family therapy. This has been successful. A further problem with training related to the identity of the many students. For several reasons training was designed around task skills rather than discipline identity. By design, students from different graduate programs trained together. Many began to have an identity confusion, not knowing their role and identity from students in other disciplines. Specific discipline discussion groups helped minimize this problem. Assigning supervisors from the same discipline has also been useful. CONCLUSIONS The original faculty conceptualized the mental health center as an integral part of the department of psychiatry. It was to be the clinical part of the department. Built into the initial concept was the idea that the programs would be started and then modified as the issues and needs became more apparent. However, almost from the day the building opened the initial programs became tradition” and difficult to change. Equally difficult was conceptualizing a vehicle for working on necessary changes. Groups of people became concerned that they might not be involved in the decision-making. Other groups of people became heavily invested in the part of the center or department they were involved in and could not see the whole picture; these people perceived any change as a threat. Initial theoretical positions became established policy. Change is not easy. Establishing a vehicle for recommending and implementing change is harder. The formation of task forces made up of equal representation from the department and the center succeeded in resolving most differences. Some in the center still feel that the department is taking over the center. Some in the department still feel that the center is “draining” the department. No matter where the pendulum stops someone will be unhappy. In retrospect, the biggest weakness might have been in having the center as the only clinical component of the department. This arrangement made each too intradependent on the other rather than interdependent. Since each has different tasks, conflicts are inevitable. To ask a department of psychiatry to arrange its priorities so that service comes before teaching or research is inappropriate. To ask a mental health center to place teaching and research before service is inappropriate. The department should have developed several clinical facilities for teaching and research, the center being but one. The experiences of this department of psychiatry clearly illustrate the advantages of having a mental health center. Each strengthens the other but each must be autonomous. Neither can survive if each is intradependent on the other.U
Disaster- Relief Training and Mental Health
“
JANE BROWNSTONE, Director, Psychological Malcolm Bliss Mental St. Louis, Missouri
ELIZABETH C. PENICK, PH.D. Research Project Director University of Kentucky Medical School Lexington, Kentucky STEPHEN W. LARCEN, Doctoral Candidate University of Connecticut Storrs, Connecticut BARBARA Assistant University Lexington,
J. POWELL, Professor of Kentucky Kentucky
HOSPITAL
& COMMUNITY
PSYCHIATRY
MA.
PH.D. Medical
School
ANN F. NORD, PH,D. Clinical Psychologist St. Louis (Mo.) State Hospital The author describes a training program in disasterrelief work for representatives of both mental health and disaster-relief agencies. The program is designed to improve their over-all understanding of disaster-relief work and to increase their sensitivity to the emotional needs of disaster victims. Based on the recommendations of a state task force report, It consists of a workDr. Brownstone’s Missouri 63104.
30
PH.D. Services Health Center
address
at the
center
is 1420
Grattan,
St.
Louis,
shop that makes use of videotapes and learning exercises to help participants improve their listening skills, learn problem-solving techniques, become aware of behavioral signs that can alert them to victims’ emotional reactions, and familiarize them with the work of other relief agencies. #{149}Asmaterial resources available to disaster victims have increased, attention has begun to focus more closely on the psychological and emotional needs of victims. The Disaster Relief Act of 1974 (Public Law 93-288) gave legislative recognition to the need for a merger between mental health and disaster-relief services, though well-established voluntary disaster-relief organizations have for years combined counseling with material assistance. However, disaster-relief work has grown increasingly complex, and negotiating the system can be potentially overwhelming for a victim whose coping mechanisms are temporarily weakened. Sensitivity to these factors, along with the increasing influence of mental health agencies in planning community programs, resulted in the development of a special Lieutenant Governor’s Task Force in St. Louis, following a severe flood in the spring of 1973. Representatives from the mental health professions, along with staff from several disaster-relief organizations and agencies, served on the task force. Their final report contained recom mendations for collaboration between mental health and disaster-relief agencies. These recommendations included: . Providing short-term, immediate emotional support and assistance to essentially normal people who experience a crisis reaction after a disaster. The task force recognized that, to be most effective, emotional assistance must be offered in conjunction with adequate material assistance. . Training front-line disaster workers in the rudimentary techniques of group screening and crisis intervention in order to extend mental health knowledge and skills to disaster victims. . Employing the mental health professional as a back-up consultant to the front-line disaster worker. . Including mental health workers in some aspects of preparedness planning, staff training, and program development. In addition to establishing communication between mental health and disaster-relief workers, the task force also initiated a mental health survey of disaster victims in Missouri. Interviews were held with 136 flood victims and 26 tornado victims. The major purpose of the survey was to determine the shortand long-term emotional effects of a disaster, the kinds of services that were provided to victims, and how beneficial the services were. The results of the survey indicated that three to six months after the disaster none of the victims had experienced a serious mental breakdown. Approximately half of the victims believed the disaster had caused them to be more strained, tense, and nervous. The most common symptoms reported were restlessness, feeling
blue, fatigue, irritability, sleeplessness, and minor somatic complaints. A third of those interviewed indicated that the disaster had caused emotional and social changes in memhers of their family, but most felt that such symptoms were natural and would disappear in time. Less than 10 per cent of the victims who reported symptoms of emotional stress said they would see a mental health professional for those problems. Most said they would prefer talking to a relative, a clergyman, or their family doctor. The vast majority of respondents expressed some serious complaint about one or more of the disasterrelief services they did receive. Many complained of the brusque manner in which they were treated by agency personnel. Others mentioned the confusing procedures victims had to follow to obtain services and the conflicting information they received from different agencies. Virtually all the victims complained about the length of time it took to receive services from some agencies. Thus the mental health survey showed that, although the victims as a group did suffer postdisaster emotional discomfort, they were not incapacitated or in need of psychiatric care. The great majority of victims with emotional symptoms reported that they experienced the types of crisis reactions that are often found in relatively normal people after a personal tragedy. Over-all, the results of the survey suggest that disaster victims suffering emotional discomfort would benefit more from short-term crisis intervention provided by a crisis worker, backed up by a mental health professional, than from traditional psychiatric assistance. The results of the survey also underscore the need to plan service systems that minimize confusion and misunderstanding. TRAINING Based report,
FRONT-LINE
WORKERS
on the results of the survey and the the mental health and disaster-relief
task task
force force
developed a videotape training program designed to help the front-line worker provide emotional first-aid to victims. It was created and produced by psychologists from the Malcolm Bliss Mental Health Center and St. Louis State Hospital, as well as disaster-relief and nursing personnel from the American Red Cross of the Midwestern area, all located in St. Louis. The training package was designed to serve two purposes: to stimulate greater communication and collaboration among disaster-relief and mental health groups and to allow mental health professionals to contribute knowledge and skills to the disaster effort in a practical and economical way. A major goal of the workshop was to provide front-line mental health and disaster-relief personnel with information and experience to improve their over-all understanding of disaster work and increase their sensitivity to the emotional needs of disaster victims. The workshop takes approximately eight hours to complete. Ideally, participants represent both mental
VOLUME
28 NUMBER!
JANUARY
1977
31
health and disaster-relief agencies, with the latter making up about two-thirds of the group. Basic materials include a leader’s manual, a workbook for participants, and four 30-minute videotapes. The leader’s manual provides guidelines specific enough for an inexperienced group leader to conduct a successful training program. It contains details on the background of the workshop and instructions for using the manual, organizing the workshop, and conducting the experiential exercises. Also included are forms for evaluating the workshop, copies of the videotape scripts, and a list of suggested readings. The participants’ workbook contains materials needed for the exercises as well as lists of federal, state, and local agencies involved in disaster relief and of public health services in Missouri; a description of behavioral signs useful in identifying victims in need of crisis intervention; guidelines for effective listening; and an outline of effective problem-solving steps. The training program is divided into four sessions, each consisting of a half-hour videotape accompanied by group exercises designed to facilitate participation and learning. The first video session, Overview of Disaster Relief,’ provides a general overview of disaster work and pictures damage caused by different kinds of natural disasters. Also described are five stages of disaster work and the types of services made available to disaster victims from public and private organizations. Exercises in this session give the workshop participants an opportunity to learn about each other, the jobs they do, and the organizations for which they work. They also discuss their previous experience with natural disasters, as well as their apprehensions, expectations, and limitations as front-line disaster workers. The second video session, Mental Health and Disaster Relief,’ is designed to correct some common myths about the behavior of individuals and communities at the time of a natural disaster and to clarify misunderstandings about the field of mental health. It presents ways in which mental health techniques can be used by disaster organizations and describes simple screening procedures for assessing the emotional impact of the disaster experience. The learning exercise in the second session concentrates on the roles of the mental health workers in planning for and giving disaster relief, with attention given to the list of behavioral signs that may alert the worker to different emotional reactions. The need for development of an ongoing relationship between mental health specialists and disaster-relief personnel is also emphasized. The third video session, “Helping Styles of the Disaster Workers,” emphasizes reducing postdisaster strain and facilitating constructive problem-solving through the personal characteristics of the helpers themselves. Helping styles are demonstrated in simulated videotape interviews with disaster victims, and the accompanying learning exercises focus on the development of empathic listening and interpersonal styles that create good helping relationships. Participants practice these techniques and achieve a group consensus on the personal charac‘ ‘
‘
‘ ‘
‘
32
HOSPITAL
& COMMUNITY
PSYCHIATRY
teristics and attributes that are found in the effective disaster worker. “Crisis Intervention Skills,” the fourth video session, is a more detailed presentation of crisis intervention techniques and guides for good listening. It includes an outline of steps that can be used to help a disaster victim engage in successful problem-solving, and a simulated interview is used to illustrate those steps. During the learning exercises, participants practice listening skills and use crisis intervention techniques in roleplaying situations. WORKSHOP
EVALUATION
At the end of each workshop, participants rate the program on over-all worth, relevance of the four videotape topics, and effectiveness of the participant exercises. Ratings are given on a 5-point scale with 5 the highest and 1 the lowest rating. There is also opportunity for participants to express an interest in follow-up workshops and to write comments. Fifteen disaster-training programs have been presented to approximately 250 people in various locations throughout Missouri in conjunction with different mental health facilities. Participants from a variety of agencies-the Department of Housing and Urban Development, the Salvation Army, law enforcement agencies, fire departments, the American Red Cross, and the Small Business Administration, for examplehave been included in each workshop. In addition, representatives of the American Psychological Association, the National Institute of Mental Health, and the national headquarters of the American Red Cross have participated in and reviewed the workshop. Demonstrations have also been conducted in Kansas, Minnesota, Kentucky, Texas, Washington, D.C., and Illinois by nursing and health program personnel of the American Red Cross of the Midwestern area. Feedback from participants of diverse backgrounds indicates that this program has been well received and has been found to be informative and relevant. Ratings were similar from group to group, so that mean cornposite scores or percentages are an accurate reflection of feedback from each group. Sections covering listening and interview styles tended to be ranked highest. Overall, about 70 per cent of the ratings were 4 or 5, while 91 per cent of the ratings were 3, 4, or 5. Criticisms included a desire for more information on how disaster relief would operate in participants’ communities and more time spent on crisis skills and problem-solving sections. A follow-up workshop was recommended by 63 per cent of the participants. The disaster-relief training program developed from the task force report provides one model for collaborative interchange between mental health agencies and other community support systems and has stimulated wide community participation in Missouri. Other states have shown an increasing interest in using the training package as a method for sensitizing potential workers to the psychological needs of disaster victims.U
Disaster- Relief Training and Mental Health
“
JANE BROWNSTONE, Director, Psychological Malcolm Bliss Mental St. Louis, Missouri
ELIZABETH C. PENICK, PH.D. Research Project Director University of Kentucky Medical School Lexington, Kentucky STEPHEN W. LARCEN, Doctoral Candidate University of Connecticut Storrs, Connecticut BARBARA Assistant University Lexington,
J. POWELL, Professor of Kentucky Kentucky
HOSPITAL
& COMMUNITY
PSYCHIATRY
MA.
PH.D. Medical
School
ANN F. NORD, PH,D. Clinical Psychologist St. Louis (Mo.) State Hospital The author describes a training program in disasterrelief work for representatives of both mental health and disaster-relief agencies. The program is designed to improve their over-all understanding of disaster-relief work and to increase their sensitivity to the emotional needs of disaster victims. Based on the recommendations of a state task force report, It consists of a workDr. Brownstone’s Missouri 63104.
30
PH.D. Services Health Center
address
at the
center
is 1420
Grattan,
St.
Louis,
shop that makes use of videotapes and learning exercises to help participants improve their listening skills, learn problem-solving techniques, become aware of behavioral signs that can alert them to victims’ emotional reactions, and familiarize them with the work of other relief agencies. #{149}Asmaterial resources available to disaster victims have increased, attention has begun to focus more closely on the psychological and emotional needs of victims. The Disaster Relief Act of 1974 (Public Law 93-288) gave legislative recognition to the need for a merger between mental health and disaster-relief services, though well-established voluntary disaster-relief organizations have for years combined counseling with material assistance. However, disaster-relief work has grown increasingly complex, and negotiating the system can be potentially overwhelming for a victim whose coping mechanisms are temporarily weakened. Sensitivity to these factors, along with the increasing influence of mental health agencies in planning community programs, resulted in the development of a special Lieutenant Governor’s Task Force in St. Louis, following a severe flood in the spring of 1973. Representatives from the mental health professions, along with staff from several disaster-relief organizations and agencies, served on the task force. Their final report contained recom mendations for collaboration between mental health and disaster-relief agencies. These recommendations included: . Providing short-term, immediate emotional support and assistance to essentially normal people who experience a crisis reaction after a disaster. The task force recognized that, to be most effective, emotional assistance must be offered in conjunction with adequate material assistance. . Training front-line disaster workers in the rudimentary techniques of group screening and crisis intervention in order to extend mental health knowledge and skills to disaster victims. . Employing the mental health professional as a back-up consultant to the front-line disaster worker. . Including mental health workers in some aspects of preparedness planning, staff training, and program development. In addition to establishing communication between mental health and disaster-relief workers, the task force also initiated a mental health survey of disaster victims in Missouri. Interviews were held with 136 flood victims and 26 tornado victims. The major purpose of the survey was to determine the shortand long-term emotional effects of a disaster, the kinds of services that were provided to victims, and how beneficial the services were. The results of the survey indicated that three to six months after the disaster none of the victims had experienced a serious mental breakdown. Approximately half of the victims believed the disaster had caused them to be more strained, tense, and nervous. The most common symptoms reported were restlessness, feeling
blue, fatigue, irritability, sleeplessness, and minor somatic complaints. A third of those interviewed indicated that the disaster had caused emotional and social changes in memhers of their family, but most felt that such symptoms were natural and would disappear in time. Less than 10 per cent of the victims who reported symptoms of emotional stress said they would see a mental health professional for those problems. Most said they would prefer talking to a relative, a clergyman, or their family doctor. The vast majority of respondents expressed some serious complaint about one or more of the disasterrelief services they did receive. Many complained of the brusque manner in which they were treated by agency personnel. Others mentioned the confusing procedures victims had to follow to obtain services and the conflicting information they received from different agencies. Virtually all the victims complained about the length of time it took to receive services from some agencies. Thus the mental health survey showed that, although the victims as a group did suffer postdisaster emotional discomfort, they were not incapacitated or in need of psychiatric care. The great majority of victims with emotional symptoms reported that they experienced the types of crisis reactions that are often found in relatively normal people after a personal tragedy. Over-all, the results of the survey suggest that disaster victims suffering emotional discomfort would benefit more from short-term crisis intervention provided by a crisis worker, backed up by a mental health professional, than from traditional psychiatric assistance. The results of the survey also underscore the need to plan service systems that minimize confusion and misunderstanding. TRAINING Based report,
FRONT-LINE
WORKERS
on the results of the survey and the the mental health and disaster-relief
task task
force force
developed a videotape training program designed to help the front-line worker provide emotional first-aid to victims. It was created and produced by psychologists from the Malcolm Bliss Mental Health Center and St. Louis State Hospital, as well as disaster-relief and nursing personnel from the American Red Cross of the Midwestern area, all located in St. Louis. The training package was designed to serve two purposes: to stimulate greater communication and collaboration among disaster-relief and mental health groups and to allow mental health professionals to contribute knowledge and skills to the disaster effort in a practical and economical way. A major goal of the workshop was to provide front-line mental health and disaster-relief personnel with information and experience to improve their over-all understanding of disaster work and increase their sensitivity to the emotional needs of disaster victims. The workshop takes approximately eight hours to complete. Ideally, participants represent both mental
VOLUME
28 NUMBER!
JANUARY
1977
31
health and disaster-relief agencies, with the latter making up about two-thirds of the group. Basic materials include a leader’s manual, a workbook for participants, and four 30-minute videotapes. The leader’s manual provides guidelines specific enough for an inexperienced group leader to conduct a successful training program. It contains details on the background of the workshop and instructions for using the manual, organizing the workshop, and conducting the experiential exercises. Also included are forms for evaluating the workshop, copies of the videotape scripts, and a list of suggested readings. The participants’ workbook contains materials needed for the exercises as well as lists of federal, state, and local agencies involved in disaster relief and of public health services in Missouri; a description of behavioral signs useful in identifying victims in need of crisis intervention; guidelines for effective listening; and an outline of effective problem-solving steps. The training program is divided into four sessions, each consisting of a half-hour videotape accompanied by group exercises designed to facilitate participation and learning. The first video session, Overview of Disaster Relief,’ provides a general overview of disaster work and pictures damage caused by different kinds of natural disasters. Also described are five stages of disaster work and the types of services made available to disaster victims from public and private organizations. Exercises in this session give the workshop participants an opportunity to learn about each other, the jobs they do, and the organizations for which they work. They also discuss their previous experience with natural disasters, as well as their apprehensions, expectations, and limitations as front-line disaster workers. The second video session, Mental Health and Disaster Relief,’ is designed to correct some common myths about the behavior of individuals and communities at the time of a natural disaster and to clarify misunderstandings about the field of mental health. It presents ways in which mental health techniques can be used by disaster organizations and describes simple screening procedures for assessing the emotional impact of the disaster experience. The learning exercise in the second session concentrates on the roles of the mental health workers in planning for and giving disaster relief, with attention given to the list of behavioral signs that may alert the worker to different emotional reactions. The need for development of an ongoing relationship between mental health specialists and disaster-relief personnel is also emphasized. The third video session, “Helping Styles of the Disaster Workers,” emphasizes reducing postdisaster strain and facilitating constructive problem-solving through the personal characteristics of the helpers themselves. Helping styles are demonstrated in simulated videotape interviews with disaster victims, and the accompanying learning exercises focus on the development of empathic listening and interpersonal styles that create good helping relationships. Participants practice these techniques and achieve a group consensus on the personal charac‘ ‘
‘
‘ ‘
‘
32
HOSPITAL
& COMMUNITY
PSYCHIATRY
teristics and attributes that are found in the effective disaster worker. “Crisis Intervention Skills,” the fourth video session, is a more detailed presentation of crisis intervention techniques and guides for good listening. It includes an outline of steps that can be used to help a disaster victim engage in successful problem-solving, and a simulated interview is used to illustrate those steps. During the learning exercises, participants practice listening skills and use crisis intervention techniques in roleplaying situations. WORKSHOP
EVALUATION
At the end of each workshop, participants rate the program on over-all worth, relevance of the four videotape topics, and effectiveness of the participant exercises. Ratings are given on a 5-point scale with 5 the highest and 1 the lowest rating. There is also opportunity for participants to express an interest in follow-up workshops and to write comments. Fifteen disaster-training programs have been presented to approximately 250 people in various locations throughout Missouri in conjunction with different mental health facilities. Participants from a variety of agencies-the Department of Housing and Urban Development, the Salvation Army, law enforcement agencies, fire departments, the American Red Cross, and the Small Business Administration, for examplehave been included in each workshop. In addition, representatives of the American Psychological Association, the National Institute of Mental Health, and the national headquarters of the American Red Cross have participated in and reviewed the workshop. Demonstrations have also been conducted in Kansas, Minnesota, Kentucky, Texas, Washington, D.C., and Illinois by nursing and health program personnel of the American Red Cross of the Midwestern area. Feedback from participants of diverse backgrounds indicates that this program has been well received and has been found to be informative and relevant. Ratings were similar from group to group, so that mean cornposite scores or percentages are an accurate reflection of feedback from each group. Sections covering listening and interview styles tended to be ranked highest. Overall, about 70 per cent of the ratings were 4 or 5, while 91 per cent of the ratings were 3, 4, or 5. Criticisms included a desire for more information on how disaster relief would operate in participants’ communities and more time spent on crisis skills and problem-solving sections. A follow-up workshop was recommended by 63 per cent of the participants. The disaster-relief training program developed from the task force report provides one model for collaborative interchange between mental health agencies and other community support systems and has stimulated wide community participation in Missouri. Other states have shown an increasing interest in using the training package as a method for sensitizing potential workers to the psychological needs of disaster victims.U
