Cross-cultural Counseling In Disaster Settings
This article reviews cross-cultural counseling, presents a review of a number of studies involving disaster victims and workers in other cultures and presents information about cross-cultural aspects of grief. It discusses some general methods and approaches that disaster mental health professionals should consider when contemplating providing disaster mental health services outside of their own culture. Emphasis is made that collaboration with providers and/or "culture-brokers" from the culture should be sought. Most common findings across cultures for those affected by disasters was that most symptoms of victims were those associated with PTSD, depression, and anxiety disorders. Understanding the role of families is discussed as well as effects of disasters on children. The research and literature suggest that children are at risk for PTSD, depression, and anxiety disorders as well as developmental delays as a result. Sensitivity in dealing with grief and grief rituals across cultures is emphasized. The development of an international disaster mental health services model with a strong emphasis on cross-cultural factors, consultation, collaboration, and education is suggested as a method to help mitigate and plan appropriate responses to disaster related mental health responses and problems.
Cross-cultural Counseling In Disaster Settings
Responses to disasters (natural and man-made) are handled initially by those in the area immediately affected. When there are insufficient local resources available or the extent of the disaster is overwhelmingly large, outside assistance is usually called for. Developed countries like the United States and Canada have prepared disaster response plans that address the situation and help people affected through a national response (Lystad, 1990). Within countries having pluralistic populations such as Canada and the United States, disaster workers need to be aware of, and sensitive to, cultural mores and differences. When disaster workers from these and/or other countries seek to assist with disasters in another country, it is essential that they have an understanding of the cultural norms and expectations of the population they hope to assist (Marsella, Friedman, & Gerrity, 1996). This is especially true for disaster mental health professionals. How different cultural groups handle stress and deal with stressors, their abilities, needs and desires for certain types of assistance, their motivations, their senses of honor and pride, their religious orientations and beliefs, their political systems and leadership, and their ways of handling and dealing with grief and loss are just some of the variables which are affected by cultural differences (Mak & Nadelson, 1996). Another one is communication - not just language differences, but also the nuances of specific words, phrases, slogans, proverbs, and colloguialisms. Well-intentioned attempts to help can easily be at risk for being misunderstood as meddling, interference or even as political attempts to influence and/or control.
This paper reviews some cross-cultural aspects of counseling and therapy. It then proceeds to review studies involving disaster victims and workers in other cultural and national settings, discusses some aspects of grief and loss across cultures, and suggests general methods and approaches to be considered by disaster mental health professionals who seek to provide those services outside of their own culture.
There has been a powerful development of comprehensive mental health services throughout the world. Much of the literature in this field has been devoted to the maladaptation and stress of the culture contact situation (Draguns, 1981; Higginbotham, 1976, 1979a, 1979b); Diop, Collignon and Gueye, 1976; Pedersen, Lonner and Draguns, 1976; Taft, 1977; Pinter, 1969). The problems of people removed from their cultural roots through migration, sojourn or involuntary displacement occupy the work of a great many culturally-oriented mental health professionals.
There is a considerable amount of information available on how to help people who are casualties of intercultural mobility. Some examples include distraught college students, confused immigrants, traumatized expellees and refugees, discouraged and dissatisfied Peace Corps volunteers. Pinter (1969) reported a number of attempts to sketch a composite portrait of an individual who is least or most likely to succumb to such stress. Characteristics of host environments have also been scrutinized in attempts to identify those features which contribute to making such an environment particularly stressful or unusually stress-free for newcomers (Pinter, 1978).
There is a sizeable background of literature which deals with psychotherapy and counseling with individuals who have been transplanted to a new cultural setting (Szapocznik, Scopetta, Arondale & Kurtines, 1978; David, 1976). This body of writing provides practical relevant information for the professional involved in extending services to immigrants, sojourners or returnees from intensive cross-cultural encounters.
All people respond to stimuli and situations by either changing themselves or the environment and by combining these two operations in various proportions. Historically, the implicit goal of counseling and psychotherapy has been to bring about a greater degree of conformity to the norms of the dominant majority group. The contemporary cross-cultural counselor or therapist faces a choice. He/she can prepare the client for changing obstacles in the environment, or he/she can equip the client for a greater degree of accommodation to the social structure in its current state. The increase in the individual's options also involves choices on the extent and nature of one's relationships, reference groups, and identity, especially in relation to one's ethnic or cultural group.
Wrenn (1962) was among the first to sensitize counselors to the problem of cultural encapsulation and warned against the imposition of culturally alien goals, values and practices upon clients across cultural lines. Pedersen (1976) took the position that, at least in a multicultural setting like the United States, crossing the cultural gulf in the mental health field is the rule rather than the exception.
The Vail Conference on Clinical Psychology which was sponsored by the American Psychological Association elevated the knowledge of the cultures of one's clients to an ethical imperative (Korman, 1974). As a result, doing therapy or counseling without cultural sensitivity, knowledge or awareness is not just problematic. It has been declared unethical. The implication of these recommendations is that the knowledge on therapy and culture has ceased to be an esoteric field. Instead, it has become a matter of direct and practical concern for those who provide services across cultures.
What features of a culture are reflected in its therapeutic services? What kinds of models are implicitly emulated in the conduct of psychotherapy? One can only point to statements placing psychotherapy in its respective cultural context and relating it to the needs, expectations, models and opportunities experienced in that culture (Draguns, 1975; Neki, 1973; Wittkower & Warnes, 1974). Does addition of healers of one's own cultural tradition result in the enhancement of effectiveness of mental health services? One area where such an investigation has been made was about the efficacy of Morita Therapy (Miura and Usa, 1970; Reynolds, 1976) and Naikan Therapy (Tanaka-Matsumi, 1979) in Japan. These are two procedures indigenous to their culture, yet developed and practiced by modern mental health professionals.
In Japan, the two indigenously developed therapies, Naikan and Morita, are based on guilt induction and control and on suppression of communication respectively. In the Naikan system, the client is admonished to think of all the ways in which he has wronged his mother (Tanaka-Matsumi, 1979). In the course of Morita therapy, what the client may say and when and how it is said is elaborately restricted and ritualized (Reynolds, 1976). The contrast between Western expectations and Japanese therapy is stark. Documentation on Morita therapy indicates that this therapy works in a substantial proportion of cases on its home grounds. As Sue (1977) has pointed out, therapy and counseling services geared to a culturally distinct group have to be appropriate in process and in goals to be acceptable and effective.
One of the things that therapists of different orientations and cultures share is the ability to generate perceptions of competence and concern in their clients (Torrey, 1972). The role of the therapist, regardless of technique, is catalytic, enabling the client to make use of his/her existing assets and strengths (Prince, 1976, 1980). Non-western cultures have tended to rely to a greater extent than the West upon the induction of altered states of consciousness to bring about these catalytic effects.
Jilek-Aal (1978) noted the effectiveness of the Salish Indian spirit dance in promoting therapeutic change in that cultural group. It induces regression through an altered state of consciousness, promotes the experience of death and rebirth, and provides the participant with
a new identity reoriented toward the ideal of the Salish culture. The rationale and the procedure appear to be reminiscent of the fixed-role therapy of George Kelly (1955) with the exception of greater reliance on affective and regressive processes, and on altered states of consciousness.
Collomb (1973) attempted to answer the question: What impels a mental health professional to offer services outside his or her usual geographic and cultural milieu, and how may these motives interfere with his or her optimal functioning as a therapist? He presented a provisional typology of what might be called the cultural distortions of counter-transference. On the basis of his observations, he distinguished three attitudes that could be described as those of universalism, cultural uniqueness, and rejection of one's own culture of origin. One prerequisite with which it is difficult to disagree is that the therapist, as part of his/her expertise and competence, should know the culture within which he/she operates. Devereux (1969), for example, applied himself to a thorough study of the "Plains Indians", preparatory and concurrent to conducting psychotherapy with one of them.
Therapists working in a cross-cultural setting should approach this task with a maximum of self-awareness and be prepared to deal with their own distortions of the therapy experience and relationship. In her work with members of other cultures in Miami, Florida, Weidman (1975) pioneered the concept of culture-broker - a well-informed intermediary whose inputs are brought to bear on the therapy process. The client remains the major source of information about those features of his/her cultural experience which might otherwise baffle the therapist. The limit of this mode of inquiry is that the individual, not the culture, is the focus of all therapy (Draguns, 1981). Sessions should not deteriorate into ethnographic data-gathering in its own right and for its own purpose nor to satisfy the therapist's curiosity. Rather, the referent should be: Is this information needed for therapy, and, if so, how?
In summary, counselors should have knowledge of the culture they work in as part of their expertise and competence. Giordano and Giordano (1976) provided some very valuable and specific information to keep in mind when initiating and maintaining contact with clients of another culture. The knowledge of the culture of one's clients provides the counselor with an entree and/or point of departure. The experience of the counselor with a cultural group or the information on it in the relevant professional literature serves as a source of hypotheses, to be verified, discarded and/or modified based on acquisition of further information. Working together with a counselor/healer from the culture could vastly improve the probability of success in appropriate interventions. This would be of special concern in a disaster or major crisis situation.
Whereas physical health risks and injuries sustained as the result of a disaster are generally similar across cultures, the psychological responses to disasters, loss and surrounding stressors tend to be different among cultures (Lechat, 1990). PTSD, depression and anxiety appear to be the most common reactions to severe crises and disasters. There are a number of clinical
and epidemiological studies of natural and man-made disasters in various countries. Studies of victims and survivors of disasters provide data about these responses. For example, de la Fuente's (1990) article on the psychological impact of the 1985 Mexican earthquakes reported that 32% of the victims displayed PTSD, 19% had generalized anxiety and 13% had depression.
Zhang & Zhang (1991) examined the long-term psychological effects of the 1976 Tangshan earthquake in China. They administered the 16PF, 2 attitude tests, and individual interviews to 110 paraplegic (aged 25-70) and 100 non-paraplegic subjects (aged 20-70). Results suggested the presence of long-term psychological effects. The authors suggest that the after-effects of earthquakes should be considered not only as physical disasters, but also with reference to the psychological shock caused by the earthquake.
In a study exploring the role of primary care workers in providing mental health services to adult victims following a volcanic eruption in Armero (Colombia) and earthquakes in Imbabura (Ecuador), Lima et al (1990) used a self-reporting questionnaire 7-20 months after the disaster. 200 adults in 4 camps in Armero were interviewed. Twelve months following the disaster the questionnaire was given to 100 clinic patients in the same area. They replicated the study in Ecuador with 150 adult clinic patients. Results showed the frequency of emotional disorders among disaster victims was proportional to the magnitude of the catastrophe. Victims from different disasters showed similar profiles. Lima and Pai (1992-1993) summarized the findings of the Colombian and Ecuadorian projects. A high prevalence of emotional distress was reported at the baseline surveys (55%-40%). This was 3-4 times greater than the rates seen in ordinary clinical situations. This distress corresponded to well-defined psychiatric disorders, mostly PTSD and major depression. Lima and Pai emphasized the importance of relying on general health care workers to provide adequate mental health care to disaster victims and discussed 3 models for planning service delivery.
Joh (1997) studied disaster stress resulting from the 1995 Kobe earthquake in Japan. He examined the mental and physical stress disorders among 748 victims (aged 4-88) in the first month after the earthquake. These were analyzed according to refugee conditions, gender, age/generation, and degree of housing damage. Results showed that:
This suggested that losing a house is a great mental burden.
Canino, Bravo, Rubio-Stipec, & Woodbury (1990) examined effects of the 1985 floods in Puerto Rico on mental health symptoms and diagnoses to determine the extent to which such effects were influenced by demographics and previous symptoms. They studied 912 people between the ages of 17-68 using a Spanish version of the Diagnostic Interview Schedule. They found that the onset of depression, generalized anxiety and PTSD was significantly more common among those exposed to a disaster than among those not exposed. They suggested that the increase in stress-related disorders in exposed Ss indicated that the stress of disaster increased their mental morbidity.
In another study, Escobar, Canino, Rubio-Stipec & Bravo (1992) interviewed 375 individuals before and after severe floods and mudslides in Puerto Rico. They used a Spanish version of the Diagnostic Interview Schedule to study the prevalence of somatization symptoms. 139 individuals were classified as having been exposed to disaster and 236 as not exposed. They found that exposure to disaster was related to a higher prevalence of medically unexplained physical symptoms. The most prevalent symptoms were gastrointestinal (abdominal pain, vomiting, nausea, excessive gas) and pseudoneurological (amnesia, paralysis, fainting, unusual spells, etc).
Guarnaccia (1993), in the first community based study of ataques de nervios (attacks of nerves), discussed the issue of categorizing it as a culture-bound syndrome. He conducted a psychiatric epidemiology survey using 912 subjects between the ages of 17-68 in Puerto Rico. This study was performed in 1987 to measure the psychosocial effects of a disaster which occurred on the island in 1985. He also had access to earlier data from a survey done in 1984. Guarnaccia identified stressful situations surrounding ataques. They were correlated with other psychiatric diagnoses and it was found that Ss who reported ataques de nervios were more likely to meet criteria for depression, dysthymia, generalized anxiety disorder, panic disorder, and PTSD. Guarnaccia suggests that the term "popular illness" is a better descriptive term for the syndrome than is "culture-bound syndrome".
The 1985 floods and mudslides in Puerto Rico caused considerable damage and death. As part of a major study (Guarnaccia, Canino, Rubio-Stipec, & Bravo, 1993) an additional question was added to the Diagnostic Interview Schedule/Disaster Supplement concerning ataques de nervios. Using this, researchers studied the category using a representative, community based sample of 912 people. 145 reported an ataque de nervios. Of these most were female, older, less educated, and formerly married. They were also more likely to meet criteria for anxiety and depressive disorders than those who had not experienced an ataque.
In summary, it appears that the most common symptoms displayed across the cultures sampled in the above studies of victims of various disasters were those associated with the diagnoses of depression, anxiety and PTSD. They manifest themselves in different ways within cultures, but the symptoms tend to fit the general diagnostic criteria for depression, anxiety disorders and PTSD. How to approach dealing with these in a culturally relevant counseling context is the task faced by the cross-cultural counselor providing disaster mental health services and psychological first aid.
Solomon, Bravo, Rubio-Stipec, and Canino (1993) hypothesized that family roles (marital and parental status) would moderate effects of disaster exposure on the mental health of victims. Their study included residents of St. Louis who were exposed to floods and dioxin and Puerto Rican residents exposed to floods and mudslides. Worst outcomes in St. Louis were found for single and married parents who were exposed to disaster. Their symptoms significantly exceeded those of non-exposed, non-victim single parents. Puerto Rican victims without families were reported as having higher levels of alcohol abuse symptoms than any other subgroup. The authors found that perceived emotional support was an important moderator of disaster effect on psychiatric distress in Puerto Rico and generally overrode the effect of family role.
In a related study, Solomon and Canino (1990) looked at the appropriateness of DSM-III-R criteria for PTSD. They examined whether 1) the psychiatric sequelae resulting from exposure to extraordinary traumatic events (stressor criterion A) differed from the sequellae resulting from exposure to more common yet stressful life experiences, and 2) PTSD sequellae (criteria B&D) accurately described the responses of victims even of extreme events fitting the DSM-III-R definition of stressor. They used data from 452 St. Louis victims exposed to floods and/or unsafe dioxin levels and 912 Puerto Rico victims of mudslides/flooding. Some common stressful events (e.g. moving, money problems) were found to relate more closely to PTSD symptoms than did extraordinary events. They found that exposure to disaster strongly related to symptoms of re-experiencing (criterion B). Reports of symptoms related to avoidance (criterion C) were uncommon.
In a study of acute stress reaction in family members, Ma, Lu, Liu, A-Er-Ken, et al (1995) worked with family members of the victims from a fire disaster in Kelamayi, Xinjiang Province, China which took place on December 8, 1994. Participants included 9 male and 72 female adults (aged 18-61). Those who visited the mental health clinic within one week of the event were identified with acute stress reaction according to the International Classification of Diseases-10 (ICD-10). Participants who visited the clinic within 3-5 weeks of the event were diagnosed with acute stress reaction according to family members' description. Subjects clinical manifestations (e.g. extreme sadness, agitating activity, stuporous state, and loss of consciousness), treatment (supporting or sub-hibernation therapy and the use of benzodiazapines), remission (within 48 hours - 2 weeks), frequency of diagnoses, correlation of stress from the event, and severity of acute stress reaction were the focus of their concerns.
Some cultural/ethnic groups place more value and receive more support from an extended family and/or community structure than others (Doherty, 1987). It is incumbent on the visiting counselor to have an understanding of the roles of these groups in order to provide more adequate and appropriate interventions for families and family members within the context of their own cultures.
In an article about psychosocial intervention in disaster management in the Philippines, Ladrido and Perlas (1996) identify 3 phases of intervention: impact, inventory, and reconstruction/rehabilitation. In this framework, psychosocial processing (PSP) is aimed at helping victims re-establish equilibrium and harmony following a disaster and at regaining personal control. They identified six types of PSP activities: critical incident stress debriefing; multiple group; action-related; activity-based (for special groups such as children and adolescents); team-building; and community organization for crisis management. Ladrido and Perlas contend that delivery of psychosocial intervention to disaster victims in general, and children in particular, has a beneficial filtering effect that can significantly reduce the number of those suffering from incapacitating symptoms.
Children exposed to disasters are at risk for a number of mental health related problems. The type and severity depend on the nature and extent of disaster trauma, the influence of family and community, the resilience or vulnerability of the child, and symptom onset and duration (Aptekar& Boore, 1990). Levels of functioning and cross-cultural differences also play an important part.
Schreiber (1999) described a firestorm which struck Laguna Beach, CA on October 30, 1993 in which 400 homes were lost. He described a FEMA supported program which provided services for affected children and parents over a 17 month period. The results he reported found that levels of PTSD and comorbid depression were significantly higher in children whose homes were destroyed. Current dissatisfactions with living arrangements and perceptions of greater difficulty in school were seen as being strong correlates of distress. He discussed factors related to sustained vulnerability, post disaster stresses, adversities and traumatic reminders. The findings presented were suggested as confirming the need for extended mental health services beyond the initial event as the risk from disaster exposure continued to accrue over time.
It is well established that children and adolescents can manifest adult-like PTSD after experiencing a life-threatening stressor (Yule, 1994). Delamater and Applegate (1999) examined post-traumatic stress disorder (PTSD), behavioral adjustment, and developmental outcomes in preschool children exposed to Hurricane Andrew in 1992. Their study measured mothers' self-reports of their child's symptoms of PTSD. They concluded that many young children can be expected to exhibit PTSD symptoms and other behavioral disruptions for at least 18 months following exposure to a natural disaster. Their study demonstrated that preschool age children exposed to the stress of a major hurricane are more likely to exhibit symptoms of PTSD than a comparison group who are less exposed. Children with PTSD at 12 months were reported as being more likely to be developmentally delayed at 18 months and those with PTSD at 18 months were also likely to be delayed. They suggest the children are at risk for failure to achieve normal development in cognitive, social and emotional skills and conclude that children with PTSD are at risk for developmental delays. This study is one of the first to examine the effects of PTSD on the general development of young children and presents information that will require further study in this important area.
In the light of recent school incidents in the United States, it is of importance to find ways to develop approaches for dealing with some of the psychological, social and educational aspects of the critical challenges faced during severe crises. Stein (1997) offers a blueprint for the school psychology profession to take a leadership role in these areas. Some of the challenges he identifies include preparing communities to cope effectively with crises at the individual, school, community, and national levels; preparing children and adults to deal with potential and actual disasters; intervening on the spot during crises; and treating the psychological problems that may manifest in the aftermath. Using experiences of the past 20 years in Israel, including the relatively recent traumatic events such as the assassination of prime minister Yitzhak Rabin, Stein presents a model in which he describes different stages of reaction. In his model he places emphasis on the role of the schools and of school psychologists in developing and implementing prevention programs which emphasize the fostering of inner strengths and resources in children and teachers and making provision for the professionals helping the community in times of crisis. He also suggests future development of the school psychology profession into a broader community service.
Saylor (1993) provides a valuable resource for disaster planners, crisis interventionists, clinicians, and researchers in a book dealing with the prevention and treatment of children's mental health problems following disasters. Along with other colleagues, Saylor discusses basic theory, assessment and intervention techniques and provides a critical survey of relevant literature. Children's perceptions of disasters and crises are largely determined by the reactions of their parents. Depending on their ages, experiences, cultural teachings, beliefs, etc. they tend to have a number of common physical, emotional, cognitive and behavioral reactions. Younger children may experience different levels of contagious, objective and/or profound anxiety. Older children (adolescents), due to the disaster or crisis, may suddenly have to assume the role as head of the family. How they see these responsibilities depends to a large extent on such factors as cultural background, age, religious views, education, personal equilibrium and how they view life in general.
In summary, children may appear more resilient in their response and recovery from disaster. However, the research and literature suggest they are at risk for PTSD, depression and anxiety disorders as well as possible developmental delays as a result. Children will follow the leads of their parents, cultural/ethnic groups and belief systems. Interventions should involve, wherever possible, collaboration with a "culture-broker" or practitioner from the affected cultural group.
For workers who are going to assist internationally in another culture, Paton (1996) identified several important issues that relief agencies should address prior to deployment. These include:
Covering these areas in a pre-brief for workers and their families can help prevent and mitigate later problems and difficulties.
De Girolamo (1993) summarized the literature on treatment and prevention of PTSD among victims of natural disasters in different countries. He concluded that natural disasters are an important source of psychiatric adjustment difficulties among survivors regardless of the country in which the disaster occurred. For example, Weisaeth (1989) found a direct relationship between the severity of trauma exposure and PTSD symptoms among survivors of a paint factory explosion in Norway. This suggests that PTSD is not a culture-bound syndrome. It does not only occur among traumatized persons in Western industrialized cultures.
Depression, anxiety and PTSD appear to be the most prevalent results of disasters in those who have been exposed to them. Follow-up with workers after a relief effort is an important disaster mental health function. Mental disorders resulting from intense exposure to disaster incidents are possible even among seasoned veterans (McFarlane, 1990).
Cultural beliefs can be both resources and barriers in providing support for grieving families. Across cultures, people differ in what they believe and understand about life and death, what they feel, what elicits those feelings, the perceived implications of those feelings, the ways they express those feelings, the appropriateness of certain feelings, and the techniques for dealing with feelings that cannot be directly expressed (Rosenblatt, 1993). Historical studies have shown how individuals in western culture have mourned differently over time (Newnes, 1991; Kohn & Levav, 1990). A cross-cultural perspective shows an infinite variety in people's responses to death, in how they mourn, and in the nature of their internalization of the lost object. Rather than being process-oriented, mourning is seen as an adaptive response to specific task demands arising from loss that must be dealt with regardless of individual, culture, or historical era (Hagman, 1995).
Americans report thinking significantly more about grief, religious feelings and death than do Japanese (Asai & Barnlund, 1998). Ancestor worship in Japan is ritual. It is supported by a sophisticated theory through which the living manage their bonds with the dead. It is a process similar to the resolution of grief in the modern west (Klass, 1996). Klass & Heath (1997) explored the grief of Japanese parents after abortion and the ritual by which the grief is resolved. The ritual is Mizuko Ruyo. Mizuko means child of the water. Ruyo is a Buddhist offering. In a ritual drama played out by Jizo, the bodhisattva who suffers for others, the parents' pain and the child's pain are connected. In that connection, the pain of each is resolved. The child is made part of the community and does not become a spirit bringing harm to the family. The parents can fulfill their obligation to care for the child and transform the sense of kurnon, sickness unto death, into a realization of Buddhism's first noble truth, that all life is suffering. In a slightly different cultural context, The Bardo Thodol (Tibetan Book of the Dead) together with its associated ritual provides a way to understand how Buddhism in Tibetan culture manages the issues associated with what is called grief in Western psychology. The resolution of grief in the survivors is intertwined with the journey to rebirth of the deceased (Goss & Klass,1997).
The primary mental health benefits of ritual are closely tied to the relational aspects of the ritual process. These act to validate and encourage the healthy expression of a wide range of human emotions. Jacobs (1992) concludes that religious ceremony and ritual functions mitigate anxiety and deal effectively with other problematic emotional states. Religious rites have a cathartic effect as emotions are released and expressed through attachment and connection to significant others. Reeves (1989, 1990) suggests that ritual can be used to assist individuals to move from a maladaptive to an adaptive style of grieving.
Rubin (1990) used social network theory to compare mourning behaviors in the United States with those in Israeli kibbutz. He found that, in a dense social network such as a small or medium-sized kibbutz, mourning is part of a wider circle of family, friends, neighbors, and co-workers. He suggests that the funerals in the United States may force loose social networks to generate an image of social support. Rubin suggests using social network theory as a basis for cross-cultural analysis of the range of participation in mourning rituals.
Hagman (1995) reviewed the standard psychoanalytic model of mourning and suggests that the model may not be generally valid. The psychoanalytic literature and data from clinical practice fail to confirm basic components of mourning theory. Stroebe (1992,1993) challenges the belief in the importance of "grief work" for adjustment to bereavement (the grief work hypothesis). She examined claims made in theoretical formulations and principles of grief counseling and therapy concerning the necessity of working through loss. Reviews of empirical evidence and cross-cultural findings document alternative patterns of coping with grief. Stroebe argues that there are grounds for questioning the hypothesis:
She proposes a revision of the definition of grief work, which overcomes the confounding of the process with symptomatology and should facilitate future empirical testing, and suggests a differential approach.
Teams of counselors dispatched to mass casualty disaster sites can at times be an overwhelming presence. Sensitivity to cultural needs and desires are necessary to provide appropriate and desired services. Newell (1998) in a cross-cultural study of privacy found that the majority of students (aged 17-45) from Ireland, Senegal and the United States in their study believed that not being disturbed was the most important element of privacy and grief. Fatigue and need to focus were the main affective sets associated with seeking privacy. The affect associated with a desire for privacy, the definition of privacy as a condition of the person, the duration of the average privacy experience, and the change in affect at the completion of the experience suggested that privacy has a therapeutic effect.
In summary, sensitivity to the culturally appropriate needs for ritual in responding to grief and providing for privacy and personal needs are paramount. Imposing a "one size fits all" grief model on people, however well intentioned, may cause more harm and ill feeling than good. Respect for the beliefs, rituals and desires of those affected can accomplish far more than unwanted attention and interventions.
Managing disaster situations is difficult at best. Strategies for improving international disaster operations can help develop and provide more effective responses. It is important to learn from crisis events, coordinate international disaster assistance, provide adequate and accurate information in disaster environments, learn how to take appropriate actions, and develop trust in disaster operations (Comfort, 1989; Paton, 1996).
The roles of local health and mental health professionals in assisting victims in coping with disasters is outlined in a book published by the World Health Organization (1989). It sets out a clear guide to what should be done by the community and local health personnel at the time of a disaster to organize rescue work and emergency care and to solve the many survival and health problems which can result from the disaster. It describes various emergencies resulting from disasters and steps that communities and local health personnel can take to prepare for the eventuality of a disaster and to prevent and mitigate its consequences. Another good resource in this area are the publications and manuals on psychosocial services in emergency measures situations prepared by the Ministry of Health and Social Services of the Government of Quebec, Canada (Martel, 1999). Health Canada's Emergency Services Division's Disaster Mental Health Manual (1999) is another good resource. In the United States, there are numerous publications available through the American Psychological Association (APA, 1996), American Red Cross (1991, 1998), and the Federal Emergency Management Agency (FEMA, 1994, 1995). Additionally, a comprehensive manual is available through the Department of Social Work at Walter Reed Hospital and the National Center for Posttraumatic Stress Disorders Disaster Mental Health Services (Young, Ford, Ruzek, Friedman, & Gusman, 1999).
In an article on the prevention of the consequences of man-made and natural disasters, de Jong and Joop (1995) reviewed a number of preventive initiatives. They proposed a model that deals with prevention on several levels, going from the International and National levels to communities of displaced persons and refugees, families and individuals. Their model integrates concepts from the fields of public health, psychology, anthropology and psychiatry. Using a matrix structure, they propose multi-modal preventive interventions relative to the different societal levels involved, emphasizing prevention of psychosocial and mental health consequences.
Parkes (1997) examined the types of psychosocial problems likely to occur in different types of disasters. Using examples from actual recent disasters, he developed a rather simplified typology which could provide a basis for development of adequate and appropriate psychosocial response plans. He identified nine types of disasters:
Within the context of such plans, one way to address identified needs would be through the use of operational definitions for health and culture. Waxler-Morrison, Anderson & Richardson (1990) offer a way to do this by suggesting a number of questions:
These areas are going to be different for different cultures, making it important to understand prior to offering any psychosocial services. Using this approach along with Maslow's (1987) model for universal human development can provide a more focused and culture-specific approach to providing mental health services in any cross-cultural setting. Taylor (1998) presents an interesting example of how this might be accomplished in an article outlining his approach to providing services following a very destructive cyclone in the Cook Islands in 1997.
Middleton and Raphael (1990) examined consultation in disasters. They looked at major problem areas with respect to psychiatric consultancy in planning responses to disasters. They identified seven major areas of concern:
To successfully accomplish the goals of providing adequate and appropriate cross-cultural disaster mental health services, it is essential for psychologists and other disaster mental health professionals to establish collaborative supportive international relationships (Ring & Vazquez, 1993).
The development of a general model of international disaster mental health services with a strong emphasis on cross-cultural factors is needed along with plans for response based on the needs, beliefs, and desires of different countries. Consultation and collaboration with providers and planners in other countries and development of in-country disaster response plans combined with a strong educational component is necessary to help mitigate disaster mental health related responses and problems.
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