After the earthquakes: immediate post-disaster work with children and families.
|Abstract:||Following the recent major Christchurch earthquakes, a huge amount of work has been carried out by a range of volunteers and professionals throughout the Canterbury area. We were able to make a small contribution these initiatives. Our team had the privilege of being involved in a special project offering a series of workshops to frontline workers in Christchurch, based on work we delivered to affected communities in Samoa after the 2009 tsunami. In March and April 2011 we delivered 14 workshops in Christchurch for a range of helping professionals and volunteers. Those attending were private practitioners as well as volunteers and staff personnel from a broad range of NGO's, including social service agencies, schools, health centres, local churches, refugee and migrant services, and Salvation Army volunteers. A total of 790 participants attended the 14 workshops. In this paper we first present some general principles and cautions regarding psychological support following the trauma of disaster. Next, our work in Samoa will be presented, noting the importance of avoiding re-traumatising and focusing on building the resilience of those affected. Some of the innovative approach with families and children in Samoa will be summarised, focusing on some principles for guiding post disaster intervention and a particularly helpful therapeutic technique called double listening. Finally we explain how this experience was translated into training in Christchurch: the workshop objectives will be identified, then some of the content of the workshop will be presented, bearing in mind that a 3-hour workshop is being outlined within the context of a brief paper. Finally a brief summary of the outcomes of the workshops will be outlined.|
Tamasese, Taimalieutu Kiwi
|Publication:||Name: New Zealand Journal of Psychology Publisher: New Zealand Psychological Society Audience: Academic Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2011 New Zealand Psychological Society ISSN: 0112-109X|
|Issue:||Date: Oct, 2011 Source Volume: 40 Source Issue: 4|
It is now well understood in the literature, but not well understood by some helping professionals and volunteers who have not lived through a disaster with multiple deaths, that some aspects of normal counselling, psychotherapy and psychological debriefing can unintentionally retraumatise people and leave them considerably worse off than before the engagement.
Counselling and therapy in normal situations usually encourages people to address the pain in their lives, and work through it. However, in a post disaster situation, if people do not want to talk about the events of the disaster, it is better not to intrude. It is perfectly healthy for people to protect themselves. Helpful questions will encourage stories of survival, resilience and strength since the disaster rather than focus on their trauma or their symptoms. Masten (2001) summarises the point well:
Resilience does not come from the rare and special qualities but from the everyday magic of ordinary, normative human resources in the minds, brains and bodies of children, in their families, relationships and their communities. It follows that efforts to promote confidence and resilience of children at risk should focus on strategies that protect or restore the efficacy of these basic systems. (p. 227)
Shalev and Errera (2008) express a similar notion based on the work of Rutter: "Minor gains can, sometimes, launch a process of reconstitution. Often-heard expressions, such as 'I lost a son, but realized how many friends I have' can make the point: having friends cannot be measured against losing a son. However, the presence of a small 'but' is of essence, because it completely denies the totality of the loss. In evaluating people's inner resources following trauma one might wish to be tuned to the 'but'" (Shalev & Errera, 2008, p.157).
The World Health Organisation (WHO) strongly warns against the use of single session psychological debriefing. Much of the critical evidence on debriefing is quite recent, which explains why many well-meaning agencies and professionals who are not aware of this recent evidence, are still involved and without a doubt will continue to be involved in psychological debriefing. In summary WHO states that (a) emergencies are associated with wide distress and elevated rates of common mental disorders and trauma-related problems, (b) single-session psychological debriefing to the general population is not recommended as an early intervention and (c) a range of social and mental health interventions exist to address social and mental problems during and after emergencies.
The WHO report recommends that most presenting mental health problems during the acute emergency phase are best managed without medication following the principles of psychological first aid: listen, convey compassion, assess needs, ensure basic physical needs are met, do not force talking, provide and mobilise company from preferably family or significant others, encourage but do not force social support and protect from further harm. (WHO, undated).
Five Principles of Trauma Intervention
A very comprehensive and seminal review of the literature by a worldwide panel of experts (Hobfoll et al., 2007) summarises and analyses various studies and proposes a set of principles that guide the overall effectiveness of post disaster interventions. The interventions that were found to be helpful were grouped under the following principles, of those that promote:
* a sense of safety
* a sense of self collective efficacy
* connectedness and
For the people of Saleapaga relocating the main village inland after the tsunami provides a good example of promoting safety. In a short space of time many households had moved and relocated. There were very few roads and no water reticulation inland so these needed to be built. In this situation there are the challenges of no fresh water or toilets so there is a range of physical requirements that need to be addressed before any psychological work can be of much benefit.
The Pacific Context
In the Pacific we are connected to multiple sites of disasters, but we are also connected to multiple sites of resilience. If we look throughout the Pacific, we see great stories of survival and resilience in many communities: locally here in Christchurch; in Queensland after the devastating floods; in Japan after the recent earthquake; in Samoa after the 2009 tsunami.
In the spirit of "alofa" through love and connection Tui Atua Tupua Tamasese Efi, the Head of State of the independent state of Samoa said in November 2009 after the tsunami at the New Zealand Families Commission Pasifika Families' Fono in Auckland:
"O le e lave i tiga, ole ivi, le toto ma le aano' (You who rally in my hour of need, you are my kin). Today I want to acknowledge our kinship with New Zealand. Samoa and New Zealand share so much. We share history, culture and rugby players. We share genealogy, faith, common environment and a future. New Zealand and Samoan family values and ties have changed so markedly over the years that the response of New Zealanders to the September 29th tragedy can only be described in terms of what would be the response of loving kin. The same must be said of Australia."
The Family Centre Psychosocial Unit in Samoa
It was with this sense of alofa and wanting to support the people of Christchurch that we and many others rallied to offer assistance to those affected. There are some similarities with the level of devastation between that experienced in Christchurch and Samoa. In a population approximately half the size of Christchurch there were 143 fatalities in Samoa alone. The most vulnerable sectors affected were female, young and the elderly. After the tsunami within a short space of time the Family Centre Psychosocial unit was mobilised. Our team leader, Taimalieutu Kiwi Tamasese travelled to Samoa within 24 hours of the event and Charles Waldegrave our other team leader invited and coordinated various health professionals associated with the Family Centre in various parts of the world. Both Allister Bush and Richard Sawrey, both previous staff members at the Family Centre, also travelled to Samoa to assist with the Family Centre Psychosocial Unit's response. The partners involved with the response in Samoa were the Catholic Archdiocese of Samoa, a local Samoan NGO: Afeafe o Vaetoefaga, and The Family Centre.
Catholic Archbishop of Samoa Alapati Lui Mataeliga gave strong support for the project offering 25 catechists, priests and lay workers from the Catholic Church to assist with the work. We also had a local partnership with Samoan NGO Afeafe o Vaetoefaga. The Family Centre, of course, was centrally involved. The Family Centre was established in 1979 and has been involved in various developments in family therapy, psychology, community work, and social policy research for many years. Three important features of the work of the Family Centre informed our approach to the Samoan disaster:
* Cultural Knowledge: The Asiasiga Approach: The Three Elements of the Self: The Spiritual, Mental and Physical. The Importance of Connections and Relationships. Theological Knowledge. Rhythms of Nature. Personal, Collective Agency (Bush, Collings, Tamasese, & Waldegrave , 2005; Tamasese, Peteru, & Waldegrave, 1997).
* Just Therapy: Sacredness, Belonging, Liberation (Waldegrave, Tamasese, Tuhaka, & Campbell, 2003)
* Narrative Ideas and Practices: Externalising Problems. Highlighting Stories of Resistance and Hope. Focus on Community Resilience (Denborough, 2006; Denborough, Freedman, & White, 2008)
What was the approach that we found helpful in the context to Samoa? Cultural knowledge was paramount, to work within the cultural framework of the people of Samoa. Asiasiga is a common principle within the Samoan context where people who are grieving or hurting would often be visited in their home for pastoral support, counselling and encouragement. In a Western context we might think it strange to have a psychologist knock on our door and say "would you like some help?", however in the Pacific context it was seen as an act of love, alofa. So for every village that we visited we made contact with the local mayor or pulinuu for permission to visit the families affected. In such meetings there were formal rituals of greeting to the pulinuu. In every village that we visited we were warmly welcomed and invited to visit each household affected. We were working with a strong emphasis on the Samoan concept of well-being, where the spiritual, mental and physical aspects of people and families are interconnected. Dominance is given to people's connections, places of belonging and relationships (Bush, Collings, Tamasese, & Waldegrave, 2005; Tamasese, Peteru, Waldegrave, 1997).
[FIGURE 1 OMITTED]
[FIGURE 2 OMITTED]
In Samoa we delivered a group programme to affected children. It was very well received, with large numbers of children attending. In these programmes, some interventions were offered to affected children that promoted calming, such as repetitive physical exercises, introduced by a visiting counsellor and mentor William Spears, and adapted by trained youth leaders to fit the local context (Berger & Gelkopf, 2009). Anxiety is held in our bodies through muscular tension so after these physical, repetitive and fun exercises the children according to reports from some of their teachers were "much happier and more relaxed."
[FIGURE 3 OMITTED]
In the children's programme an activity that promoted self and collective efficacy was the tree of life activity. This is a very effective and helpful narrative group activity that has been developed by Ncazelo Ncube and the Dulwich Centre team in Adelaide (Denborough, 2008). It has been delivered to a wide range of communities experiencing trauma including Rwanda, Palestine, and Zimbawe.
The approach uses the metaphor of a tree to build resilience and healing. Children were facilitated in small groups to each draw their own tree and write on the various parts of the tree their responses to the following questions:
* Roots: Who are your people and places of belonging?
* Trunk: What are your strengths? What things can you do?
* Branches: What are your hopes and dreams?
* Leaves: Who are the people close to your heart?
* Fruits: What are the gifts you've been given by others?
The drawings are then presented to the group together and displayed to represent a forest which offers the metaphor of gathering and supporting each other in times of distress or 'storms of life'.
Another activity that was offered in Samoa was messages to groups or families from previously visited groups. This strongly promoted a sense of connectedness between people. Affected families and groups of children from the children's programme were invited to offer messages of hope or support to other families and communities. The messages emphasised people's actions in response to trauma and the contribution they can give to others facilitating their ongoing connection with each other. In doing this, we give people who have been traumatized the opportunity to assist and offer comfort to others, encouraging their movement from victim and pathologising identities towards the positive contribution they can give to others.
Psycho-education is also very helpful, particularly normalising people's reactive anxiety symptoms to traumatic events--such as saying things like: "These are normal reactions to an abnormal event". Also people's experience of psychological numbing can be seen as functional rather than dysfunctional. Such a response could be viewed as assisting with self protection and calming.
[FIGURE 4 OMITTED]
[FIGURE 5 OMITTED]
An example of collective efficacy is shown through the White Sunday commemorations. White Sunday occurred just two weeks after the tsunami--White Sunday is an annual church service that celebrates children's leadership in Samoa. So in a short space of time the children of Samoa were showing leadership, returning to normal rituals. Of course there were tears but these events were also rituals of resilience and healing. We attended the White Sunday services in Poutasi and were privileged to be witnesses of people's resilience and healing and our presence was acknowledged by the church elders, that we were joining them in their suffering, resilience and healing.
The Christchurch Workshops
Workshop Objectives were that participants will:
* become aware that some aspects of normal counselling, psychotherapy and psychological de-briefing can unintentionally retraumatise people and leave them considerably worse off than before the engagement.
* develop therapeutic responses and helpful question lines that avoid re-traumatisation by identifying strengths in people's stories of survival, their important points of social and family connections, and their critical people, symbols and places of meaning.
* learn ways of working with children experiencing grief or trauma individually and in schools that encourage resiliency and centres on strengthening personal resources, learning to control their bodies in stressful situations, understanding feelings and emotions and enhancing relationships.
* become informed about the evidence base and relevance of this approach.
Exposure to the media can have positive and negative effects so it is important to censor and limit disturbing and recurring images and stories of the disaster, particularly to children.
A positive image from the Christchurch Press after the most damaging earthquake was Somali women preparing meals for the emergency workers.
Other images from the Christchurch Press show the Student Volunteer Army with great spirit and energy helping with the clean up. The flip side to this, of course, is being careful of what your children are exposed to and what you are exposed to. After some time of exposure to the media surrounding the disaster, people not living in Christchurch have reported needing to turn the radio and TV off. So we need to be careful what images we are exposed to and what children are exposed to.
Double listening is one technique from Narrative Therapy that we had found to be very helpful in our work in Samoa. There are multiple ways to listen to a story. In our profession we are really attuned to psychological symptoms that might be problematic. We are good at that. However, alternatively we can instead focus on people's responses to a traumatic event--what is called the counter narrative. Just to give you a brief example: "The room shook, I was fearful, I stood up, I ran for the door, I looked for the kids, I was shaking with fear, I ran out onto the grass, I was scared, I called out to my neighbours". Now amongst that you can tune into the fear (being scared, the person shaking) and the trauma line of the story. Or you can listen to the person's responses and actions: "I stood up", "I looked for the kids", "I called out to my neighbours", with a focus on their implications: "I ran for the door"--the moving away from the danger. In amongst that story, therefore, in a very short space of time, you have already got some of Hobfoll et al's (2007) principles represented: promoting safety, self efficacy, and connection with others. So searching for the positive responses, the counterpoint to the story is the focus. In the context of the workshops in Christchurch we invited participants to interview each other using these ideas:
Scenario for role play
In groups of three participants
* Distressed Person: Think of a person who has been significantly distressed/traumatised by the quakes and the impacts on their family and livelihood. Take that role
* Interviewer: Listen, and then practice double listening and ask some questions that encourage resilience, for example: How have you managed since the quakes? Have you been able to help or support anyone else? What has sustained you during this time? How have you held on to hope since the quakes?
* Observer: Take notes that record helpful and unhelpful questions.
We then gathered together in larger groups for feedback and discussion regarding the helpful and unhelpful responses during the role play.
In terms of outcomes, the team was really humbled because we are not from Canterbury. It was very encouraging to see the large number of people who made the effort to attend the workshops. There was a very real warm sentiment experienced at all the workshops. We hoped there would be the understanding that we were coming with the spirit of being "loving kin", rather than outsiders thinking that we had something "expert" to share. The feedback was therefore very encouraging from the evaluation forms. A total of 790 participants attended the 14 workshops; 80% of participants rated the workshops as extremely or very helpful; 80% rated the workshops as extremely or very informative; 92% of participants identified examples (over 20 topics) of things they learned from the workshops, most of which referred to avoiding re-traumatisation, listening closely to clients and emphasising resilience; 97% of participants identified examples (23 topics) of things they had learned and were most likely to try out. The majority of these referred to encouraging resilience and positive questioning/double listening. Overall 80% rated the workshops as either extremely or very useful.
Berger, R., & Gelkopf, M. (2009) School-based intervention for the treatment of tsunami-related distress in children: A quasi-randomized controlled trial. Psychotherapy and Psychosomatics, 78, 364-371.
Berkowitz, S., et al. (2010). Skills for psychological recovery: Field operations guide. Washington, DC: The National Center for PTSD and the National Child Traumatic Stress Network.
Bush, A., Collings, S., Tamasese, K. & Waldegrave, C. (2005). Samoan and sychiatrists' perspectives on the self: Qualitative comparison. Australian and New Zealand Journal of Psychiatry, 39, 621-626.
Denborough, D. (2006). Trauma: Narrative responses to traumatic experiences. Adelaide, Australia: Dulwich Centre.
Denborough, D. (2008). Collective narrative practice: Responding to individuals, groups, and communities who have experienced trauma. Adelaide, Australia: Dulwich Centre.
Denborough, D., Freedman, J., & White, C. (2008) Strengthening resistance: The use of narrative practices in working with genocide survivors. Adelaide, Australia: Dulwich Centre.
Forbes, D., Fletcher, S., Wolfgang, B., Varker, T, Creamer, M., et al.(2010). Practitioner perceptions of Skills for Psychological Recovery: A training program for health practitioners in the aftermath of the Victorian bushfires. Australian and New Zealand Journal of Psychiatry, 44, 1105-1111.
Hawker, D. M., Durkin, J., & Hawker, D. S. J. (2010). To debrief or not to debrief our heroes: That is the question. Clinical Psychology and Psychotherapy, 18, 453-463.
Hobfoll, S.E., Watson, P., Bell, C.C., Bryant, R.A., Brymer, M.J., Friedman, M.J., Friedman, M., Gersons, B.P.R., de Jong, J.T.V.M., Layne, C.M., et al. (2007). Five essential elements of immediate and mid-term mass trauma intervention: Empirical evidence. Psychiatry 70(4), 283-315. doi:10.1521/psyc.2007.70.4.283
Masten, A. (2001). Ordinary magic: Resilience processes in development. American Psychologist, 56, 227-238.
McDermott, B.,& Cobham, V. (2011) Personal email communication.
Rajkumar, A., Premkumar, T., & Thayan, P. (2008) Coping with the Asian tsunami: Perspectives from Tamil Nadu, India, on the determinants of resilience in the face of adversity. Social Science and Medicine, 67, 844-853
Rutter, M. (1993). Resilience: some conceptual considerations. Journal of Adolescent Health, 14, 626-631.
Shalev, A., & Errera, Y. (2008). Resilience is the default: How not to miss it. In M. Blumenfield & R. Ursano (Eds.), Intervention and resilience after mass trauma (pp. 149-171). Cambridge, UK: Cambridge University Press.
Tamasese, K., Peteru, C., & Waldegrave, C. (1997). Ole taeao afua, the new morning: A qualitative investigation into Samoan perspectives on mental health and culturally appropriate services. Wellington, NZ: The Family Centre.
Waldegrave, C., Tamasese, K., Tuhaka, F., & Campbell, W. (2003). Just Therapy a journey: A collection of papers from the Just Therapy team, New Zealand. Adelaide, Australia: Dulwich Centre.
Williams, R., & Dury, J. (2009). Psychosocial resilience and its influence on managing mass emergencies and disasters. Psychiatry, 8, 293-296.
World Health Organisation (2003). Mental health in emergencies: Mental and social aspects of health of populations exposed to extreme stressors. Geneva, Switzerland: Department of Mental Health and Substance Dependence
World Health Organisation (undated) Single-session Psychological Debriefing: Not Recommended http ://www. who. int/hac/techguidance/p ht/13643.pdf
Richard Sawrey at Narrative Consultations, PO Box 44, Paekakariki, New Zealand, richard. email@example.com or Charles Waldegrave at The Family
Centre, PO Box 31050, Lower Hutt, Wellington, New Zealand, firstname.lastname@example.org.
Our team wishes to state that our hearts go out to all the people of Christchurch. You have endured much but you have also sustained much and our hearts are with you in all that you have sustained in the last few months, and continue to do so.
We wish to offer much warm encouragement to those who continue to be involved in supporting the healing of the people and communities of Christchurch and Canterbury.
Mihi aroha ki a koutou. Alofa atu. Manuia. Soifua.
Richard Sawrey, Narrative Consultations
Charles Waldegrave, The Family Centre
Taimalieutu Kiwi Tamasese, The Family Centre
Allister Bush, Capital Coast District Health Board
|Gale Copyright:||Copyright 2011 Gale, Cengage Learning. All rights reserved.|