obvious; St. John’s is the first church I’ve seen with a Jewish mezuzah on its doorway.)"

We stumble upstairs to a large airy room and have dinner. This dinner, to be repeated every night we are here, consists of cold rice noodles, a sauce of coconut milk with a yellow spice in it, a curry with chucks of meat and bone, cut up and steamed carrots and green beans. We see there are no utensils, so we follow Nimmi and Prabha’s lead as we eat with our hands. One never touches food with the left hand, ever, as that hand is used for cleaning oneself. Joe, who is left handed, has to sit on his left hand in order not to use it. I find that I cannot bring myself to eat any fish here, fearing, as the villagers do, that the fish might have eaten the dead. There are charts in the papers to show what fish feed on, to reassure us that the fish are safe to eat, but I can't make myself do it.

The room upstairs is large and airy, and we think it will be a good place to sleep. We find out, however, that only the men will sleep there. The women go down to beds in the girl’s dormitory, bunk beds. The girls flock to us, touching, talking in Tamil. They are very curious about us, and call us “Auntie’, which is a sign of respect given to an older woman. They quickly find something to tease us about; for Valerie it is her long nose (which to my Western aesthetic seems on the short side), for me it is my lack of earrings, as I have removed my earrings due to sore piercings. They tug at their earrings and then reach for my sore and inflamed ear lobes. I am determined to find earrings that are not as heavy as the ones I was wearing, and put antibiotic ointment on my earlobes before bed.

Getting ready for bed is a challenge. The girls are very modest, and so I take my clothes with me to the shower. What shower? Bathing take place in a large red bucket, with a smaller pitcher. You use the pitcher to pour water over you, then soap down, and rinse again with water from the pitcher. There is no hot water, and by the end of our stay there, I am in agreement with the ‘what do you need hot water for in the tropics anyway?’ school of thought. Right now, it is a shock, and I just cannot deal with it.

After the plane trips, the long ride from Colombo, dinner eaten with my hands, I confess to a moment of Western princessness; I want a real shower and a room of my own! Not. Instead of braving the shower, the big red bucket, I use wipes to clean myself, and try to change into sleeping clothes without getting them wet, as there is water everywhere in the floor. I do a little dance of rolling up my pants leg, getting my feet in and out of my flip-flops, getting my legs through the pants, without getting them wet. I am not quite successful, so spend the first night with pants wet around the ankle. At least it is water from the bath, and not the toilet! What we lack in comfort at the orphanage, however, is more than compensated for by the warmth with which we are embraced by the children and staff at St. John's.

                        

Things have become complicated in the orphanage lately, as the Tamil Tigers, as a gesture of good will, released their child soldiers to Unicef. Unicef turned the children over to the orphanages, the place where they would be safest. Selvie, the housemother, has to integrate adolescent girls who were soldiers into the community of proper Christian-schooled girls. The child soldiers are the ones with short hair, and they stick together. The culture of the army and the culture of the orphanage are quite different, and I wonder how long, if ever, it will take for the soldiers to blend in with the cloistered girls.

Tuesday
I awake at 4:30 a.m. to the chatter and laughter of girls, the sounds of sweeping and mopping. Bathing is done by seniority, so if the younger girls want to bathe, they must get up very early to complete their chores before the ‘showers’ are taken over by the older girls.

We get into the van to go meet the people who have arranged the training. En route, we see houses damaged, and ask it is from the Tsunami. “No, it is from the war. Fighting was here; this house was damaged by a bomb, here you see bullet holes.” We realize, that, other than flooded rice fields (a huge concern, as the fields were inundated with salt water and sewage…how will there be enough rice to feed the people?) we have yet to see Tsunami damage.

We are greeted by Father Paul Satkunayagam, Director and Co-founder of the “Butterfly Peace Garden”. Children traumatized by the war can come here to begin healing, and groups are run to promote understanding and peace. I fall in love with The Butterfly Peace Garden, and its mission:

The Butterfly Peace Garden is located in the Batticaloa district of Sri Lanka, a region where many lives and communities have been profoundly affected by a long-running civil war....

The Butterfly Peace Garden opened its gates on September 11, 1996, and since then it has been bringing together artists, peace-workers, ritual healers and counselors with children from Batticaloa's various ethnic and religious groups - Tamil, Muslim, Hindu, Christian - in an oasis of peace amid the devastation of a civil war that has raged for two decades. The children of the Butterfly Peace Garden are a remarkable tribe of magicians who provide living testimony of the power of play as a tool in the lost art of making peace."

"Children from six to sixteen years of age attend the Butterfly Garden for nine months, one day a week, in groups of fifty drawn from the local Tamil and Muslim populations. Many of them have endured profound family loss and witnessed great horror: they are the children of terror. In the Butterfly Garden these children are slowly restored to themselves and to the world through play and storytelling, music and drama, the arts of painting and puppetry and participation in the life of a garden.... Many of the Butterfly Garden staff were themselves child victims of the war, and working there is for them a process of healing and recovery."(source: Geist No. 33, 1999

We are met here by a group of several men, called MEESAN (Modern Economics Education and Social Affairs Network) who want to hear about what we intend to do, and to make sure it is culturally sensitive. Too many Westerners have come in to work and apparently, they either leave the children a wreck (we hear of someone who came to do EMDR with the children, and left them all sobbing and unglued as she or he caught a flight back to the States) or just come in and lecture the workers about what the children need. We are determined to be different. We decide the best use of our time and talents is to ‘train the trainers’, and so a group of 18 people who work with children are invited to come to our trainings. David explains the exercises and play activities to the group.

The men also review our exercises, cognitive behavioral puppet shows and games that are geared toward mastery of trauma, and agree that they will not disrupt the culture. Where we are, in the East, most of the children are Hindu or Muslim. The team in the South is dealing with Buddhist children. Each team finds quickly that we need to modify certain elements of our games.

That afternoon we meet with the trainers to find out their needs, teach them our techniques, and get to know each other. I become the designated icebreaker, and while the rest of the team sets up, I put a butterfly sticker on each person's hand. I make eye contact when I do, and see incredible wisdom and pain in their eyes.

As I hand out the stickers, they tell me that a butterfly is called “Vannathupoochi” in Tamil, and I try to say it to each person. When I get toward the end of the group, someone started singing a song about “Vannathupoochi” in Tamil, which amazingly, goes to the tune of “Frère Jacques”. I try to sing along, bringing gales of laughter from the people. This song becomes my theme, and somehow, by osmosis, the children at the orphanage start singing it to me as well. It is perfect, and when I tell the trainers how the butterfly motif has appeared spontaneously in the psyches of children with whom I have worked that are facing death, they nod in agreement. I tell them of the children in the concentration camps who had carved butterflies with their fingernails in the wood, and again they nod "yes". They know firsthand the grave loss and despair that seems to summon the butterfly.

Sri Lankan nodding “yes” is like that of a dancer; somehow, the head goes back and forth, and the neck moves sideways. When I try it, I feel like I do when I try to show children how an owl can look backwards; my neck muscles cannot do this at all! More gales of laughter when we try to nod ‘yes’ to the trainers. This learning to nod becomes David’s theme with the trainers; they tease him as he good humoredly tried to do it. We learn there is a subtle difference between nodding ‘yes’ and ‘I don’t know” and “no”; I think I would have to stay for years to understand the nodding, much less master it.

The men and women animators are amazing; they have such a depth of compassion for the children. We start by asking them what they want from us. They are exhausted, and need some new ideas, specific to the Tsunami. We learn later that two of the women who are working with the children are also refugees; they have lost everything, and are living in tents side by side with the children. We realize that these workers are suffering from ‘compassion fatigue’, so part of our plan is to help them refuel, to play with them, and give them an opportunity to tell us what it is like for them. We know, however, not to push, but to hold the space so that if they feel safe enough, they may tell us what they are going through. I am in awe of these animators, who have been on the front lines of trauma for years: first the war, and now the Tsunami; yet still, they smile. One of the animators, Shanty, shows us a drawing and story by a girl who was rescued by a helicopter; she was in the water from the time of the Tsunami at 8:00 a.m. to her rescue after 3:00 p.m. Her story shows the progression from the trauma to the rescue, showing great resilience. Shanty tells us the girl is only 11 years old; she is living in the refugee camp now.

I ask the man sitting near me if he could please translate, as our Tamil speakers are elsewhere. He graciously agrees, and I find out later (with embarrassment!) he is Mr. Sornalingam, of the Sri Lanka Centre for Development Facilitation (SLCDF), and a very important man. Again and again, I see great humility in the people here, and incredible beauty. I can hardly imagine what their lives must be like - 20 years of civil war, and now the Tsunami. One woman said it so eloquently to Prabha, “We lost so many in 20 years of fighting, and then we lost more in 20 minutes of the Tsunami.” I have such respect for these trainers, and know that they will teach me more than I could possibly teach them. They have been to hell and back, and survived, still their faces shine, and they smile through tear-filled eyes. We adapt some of our exercises based upon their feedback; “Go fish” becomes “Go choose” until we realize that card games of any type are taboo, due to the association with gambling. Our game of "fishing”; using a pole with a magnet on it to pick up a felt fish with a coping method written on it, becomes instead "bobbing for apples". We don’t want the fish aspect to be a ‘trauma trigger’ but instead want the children to concentrate on the coping methods. “Stone soup” becomes “Tsunami Samba”, samba being a type of stew.

 

We then drive to the beach to see the damage first hand. We are shocked, speechless, horrified. There are no words.

 

We are stunned into silence. The devastation is immense. Cement foundations are cracked, walls torn off houses and temples. One beautiful Hindu temple was halved; we speak to the priest, who was inside praying at the time of the Tsunami. He was safe in the inner sanctum of the temple; it is considered a miracle. The back of the temple is torn off, the front still intact.

                            

We see a beach that was covered with fishing shacks; this beach looks empty, there is no sign that any homes had once been there. But on the beach where we are now, there were hotels, and houses made of cement and stone. All is demolished. Coconut trees are downed. Some of the trees have saris still caught in them. These are the saddest, because these trees had women clinging to them, women who were then torn out of their clothes, out of the trees, to their deaths. We see an occasional shoe, a flip-flop, a dress in the debris.

 

A few people are working, trying to remove debris from where their homes were. They are carrying away broken boards, bricks and chunks of cement by hand, and in baskets. There is no sign of any heavy equipment.

 

In the East, Tamil country, people believe that all the resources are going to the South, to the Singhalese. We hear later, from our Southern team, that the people in the South believed all of the help is going to the East. We wonder where the billions of dollars of aid are going; certainly not to clearing the beaches of rubble, should people decide to rebuild. This is more than one month after the Tsunami, yet very little clean-up appears to have been done. We see white flags of mourning, and a grave, or memorial marker, surrounded by red flags. So much is lost.

We hear from people that after the Tsunami, there were hundreds of bodies on this beach. It is impossible to imagine such devastation looking at the sea today, which is calm and brilliantly blue.

We hear that snakes caused the Tsunami. In fact, two days before the Tsunami, blue water snakes curled around a nearby bridge. People were frightened, and believed that it meant war was returning. Later speculation was that the snakes somehow sensed the heat generated by the ensuing earthquake, so fled to the bridge. We drive over that bridge; the snakes are gone now.

We heard repeatedly of the animals; that shortly before the Tsunami hit, the animals all fled to higher ground. Many people died, while few of the animals did. Reuters reported on December 29, 2004, "The strange thing is we haven't recorded any dead animals," H.D. Ratnayake, deputy director of the national Wildlife Department, told Reuters on Wednesday. "No elephants are dead, not even a dead hare or rabbit," he added. "I think animals can sense disaster. They have a sixth sense. They know when things are happening."

Another story was that a statue of the Buddha floated over from Thailand, and caused the Tsunami upon hitting the Sri Lankan shore. We heard of two temples to different deities that were too close together; the gods of these temples warred, and caused the Tsunami. We hear that UFOs were sighted before the Tsunami hit. Another rumor swirling around was that underground nuclear testing that caused the Tsunami.

Walking on the beach, we see few people. Those that are there look absolutely haunted. The ones who want to talk come up to us and tell their stories. Through translation, we hear again and again stories of death and destruction. “The first wave took my house, the second wave my children, and the third wave my wife. What do I have to live for?” “My baby was ripped out of my arms.” We are near Kalmunai, where the famous "Baby 81"; the eighty-first person admitted to the hospital, was found. So far, eight heartbroken and desperate couples have claimed this baby as their lost child. “I lost my 5 year old son, my 10 year old son.” “Lost, lost, all is lost.”

We are sobered, going back to the orphanage. Here the children talk with us, some are studying English. They all want us to know their names and ages. One girl tells me about the “bomb” that killed her mother, her father, and her brother during the war. The little house was left for her was destroyed during the Tsunami. "Bomb", "dead", and "gone" are her English words. The children are full of sorrow and joy, reflecting both in their wise eyes. They have lived through things we in America have no inkling of; civil war and then the Tsunami. I am grateful for the orphanages, knowing the huge amount of child trafficking and prostitution that occurs to orphans. My heart breaks again and again.

The girls see my butterfly sticker, and repeat “Vannathupoochi”. I hum a few bars of ‘Frère Jacques’ and the girls sing the butterfly song to the same tune. They try to teach me the words, giggling at my Tamil pronunciation. Later, every time they see me, they call out, “Amahmah, Grandma, Vannathupoochi” and start to sing the sound, with accompanying arms gestures as butterfly wings.

Vannat-hu-poo-chi
Vannat-hu-poo-chi

Parakkuthu Par
Parakkuthu Par

Ailagana Chettai
Ailagana Chettai

Adikkuthu Par
Adikkuthu Par

(very rough translation...if anyone knows the correct spelling and meaning, please e-mail me!
Here's the tune, courtesy of Mickey Gentle at Laura's Midi Heaven)
Butterfly
Butterfly

Wings we see
Wings we see

Beautiful Wings
Beautiful Wings

See the flight
See the flight

We have dinner, and the team talks about the day, what worked, what didn't, what we want to do tomorrow. We share our sadness and shock about being on the beach, when the full horror of the Tsunami hit us. Daily debriefing became very important to us, as we needed to help each other deal with the torrent of loss and pain we were facing and feeling. The name for this phenomenon is “vicarious traumatization”; it describes how a person can feel holding so much of another’s pain. We needed each other, and the laughter of the children at the orphanage helped as well.

That night I braved the shower. Sri Lanka is very humid, and I felt so sweaty and sticky that the idea of dumping a pitcher of water over my head was quite appealing. In fact, if someone had offered me an opportunity to go to Sri Lanka, to a land of malaria-bearing mosquitoes, snakes, head lice, humidity, showers that were buckets of cold water, unmentionable toilets, winding, dangerous roads, I would have said they were insane. I would have declined, even if they had paid me to go. Yet here I was, volunteering, having paid my own way, and truly loving it. Go figure…I think it is the people who made the difference, as they are so warm and wonderful, and perhaps the hope that I could help even a little bit.

I go to bed, wishing I had known our lodging arrangements prior to leaving home, as mosquito netting would have made a huge difference in my comfort level. I tried to read a bit in bed, but soon fall asleep. I was a bit nervous that my childhood and young adulthood nightmare of a huge wave, black with fury, would recur in the land where the Tsunami had hit, but it did not. I was surprised, though, at how much my dream Tsunami matched that of the survivors' descriptions. I never knew consciously that tidal waves were black, yet my nightmare wave always was. Again and again we heard of the big black wave that took everything.

Wednesday
After breakfast, we go to a new space, the Mangrove Center, to continue to train the trainers.

We teach the workers our games and exercises, and then, when the rain clears, go outside to show them a version of "Follow the Leader”. This is Valerie’s contribution, and she is wonderful - very animated and joyful. She includes some yoga. My favorite exercise is when she has us “reach for the stars” grab them, then, “Whoosh” bring them down to earth. She is the leader in "Follow the Leader”, and then, having learned the the Tamil word for leader, points to someone else in the group, designating him or her as the leader, and we all follow. Soon we are jumping, hopping, and laughing.

An older woman wanders in to the yard in which we are playing. Two young girls accompany her. We invite them all to join us. They do, and then suddenly the woman starts sobbing and keening. I go over to her, and I hold her and rub her back as sobs pour out of her. She wails with pain, her cries almost a song. She somehow communicates to me that she has lost 41 members if her family in the Tsunami. 41! I cannot even begin to imagine her pain. A world of pain. Sometimes there is nothing to do except hold someone, rock with them in their pain. Show up. Be as human, and humble as you can, because you certainly cannot fix it, or heal it, or make it go away, or even comprehend this level of loss. She gestures, and somehow I know she has lost children and grandchildren.

She makes a slashing gesture around her neck, and I am concerned that she is suicidal. Sri Lanka has one of the highest suicide rates in the world, and I am very worried about this woman. I call Anita, our translator, over, and describing the woman’s gesture, ask her to find out what it means. Anita listens for a while, and tells me the woman is referring to her husband, to the necklaces she wore when she was married. She was gesturing that she had lost her husband in the Tsunami, not that she was suicidal. She had been in the hospital when the Tsunami hit, killing most of her family. The two little girls with her are the two grandchildren who survived, and they look like they are in shock. One of our workers plays with them as I try to console the woman; knowing that consolation is impossible. So I witness her pain, rocking with her. When she looks into my eyes, she sees my tears, mutely reflecting her excruciating pain. The little girls keep looking at their grandmother, not knowing what to do. They look very scared, they too have lost almost everything and everybody. One of the trainers comes up and agrees to help the grandmother find the resources she needs.  My heart breaks; this woman's unbearable loss stays with me.

We finish the morning training session, have a quick lunch in town, and then head to a refugee camp. This camp, Valaichenai, is housed at the Pentecostal Church, Karuwakerni mission building; it is a huge open two-story building. Shanty and her co-workers, Thaya and Mansulla greet us. Shanty takes me inside and shows me a young boy who is lying on a mat. She explains that he has lost his two brothers, one age 5, one age 10. His mother sits up, looking at us with tear-rimmed eyes. His father is also lying down. Shanty says the boy hardly moves, ever. She is very worried about him. Looking at him, I realize that my project for the day, drawing, should be done in the shelter, because children like this boy will not come to another space.

Our team decides who will do what; Prabha and David will do the puppet show, and Valerie (with Ravi's help) will do active, outdoor activities, like cricket, volleyball, and follow the leader, while Joe will make “support necklaces”. In this activity, a child makes a necklace out of colorful pieces of foam, putting on the foam the names of people they can count on to be there for them. Joe has a very calm manner, and the children flock to him. I will do art, hoping to do a sequence of drawings with the children (and maybe some parents, who knows?) in which they can draw whatever they want. If they draw the Tsunami, my task is to lead them through a series of questions, “What happened next?” to the realization of where they are now, and that they were relatively safe. It is very hard to do trauma work in a refugee camp, because of the hierarchy of needs; food and shelter come before anything else. Yet play and drawing are the first languages of children, and we could see how depressed the children and adults were. It was eerily silent; later we learned there were hundreds of children in the camp, with no toys, no supplies, nothing. And this is more than one month after the Tsunami. Government reports of January 11 state there were 416 families, a total of 1,263 people, housed in this camp alone.

 

My goal was simple: to try to engage some of the children and parents in an art/play activity. The lethargy in the camp was palpable; many children and adults just lay on mats, depressed. People were surrounded by their belongings; pitifully small amounts that they were able to salvage, or had been given to them. I imagine for a minute if everything I had was lost; if all I had were a few items of donated clothing, maybe a few mats on which to put on the concrete floor. Yet, that would pale if I had lost my family. I keep remembering the woman at the Mangrove Center who had lost 41 members of her family. How do you go on after that?

I went to a clear space on the floor and started to sit down. Before I knew it, mats were appearing. I sat on a mat and put out some brightly colored paper, markers, and crayons, thinking perhaps a few children would come, and then maybe I could engage their parents.  Within minutes, children and adults surrounded me. I was handing out paper and crayons like mad. This was not going to be a small group exercise, leading people through the "what happened next?" scenario; this was free-form chaos. Adults as well as children wanted to draw, mostly pictures of the Tsunami. I gave no direction, they sat and drew, and drew. Children and adults approached, showing me their drawings. Almost everyone wanted their picture taken with their drawing.

Once people were settled into drawing, I walked around the shelter, giving out paper and crayons to the ones who had not come forward. These were the people I was most concerned about, the children and adults so overcome with depression that they lay on their mats on the concrete floor. The first family group I gave art supplies to is that of the little boy who Shanty had pointed out, the one who hardly moved. I wandered through the camp, handing out markers, crayons, and paper. There are so many children here! I could only give a few crayons to each child; I wished for the abundance of being able to give each child a whole pack of crayons, so that he or she could have all the colors from which to choose.

Returning to the main group, I see the drawings range from depictions of the Tsunami to lotuses and doves. Some of the people have included a chronology in the drawings; you can see a whole sequence of events portrayed. These people had discovered the "what happens next?" technique on their own.

               

It is hard to say good-bye to the children. Joe shows the children their images from the back of his digital camera; like all children, they love to see themselves.

 

I think we are all feeling inadequate to the task, overwhelmed by the numbers of children and adults. I wish I could have a year just to work with the people at this one shelter.

 

 

 

As we leave, I am pleased to see the boy who had been lying on his mat, so depressed, had joined the circle of children drawing.

 

 

After our visit to the camp, our translator, Anita, suggests that we go to the beach in Batticaloa where the people we had just seen in the shelter had lived. She tells us she used to go a hotel there; all is gone. Nothing is left. Again, it is seeing the saris caught on the ruins and in the trees that make my heart clutch. Were women torn out of them by the Tsunami?

 

 

Thursday

Again, we are up and out the door. I am finding it difficult to have so little time and solitude. I have not been alone since boarding the Airporter bus in San Francisco. Technology is defeating me; it is difficult to use the laptop to write, and downloading photographs is impossible. In Batticaloa, there are intermittent power outages, and the system to charge a battery-operated device, such as a camera or laptop, takes all of Joe's knowledge and wizardry.  My adaptors and transformers don't work at all.

Thursday morning we return to the Butterfly Peace Garden to meet with the trainers, and again I greet them with butterfly and flower stickers, and the now famous (or infamous) butterfly song. Valerie has threatened me with death, because she can't get the butterfly song out of her head. When one of the workers comments that I am a "little crazy" about butterflies, I laugh, and agree. How do I explain the synchronicity of the stickers, the song, the butterfly peace garden? I think butterflies picked us, we did not choose them.

We again start the session asking the animators what they need, and, after teaching a few more protocols, they begin to speak of their experiences. Shanty tells us her sister lost both of her children in the Tsunami. Fajriya and Rifaya are refugees, living in the camp in which they work. Everyone speaks of loss, of burnout. They have no more creative energy to come up with ideas - every cell in their bodies is saturated with pain and trauma; they are exhausted. We hold them as a group; hoping our containment and caring can at least let them know that we care. It would be arrogant to say that 'we know', because, how could we? Our group has developed such respect for these workers, and such humility. As always, they have taught us much more than we have taught them; given us more than they have given us. They humble us.

Thursday afternoon, the group returns to the Butterfly Peace Garden. Learning from the chaos of our visit to the camp, and the difficulty of working with so many children at once, has led us to the idea of creating 'stations'; Joe, Prabha, Valerie and David each take an activity, and working with one of the Sri Lankan trainers, play with a group of children. The children rotate through the stations, so, instead of all the children doing an activity at once, only a quarter of them do. 

I stay back at the orphanage to do an exercise with the younger children. As we call them, more and more children come, so at the end there seem to be over 100 young children. Their housemothers help me, and we make “Vannathupoochis”,folding a piece of paper in half, and drawing one side of a butterfly on the paper. Cutting it out, when you open the paper, there is a full butterfly. The children then use crayons and stickers to decorate the butterflies. They are beautiful; each child wants me to admire her “Vannathupoochi”.

                                

We end by singing the Butterfly song
.

 

 

 

 

Friday

This was our last morning at the orphanage and camps before we began the long journey home. None of us wanted to leave; we wanted to go North to Jaffna, to work with the people there. Saying good-bye to the children and staff at the orphanage was very difficult; I know I was sad to leave, in spite of mosquitoes, showers from a bucket, hand-washing laundry in a pail, head lice, the unspeakable toilets, and the 4:30 a.m. wake-up. The people were so warm and gracious; they will stay in my heart.

We went back to the Butterfly Peace Garden for a good-bye session and feedback from the trainers. They most appreciated our playfulness; that we, as adults, would play with them, and with the children. They said they were now playing more. Saying good-bye to these dedicated workers was very difficult. We then went to a Muslim camp, Firthous Refugee Camp, Kattankudy.  We are greeted by Fajriya and Rifaya and people from Meesan. Conditions were dismal there; people were living in tents with no floors. I heard later that the temperature inside the tents could reach 110°.

                

 

We began to hear reports that many elders perished in the Tsunami; that the most vulnerable, the children and the elders, were the least able to escape the devastation. In fact, we see only a few older people at the refugee camps.

We have only a little time here, so we go to the classroom to meet the children. Here we find out that the children are school-aversive; an unusual thing in Sri Lankan society. The children are very dedicated to school; literacy rates are extremely high, education is seen as the only way out of poverty. Generally the children wake up early to do chores and study, then go to school, then have an hour for chores and play time. At 4:30 homework starts. (I am going to try this schedule with my son when I get home...right!) We are amazed at how well behaved the children are - they listen to the adults, they sit quietly, and are so well socialized that I agree when Joe says, "Actually, we could learn a lot about how to raise children from the people here."

The children in the camp are avoiding school; we don't know if it is that they are reluctant to leave their parents (or are the parents reluctant to have their surviving children out of their sight?) or is it because the school faces the sea? I know that if I had sustained the losses these people had, I would never let go of my surviving children, never let them out of my sight. At first the children appear very serious and sad; as we leave they are smiling.  We have given them letters and drawings done by children from all over the world, and, or course, stickers. They sing “Vannathupoochi” with me, singing more verses than I ever imagined existed. Valerie did her magic with "Follow the Leader", and David, as our leader, was honored by having his hands painted with henna. The woman who did the henna never once touched his hand; indeed, men surrounded her as she worked to make sure that did not happen.   

          

 

After we saw the children we walked on the beach, this time with the people who had lost their homes. Children would come up to me and say, pointing to a pile of rubble, "This is my house."  My broken heart surely broke a million more times that day. We reluctantly said good-bye to begin the long journey home.

 

 

 

Sri Lanka Tsunami Victims
Photograph courtesy of Meesan

Center for the Study of Traumatic Stress
Uniformed Services University School of Medicine
Disaster response education and training project

Information for Relief Workers on Emotional Reactions to Human Bodies in Mass Death
In your work with this disaster you are likely to see, smell, and handle the dead bodies of men women and children of all ages. Working with or around human remains may arouse strong feelings of pity, horror, repulsion, disgust, and anger at the senselessness of this tragedy. You may feel guilty for not helping enough. These reactions are normal and a part of being human. You may feel emotionally numb, or you may even use “graveyard humor” to make the suffering and death seem less terrible. These are also normal responses. Strong emotions or reactions may be most painful when a victim is a child, or reminds you of someone you love, or of yourself. Even if you’ve worked in disaster environments before you may react differently here than you have in the past. Remember strong emotions are honorable and they confirm your humanity.

Here are lessons learned by other people who have worked with bodies in disaster environments. Although these tips cannot make a horrible event easy they will help you continue to work, and to live with your experiences and memories without being haunted by them:

• Remember the larger purpose of your work. By recovering bodies for identification and respectful burial you are showing care, giving hope, and preventing disease for the living. Your supervisor must be aware of all body recovery work that you do and coordinate with the local authorities requesting assistance in this important effort.
• It may be difficult to prepare yourself mentally for what you will see and do. Specific information about job requirements and the experience of others can be helpful.
• While on the job wear protective gloves and coveralls to reduce your risk of disease, take frequent breaks, maintain hygiene, drink plenty of fluids, and eat good food. Rest (off of your feet) when not working. Facilities for rest, washing hands and face, for showers and fresh clothes should be available.
• Talking with others while working and during down time is very important. This helps prevent getting lost in your own thoughts or emotions.
• Help others in distress by being a good listener. Don’t mistake expression of feelings for weakness. Remind others that strong emotions are normal and honorable.
• Humor is a good stress release. Even “graveyard humor” privately among friends may be helpful but this will be offensive to some. Don’t get too gross or too personal (e.g. no picking on each other; no practical jokes).
• Limit your exposure to bodies as much as possible. Limit the exposure of others, also, by using screens, poncho curtains, partitions, covers, body bags, and barriers whenever possible.
• Since perfumes or aftershaves used to “mask” odors may trigger later memories, it may be better to breath through your mouth than to use these items to cover up unpleasant smells.
• Be compassionate, but AVOID FOCUSING on any individual victim--especially those you most identify with. Don’t focus on personal effects more than necessary as this can be particularly distressing.
• Personal effects found near bodies may be important for identification. They may also become important reminders for surviving family members or loved ones so they should not be taken as souvenirs.
• Remind yourself that bodies are not people anymore--just the remains.
• It’s OK to say silent prayers, but let local religious leaders conduct memorial services or more public ceremonies. It is important to be respectful of local cultures and religious beliefs that may be very different from your own.
• As time allows, have your team get together for mutual support and encouragement. Acknowledge horrible aspects of the work but don’t dwell on memories of the details. You should let your supervisor know if an aspect of your work is particularly difficult or stressful for you—a job change may be helpful.
• Afterwards, don’t feel guilty about having distanced yourself mentally from the suffering or tragic deaths of individuals.
• Some people find debriefings with trained counselors helpful but others do not. Participation should be voluntary. Any group debriefings should be with people who shared your experiences.
• Strange dreams or nightmares, feeling tense, or having intrusive memories are common during or shortly after stressful work with human remains. Sharing your emotional reactions with loved ones is often helpful but may be very difficult to do. If you cannot talk about your experiences (even though you want to), if your personal reaction is particularly distressing, or if anxiety, depression, sleep difficulties or irritability persist more than two weeks after your return home you should seek assistance from a counselor or a physician. For more information see http://www.usuhs.mil/psy/hurricane.html

Field Manual for Mental Health and Human Service Workers in Major Disasters
Department of Health and Human Services
Substance Abuse and Mental Health Services Administration
Center for Mental Health Services

Author: Deborah J. DeWolfe, Ph.D., M.S.P.H.
Editor: Diana Nordboe, M.Ed.

INTRODUCTION
This Field Manual is intended for mental health workers and other human service providers who assist survivors following a disaster. This pocket reference provides the basics of disaster mental health, with numerous specific and practical suggestions for workers.
Essential information about disaster survivors' reactions and needs is included. "Helping" skills are described with guidance for when to refer for professional assistance. Strategies for worker stress prevention and management are presented in the last section.
The Field Manual condenses and focuses material contained in the Training Manual for Mental Health and Human Service Workers in Major Disasters, second edition (Publication No. ADM 90-538). Separate publications on children, older adults, people with serious and persistent mental illness, rural communities following disasters, and disaster mental health services are available through the Center for Mental Health Services.

SURVIVORS' NEEDS AND REACTIONS
Floods, tornadoes, hurricanes, earthquakes, hazardous materials accidents, terrorist acts, and transportation accidents cause many similar and predictable reactions. While there may be specific disaster-related stressors, underlying concerns and needs are consistent. These are:
A concern for basic survival
Grief over loss of loved ones and loss of valued and meaningful possessions
Fear and anxiety about personal safety and the physical safety of loved ones
Sleep disturbances, often including nightmares and imagery from the disaster
Concerns about relocation and the related isolation or crowded living conditions
A need to talk about events and feelings associated with the disaster, often repeatedly
A need to feel one is a part of the community and its recovery efforts
In the days and weeks after a disaster, the most common types of problems encountered are problems in living. These might include transportation problems, unemployment, loss of child care, inadequate temporary accommodations, inability to locate a missing loved one, filling prescriptions, lost eyeglasses, difficulty applying for disaster relief loans, or public health concerns. Disaster workers often find that as they assist a survivor with the immediate problems at hand, they earn the survivor's trust and are told about his or her unique struggles and emotions.

DISASTER COUNSELING SKILLS
Disaster counseling involves both listening and guiding. Survivors typically benefit from both talking about their disaster experiences and being assisted with problem-solving and referral to resources. The following section provides "nuts-and-bolts" suggestions for workers.
ESTABLISHING RAPPORT
Survivors respond when workers offer caring eye contact, a calm presence, and are able to listen with their hearts. Rapport refers to the feelings of interest and understanding that develop when genuine concern is shown. Conveying respect and being nonjudgmental are necessary ingredients for building rapport.
ACTIVE LISTENING
Workers listen most effectively when they take in information through their ears, eyes, and "extrasensory radar" to better understand the survivor's situation and needs. Some tips for listening are:
Allow silence - Silence gives the survivor time to reflect and become aware of feelings. Silence can prompt the survivor to elaborate. Simply "being with" the survivor and their experience is supportive.
Attend nonverbally - Eye contact, head nodding, caring facial expressions, and occasional "uh-huhs" let the survivor know that the worker is in tune with them.
Paraphrase - When the worker repeats portions of what the survivor has said, understanding, interest, and empathy are conveyed. Paraphrasing also checks for accuracy, clarifies misunderstandings, and lets the survivor know that he or she is being heard. Good lead-ins are: "So you are saying that . . . " or "I have heard you say that . . . "
Reflect feelings - The worker may notice that the survivor's tone of voice or nonverbal gestures suggests anger, sadness, or fear. Possible responses are, "You sound angry, scared etc., does that fit for you?" This helps the survivor identify and articulate his or her emotions.
Allow expression of emotions - Expressing intense emotions through tears or angry venting is an important part of healing; it often helps the survivor work through feelings so that he or she can better engage in constructive problem-solving. Workers should stay relaxed, breathe, and let the survivor know that it is OK to feel. SOME DO'S AND DON'T'S
Do say:
* These are normal reactions to a disaster.
* It is understandable that you feel this way.
* You are not going crazy.
* It wasn't your fault, you did the best you could.
* Things may never be the same, but they will get better, and you will feel better.
Don't say:
* It could have been worse.
* You can always get another pet/car/house.
* It's best if you just stay busy.
* I know just how you feel.
* You need to get on with your life.
The human desire to try to fix the survivor's painful situation or make the survivor feel better often underlies the preceding "Don't say" list. However, as a result of receiving comments such as these, the survivor may feel discounted, not understood, or more alone. It is best when workers allow survivors their own experiences, feelings, and perspectives.
PROBLEM-SOLVING
Disaster stress often causes disorganized thinking and difficulty with planning. Some survivors react by feeling overwhelmed and become either immobilized or unproductively overactive. Workers can guide survivors through the following problem-solving steps to assist with prioritizing and focusing action.
* Identify and define the problem
Describe the problems/challenges you are facing right now.
Selecting one problem is helpful, identify it as the most immediate, and focus on it first. The problem should be relatively solvable, as an immediate success is important in bringing back a sense of control and confidence.
* Assess the survivor's functioning and coping
How have you coped with stressful life events in the past?
How are you doing now?
Through observation, asking questions, and reviewing the magnitude of the survivor's problems and losses, the worker develops an impression of the survivor's capacity to address current challenges. Based on this assessment-the worker may make referrals, point out coping strengths, and facilitate the survivor's engagement with social supports. The worker may also seek consultation from medical, psychological, psychiatric, or disaster relief resources.
* Evaluate available resources
Who might be able to help you with this problem?
What resources/options might help?
Explore existing sources of assistance and support such as immediate and extended family, friends, church community, health care providers, etc. and how the survivor might obtain their help. Refer the survivor to the appropriate relief agencies and assess if the survivor is able to make the calls and complete the required applications. Assist with accessing resources when necessary.
* Develop and implement a plan
What steps will you take to address this problem?
Encourage the survivor to say aloud what he or she plans to do and how. Offer to check-in with the survivor in a few days to see how it is going. If the worker has agreed to perform a task for the survivor, it is very important to follow through. Workers should promise only what they can do, not what they would like to do.
A WORD OF CAUTION
When confronted with a disaster survivor's seemingly overwhelming needs, workers can feel the understandable impulse to help in every way possible. Workers may become over involved and do too much for the survivor. This is usually not in the best interest of the survivor. When survivors are empowered to solve their own problems, they feel more capable, competent, and able to tackle the next challenge. Workers should clearly understand the scope of their role in the disaster relief effort and recognize that empowering survivors is different from doing for them.
CONFIDENTIALITY
A helping person is in a privileged position. Helping a survivor in need infers a sharing of problems, concerns, and anxieties-sometimes with intimate details. This special sharing cannot be done without a sense of trust, built upon mutual respect, and the explicit understanding that all discussions are confidential and private. No case should be discussed elsewhere without the consent of the person being helped (except in an extreme emergency when it is judged that the person will harm himself or others). It is only by maintaining the trust and respect of the survivor that the privilege of helping can continue to be exercised.

WHEN TO REFER FOR MENTAL HEALTH SERVICES
Referrals to mental health and other health care professionals are made as workers encounter survivors with severe disaster reactions or complicating conditions. The following reactions, behaviors, and symptoms signal a need for the worker to consult with the appropriate professional and, in most cases, to sensitively refer the survivor for further assistance.
Disorientation - dazed, memory loss, inability to give date or time, state where he or she is, recall events of the past 24 hours or understand what is happening
Depression - pervasive feelings of hopelessness and despair, unshakable feelings of worthlessness and inadequacy, withdrawal from others, inability to engage in productive activity
Anxiety - constantly on edge, restless, agitated, inability to sleep, frequent frightening nightmares, flashbacks and intrusive thoughts, obsessive fears of another disaster, excessive ruminations about the disaster
Mental Illness - hearing voices, seeing visions, delusional thinking, excessive preoccupation with an idea or thought, pronounced pressure of speech (e.g., talking rapidly with limited content continuity)
Inability to care for self - not eating, bathing or changing clothes, inability to manage activities of daily living
Suicidal or homicidal thoughts or plans
Problematic use of alcohol or drugs
Domestic violence, child abuse, or elder abuse

POTENTIAL RISK GROUPS
Each disaster-affected community has its own demographic composition, prior experience with disasters or other traumatic events, rural or urban setting, and cultural representation. Consideration should be given to the following groups, as well as additional groups with particular needs residing in the disaster-affected area:
Age Groups
Cultural and Ethnic Groups
People with Serious and Persistent Mental Illness
People in Group Facilities
Human Service and Disaster Relief Workers
AGE GROUPS
Each age group is vulnerable in unique ways to the stresses of disaster. Different issues and concerns become relevant during the progression of phases in the post-disaster period. Some disaster stress reactions listed below may be experienced immediately, while others may appear months later. The following table describes possible disaster reactions of the different age groups and helpful responses to them.
Disaster Reactions and Intervention Suggestions
Ages
Behavioral
Symptoms
Physical
Symptoms
Emotional
Symptoms
Intervention Options
AGES 1-5
* Resumption of bed-wetting, thumb sucking, clinging to parents
* Fears of the dark
* Avoidance of sleeping alone
* Increased crying
* Loss of appetite
* Stomach aches
* Nausea
* Sleep problems, nightmares
* Speech difficulties
* Tics
* Anxiety
* Fear
* Irritability
* Angry outbursts
* Sadness
* Withdrawal
* Give verbal assurance and physical comfort
* Provide comforting bedtime routines
* Avoid unnecessary separations
* Permit the child to sleep in parents' room temporarily
* Encourage expression regarding losses (i.e., deaths, pets, toys)
* Monitor media exposure to disaster trauma
* Encourage expression through play activities
AGES 6-11
* Decline in school performance
* Aggressive behavior at home or school
* Hyperactive or silly behavior
* Whining, clinging, acting like a younger child
* Increased competition with younger siblings for parents' attention
* Change in appetite
* Headaches
* Stomach aches
* Sleep disturbances, nightmares
* School avoidance
* Withdrawal from friends, familiar activities
* Angry outbursts
* Obsessive preoccupation with disaster, safety
* Give additional attention and consideration
* Relax expectations of performance at home and at school temporarily
* Set gentle but firm limits for acting out behavior
* Provide structured but undemanding home chores and rehabilitation activities
* Encourage verbal and play expression of thoughts and feelings
* Listen to the child's repeated retelling of a disaster event
* Involve the child in preparation of family emergency kit, home drills
* Rehearse safety measures for future disasters
* Coordinate school disaster program for peer support, expressive activities, education on disasters, preparedness planning, identifying at-risk children
AGES 12-18
* Decline in academic performance
* Rebellion at home or school
* Decline in previous responsible behavior
* Agitation or decrease in energy level, apathy
* Delinquent behavior
* Social withdrawal
* Appetite changes
* Headaches
* Gastrointestinal problems
* Skin eruptions
* Complaints of vague aches and pains
* Sleep disorders
* Loss of interest in peer social activities, hobbies, recreation
* Sadness or depression
* Resistance to authority
* Feelings of inadequacy and helplessness
* Give additional attention and consideration
* Relax expectations of performance at home and school temporarily
* Encourage discussion of disaster experiences with peers, significant adults
* Avoid insistence on discussion of feelings with parents
* Encourage physical activities
* Rehearse family safety measures for future disasters
* Encourage resumption of social activities, athletics, clubs etc.
* Encourage participation in community rehabilitation and reclamation work
* Coordinate school programs for peer support and debriefing, preparedness planning, volunteer community recovery, identifying at-risk teens
ADULTS
* Sleep problems
* Avoidance of reminders
* Excessive activity level
* Crying easily
* Increased conflicts with family
* Hypervigilance
* Isolation, withdrawal
* Fatigue, exhaustion
* Gastrointestinal distress
* Appetite change
* Somatic complaints
* Worsening of chronic conditions
* Depression, sadness
* Irritability, anger
* Anxiety, fear
* Despair, hopelessness
* Guilt, self doubt
* Mood swings
* Provide supportive listening and opportunity to talk in detail about disaster experiences
* Assist with prioritizing and problem-solving
* Offer assistance for family members to facilitate communication and effective functioning
* Assess and refer when indicated
* Provide information on disaster stress and coping, children's reactions and families
* Provide information on referral resources
OLDER ADULTS
* Withdrawal and isolation
* Reluctance to leave home
* Mobility limitations
* Relocation adjustment problems
* Worsening of chronic illnesses
* Sleep disorders
* Memory problems
* Somatic symptoms
* More susceptible to hypo- and hyperthermia
* Physical and sensory limitations (sight, hearing) interfere with recovery
* Depression
* Despair about losses
* Apathy
* Confusion, disorientation
* Suspicion
* Agitation, anger
* Fears of institutionalization
* Anxiety with unfamiliar surroundings
* Embarrassment about receiving "hand outs"
* Provide strong and persistent verbal reassurance
* Provide orienting information
* Use multiple assessment methods as problems may be under reported
* Provide assistance with recovery of possessions
* Assist in obtaining medical and financial assistance
* Assist in reestablishing familial and social contacts
* Give special attention to suitable residential relocation
* Encourage discussion of disaster losses and expression of emotions
* Provide and facilitate referrals for disaster assistance
* Engage providers of transportation, chore services, meal programs, home health, and home visits as needed.
CULTURAL AND ETHNIC GROUPS
Workers must respond specifically and sensitively to the various cultural groups affected by a disaster. Ethnic and racial minority groups may be especially hard hit, because of socioeconomic conditions that force the community to live in housing that is particularly vulnerable. Language barriers, suspicion of governmental programs due to prior experiences, rejection of outside interference or assistance, and differing cultural values can present challenges for workers in gaining access and acceptance.
Cultural sensitivity is conveyed when disaster information and application procedures are translated into primary spoken languages and available in non-written forms. Cultural groups have considerable variation regarding views of loss, death, home, the family, spiritual practices, grieving, celebrating, mental health, and helping. It is essential that workers learn about the cultural norms, traditions, local history, and community politics from leaders and social service workers indigenous to the groups they are serving. Establishing working relationships with trusted organizations, service providers, and community leaders often facilitates increased acceptance. It is especially important for workers to be respectful, well-informed, and to dependably follow through on stated plans.
PEOPLE WITH SERIOUS AND PERSISTENT MENTAL ILLNESS
Many disaster survivors with mental illness function fairly well following a disaster, if most essential services have not been interrupted. They have the same capacity to "rise to the occasion" and perform heroically as the general population during the immediate aftermath of the disaster. However, for others who may have achieved only a tenuous balance before the disaster, additional mental health support services, medications, or hospitalization may be necessary to regain stability. For survivors diagnosed with Post-traumatic Stress Disorder (PTSD), disaster stimuli (e.g., helicopters, sirens) may trigger an exacerbation due to associations with prior traumatic events.
The range of disaster mental health services designed for the general population is equally beneficial for survivors with mental illness; disaster stress affects all groups. Workers need to be aware of how people with mental illness are perceiving disaster assistance and services and build bridges that facilitate access where necessary.
PEOPLE IN GROUP FACILITIES
People who are in group facilities or nursing homes during a disaster are susceptible to anxiety, panic, and frustration as a consequence of their limited mobility and dependence on caretakers. The impact of evacuation and relocation on those with health or functional impairments can be tremendous. Dependence on others for care or on medical resources for survival contributes to heightened fear and anxiety. Change in physical surroundings, caregiving personnel, and routines can be extremely difficult.
Both the staff and patients/residents of evacuated or disaster-impacted group facilities are in need of support services. Interventions for these groups include reestablishing familiar routines, including residents in recovery and housekeeping activities when appropriate, providing supportive opportunities to talk about disaster experiences, assisting with making contact with loved ones, and providing information on reactions to disaster and coping.
HUMAN SERVICE AND DISASTER RELIEF WORKERS
Workers in all phases of disaster relief, whether law enforcement, local government, emergency response, or survivor support, experience considerable demands to meet the needs of the survivors and the community. Depending on the nature of the disaster and their role, relief workers may witness human tragedy, fatalities, and serious physical injuries. Over time, workers may show the physical and psychological effects of work overload and exposure to human suffering. They may experience physical stress symptoms or become increasingly irritable, depressed, over-involved or unproductive, and/or show cognitive effects like difficulty concentrating or making decisions. Mental health workers may intervene by suggesting or using some of the strategies described in the next section.

STRESS PREVENTION AND MANAGEMENT
Working with disaster survivors is inevitably stressful at times. The long hours, breadth of survivors' needs and demands, ambiguous roles, and exposure to human suffering can affect even the most experienced professional. While the work is personally rewarding and challenging, it also has the potential for affecting workers in adverse ways. Too often, staff stress is addressed as an afterthought.
Preventive stress management focuses on two critical contexts: the organizational and the individual. Adopting a preventive perspective allows both workers and programs to anticipate stressors and shape crises rather than simply reacting to them after they occur.

Organizational Approaches for Stress Prevention and Management
Dimension
Response
EFFECTIVE MANAGEMENT STRUCTURE & LEADERSHIP
* Clear chain of command and reporting relationships
* Available and accessible clinical supervisor
* Disaster orientation provided for all workers
* Shifts no longer than 12 hours with 12 hours off
* Briefings provided at beginning of shifts as workers exit and enter the operation
* Necessary supplies available (e.g., paper, forms, pens, educational materials)
* Communication tools available (e.g., cell phones, radios)
CLEAR PURPOSE & GOALS
* Clearly defined intervention goals and strategies appropriate to assignment setting (e.g., crisis intervention, debriefing)
FUNCTIONALLY DEFINED ROLES
* Staff oriented and trained with written role descriptions for each assignment setting
* When setting is under the jurisdiction of another agency, staff informed of mental health's role, contact people and expectations
TEAM SUPPORT
* Buddy system for support and monitoring stress reactions
* Positive atmosphere of support and tolerance with "good job" said often
PLAN FOR STRESS MANAGEMENT
* Workers' functioning assessed regularly
* Workers rotated between low-, mid-, and high stress tasks
* Breaks and time away from assignment encouraged
* Education about signs and symptoms of worker stress and coping strategies
* Individual and group defusing and debriefing provided
* Exit plan for workers leaving the operation: debriefing, reentry information, opportunity to critique, and formal recognition for service
Individual Approaches for Stress Prevention and Management
Dimension
Response
MANAGEMENT OF WORKLOAD
* Task priority levels set with a realistic work plan
* Existing workload delegated so workers not attempting disaster response and usual job
BALANCED LIFESTYLE
* Physical exercise and muscle stretching when possible
* Nutritional eating, avoiding excessive junk food, caffeine, alcohol, or tobacco
* Adequate sleep and rest, especially on longer assignments
* Contact and connection maintained with primary social supports
STRESS REDUCTION STRATEGIES
* Reducing physical tension by taking deep breaths, calming self through meditation, walking mindfully
* Using time off for exercise, reading, listening to music, taking a bath, talking to family, getting a special meal-to recharge batteries
* Talking about emotions and reactions with coworkers during appropriate times
SELF-AWARENESS
* Early warning signs for stress reactions recognized and heeded
* Acceptance that one may not be able to self-assess problematic stress reactions
* Over identification with survivors'/victims' grief and trauma may result in avoiding discussing painful material
* Understanding differences between professional helping relationships and friendships
* Examination of personal prejudices and cultural stereotypes
* Vicarious traumatization or compassion fatigue may develop
* Recognition of when own disaster experience or losses interfere with effectiveness

National Mental Health Information Center
Article location: http://www.mentalhealth.samhsa.gov/publications/allpubs/ADM90-537/Default.asp

This publication was produced under an interagency agreement between the Federal Emergency Management Agency and the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration. Portland Ridley served as CMHS publications and -editorial coordinator.
Copies are available at no charge from the Center for Mental Health Services:
SAMHSA's National Mental Health Information Center
P.O. Box 42557
Washington, D.C. 20015
Toll-Free Information Line 1-800-789-2647
(TDD) 866-889-2647
FAX 240-747-5470
Website www.mentalhealth.samhsa.gov
All material appearing in this volume, except quoted passages from copyright sources, is in the public domain and may be produced or copied without the permission from the Administration or the -authors. Citation of the source is appreciated.
DHHS Publication No. ADM 90-537
Substance Abuse and Mental Health Services Administration
Printed 2000
Author: Deborah J. DeWolfe, Ph.D., M.S.P.H.
Editor: Diana Nordboe, M.Ed.
____________________________________________________________________________

Biloxi, Miss., September 3, 2005 -- A member of the Indiana Task Force 1 Urban Search and Rescue (US&R) team marks a damaged house after searching for victims of Hurricane Katrina. The gulf coast of Mississippi sustained extreme damage from the hurricane. FEMA/Mark Wolfe

 

A Guide for Emergency and Disaster Response Workers
Normal Reactions to a Disaster Event
Signs That You May Need Stress Management Assistance

Ways to Help Manage Your Stress
Normal Reactions to a Disaster Event
* No one who responds to a mass casualty event is untouched by it
* Profound sadness, grief, and anger are normal reactions to an abnormal event
* You may not want to leave the scene until the work is finished
* You will likely try to override stress and fatigue with dedication and commitment
* You may deny the need for rest and recovery time
Signs That You May Need Stress Management Assistance
* Difficulty communicating thoughts
* Difficulty remembering instructions
* Difficulty maintaining balance
* Uncharacteristically argumentative
* Difficulty making decisions
* Limited attention span
* Unnecessary risk-taking
* Tremors/headaches/nausea
* Tunnel vision/muffled hearing
* Colds or flu-like symptoms.
* Disorientation or confusion
* Difficulty concentrating
* Loss of objectivity
* Easily frustrated
* Unable to engage in problem-solving
* Unable to let down when off duty
* Refusal to follow orders
* Refusal to leave the scene
* Increased use of drugs/alcohol
* Unusual clumsiness
Ways to Help Manage Your Stress
* Limit on-duty work hours to no more than 12 hours per day
* Make work rotations from high stress to lower stress functions
* Make work rotations from the scene to routine assignments, as practicable
* Use counseling assistance programs available through your agency
* Drink plenty of water and eat healthy snacks like fresh fruit and whole grain breads and other energy foods at the scene
* Take frequent, brief breaks from the scene as practicable.
* Talk about your emotions to process have seen and done
* Stay in touch with your family and friends
* Participate in memorials, rituals, and use of symbols as a way to express feelings
* Pair up with a responder so that you may monitor one another's stress
National Mental Health Information Center
Article location: http://www.mentalhealth.samhsa.gov/publications/allpubs/KEN-01-0098/Tips for Managing and Preventing Stress:
------------------------------------------------------

Guiding Principles (It is helpful to keep these points in mind when preparing for or responding to a disaster.)

• No one who experiences a disaster is untouched by it.
• Most people pull together and function during and after a disaster, but their effectiveness is diminished.
• Mental health concerns exist in most aspects of preparedness, response and recovery.
• Disaster stress and grief reactions are “normal responses to an abnormal situation.”
• Survivors respond to active, genuine interest and concern.
• Disaster mental health assistance is often more practical than psychological in nature (offering a phone, distributing coffee, listening, encouraging, reassuring, comforting).
• Disaster relief assistance may be confusing to disaster survivors. They may experience frustration, anger, and feelings of helplessness related to Federal, State, and non-profit agencies’ disaster assistance programs. They may reject disaster assistance of all types.

Survivor Needs & Reactions (Responses differ, but there are common needs.)

• A concern for basic survival
• Grief over loss of loved ones and loss of valued/meaningful possessions
• Fear and anxiety about personal safety and physical safety of loved ones
• Sleep disturbances, often including nightmares and imagery from the disaster
• Concerns about relocation and the related isolation or crowded living conditions
• A need to talk, often repeatedly, about events and feelings associated with the disaster
• A need to feel one is a part of the community and its recovery efforts

Reactions that Signal Possible Need for Mental Health Referral (Many responses to trauma can be expected, but some are cause for extra attention/concern.)

• Disorientation (dazed, memory loss, unable to give date/time or recall recent events…)
• Depression (pervasive feeling of hopelessness & despair, withdrawal from others…)
• Anxiety (constantly on edge, restless, obsessive fear of another disaster…)
• Acute psychosis (hearing voices, seeing visions, delusional thinking…)
• Inability to care for self (not eating, bathing, changing clothing or handling daily life)
• Suicidal or homicidal thoughts or plans
• Problematic use of alcohol or drugs
• Domestic violence, child abuse or elder abuse

Common Disaster Worker Stress Reaction Checklist (It is not unusual for responders to have these reactions. Check yourself and your buddies.)

Behavioral and Emotional Responses/Symptoms

• Anxiety, fear
• Grief, guilt, self-doubt, sadness
• Irritability, anger, resentment, increased conflicts with friends/family
• Feeling overwhelmed, hopeless, despair, depressed
• Anticipation of harm to self or others; isolation or social withdrawal
• Insomnia
• Gait change
• Hyper-vigilance; startle reactions
• Crying easily
• Gallows humor
• Ritualistic behavior

Cognitive Responses/Symptoms

• Memory loss, Anomia (difficulty naming objects or people)
• Calculation difficulties; Decision making difficulties
• Confusion in general and/or confusing trivial with major issues
• Concentration problems/distractibility
• Reduced attention span and/or preoccupation with disaster\
• Recurring dreams or nightmares

Physiological Responses/Symptoms

• Fatigue
• Nausea
• Fine motor tremors
• Tics
• Paresthesia
• Profuse Sweating
• Dizziness
• GI Upset
• Heart Palpitations
• Choking or smothering sensation

Mis-Attribution of Normal Arousal (Misinterpretation of normal physiological responses can increase anxiety and the number of unnecessary ER visits.)

• Interpretation of normal physiological arousal as serious illness
• Misinterpretation often is increased by rumors and false information
• Increased by hyper-suggestibility in victim fueled by changes in routine and surroundings
• Risk communication and rumor control can help reduce unnecessary drains on healthcare

Longer-Term Effects Checklist (Potential down-stream consequences of exposure to a natural or human-caused disaster.)

• Nightmares
• Intrusive thoughts
• Uncontrolled affect
• Relationship problems
• Job/school related problems
• Decreased libido
• Appetite change
• Blame assignation
• Decreased immune response

Sources of Stress for Responders Checklist (These can increase stress.)

• Role ambiguity
• Lack of clarity of tasking
• Mismatching skills with tasks
• Lack of team cohesion
• Discomfort with hazardous exposure
• Ineffective communication within team, with non-team members, with headquarters
• Lack of or too much autonomy
• Intense local needs for information (media/health officials) that cannot await clearance delay
• Database issues, linkage between epidemiology, laboratory, and environmental sampling
• Laboratory specimen tracking, reporting
• Resources/equipment shortages
• Command and control ambiguities
• Re-integration barriers
• Coworkers had to pick up your work…or no one did and it is overwhelming
• Lack of understanding of or appreciation for what you have been through
• Domestic/family conflict

Individual Approaches to Avoid/Reduce Stress Checklist (Things you can do to help maintain your own mental, emotional, physical, spiritual balance.)

• Management of workload
  • Set task priority levels and create a realistic work plan
  • Delegate existing workload so workers not doing usual job too
• Balanced Lifestyle
  • Exercise and stretch muscles when possible
  • Eat nutritionally, avoid junk food, caffeine, alcohol, tobacco
  • Obtain adequate sleep and rest, especially on longer assignments
  • Maintain contact and connection with primary social supports
• Stress Reduction Strategies
  • Reduce physical tension by deep breathing, meditating, walking
  • Use time off for exercise, reading, listening to music, taking a bath
  • Talk about emotions & reactions with coworkers at appropriate times
• Self-Awareness
  • Recognize and heed early warning signs for stress reactions
  • Accept that one may not be able to self-assess problematic reactions
  • Be careful not to identify too much with survivors/victims’ grief and trauma
  • Understand differences between professional relationships and friendships
  • Examine personal prejudices and cultural stereotypes
  • Be vigilant not to develop vicarious traumatization or compassion fatigue
  • Recognize when own disaster experience interferes with effectiveness

Self-Care Examples Checklist (Examples, by category, of things you can do.)

• Physical Diet, exercise, sports, sleep, relaxation…
• Emotional Stay in contact with family, friends, social support
• Cognitive Training, reading, perspective
• Behavioral Civic involvement, personal & family preparedness
• Spiritual Meditation, prayer, fellowship, volunteerism
  (source: Centers for Disease Control and Prevention | CDC | Disaster Mental Health for Responders: Key Principles, Issues and Questions)
  

Click here for the National Child Traumatic Stress Network (NCTSN)'s Hurricane Referral and Screening Tool for Children and Adolescents

De-escalation

People are stressed in a disaster!  You will be stressed! Sometimes the work is simply de-escalating a situation, and suggesting things that will allow your fellow workers to slow down, to take a rest, to regroup. People have made a huge commitment to volunteer at a disaster, and I always try to assist a stressed worker so that he or she will not be sent home.

I know mental health workers who have written reminders of self-care on their hands. These are not complex; we don't write things like:

Set task priority levels and create a realistic work plan
Exercise and stretch muscles when possible
Eat nutritionally, avoid junk food, caffeine, alcohol, tobacco
Obtain adequate sleep and rest, especially on longer assignments
Maintain contact and connection with primary social supports
Reduce physical tension by deep breathing, meditating, walking
Use time off for exercise, reading, listening to music, taking a bath
Talk about emotions & reactions with coworkers at appropriate times
Maintain Self-Awareness

Our hands aren't big enough!

Instead, we write:

Water
Breathe

Another important resource is to cultivate a friend or buddy, someone who will send you out for a walk if you are unraveling. I have told other mental health workers to take a walk, to think about his dog (I knew about the worker's closeness to his dog from a previous conversation). I have ordered (yes, ordered!!) disaster mental health workers and other volunteers to take a day off. People have told me to "chill" or "Let it go!" You have to be able to let go of what is stressing you out and trust your co-workers enough to listen when they tell you that you are unraveling. Cultivate your team! They will keep you sane!

"He must clear his eyes and listen intently,
so that he and his subjects may together be molded by spirit and transformed."

Quote from a 1,000 year old Chinese scroll, a letter of advice to a newly appointed magistrate on how to spread a civilizing influence.
From The Embodied Image: Chinese Calligraphy from the John B. Elliott Collection
by Robert E. Harrist, Jr. and Wen. C. Fong, The Art Museum, Princeton University, NJ,1999

When counseling fellow workers, it is preferable to help them with their stresses than to recommend that they be sent home.

I was in the lobby of the hotel, "smoozing", giving out stickers, when I heard one of the volunteers yelling loudly at a woman. "Stop it! You have no right to treat me that way!"One of the disaster volunteers was clearly at the breaking point. A huge African American man was yelling at a Caucasian woman. I went up to him to see what was the matter. He told me that the woman had been inappropriate with him, and had been saying things and touching him in ways that were filled with sexual innuendo. I went up to her. She was shocked that he had yelled at her. "He isn't serious, is he? I was just playing. I can't believe that he is serious."  I said it looked like he was quite serious, and asked her to go up and apologize to him. She glared at me and refused, saying everyone knew she was just joking.

I went back to him and asked him specifically what had happened. He told me, and indeed, it sounded like she had crossed a line. He knew nothing would happen, "It never does. It always goes the same way. The big black guy gets in trouble, the white woman gets off. I might as well start packing right now. "

I told him that I would do my best to see that this had a different resolution, but he had no faith that his side would be heard. He said the woman had been inappropriate with him before, and that he had explained to her that he was a married man. Her side was that she was just being friendly, and that there was no sexual element to her behavior. She was young, and seemed to have no real idea of how to be friends and colleagues with this man, without a flirtatious element. The problem was that she refused to take any responsibility for her behavior.

I called his supervisor, on his behalf, and explained what I had witnessed. He was allowed to stay, and the woman was moved to a different position, so that they were not working side-by-side.

He was able to stay in his position, but the next day I received another report about him going off, yelling at someone. This incident was more serious, as it involved swearing at a shelter resident in front of her children. Talking with his co-workers, it was evident that he had been escalating, losing his temper more and more. "He even went off on me," one of his co-workers explained. "I can handle him, and will not say anything for the record, but he is losing it."

His supervisor had had it, and she wanted him sent home. He was called to a meeting at headquarters. Without being told explicitly was the meeting was for, he knew he would be told to pack up and leave. As he was waiting for a ride to headquarters, he found me in my "office", a table in the hotel lobby. He sat down and started to talk, great sadness in his voice. "I know I am about to be sent home. I really wanted this to work. I tried so hard, but I don't know how to do it. I am from South Central L. A. I run a security company for rap stars. This is how we do it there. We have to yell, and push people out of the way. Man, it is so different here. I don't think my way works here, in Houston, with this group. I really want to learn a different way, but I don't know where  to start." He went on to say he was tired of yelling all the time, especially to his children. he wanted to change, but didn't know how.

I was struck by his remorse, and sincerity. So I called my supervisor, and asked if I could have him join me, then, with her approval, called headquarters and asked the same thing. They agreed, although they thought I was crazy. Even my partner thought I was truly insane, but I saw something in him. He became my assistant, and began to see how gifted he was with people. I would often have him join me as I was debriefing workers, and his insights and perspective were invaluable, both to the people we were debriefing, and to me. With his presence, I gained more credibility, and was able to go places that otherwise I would not be welcome. We joked that I was the only mental health worker with a bodyguard and a driver. By the end, he was calling me, "Miss Daisy".

Chris Lewis - friend and bodyguard!

After I went home, we stayed in touch. He became the head of security in San Antonio, supervising people at two shelters.

_____________________________________________________________________________

 

Once again, in my "office", I noticed a woman who was asking other volunteers if they were going upstairs to their rooms in the hotel. She seemed agitated, so I asked her if she was OK. She said she was fine, but deathly frightened of heights. He room was on the 11th floor of the hotel, and the problem was that the hotel had glass elevators and every floor opened up to the inner atrium. There was no way to avoid heights. She explained that in order to get down to the lobby, she had called a porter, who escorted her, with her eyes closed, holding onto the inner wall (to avoid the atrium balcony) to the service elevator, which was enclosed, not glass. She said she was having a terrible time with her acrophobia.

I offered to call headquarters on her behalf and see if she could be moved to a different hotel, without the glass elevators and atrium, or one that had rooms on a ground floor. She refused, saying, "I am 65 years old. My whole life has been ruled by this phobia. I am sick and tired of it, and am going to change it." I let her know that I thought she was very courageous, and was available to talk to her if she wanted.

Our next encounter was when I saw her approaching a uniformed Houston Police Officer, who had been stationed in the lobby. I caught up with her, and asked her how she was doing. "Fine", she reported, "I was just going to ask the officer to escort me to my room." I mentioned that perhaps that was not quite the thing to do. She still refused to change hotels, so we brainstormed a bit. I told her of a technique that I had used, driving the treacherous Pacific Highway on cliffs high above the ocean. "I keep a hat with a big, floppy brim in the car. If I get anxious looking over the cliffs, I put the brim down on the side of the drop. That way, I don't have to see it." She was delighted with my admission of my own acrophobia, and empathy, and said she was willing to try anything, even the "floppy hat trick."

The next time I saw her, she came up to me and gave me a big hug. She pulled an enormous floppy hat out of the  purse, and said, "It works! I can do it! I can get to my room myself".

Why do I do it? I love the intensity and authenticity of disaster mental health. In order to do well, I must be willing to face my own fears, my own shadow material. I love how real people are, and how real I must be in response, during a disaster. I also like the quickness of the interventions, which provide a contrast to my therapy practice. Being a 'lone wolf'' in my professional life, it is nice to be part of a team, working for the greater good. And I like feeling that I am doing something other than watching CNN with tears pouring down my face.

Children

Please repeat after me: "This is a normal reaction to an abnormal event..."

You will say this again and again to co-workers, children and parents.

Effects on Children
For children who experience a traumatic event, some degree of behavioral symptoms and adjustment reactions are expected and are well within the normal limits of psychological response. The psychological responses of children to disasters can range from transient mild stress reactions to the more severe and prolonged consequences of PTSD. These responses are influenced by the gender, developmental stage, inherent resilience, and social support of the child and the level of exposure of the child to the trauma. Exposure to traumatic and violent events results in expressions of fear, anxiety, and depression. In most cases, these reactions are within the realm of normal responses to a traumatic event, and as children are helped to learn to cope with this stress, their symptoms subside.

For the full text of this article, please go to:www.psychceu.com/disasterresponse/pediatrics/787.html

Hagan, Joseph F., Jr, and the Committee on Psychosocial Aspects of Child and Family Health, , and the Task Force on Terrorism,
Psychosocial Implications of Disaster or Terrorism on Children: A Guide for the Pediatrician
Pediatrics 2005 116: 787-795 (doi:10.1542/peds.2005-1498)

Boundaries
No, you may not take a baby home with you, or have sex with anyone other than your partner...  

Beware: Your Professional Boundaries may be at risk...

Professional boundaries are different at a disaster; there is no paperwork, no set frame for disaster mental health. It has been said that the therapeutic frame of having set times for patients to come, and a set amount of time for each session (the 50 minute hour, etc.) is really there to keep the therapist's craziness at bay! Face it, we are helpers, or we would not be drawn to this work, and many of us have had to learn about setting limits and codependency the hard way.

People will tug at you during a disaster, especially the children. No, you cannot take a child home with you! And I have never been at a disaster with children where I do not want to scoop up the children and make it all better for them, or just take them home and nurture them, or where the volunteers do not joke about taking home a baby.  And we never do, but the boundaries in a disaster are, by necessity, different than those in a professional practice.

Mental health workers who cannot let go of a client after a shift, or after a deployment, are at risk here. The best thing to do when you are pulled this way is to find another mental health worker and talk about it, before you do anything!  I have heard tales of mental health workers staying in contact with disaster victims after a disaster, and making promises to help them when they get home. Do not do this, unless it is in the charter of the organization with which you are working.

Danger signs:

Finding a 'special client'
Wanting to give this client food, money, etc.
Not being able to let go of this client when your shift is over
Obsessing about what you can do to help this client when you get home
Making promises
Not being able to let go of this client when your deployment is over
Staying in contact with a client when you are back home

Beware: Your Personal Boundaries may be at risk...
or sex, drugs, rock & roll

Bonding with your team and coworkers at a disaster is an important aspect of disaster mental health. Here are people who are "in it" with you, experiencing the intensity of helping out during a disaster.This is the "movie set syndrome"; how people on a set become a sort of family, sharing the same experiences, and sometimes sleeping with co-workers...) Bonding is good; however, time and time again I have seen volunteers (even, and perhaps especially, mental health professionals) stretch or lose their personal boundaries at disasters. Disasters are stressful, and bonding happens very quickly. Your team will become extremely important; in the moment, sometimes more important than even your home life. Sex is a good antidote for death, drugs and alcohol are often ways in which we de-stress, and the intensity of the moment may cause you to do things that you later regret. If at all possible, find a way to call home daily. Bring pictures of your  loved ones, and kiss the pictures good-night every night.

Danger signs:

Bonding with a coworker to the point in which you dress up for your shift (yes, dressing up is an odd concept in a disaster) If you find yourself paying more attention to your hair, or make-up, or how clean you shave; or what you wear) then, beware!
Wanting to meet this coworker for drinks after each shift, to the exclusion of other team members. (We do know by now that alcohol blurs boundaries and judgment.)
Not being able to let go of this coworker when your shift is over.
Obsessing about what you said, or should have said, to this person
Too much touching
Obsessing about what you can do to stay in touch when you get home
Making promises
Having a crush on a coworker
Lying to your spouse or domestic partner about this coworker
Staying in contact with the coworker when you are back home (other than an occasional phone call or e-mail)
Do not have sex with a coworker (or, heaven forbid, a client!!!!!)!  Remember, if it is true love, then it will endure when you get home.

Debriefing

• Talk to your team and buddies several times a day
• Let your hair down - confide to them where you feel you have helped, and where you feel you have failed!
• Draw, write, sing, move - creative expression helps to release trauma from the cells
• Dance, Dance, Dance!

Sri Lanka Dancing
Photograph by Kate Amatruda

• The best debriefing I ever had was dancing at St. John's Orphanage in Sri Lanka (Cultural Alert: only the girls and women could dance; the men were outside, peering in the windows!)
  
• Evaluation - In many deployments, you will have a formal debriefing and be given an evaluation.

Photograph by Chris Lewis

Time to Go Home

Going home is hard! I always feel like I should stay longer, yet when the time approaches to go home, I get excited. It will be hard to say good-bye to your colleagues. Sharing a disaster is intense, and the relationships you form may not survive your re-entry into normal life.

Re-entry into your Life

These are recommendations by:

Rocky Mountain Region Disaster Mental Health Newsletter - May 18, 2001

Until recent years, little attention has been paid to the emotional issues faced by those who work on site following disasters. Homecomings in particular are frequently not as pleasant and rewarding as the worker had hoped and planned. Below are some ideas and suggestions for workers when thinking about and planning for going home:
REST
* Few workers get enough rest while working on a disaster. They are usually exhausted when they return home. it is very important to catch up on rest. This may take several days.
* The need for rest may cause family problems. The family may want and need the worker's attention, time, and energy. Their needs must be considered. Try to anticipate the problem and negotiate your respective needs carefully.
PACE
* Disaster work is usually fast paced. you may find it difficult to gear down to a normal pace. You might find yourself rushing through tasks, moving quickly to additional tasks, or feeling guilty when you are not actively engaged in something.
* Try to be tolerant of others who are moving at a slower pace. They are usually going at a normal pace! Resist the temptation to see others as lazy, slow, or uncommitted.
* Before returning, try to anticipate the areas in which problems concerning pace might come up - both at home and at work. Thinking through situations where problems might develop will help you prepare for the actual situation.
Discussing The Disaster
* You may want to talk a lot about your disaster experience. Others may be interested. However, anticipate that: ~ others may not be interested ~ while they may be interested, they have not gone through the experience and may not feel as intensely as you. ~ others may want to tell you what has been happening to them during your absence. Be tolerant and understanding. What they have been through is as important to them as your experiences are to you.
* Remember that just because people seem uninterested in hearing about the disaster, they aren't uninterested in you. The disaster has been so much a part of your life for the last few days and weeks that you may be pre-occupied with your experience when you return home. While others will be concerned about your well-being, they may have little interest in your disaster experience.
* You may not want to talk a lot about your disaster experience - especially if the experience was a particularly difficult one for you or if you are very fatigued. Help those around you understand that you are still processing or recovering from your experience and are not ready to talk yet. You may want to reassure them that this is not an effort to exclude them, but that you just need some time.
* Understand that you may alternate between wanting and not wanting to talk about your disaster experience. This switching may be disconcerting because you may not be able to predict or control these shifts. You probably heard the same thing from victims who were afraid because they could not control their emotions. Over time, these shifts will become less frequent and surprising. Understand, and help those around you understand, that this is a normal and natural response.
Emotional Reactions
Most workers, upon returning home, have emotional reactions that surprise and sometimes frighten them. If you can anticipate some of these emotions, you can manage them better. Below are some examples:
* Disappointment often results when expectations about returning home do not match the reception. You may have anticipated happy reunions with family and colleagues only to find them angry because of your absence. Try to keep reunion expectations realistic.
* Workers sometimes experience frustration and conflict when their needs are inconsistent with the needs of family and colleagues. You often hear of the disaster worker who returns home after weeks of eating hotel food, desperately wanting a home-cooked meal, only to find a spouse who can't wait to go out for dinner!
* You may become angry when you are exposed to people's problems that seem minor or even trivial compared to what you have seen at the disaster site. This may happen reading the paper, watching TV, or talking with family and friends. It is important to remember that you can easily hurt people by minimizing their concerns and problems.
* Most workers have been introduced to the concept of "victim identification". You have a strong emotional response to some victims because, in some way, they remind you of yourself or someone important to you. The flip side of the same concept occurs when you return home. That is, friends and family members (children, spouse, parents, etc.) may remind you of disaster victims you have seen. This may produce intense emotional reactions that not only surprise you, but also surprise and confuse the unwitting recipient of these emotions. Help others understand this phenomenon.
* Mood swings are common upon return home. You may change frequently from happy to sad, tense to relaxed, outgoing to quiet, etc. These mood swings are normal and natural. They are part of the process by which you resolve conflicting and contradictory feelings. As time passes, these mood swings will become less dramatic, less frequent, and less surprising.
Children
Dealing with children upon returning home deserves some special note. It is important to give children information in ways that help increase their understanding and do not confuse or frighten them. Help young children understand why you were away and what you did. Think in advance about the kind of information they might want and the level of detail you should provide. It is usually not advisable to provide dramatic stories or graphic details of damage that might frighten children and generate fears of their own vulnerability as well as yours. If you have collected newspaper pictures and stories, you may want to share them with older children. Don't forget to encourage children to talk about what happened in their lives during your absence. They will find your interest reassuring.
Growth
The days and weeks after returning home from working on a disaster provide good opportunities for introspection. You have seen stress, disruption, and destruction. You have seen people at their strongest and at their most vulnerable. You have worked under difficult and stressful circumstances. You have been pulled away, for a variety of motives, from your day-to-day life, worked and lived in strange surroundings, and returned home again. You have undoubtedly gone through some personal growth. To help understand how you may have changed, ask yourself the following questions:
* Have you learned anything that can help you grow?
* What was rewarding about the experience?
* What have you learned about your own abilities?
* What have you learned about other people?
* Are there things you would like to do differently in the future?

 

Integration

Sri Lanka
Photograph by Kate Amatruda

Re-entry is hard!  I nearly burst into tears at the grocery store, overwhelmed in the shampoo section by how many types and brands there are. I wanted to pack off everything in the store and send it to Sri Lanka, to the people in the camps and the children in the orphanages. I was not sleeping very well; I do not think it is jet lag, but rather "soul lag". I wake up in the middle of the night and start to write. How can I be here when so much of my heart is there?

I keep thinking, "What next?" What can we, as humans, do, for other humans who are suffering? I don't know the answer, other than the feeling that we, who have so much, are not doing enough for those who have lost everything.

It is still the eyes that haunt me; the eyes of the woman who lost 41 people in her family, of her two shell-shocked granddaughters, of the mother whose children were swept away, of the man whose wife and children's bodies have not been found. It is the eyes of the listless children at the refugee camps, and the eyes of the children who sadly point out where they used to live. My heart goes out to these people, who have seen war, and death and destruction. I see pain, shock, and loss on the faces of the survivors - everything can change in a nanosecond. Life is fragile and precious. How do you go on when your village, your home, your family, is destroyed? I see the faces of those who I met in the refugee camps, and it is the eyes that capture me. And it is the eyes of the children that haunt me, and make me unable to sleep through the night.

My heart is touched forever by working with the survivors of the tsunami and the hurricane. I am transformed; less likely to take things for granted; more appreciative of the people in my life; more aware of each moment.

Ultimately, for me, disaster mental health is about mindfulness. Showing up, being as authentic and in the moment as possible, with my heart open is deeply transformative. I have learned so much from the children and adults who have survived a catastrophe.
Having seen first hand how life can end in a second, and how a disaster can change everything, I appreciate life each day. Life is fragile and precious.

Thank you!

S

Images may be subject to copyright.

Links:

International Critical Incident Stress Foundation, Inc.

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