20 Psycho-Social Care and Trauma Management

Dr. Lubna Siddiqui

Rationale

Psycho-social care and trauma management enables communities deal with the impact of crises, build mental resilience and helps them in recovering back from the tragic event. It is an essential element in any disaster intervention whereby communities are able to deal with the various stress situations during and after disasters. This module aims to introduce principal elements of Psycho Social Care and Trauma Management.

Learning Objectives

1. To develop a preliminary understanding of mental health and psycho social care

2. To understand the impact of disasters on mental health

3. To introduce the standards and guidelines for psycho-social care and trauma management post disasters

4. To reflect on the Indian context of psycho-social care and trauma management

Unit 1–Psycho Social Care and Trauma Management

Psychosocial support can be defined as “a process of facilitating psychological resilience within individuals, families and communities”. It enables families recuperate back from the impact of a disaster and helps them deal with such events in the future.

To understand the principles and process of Psycho social care and trauma management, let us first look into what is psychosocial well being. It is best defined with respect to three domains:

Human capacity– It refers to   physical and mental health  and specifically considers individuals’ knowledge, capacity and skills. Identifying an individual’s own human capacity is the same as realizing his or her own strengths and values.

Social ecology– It refers to social connections and support, including relationships, social networks, and support systems of the individual and the community. Mental health and psychosocial  well-being  are  dependent  on  cohesive  relationships  that  encourage  social equilibrium.

Culture and values– It refers to cultural norms and behavior that are linked to the value systems in each society, together with individual and social expectations. Both culture and value systems influence the individual and social aspects of functioning, and thereby play an important role in determining psychosocial well-being.

Psychosocial well-being is also dependent on the capacity to draw on resources from these three core domains in response to the challenge of experienced events and conditions. However, this doesn’t prevent other extenuating factors like loss of physical and economic factors to have a significant influence on well-being (IFRC, 2009).

Disaster induced stressors and concerns

Emergencies create a wide range of problems which are experienced at individual, household, community and societal levels.

Pre-existing social problems (e.g. extreme poverty; belonging to a group that is discriminated against or marginalized; political oppression, mentally ill)

Emergency-induced social problems (e.g. family separation; disruption of social networks; destruction of community structures, resources and trust; increased gender-based violence, going into a state of dementia)

Humanitarian aid-induced social problems (e.g. undermining of community structures or traditional support mechanisms).

Cross cutting issues (disparities in food distribution, having no place to live, Relocation and displacement, humiliation and disempowerment arising from relief distribution etc.)

Similarly, problems of a predominantly psychological nature include:

Pre-existing problems (e.g. severe mental disorder; alcohol abuse)

Emergency-induced problems (e.g. grief, non-pathological distress; depression and anxiety disorders, including post-traumatic stress disorder or PTSD)

Humanitarian aid-related problems (e.g. anxiety due to a lack of information about food distribution)

Thus, mental health and psycho-social problems in emergencies encompass far more than the experience of PTSD. These negatively impact the psychosocial well-being of an individual or a community. Research shows that although most of the victims of disasters, terrorisms or other shocking events recover on their own merit, but a sizeable amount of them develop long-term disaster-related problems (Norris, Friedman, & Watson, 2002).Sphere standards mention that people should have access to social and mental health services to reduce mental health morbidity, disability and social problems (The Sphere Project 2004, Humanitarian Charter and Minimum Standards in Disaster Response).

How psychosocial care and trauma management helps?

The fundamental idea in psychosocial intervention following disasters is to transform those affected from being victims to survivors. What differentiates a victim from a survivor is that the former feels himself/ herself subject to a situation over which he has no control, whereas a survivor has regained a sense of control and is able to meet the demands of difficulty confronts him. A victim is passive and dependent upon others; a survivor is not – he is able to take an active role in efforts to help his community and himself recover from the disaster (Ehrenreich, 2001).

Thus, psycho social interventions aim to provide “a state of well-being through emotional, mental and social stability after traumatic events. This is achieved through timely & periodic interventions which are context, need & target specific and are individual, group and community centric”. By respecting the independence, dignity and coping mechanisms of individuals and communities, psychosocial support promotes the restoration of social cohesion and infrastructure (IFRC, 2009)

Stages of psycho-social intervention

Initial interventions are primarily designed to promote safety, assist coping and stabilize the individual and their environment. In contrast, subsequent interventions are designed more to prevent or treat psychopathological responses that have begun to emerge after the disaster. The intervention pyramid depicted in the image below shows different phases of intervention. The preliminary phase promotes social considerations in basic services and security, followed by strengthening community and family supports and focused non specialized supports. Few of the disaster affected people are likely to develop significant mental health conditions post traumatic event which might require specialised services. Decisions regarding the level and timing of this care require careful clinical judgment, with the recognition that formal intervention may not be appropriate until sometime after the event

The timeframe for short or intermediate-term intervention is not defined. If a disaster is discrete and the effects are short-lived, then one may define a short-term intervention as occurring within days, and an intermediate intervention as occurring within a month. In the aftermath of a more extreme disaster that has long lasting effects, it may not be appropriate to consider an intermediate intervention until several months has passed. For instance, following Hurricane Katrina, many people’s lives were disrupted for lengthy periods because of relocation, lack of housing, and loss of basic infrastructures.

Competencies for psychosocial support workers

The workers providing psychological and social support during and after disasters are considered important functionaries for psychosocial interventions. To become psychosocial workers, certain core competencies are required. Given below is an outline model for intervention competencies. The required competencies include generic competencies in psychological therapy, basic competencies, specific technical competencies and certain meta-competencies.

    Principles for psychosocial intervention

The core principles that guide both specific techniques and their adaptations in case of psychosocial interventions are:

Safety and material security underlie emotional stability

Emotional response to disasters are normal phenomena

Interventions should be matched to various disaster phases

Integrate psychosocial assistance with the overall relief programs

Interventions must take people’s culture into account

Direct Interventions have an underlying logic

Women and Children have special needs

Residents of refugee camps and Rescue & Relief workers ( including journalists and human rights workers) have special needs

Unit 2 –Standards and guidelines for psycho social care and trauma management

High quality standards and guidance for care providers ideally uses evidence-based procedures.Access to psychosocial support should be on the basis of equity and non-discrimination (UDHR). The standard of “do no harm” should be observed at every stage of planning, implementing and evaluating psychosocial programmes. The first communication within a community is always the most important in moving towards a holistic and integrated psycho-social approach. We should ensure that the first responders include volunteers who can relate to the target’s needs and the context. Interventions should therefore include community members at different levels of social interaction – individuals, households, different subgroups in the community, whole communities (IFRC, 2009).

Interventions based on common mental reactions post disasters

Interventions for acute/chronic mental reactions post disasters

    Psychosocial Interventions

1. Counseling interventions (Organization, 2005)

Trauma counseling: Creating safe opportunities for people to focus their thoughts, talk about them and express associated feelings.

Grief counseling: Helps bereaved survivors by encouraging them to talk about their lost ones.

Anticipatory Guidance: helps victims to accept their reactions as ‘normal’, provide information about the natural stress reactions and also focuses on what survivors can do to deal with these reactions

Crisis counseling: for those survivors who were victims of a pre-existing personal crisis. A disaster event will only pressurize the survivor by adding to his several stressors and therefore requires a sensitive handling of the issue.

Problem solving counseling: helps survivors by finding solutions to problems in a systematic way

2. Stakeholders Intervention

Self and family care: In case of normal stresses that arise from a haphazard event survivors try to handle the stress by themselves with support and care from friends and family.

Individuals from outside the family (Informal Support): In cases where the survivor has lost hope in the meaning of life they are supported by outsiders like teachers, priests, swamis and disciples.

Social and Cultural Interventions: Being part of religious rituals, community festivals etc. are another form of intervention wherein diverting the survivor’s attention to the brighter side of life is encouraged .

Humanitarian Agencies (Formal Psychological Support Services): These include NGOs and INGOs who provide formal psychological support services through trained staffs and youths within the affected community. These organizations also indulge in conducting counseling sessions and awareness programmes for children, adults and youths.

Mobile Mental Health Team comprises of doctors and psychologists providing psychosocial support.

Mental Health Care PHC

Acute Inpatient care is part of a therapeutic pathway towards recovery. The purpose of acute inpatient care is to provide treatment when a person’s illness cannot be managed in the community, and where the situation is so severe that specialist care is required in a safe and therapeutic space (Care, 2015).

These interventions can occur at different levels as under –

Individual level : Guided self-help is the easiest available intervention. Manuals and self-help books are provided to the survivor in need by psychosocial volunteers. Support from friends and family also helps the individual to recover in no time.

Family level: Regular home visits by nurses and other psychosocial workers, unstructured interviews by volunteers and staff to help families/ survivors in sorting out demands and setting priorities post the disaster are effective interventions.

Community level : Activities (sports, community sharing etc.) that provide opportunities for social interaction at a common venue. Through sharing of the catastrophic experience and exchanging community support, survivors may experience a short-lived sense of optimism. Activities catering to different vulnerable groups are also made available. For instance, recreational activities, games and story-telling sessions for children, engaging women in activities like handicrafts and stitching etc.

Other Interventions in this category include

Providing medicines to people who have lost their medicines during disasters.

Offering new housing without discriminating on the basis of class, caste and sex Introducing working shifts for rescue workers and medical personnel

Comprehensive team care by networking with professionals from myriad fields to deal with bio-psycho-socio-spiritual pains

Training individuals and paying them to conduct recovery activities is another way to reduce stress

Providing food as compensation to labour (Food for Work Programme)

3. Interventions in the form of psychosocial treatments

Structured counseling

Motivational enhancement Case management

Care-coordination Psychotherapy

Relapse prevention

Stress debriefing: Critical Incident Stress Debriefing Model is the most common form of debriefing for emergency service personnel following a trauma.

4. Interventions in the form of programmes/support systems

Establishment of dedicated programmes and support systems for people who are not coping well with the disaster situation.

Red Cross Reference Centre for Psychosocial Support (RCPS): Initially launched as the Psychological Support Programme in 1991, RCPS helps in developing community based psychosocial services in areas affected by catastrophic events and armed conflicts.

Disaster Response Network: Formed in response to the Black Saturday Victorian Bushfires of 2009 in Australia. In the field of psychosocial care, the DRN members will help in supporting organizations seeking psychologists to work with individuals and communities affected by disasters and also provide members with updates in the field of mental health (Disaster Response Network, n.d.)

The Green Cross Intervention: helps the traumatized through education, certification and deployment

Challenge Abuse through Respect Education (CARE): A personal safety programme initiated by the Canadian Red Cross for children between 5-9 years. The aim is to educate kids about different kinds of abuses through story-telling, puppetry and other hands-on activities.

5.  Interventions to support psychosocial care staff and volunteers

Emotional support by co-workers using active listening and reflection skills To train volunteers and staff on self-help techniques

Debriefing

Stress management workshops

Interventions during emergency, recovery & development phases of disasters (IFRC, 2009)

A. Emergency phase (0 – 6 months)

i. Active and supportive listening

ii.  Information about normal reactions to the event in the form of leaflets and banners

iii.  Psychological first aid

iv.  Support to engage in burial ceremonies

v. Support groups for different vulnerable groups (women, children, widowers, teenagers, senile men and women etc.)

vi.  Engaging in family tracing

vii.  Providing psychosocial support relief items like prayer mats, toys and games for children

viii.  Collective community actions (where all members of a community get together to clear debris, restore public institutions etc.)

B. Recovery phase (3 months to 1-3 years)

i. Forming children’s and youth clubs

ii.  Informal schooling

iii.  Life skill activities (awareness about sexual and reproductive rights of teenagers)

iv.  Group activities combined with livelihood initiatives like handicrafts, baking and cooking

Case study – Indian Ocean Tsunami, 2004

Adherence to IASC guidelines

The Inter-Agency Standing Committee Guidelines highlight the importance of facilitating conditions for community mobilization, ownership, and control of emergency response in all sectors, community self-help and social support, and appropriate communal, cultural, spiritual and religious healing practices. The guidelines underscore the principles of preventing separation and facilitating support for young children (0–8 years) and their caregivers, and strengthening access to safe and supportive education. Interestingly, for people who are unable to return to their own communities, it is recommended that social considerations such as safe, dignified, culturally and socially appropriate assistance in site planning and shelter provision, and in the provision of water and sanitation are taken into account. The IASC Guidelines also call for mapping local resources by asking community members about the people they turn to for support at times of crisis (Care, 2015). This will help in identifying people who are in dire need of help and also potential locals who can aid in providing psychosocial support. The IASC Action sheet entitled “Facilitate community self-help and social support” also gives a series of recommendations community level interventions. In the psychosocial support that was provided by IFRC and Mercy Corps following the tsunami of 2004 they’ve tried to adhere to these guidelines.

 Co-ordination

Following Tsunami disasters along the Indian ocea , a coordinating body was set up by IFRC in the Batticaloa district of Sri Lanka. This body ensured the protection of affected communities from poorly integrated services and became a facilitator of inter-agency cooperation and a forum for discussing emerging secondary issues following the crisis. The body which comprised of representatives from myriad organizations became a success not only because of their efficacy in coordination, but also owing to their functioning according to a set of clearly defined and equitable principles – humanity, impartiality, neutrality, Independence, Voluntary Service, Unity and Universality.

Social cohesion

Volunteer groups in Sri Lanka were encouraged to make a map of the affected area marking the sea, houses, social institutions and other important resources that were available in the island before the disaster. The exercise helped in bringing a shattered community together and gave them a platform to express personal challenges as the map also brought to light the percentage of destitute people and also those who are capable of providing support. The intervention (headed by IFRC) also helped in understanding and strengthening of bonds between the group.

Social inclusion

MERCY Malaysia brought together Tamil speaking mental health volunteers to cover trauma counselling and psychosocial activities of nearly a million displaced persons. Moreover, the psychosocial intervention was on an individual and family basis thereby catering to the needs of everyone who was traumatized. Artwork and illustrative posters on tsunamis were also developed by volunteers which helped communities immensely in dealing with their experiences. Under the leadership of the Danish Red Cross and Sri Lanka Red Cross Society, psychosocial support to cater to the needs of specific vulnerable groups/ sub-groups was initiated. An excellent intervention was providing employment to widowed women who were prohibited from leaving their houses according to their religious norms. Red Cross intervened and provided sewing machines to such women groups to make them empowered and independent.

Efficient stakeholders and timely psyco-social care

The Department of Mental Health, Thailand, on the other hand, mobilized staff response teams with psychologists, psychiatrists, social workers, nurses and pharmacists in each of the affected districts. Individual and group counselling as well as medication was provided to those in dire need. During the initial stage of intervention weekly home visits were conducted followed by monthly visits for two years. Mental Health Centres were developed to deliver interventions and rehabilitation support and monitor tsunami survivors, particularly in the worst affected areas. Psychological education was also provided to children at schools.

Psychosocial care in the form of employment

Training individuals in masonry and paying them for indulging in recovery activities was an excellent intervention adopted in the Andaman and Nicobar Islands to reduce stress.

Awareness programmes and activities

Leaflet featuring illustrations that were culturally appropriate to families and their reactions was another intervention that was adapted in Banda Aceh, Indonesia. The objective was to educate adults on normal reactions to what they had experienced. For children, Red Cross in collaboration with UNICEF had come up with “Return of Happiness”, a psychosocial support programme where puppet shows and games were arranged for children by youth volunteers. The motto was “with youth, for youth and by youth” while bringing together two of most vulnerable and silent victims in a community post traumatic event.

Care to special groups

A psychosocial intervention post tsunami to reduce shock and distress among internally displaced people due to violence was ensuring that bathrooms or water-collection points were close to the survivors’ place of stay. Community meetings to reinforce public knowledge on abuses were also held.

Importance to long-term intervention

The Turkish Red Crescent Society committed to build a community centre in Indonesia to promote psychosocial interventions at community level in the form of sports, art classes and competitions and fun activities for all age groups.

Flexibility

Following the implementation of community level activities unfortunately not many men turned up participating in the events organized in Sri Lanka and Indonesia. Later on it was observed that the support activities were held during the day period, when most of the male population were out for working. Since social inclusion and reconnecting strained bonds was the underlying objective, all psychosocial interventions post tsunami; the organizers’ willingness to reschedule activities to a time when every member of the community was available should be appreciated.

Culturally sound interventions

In line with the IASC guidelines for trainers and co-trainers “cultural sensitivity and basic knowledge about local cultural attitudes and practices and systems of support” is mandatory. Following the tsunami, Shantiham, a reputable training institution in Sri Lanka provided immediate locally appropriate psychosocial training to the Sri Lankan Red Cross staff and volunteers.

Limitations in existing practices/ interventions

In spite of all the development in psyco-social care, there still exists gap between norms/ guidelines and expected practice on the ground.

1. Accountability

The major concern in post disaster psychosocial care is the lack of accountability. The two connotations that come with accountability is answerability (the obligation of public officials to inform about and to explain what they are doing); and enforcement (the capacity of accounting agencies to impose sanctions on power holders who have violated their public duties) are absent in the process of psychosocial interventions.

Sometimes professional autonomy in deciding the kind of treatment may differ from those proposed in the guidelines. It is good for the psychosocial worker to have a discretionary space but nonetheless too much freedom can also pave way to chasm.

The severity of mental health stressors that arise in the aftermath of a disaster varies from the minimal and transient level to the very severe level of distress. Unless psychosocial workers are made liable for the work they do, the quality of professionalism and ethics involved in treating patients at different levels may be poor.

2. Integration

Integrating psychosocial support with other sectors of recovery is still at a nascent stage. A complete understanding of what makes a psychosocial intervention work is lacking, as mental health stability is often not taken into consideration. Lack of integrated psychosocial services leads to the worsening of mental health.

3. Supervision

 While psychosocial support is rendered at the time of distress there are no proper systems to monitor and evaluate these interventions. There is serious lack of appropriate authority to overlook the programmes.

The lack of direction and community reluctance to act without government guidance is very evident. This exacerbates stress and anxiety levels in the community. An effective Monitoring and Evaluation of the multiple psychosocial interventions by the government is also lacking.

Volunteers willing to provide psychosocial support have to undergo brief training sessions before they are deemed fit. Having no provisions to ensure supervision of the training sessions will result in inefficient training of volunteers who are involved in offering psychosocial support.

Psychosocial support may be available but whether they’ve reach the populations at most risk is doubtful. Only a coordinated system of working professionals can ensure that help reached is timely and is also accessible to the needy.

4. Contextual understanding

Context specific and target specificity of interventions is often a concern.

Training of psychosocial volunteers who speak the same language of the community is another limitation. Survivors are often unwilling to seek help because of cultural or language barriers.

There is a tendency of volunteers to misinterpret the victim’s reactions. This is often associated to the psychological myths post disaster event. Two of them are immobilization by fear and panic.

Notions that humanitarian workers develop about a culture are often based on false representations or interpretations of what they observe, or on general notions about the culture in question. Going by humanitarian guidelines, psychosocial support should be culture specific and this is achieved only through effective community-based interventions. There is an increasing need to involve local people who can help in knowledge translation to address cultural differences.

Summary

Psychosocial support is the process of facilitating resilience within individuals, families and communities.

  Psychosocial support aims at addressing psychosocial well-being which is best defined with respect to three domains – human capacity, social ecology and culture and values.

Disasters induce multiple stressors and concerns which are both socio-economic and psychological in nature.

Fundamental idea in psychosocial intervention is to transform those affected from being victims to survivors.

Psychosocial interventions promote a state of well-being through emotional, mental and social stability post a traumatic event

There are no defined timelines for psychosocial interventions – it varies across disasters

Initial interventions promote safety, assist coping and stabilize the individual and their environment.

Subsequent interventions prevent or treat psychopathological responses.

Interventions are based on both common mental reactions post disasters and acute/chronic mental reactions post disasters.

Key concerns in psychosocial interventions which are yet to be addressed include lack of accountability, integration, supervision and contextual understanding

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