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Chapter Fifteen: Legal and Ethical Issues © 2017 Cengage Learning Introduction Crisis intervention presents intriguing ethical dilemmas and challenges for mental health workers Ethical guidelines should be honored Crisis situations create impossible situations to follow ethical guidelines Ethical codes do not specifically address crisis intervention services Workers are left to make decisions based on reflection and consultation Nuances matter The legal and ethical questions of a crisis situation can change quickly © 2017 Cengage Learning Ethical and Legal Interface with Crisis Intervention Misconceptions regarding ethical decision making Decision-making models are practical Time to consult One correct answer The role of the mental health professional Safety Calming Self and collective efficacy Connectedness Hope © 2017 Cengage Learning The Confluence of Beliefs, Emotion, Morality, and Values Vulnerability and resiliency are dynamic Crisis workers need to understand their reasons for doing crisis work Understand personal values, beliefs, and background Reflection Supervision Nonrational factors influence ethical decision-making Context Perceptions Relationships Emotions Learning processes © 2017 Cengage Learning Laws and Ethical Codes Are Living Documents Laws are mandatory Ethical codes are aspirational A good “bedside manner” is the best risk management strategy Legal requirements and ethical codes can conflict Often no single right answer Consult an attorney Choose the least harmful option Consider the effect on the community over the individual © 2017 Cengage Learning Confidentiality and Privacy Confidentiality—the legal duty to protect client’s private communication Privacy—client’s righto to choose what to say and when to say it Privileged Communication Legally prevents disclosure of confidential information Laws differ by location Limited in certain circumstances When a reasonable practitioner has the duty to protect clients or others from serious and foreseeable harm © 2017 Cengage Learning Duty to Warn, Protect, and Report (1 of 2) Duty to warn rules are location specific Tarasoff v. Regents of the University of California Duty to warn holds across counseling modality and venue Tarasoff mandated conditions for warning Must be a special relationship (e.g., client-therapist) Must be a reasonable prediction of dangerous conduct Must be a foreseeable victim © 2017 Cengage Learning Duty to Warn, Protect, and Report (2 of 2) Guidelines for action when a clear threat of violence is made Clearly state the limits of confidentiality Special rules may apply for minors Consult and document Warn identified potential victims Warn despite threats of reprisal © 2017 Cengage Learning Negligence and Liability Negligence—the unintentional breach of duty one person owes another Practitioner has a duty Duty has been breached through an unprofessional act or omission Client sustained physical or emotional harm Practitioner’s behavior caused the harm What is the professional standard of practice? Areas of vulnerability Practicing outside one’s scope Incompetence Failure to use most beneficial techniques Failure to obtain informed consent Failure to protect from harm © 2017 Cengage Learning Clinical Supervision of Crisis Workers Vicarious Liability--Supervisors may be liable for supervisee’s actions Supervisors have the authority to direct supervisee’s work Extent of vicarious liability affected by various factors Presence of an employment relationship Extent of authority supervisor holds Number of supervision levels present Which supervisor has the most direct contact with supervisee © 2017 Cengage Learning Moral Principles of Ethical Decision-Making Autonomy Client’s right to self-determination Beneficence Working for the good of the client and society Fidelity Keeping one’s promises and commitments Justice Fostering fairness, equality, and equitable access to care Nonmaleficience Avoiding actions that cause harm © 2017 Cengage Learning Using Ethical Decision-Making Models Benefits Allow crisis workers time to consider legal and ethical facets of a situation and make the best decision Limits Time is often short in a crisis situation Cultural aspects often left out of models Not always a right answer available Discernment Worker’s ability to perceive a course of action amid the chaos Affect Heuristic Decision-making primarily based on personal biases, relationships, and context © 2017 Cengage Learning Becoming a More Effective Crisis Worker Reflective Practice-- Process of thinking about: Being a crisis responder One’s clinical interventions How to improve your clinical skills Self-care Respect for one’s dignity and self-worth Recognition that self-care is how individual workers prepare to provide care for others during crisis situations © 2017 Cengage Learning Application Assignment #1: Theory, Culture, and Ethics in Crisis Intervention Instructions To prepare for this application assignment: · Review Chapter 1 in your text, Crisis Intervention Strategies, focusing on the various crisis theories. · Review Chapter 2 in your course text, focusing on the impact of culture on critical incident counseling. · Review Chapter 15 in your course text, focusing on the legal and ethical issues in crisis intervention. · Review the article, “After the Storm: Recognition, Recovery, and Reconstruction.” Pay attention to the guidelines for improving multicultural competence. · Review the article, “Developing Cultural Competence in Disaster Mental Health Programs: Guiding Principles and Recommendations.” Reflect on the importance of cultural competence in critical incident counseling. · Select a critical incident that would require response counseling for survivors and think about a culture in which this critical incident might occur. · Select one stage of human development of potential clients from the following: 6-year-old child, 14-year-old adolescent, 26-year-old young adult, 50-year-old older adult. · Select one legal or ethical issue that may occur as you work with the individual(s).   The Assignment: In a 3-5 page paper: · Provide a brief description of a critical incident (natural disaster, manmade disaster, etc.). · Provide a brief overview of a selected crisis theory you would apply to the critical incident. · Briefly, describe your “client” in terms of their stages of development (see bullet point 7 above). · Explain how you might apply the theory to the selected client age group affected by the critical incident. · Discuss multicultural implications of working with this age group during the critical incident. · Discuss one legal or ethical issue that may occur as you work with the individual(s) impacted by the critical incident. Support your Application Assignment with at least 2 resources from the learning resources tab. Use specific references to all resources used in its preparation. This assignment should be completed using APA formatting.  Requirement: When you submit your assignment in Georgia View, use the naming convention AppAssgn1+last name+first initial as the Submission Title. Bottom of Form Chapter One Basic Training Crisis Intervention Theory and Application ©2017 Cengage Learning Brief History of Crisis Intervention National Save-a-Live League (1906) The first known crisis phone line. Cocoanut Grove nightclub fire (1942) Dr. Erich Lindemann’s clinical assessment of the survivors. Community Mental Health Centers Act of 1963 Large state-run asylums were replaced by community mental health centers. ©2017 Cengage Learning The Importance of Volunteerism Tasks completed by volunteer workers may range from menial administrative chores to frontline crisis intervention with clients. The greatest number of frontline volunteers are used to staff 24-hour suicide hotlines in major cities. More than 75\% of all crisis centers in the United States report that volunteer workers outnumber professional staff by more than 6 to 1. ©2017 Cengage Learning Crisis Intervention as a Grassroots Movement Crisis intervention typically remains unrecognized by the public until victims/victim advocates exert enough legal, political, or economic pressure to cause change. As crisis agencies become crisis organizations, they gain power, prestige, and notoriety. Offer opportunities for research, clinical training sites, and employment for recent graduates. Three major grassroots movements helped shape crisis intervention into an emerging specialty. Alcoholics Anonymous (AA) Vietnam veterans Women’s movement during the 1970s ©2017 Cengage Learning Transition from a Grassroots Movement to a Specialty Area Large influx of crisis organizations from the 1970s-1990s. Recognition that immediate intervention is essential in alleviating stress related to trauma. Crisis response grows from all-volunteer efforts to bureaucratic institutions as the need for organization grows Professional recognition within the helping fields. Division 56: Trauma Psychology, American Psychology Association (2006) Accreditation standards set by the Council for Accreditation of Counseling & Educationally Related Programs (2009) and National Association of School Psychologists (2010). ©2017 Cengage Learning Influence of the Media The media has a significant influence on public consciousness. Matthew Brady’s Civil War photographs brought war images into the public discourse. Real-time news coverage of crisis events impacts our perceptions of an small, interconnected world in both positive and negative ways. POSITIVE: public recognition about crisis intervention NEGATIVE: people may rush in to help haphazardly ©2017 Cengage Learning The Case Against Too Much “Helping” The reality is that in most instances, victims of disaster are resilient and do not panic. Victims of disaster create an “altruistic or therapeutic community”-characterized by the disappearance of community conflicts, heightened internal solidarity, charity, sharing, communal public works, and a positive attitude. There is an assumption that experiencing a disaster will invariably lead to psychopathology. “Trauma tourism”-when people travel to disaster scenes to provide unrequested assistance or to gawk at survivors. ©2017 Cengage Learning Definitions of Crisis (1 of 2) There are varied definitions for both an individual and a system in crisis. For the purpose of this text, definitions have been selected. Individual crisis-crisis is the perception or experiencing of an event or situation as an intolerable difficulty that exceeds the person’s current resources and coping mechanisms. Behavioral emergency-when a crisis escalates to immediate danger for injury or death to someone involved in the crisis. Parasuicide-when a person in crisis accidentally or intentionally places themselves in a position to be killed. ©2017 Cengage Learning Definitions of Crisis (2 of 2) Systemic crisis-when a traumatic event occurs such that people, institutions, communities, and ecologies are overwhelmed and response systems are unable to effectively contain and control the event in regard to both physical and psychological reactions to it. “Metastasizing crisis”-occurs when a small, isolated incident is not contained and begins to spread. Primary Prevention-stopping a problem before it starts. Secondary Intervention-minimizing the harmful effects that have already occurred. ©2017 Cengage Learning Characteristics of Crisis (1 of 2) Presence of both danger and opportunity A crisis is dangerous because the related stress may result in pathological behavior such as injury to self or others. A crisis can be an opportunity because it may be the catalyst for the individual to seek help. Crisis can provide the seeds of growth and change Many times a person will not seek help until they can admit that they do not have control of the problem. No panaceas or quick fixes It is common that the failure of a quick fix to a problem may actually lead to a crisis situation. ©2017 Cengage Learning Characteristics of Crisis (2 of 2) The Necessity of Choice Choosing is proactive and deciding not to choose is actually a choice that typically has negative results. Universality and Idiosyncrasy Crises are universal because no one is immune to them. Crises are idiosyncratic because individuals may react differently to the same situation. Resiliency Crisis interventionists try to tap into people’s natural ability to get on their feet and move through a crisis. Perception It is the perception, not the event, that causes distress. Complicated symptomology Crisis is complex and defies linear causality. ©2017 Cengage Learning Transcrisis The events immediately following the crisis have a large impact on the duration. A crisis event may seem to be resolved, but may actually be submerged into the survivor’s unconsciousness. A transcrisis state occurs when unresolved issues from a previous traumatic event resurface because of a current stressor. Transcrisis is not synonymous with PTSD. PTSD is an a DSM-5 defined anxiety disorder resulting from a crisis Transcrisis is the re-emergence of crisis symptoms from some unresolved prior crisis event. ©2017 Cengage Learning Transcrisis Points Can be seen as therapeutically progressive and are frequently characterized by approach-avoidant behavior toward change. May occur frequently and are not regular, predictable, or have a linear progression. When transcrisis points occur, the therapists shifts from traditional therapeutic techniques to crisis intervention. The individual will experience similar affect, behavior, and cognition as the original crisis event. ©2017 Cengage Learning Theories of Crisis Intervention No single theory is 100\% comprehensive. Three major theories Basic Crisis Theory (Lindemann, Caplan) Expanded Crisis Theory (theoretically integrative) Applied Crisis Theory (Brammer) ©2017 Cengage Learning Basic Crisis Theory (1 of 2) Based on a psychoanalytic approach to crisis. Behavioral responses related to grief are normal, temporary, and can be relieved with short-term intervention techniques. Normal grief behaviors include: Preoccupation with the lost one Identification with the lost one Feelings of guilt and hostility Disorganization of daily routine Somatic complaints ©2017 Cengage Learning Basic Crisis Theory (2 of 2) Crisis occurs when something impedes one’s life goals. Equilibrium/disequilibrium paradigm Disturbed equilibrium Brief therapy or grief work Client’s working through the problem or grief Restoration of equilibrium Basic Crisis Theory vs. Brief Therapy Brief Therapy attempts to remediate ongoing emotional issues Basis Crisis Theory assists individuals in crisis and addresses their affective, behavioral, and cognitive distortions resulting from the traumatic event. ©2017 Cengage Learning Expanded Crisis Theory Explores social, environmental, and situational factors of a crisis. Is influenced by several theories Psychoanalytic Theory Early childhood experiences determines why a traumatic event becomes a crisis. General Systems Theory Examines the interdependence and relationships among people and between people and events. Ecosystems Extension of systems theory to include an environmental context ©2017 Cengage Learning Theories that Influence Expanded Crisis Theory Adaptational Theory Crisis is sustained through maladaptive behaviors. Interpersonal Theory A state of crisis can not be sustained if a person has an intact sense of self-worth and has a healthy support system. Chaos Theory Theory of evolution applied to human functioning as a self-organizing system. Developmental Theory Potential for crisis arises from developmental tasks that are not accomplished. ©2017 Cengage Learning Applied Crisis Theory Encompasses four domains: Normal developmental crises Consequence of events in typical human development that produce an abnormal response Birth of a child, graduation from college, or career change Situational crises Occurs when an uncommon event, that the individual or system has no way to predict or control, causes extreme stress. Terrorist attacks, automobile accidents, or sudden illness ©2017 Cengage Learning Four Domains of Applied Crisis Theory Existential crises A result of intrapersonal conflicts related to one’s sense of purpose, responsibility, independence, freedom, or commitment. Ecosystemic crises When a natural or human-caused disaster overtakes a person or system through no fault of their own. Natural phenomena (hurricanes, tornadoes, forest fires) Biologically derived (disease, epidemic) Politically based (war) Severe economic depression (Great Depression) ©2017 Cengage Learning Crisis Intervention Models Basic models of crisis intervention Equilibrium model Cognitive model Psychosocial transition model Models based on Ecosystemic Theory Developmental-ecological model Contextual-ecological model Models based on field-based practice Psychological first aid ACT model Game Plan model ©2017 Cengage Learning Basic Models Equilibrium Model Crises are seen as a state of psychological disequilibrium. Main focus is on stabilizing the individual. Most appropriately used for early intervention. Cognitive Model Crisis is a result of distorted thinking related to an event, not the event itself. The goal is to help people change their perception of the crisis event. Most appropriately used after the individual has been stabilized. Psychosocial Transition Model Assumes that people are products of their genes and their environment. The goal is for the person to gain coping mechanisms and establish a support system. Most appropriately used after a client is stabilized. ©2017 Cengage Learning 22 Ecosystemic Models Developmental-Ecological Model Crisis worker should assess the individual’s developmental stage, their environment, and the relationship between the two. Contextual-Ecological Model Contextual elements are layered by physical proximity and the emotional meaning attributed to the event. Reciprocal impact occurs between the individual and the system. Primary vs. secondary relationships Degree of change triggered by the event Time directly influences the impact of a crisis. The amount of time that has passed Special occasions (anniversaries, holidays, etc.) ©2017 Cengage Learning 23 Field-based Models (1 of 2) Psychological First Aid Model Seeks to address the immediate crisis needs. Non-intrusive because not everyone exposed to a traumatic event will experience a crisis. Psychological First Aid: Field Operations Guide (The National Center for PTSD) consists of 8 core actions Psychological Contact and Engagement Safety and Comfort Stabilization (if necessary) Information Gathering: Current Needs and Concerns Practical Assistance Connection with Social Supports Information on Coping Linkage with Collaborative Services ©2017 Cengage Learning 24 Field-based Models (2 of 2) ACT Model Assessment of presenting problem. Connecting clients to support systems. Traumatic reactions and posttraumatic stress disorders. Game Plan Model Developed for police-based crisis intervention Based on coaching first responders in the use of defusing and de-escalation techniques ©2017 Cengage Learning Integrated Crisis Theory Intentionally and systematically integrates valid concepts and strategies from all available approaches. Operates from a task orientation and has three major tasks. Identify valid elements in all systems and integrate them. Consider all pertinent theories, methods, and standards for evaluating and manipulating clinical data. Do not identify with one specific theory. Fuses two pervasive themes All people and all crisis are unique and distinctive Two people may experience the same traumatic event but react to it differently All people and all crises are similar There are global elements to specific crisis types ©2017 Cengage Learning 26 Characteristics of Effective Crisis Workers Effective Crisis intervention is a hybrid of science and art. Crisis workers need a mastery of technical skill, theoretical knowledge, and certain characteristics to develop this hybrid. Diverse life experiences Poise Creativity Flexibility Energy Resiliency Quick mental reflexes Assertiveness Tenacity ©2017 Cengage Learning After the Storm: Recognition, Recovery, and Reconstruction Priscilla Dass-Brailsford Lesley University On August 29, 2005, when Hurricane Katrina made landfall near the Louisiana–Mississippi border, it exposed a large number of people to extraordinary loss and suffering. The enormous swath of physical devastation wreaked across the marshes of Louisiana’s Plaquemines Parish to the urban communities of New Orleans and the coastal landscape of Mississippi and Alabama caused a notable change to the demographics of the Gulf Region, making it the most expensive natural disaster in U.S. history. This article describes a disaster responder’s experiences of working with displaced survivors of Hurricane Katrina, providing crisis and mental health support in the acute phase of the disaster. This is followed by a discussion of the importance of a multicultural approach to helping survivors of a natural disaster; several guidelines to improve multicultural competence are proposed. In particular, the importance of attending to survivors’ racial, socioeconomic, language, and religious differences is discussed. Keywords: disasters, multicultural competence, first responders, crisis, Hurricane Katrina In the last week of August 2005, a storm with winds in excess of 150 miles per hour caused 20-foot-high waves to pound the coastlines of Alabama, Florida, Louisiana, and Mississippi. Hur- ricane Katrina was predicted to hit the Gulf Coast. Severe storm surges caused the breaching of levees in New Orleans, followed by massive flooding as swollen Lake Pontchartrain emptied its waters into the city. Residents who had not evacuated their homes before the hurricane made landfall found their lives in peril. Many com- munities in New Orleans experienced severe losses in life and destruction to property. The demographics of the city would change notably. On Labor Day, about a week after Hurricane Katrina struck, I received a call from a volunteer organization in Washington, DC, deploying me to a disaster mental health team in Baton Rouge. A few days earlier, I had indicated my availability as a volunteer on a volunteer site. The caller described the deployment as one of “extreme hardship.” I made a decision to become involved in the recovery efforts without much hesitation. I knew that my training as a trauma psychologist, my work as a disaster mental health volunteer, and my past experience as the coordinator of a crisis response team were much needed in the hurricane-devastated region. In reality, I could not shake off media images of the anguished faces of survivors whose lives were forever changed by the havoc wreaked along the Gulf Coast. They reminded me of my clients at an inner city health center in the United States and township clinics I visit during my summers in South Africa. The next day I arrived in Louisiana, and later that day I picked up my volunteer badge at the Cajun Dome in Lafayette, a small town outside Baton Rouge. In the 1st week after the storm, I was the only person of color on the disaster mental health team, a team designated to meet the needs of 2,500 men, women, and children. Ninety-five percent of the people at this large shelter, where I worked for more than 18 hr a day, were Black and indigent. In this article, I initially describe my experience of working with survi- vors of Hurricane Katrina, providing crisis and mental health support in the acute phase of the disaster. This description is followed by a discussion of the importance of adopting a multi- cultural approach to helping survivors of a natural disaster; several guidelines to improve multicultural competency are proposed. In particular, the importance of attending to racial, socioeconomic, language, and religious differences is discussed. Stories of Survivorship From the outset, many of us on the disaster mental health team found it challenging to use Maslow’s (1962) hierarchy of needs in providing survivors of Hurricane Katrina with the bare necessities to promote their recovery, primarily because basic needs, such as food and water, were in short supply. Although evacuees were given three meals a day, if they did not feel like joining the long lines that usually formed hours before a meal was served or if they were not available at the designated meal times, they had to seek their own sustenance. Editor’s Note. This article was submitted in response to an open call for submissions about psychologists responding to Hurricane Katrina. The collection of 16 articles presents psychologists’ professional and personal responses to the extraordinary impact of this disaster. These psychologists describe a variety of roles, actions, involvement, psychological prepara- tion, and reactions involved in the disaster and the months following. These lessons from Katrina can help the psychology profession better prepare to serve the public and its colleagues.—MCR PRISCILLA DASS-BRAILSFORD received her EdD from Harvard University. She is a professor in the Division of Counseling and Psychology at Lesley University in Cambridge, Massachusetts. Her research interests include multicultural competence in clinical practice, the stressor of political trauma and resilient outcomes, and racial identity development. She is a recent past chair of the American Psychological Association’s Committee on Ethnic Minority Affairs and a current member of the Committee on Women in Psychology. CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Priscilla Dass-Brailsford, Lesley University, 29 Everett Street, Cambridge, MA 02138. E-mail: [email protected] Professional Psychology: Research and Practice Copyright 2008 by the American Psychological Association 2008, Vol. 39, No. 1, 24 –30 0735-7028/08/$12.00 DOI: 10.1037/0735-7028.39.1.24 24 T hi s do cu m en t i s co py ri gh te d by th e A m er ic an P sy ch ol og ic al A ss oc ia tio n or o ne o f i ts a lli ed p ub lis he rs . T hi s ar tic le is in te nd ed s ol el y fo r t he p er so na l u se o f t he in di vi du al u se r a nd is n ot to b e di ss em in at ed b ro ad ly . All survivors slept in the large open area in the middle of the dome, where football games were usually played. This also served as their primary living quarters and as a storage area for their personal belongings. Each individual was provided with a camp- style cot, which was adequate for a day or two but which took its toll physically when used for more than a week. Privacy was a luxury that was largely unavailable to all survivors who had to share the communal space. Thus, nearly all the residents were sleep deprived, hungry, and agitated most of the time. It was certainly not the optimum climate in which to address psycholog- ical concerns. On a regular basis, anxious individuals inquired about financial reparations to help them take the first steps toward healing and recovery. Many of the evacuees did not know the whereabouts of family members; downed telephone lines made the task of locating them almost impossible. A cell phone company had established a pro bono booth, and distraught individuals who were searching for family and friends waited in line for many hours to use the phones. Many individuals had lost their cell phones and other important personal possessions that stored the telephone numbers of signif- icant others in the storm. They struggled to recall these numbers from memory; as crisis responders well know, remembering even mundane information in a crisis is not easy. Several Latino families occupied almost half of an upper floor, and many of them attempted to ask me questions. I found myself often shaking my head helplessly to indicate that I did not speak Spanish. I have not regretted not speaking Spanish as much as I did in those 2 awful weeks, when I sometimes felt as powerless as the people I had come to help. On one occasion, a volunteer engaged in the task of making up beds identified a young Latino man as suicidal and in need of mental health support. The young man’s wife and children had drowned in the deluge. I was designated to provide him with assistance. In narrating his story, he haltingly described how the local sheriff found the bodies of his loved ones, tied to their beds so that they could die together and not float away in the torrid waters. The distraught young man cherished the water-blemished note written by his wife as she made the final plans for her family’s demise. His sense of loss and grief was tangible; his quest was to identify their bodies so that they could be appropriately buried. The fact that it would take several weeks to complete this impor- tant ritual was causing him immeasurable anguish in the form of sleepless nights and decreased appetite. Talking to an unfamiliar woman about his loss was stressful. His helplessness was accented by the fact that he had to communicate in English rather than Spanish, the language in which his memories were encoded. Re- alizing this, I quickly strategized on how to connect him with other Spanish-speaking survivors, who swiftly formed a warm bond of friendship around him. Days later, observing him animatedly talk- ing within a new circle of friends brought a rare smile to my lips. The significant role of kinship bonds was evident among many African American survivors, especially those who had lost family members in the storm. It was common to find a neighbor watching over children whose parents were on a treacherous journey back to New Orleans to search for family members, assess the damage to a family home, or salvage personal possessions. Social service organizations and other authorities classified children not in the care of biological parents as abandoned. The media did not hesitate to sensationally broadcast to an anxious viewing audience statistics on the increasing number of abandoned children. Frequently, I found myself advocating on behalf of African American parents by reminding authorities that the children were temporarily in a safe environment, with caring and familiar adults. A request for a broader and more diverse cultural definition of family usually led to a little patience on the part of bureaucracy. I was nevertheless always relieved when a mother returned a few days later to resume the care of her children and a potential crisis was averted. By the time I left New Orleans, all the children with whom I had worked were reunited with their primary and biological caregivers. Religious and spiritual beliefs played a significant role in the lives of many survivors of Hurricane Katrina. It quickly became apparent that many individuals viewed their pain and suffering through a religious lens. To provide culturally appropriate and effective support, responders had to have an awareness of survi- vors’ strong religious values. Stories of being “saved by Jesus” and the belief that the “Lord has a lesson for us” were common; many survivors felt that their religious beliefs had helped them endure the storm. Even children were willing to share religious perspec- tives on the disaster. Eight-year-old Victoria reminded me, “Jesus and the Devil were fighting on the night that the big winds and tons of water destroyed our house.” Helping in the aftermath of Hurricane Katrina was challenged by the social ills and other problems that survivors faced before the storm. Difficulties in accessing appropriate resources and services after the storm merely exacerbated survivors’ existing problems. Substance dependence, psychiatric disorders, domestic violence, and other relational difficulties increased under the intense and stressful conditions of living in a crowded shelter for an extended period of time. Many of these issues kept responders up all night, exploring short-term solutions to domestic disputes, alleviating methadone withdrawal symptoms, and calming down survivors who did not have their psychiatric medications. Hurricane Katrina has taught us many lessons at the social, political, institutional, and public health levels. For mental health professionals concerned with psychological and behavioral well- being, the most important lesson learned is that strategies for helping should always place culturally specific needs at the core of effective interventions. Helping requires not only good intentions and a willingness to help but also an understanding of the socio- cultural needs of a particular community. Culture undeniably in- fluences the meaning individuals attach to a traumatic event; an understanding that suffering and healing exist within a cultural context is indispensable. Another asset is the ability to effectively respond to culturally based cues and discuss cultural issues. The culturally competent responder assesses survivors’ functioning on the basis of their psychological, sociocultural, and spiritual beliefs. Finally, support for the importance of cultural understanding comes from a special report by the Substance Abuse and Mental Health Services Administration (U.S. Department of Health and Human Services, 2003), which maintained that disaster responders should be considerate of a community’s history, psychosocial stressors, language, communication styles, traditions, values, ar- tistic expressions, help-seeking behaviors, informal helping sup- ports, and natural healing practices. Minimal guidelines that can inform both local and national efforts in providing culturally appropriate mental health and social services for ethnic minority clients, especially African Americans, in the aftermath of natural disasters are outlined below. 25SPECIAL ISSUE: RECOGNITION, RECOVERY, AND RECONSTRUCTION T hi s do cu m en t i s co py ri gh te d by th e A m er ic an P sy ch ol og ic al A ss oc ia tio n or o ne o f i ts a lli ed p ub lis he rs . T hi s ar tic le is in te nd ed s ol el y fo r t he p er so na l u se o f t he in di vi du al u se r a nd is n ot to b e di ss em in at ed b ro ad ly . Multicultural Competence Even when disaster survivors no longer inhabit their original communities, they continue to carry their cultural values and practices. In fact, some values may become more heightened in unfamiliar surroundings. Thus, it is important for helping profes- sionals to understand a client’s traumatic experience in the light of cultural and sociohistorical factors (Marsella, Friedman, Gerrity, & Scurfield, 1996). An awareness and acceptance that sociocultural factors integrally affect how individuals respond to experiences, especially traumatic ones, is essential; familiarity with the unique traumatic responses of ethnic minority groups contributes to suc- cessful interventions. In times of crisis and tragedy, cultural and racial affinity be- comes strengthened; it can play a critical role in recovery. Relief organizations should therefore make a concerted effort to include responders who are reflective of survivors’ ethnic, racial, and social background. For example, studies have indicated that Afri- can American clients prefer African American therapists (Pon- terotto, Anderson, & Grieger, 1986). Furthermore, many econom- ically disadvantaged groups may have limited experience with mental health services. Aligning clients with responders who are racially and ethnically similar ultimately reduces the stress of cross-cultural interactions. It is likely to be experienced as sup- portive. However, establishing racial and ethnic affinity may not always be possible; in its absence, a primary consideration should be the racial attitudes of first responders and the knowledge that open, accepting, and empowering responders help dissolve the initial barriers of racial differences. Training in multicultural competence and experience in working with diverse clients improve this abil- ity. A disaster should not be the arena to test multicultural com- petence skills for the first time. Language Barriers One of the biggest barriers to the provision of culturally com- petent mental health care is differences in language and commu- nication. In times of stress, it is essential for individuals to express their loss and distress in a familiar language, preferably their native tongue. National disaster response organizations, such as the American Red Cross and the Federal Emergency Management Agency, have a commitment to responding in a timely manner. However, rapid responses often come at a cost to cultural factors, especially in neglecting to pay attention to language proficiency. Recovery efforts implemented after Hurricane Katrina were illus- trative of this cultural neglect. For example, in the early stages after the disaster, the language needs of survivors who did not speak English were not supported. As a result, large groups of Spanish-speaking survivors did not receive adequate information about evacuation procedures, the progress of relief efforts, and where they could obtain resources. Most significant, because of language barriers, they were unable to interact with mental health personnel. Individuals with hearing impairments suffered a similar fate. One evening, we sadly observed a deaf teenager depending on her mother to communicate her fear and anxiety and the night- mares she was experiencing from having been forcibly airlifted. None of us on the disaster mental health team had familiarity with sign language; we became helpless witnesses of the mother’s distress. Additionally, it is critical for those in the mental health field to have both an understanding of diverse forms of communication and an ability to communicate in a culturally effective manner. Socioeconomic status, education, and culture influence an individ- ual’s pattern of communication. For example, African American communication tends to be context driven (Sue & Sue, 2003). It focuses on the telling of stories rather than depending, as happens in traditional psychotherapy, on verbal communication to describe internal and psychological states. Responders who understand and respect these communication patterns quickly develop rapport with African American survivors. African American culture, especially in the South, favors physical contact to illustrate connection. A grasp of reassurance or a strong handshake should not be under- estimated for its healing powers. It was common for survivors to use endearing terms and to prefer a hug to a handshake. In contrast, survivors who perceived helpers as holding negative perceptions about their language and manner of speaking hesitated to ask for help. Socioeconomic Factors All disaster survivors must learn how to manage a shattered world, to mourn unraveled relationships, and to cope with having witnessed death and destruction. Such coping decreases confusion and increases resilience by ultimately creating physical, emotional, and spiritual balance. However, financial preoccupation inevitably impedes the recovery of socioeconomically disenfranchised indi- viduals. African Americans disproportionately bore the brunt of suffer- ing and loss after Hurricane Katrina. The Ninth Ward, 98\% Afri- can American before the storm, was completely obliterated. The skewed extent to which African Americans were affected by this natural disaster is often attributed to preexisting and ubiquitous social and economic disparities; earlier census reports indicated that 127,000 New Orleans residents did not own cars (Van Heer- den & Bryan, 2006). The hurricane magnified these disparities and attracted the attention of a wider audience so that they could no longer be ignored. Thus, in the aftermath of the hurricane, a question remains about whether the lack of a timely rescue effort was motivated by the underclass status of most of the survivors, their minority status, or both. Unfortunately, a poorly planned local and state response and delayed involvement by the federal government increased the feelings of marginalization many indigent survivors already felt; it contributed to their rapid psychological disintegration and loss of hope. The tragedy that occurred in the Gulf Coast primarily exposed the socioeconomic stratification prevalent in the United States. However, because most of those affected in New Orleans were Black, issues of racial disparities and unfair treatment by author- ities also surfaced; the complex nexus between race and class differences emerged. Nevertheless, socioeconomic factors played a major role in the dispersal of the African American population of New Orleans; poor people seldom have choices. Hurricane Katrina exposed their vulnerability and helplessness; it continues to influ- ence the direction of reconstruction in New Orleans by determin- ing who returns and who rebuilds. For example, ethnic minority groups often rely on low-income and moderate-income rental homes (Fothergill, Maestas, & Darlington, 1999). However, the 26 DASS-BRAILSFORD T hi s do cu m en t i s co py ri gh te d by th e A m er ic an P sy ch ol og ic al A ss oc ia tio n or o ne o f i ts a lli ed p ub lis he rs . T hi s ar tic le is in te nd ed s ol el y fo r t he p er so na l u se o f t he in di vi du al u se r a nd is n ot to b e di ss em in at ed b ro ad ly . rebuilding of these homes has been particularly slow after disas- ters, causing housing shortages that inevitably affect the stability of ethnic minority communities. This may explain why many African American residents who were evacuated after the storm have not returned to New Orleans; their hesitation to return may stem not from a lack of motivation but from a lack of basic shelter. Survivors continue to be plagued by the limits imposed by a low socioeconomic status, especially in accessing housing. Until these basic needs are met, attention to mental health needs will be severely delayed. Institutional and Cultural Mistrust African Americans whose ancestors endured slavery continue to live in a cultural environment that contributes to their mistrust of institutions. For example, African Americans often view the crim- inal justice system, educational institutions, and other government agencies with suspicion and cynicism. Human service agencies such as the Federal Emergency Management Agency, the Ameri- can Red Cross, and mental health institutions are not exempt from this suspicion and mistrust. First responders should be prepared to deal with African Americans who may prematurely desist from seeking help because they lack confidence in an institution’s ability to offer them adequate assistance (Terrell & Terrell, 1984). Responders, who may be motivated by a desire to help and support survivors, may find this distrust difficult to understand. However, this distrust is not unique to African American com- munities but also evident among other ethnic minority groups. For example, two studies noted that Asian American immigrants’ distrust of the U.S. government prevented them from seeking disaster services after an earthquake in California and a hurricane in Alabama (U.S. Department of Health and Human Services, 2003). Collective Worldview Many ethnic minority groups share a collective worldview that places greater importance on the community and the interrelated- ness and interconnectedness of all things, including nature and physical place. The ecosystem that surrounds an individual influ- ences his or her functioning. Survivors of Hurricane Katrina, who were forced to make new homes in distant U.S. towns and cities, have experienced a rupture in their ecological framework; in addition to their physical losses, they have lost all that was famil- iar. Research has found that survivors of a natural disaster who remain in familiar surroundings are able to maintain family cohe- sion and preserve psychological community; such survivors are also able to contribute to the recovery and reconstruction of their community (Galante & Foa, 1986; Najarian, Goenjian, Pelcovitz, Mandel, & Najarian, 2001). In contrast, those who relocate to distant areas experience a loss of connection and a weakening of communal ties. Time will shed greater light on the long-term psychological consequences of forced distant relocation on the lives of survivors of Hurricane Katrina. An ecological consideration of an individual’s political, cultural, environmental, and social realities has the additional benefit of helping responders identify his or her support networks (Kaniasty & Norris, 1999). Beaver and Miller (1992) differentiated between formal and informal community support networks, arguing that both are equally important in helping survivors recover. Formal support networks are usually those services provided by govern- mental and other nongovernmental organizations. A community’s history with these institutions determines how this support is viewed. Family, friends, and community members provide infor- mal support networks and can become a primary source of support, ameliorating the negative effects of stress for some survivors. For example, research shows that adults who are 65 and older receive more than 80\% of their support after a disaster from informal support networks (Bowie, 2003). Similarly, Tyler (2000) found that older adult survivors of a Midwest flood who possessed secure social support systems experienced fewer depressive symptoms compared with those with minimal support. When natural disasters occur, everyone in a community is affected, albeit not equally. However, the commonality of the experience gives survivors the opportunity to share experiences with each other; this decreases a survivor’s sense of isolation and carries the potential to bring people together. Disasters allow the inherent good in human nature to emerge: racial unity, unexpected acts of kindness, an increase in tolerance, displays of courage, concern for others, and a sense of goodwill. For example, in the aftermath of Hurricane Katrina, many families living in towns surrounding New Orleans did not hesitate to temporarily shelter displaced survivors. Churches provided clothing and meals for the destitute, and residents of neighboring communities volunteered at local evacuation shelters. De Wolfe (2000) described this phase of a disaster as the honeymoon phase, a period of benevolence that, unfortunately, does not last forever. The World Health Organization (2003) advised disaster re- sponse organizations to make every effort to collaborate with local resources, including traditional healers, when responding to af- fected communities. In this way, psychosocial interventions be- come locally available and culturally appropriate. Such responses maximize the use of community resources, increase the well-being of community members, and strengthen disaster-affected commu- nities. Community leaders and local healers who receive adequate consultation and support can take the lead in designing community interventions (Reyes & Elhai, 2004). Because they have knowl- edge of the unique needs of their communities, they can assist in problem solving and designing interventions. If they are direct survivors themselves, they are in a strategic position to involve survivor communities. For example, a few disaster responders supported several survivors, who were school personnel before the storm, in their attempts to make educational plans for children at the shelter where I worked. Perhaps the major benefit of collabo- rating with community members is that it restores a community’s sense of control and leaves people with the feeling that they have contributed to their own healing. Finally, community responses can sometimes make up for the physical losses individuals suffer in the aftermath of disasters. Despite substantial material losses incurred by local residents after the collapse of the Teton Dam in Wyoming in 1976, several community interventions optimized their recovery and fostered an integrated community (Golec, 1983). Moreover, these interven- tions maintained social networks, provided individuals with finan- cial compensation, and ensured an adequate supply of resources. 27SPECIAL ISSUE: RECOGNITION, RECOVERY, AND RECONSTRUCTION T hi s do cu m en t i s co py ri gh te d by th e A m er ic an P sy ch ol og ic al A ss oc ia tio n or o ne o f i ts a lli ed p ub lis he rs . T hi s ar tic le is in te nd ed s ol el y fo r t he p er so na l u se o f t he in di vi du al u se r a nd is n ot to b e di ss em in at ed b ro ad ly . Perceptions of Help and Healing White, middle class values of individualism, autonomy, and an internal focus have strongly influenced the practice of Western psychotherapy and mental health practices (Atkinson, Morten, & Sue, 1998). In contrast, many ethnic minority groups, especially African Americans, view their problems as primarily residing outside of the self (Sue & Sue, 2003). Thus, responders working with African American clients may have to seek ways of helping that have an external rather than internal focus. In addition, tradi- tional mental health approaches encourage detachment and objec- tivity and discourage the giving of advice and suggestions by the helping professional. African American clients may perceive the neutrality of the therapeutic helper as emotionally distancing; such a stance may obstruct the development of a genuine helping relationship (Schiele, 2003). People of African ancestry culturally value authenticity and a full range of emotional and therapeutic … CHAPTER TWO: CULTURALLY EFFECTIVE HELPING ©2017 Cengage Learning Culture – “That complex whole which includes knowledge, beliefs, arts, laws, morals, customs, and capabilities acquired by a person as a member of society. It is a way of life of a group of people, the configuration of all the more or less stereotyped patterns of learned behavior which are handed down from one generation to the next through the means of language and imitation” (Adler 1997). What is Culture? ©2017 Cengage Learning Knowledge of one’s own cultural biases. Basic knowledge about a variety of cultures. Willingness and ability to use skills and techniques that better match the culture of the client in crisis. Experience in counseling and crisis intervention with clients of a different culture. Four Attributes of Effective Multiculutral Crisis Intervention (Kiselica, 1998) ©2017 Cengage Learning There is a universal measure of “normal” behavior. Individuals, rather than groups, are the foundation of all societies. Definitions of presenting problems are limited by professional disciplines. Western culture relies on abstract thinking. Independence is valued over dependence. Professional Counseling is better than natural support systems. Ten Culturally Biased Assumptions (1 of 2) (Pederson, 1987) ©2017 Cengage Learning Linear causality is more accurate than circular causality. Individuals need to change to fit the system. The client’s history does not affect the current situation. Interventionists are aware of ALL of their biases. ALL TEN ASSUPMPTIONS ARE FLAWED! Ten Culturally Biased Assumptions (2 of 2) (Pederson, 1987) ©2017 Cengage Learning Universal vs. Focused Universal View examines the commonalities among racial and ethnic groups, as well as special populations, and can exclude individual differences. Focused View examines what individual cultural groups have in common and can reinforce stereotypes” Etic vs. Emic Etic – Objectively-identified by an outsider Emic – A cultural gestalt identified by an insider Multicultural View of Crisis Intervention ©2017 Cengage Learning What is the client’s world view? Self-concept, sense of well-being, emotional control, and relational and attributional styles Opposing Views Individualism vs. Collectivism High-Context vs. Low-Context High-Uncertainty vs. Low-Uncertainty Worldviews ©2017 Cengage Learning Victims of a crisis base their ability to overcome the trauma by relying on their own set of cultural survival skills. May be significantly different from the cultural skills of the crisis worker. Not recognizing the client’s worldview may lead the crisis worker to make grievous errors in assessment and treatment of crisis intervention. Multicultural perspectives in Crisis Intervention ©2017 Cengage Learning Individualism Vs. Collectivism Individualism Centralizes the personal and peripheralizes the social group. Prefer low-context direct communication. Prefer a confrontation and arbitration approach to conflict resolution. Collectivism Assumes that the individual is simply a component of the larger social group. Prefer high-context indirect communication. Prefer an accommodation approach to conflict resolution. No difference regarding one’s “sense of family obligation.” ©2017 Cengage Learning High-Context Vs. Low-Context High-Context Self-image and worth are defined in reference to a group. Information is expressed implicitly and non-verbally. May become embarrassed when talking directly about the crisis event. Low-Context Self-image and worth are defined in individual terms. Information is expressed explicitly. Does not like the use of stories, proverbs, metaphors, etc. as a method of communication. ©2017 Cengage Learning Uncertainty Avoidance High-Uncertainty Avoidance Abides by a broad range of rigid rules, regulations, and procedures that cover a multitude of situations. Low-Uncertainty Avoidance Abides by a more laid-back attitude of acceptance of the situation and gratitude for survival. “I’m alive, that’s all that matters, I’ll figure the rest out later.” ©2017 Cengage Learning Mother Wife Daughter Sister Friend Athlete Raised in a small town Lives in an urban area Catholic Employee Musician Recovering Alcoholic Alumni of Indiana University Member of Junior Auxiliary Social Locations ©2017 Cengage Learning What are the individual components of your identity? ADDRESSING Age Development Disability Religion Ethnicity Social class Sexual orientation Indigenous heritage National orientation Gender Social Location Models (1 of 2) For a complete list, include geographic location, living area (urban, suburban, rural), occupation, education, and marital/partner status. ©2017 Cengage Learning SAFETY Stability Affect Friction Environment Temperament Yearning Social Location Models (2 of 2) ©2017 Cengage Learning Ecology – the living environment in which the intervention occurs. Social Locations Graph ©2017 Cengage Learning Lack of consensus on key terms. Ethnicity Race Ethnic and racial identity Culture assumption that current theories of counseling, psychotherapy, and crisis intervention are inherently biased and oppressive may be inaccurate. Shortcomings of a Multiculturalist Approach to Crisis Intervention ©2017 Cengage Learning Much of the literature on multicultural competencies has not been peer reviewed or is not based on empirical research. False acceptance of the division between collectivist and individualist cultures. Shortcomings ©2017 Cengage Learning Empathic Caring Demonstrates positive regard Advocates Genuine belief that humans are more alike than they are different Characteristics of Effective Multicultural Counselors ©2017 Cengage Learning Do’s Examine and understand the client’s worldview. Use alternative roles that are appealing to the client. Assist the client in utilizing culturally indigenous support systems. Take your time to fully triage the situation. If possible, normalize the reaction to a traumatic event. Empower the client. Don’ts Impose personal values and expectations onto the client. Stereotype the client, client behaviors, or culture. Force unimodal counseling approaches upon the client. Interfere with long-held issues ingrained in the client. Effective Strategies of Multicultural Crisis Intervention ©2017 Cengage Learning Language Barriers Confidentiality Translators Family member vs. professional translator Religion/Spirituality often mistakenly avoided by the crisis worker Religion, spirituality, and faith are often a large part of the crisis response. Do NOT merely suggest the client consult with their religious/spiritual leader as a means to abdicate your responsibility as a crisis worker. Obstacles to Effective Multicultural Crisis Intervention ©2017 Cengage Learning Social Support System May not be used in a linear way. “Family” may not be limited to those living in the house of the client. Using professional services may be taboo in some cultures. Occupation Many crisis workers often mistakenly fail to address this significant social location. Rural Geographic Locale Typically lack resources and do not have the population to warrant federal aid. May be suspicious of professional service workers from other communities. Obstacles ©2017 Cengage Learning definition of “help” may differ between the crisis worker and the client. Who’s turf is it? Cultural differences are exacerbated when an “outsider” crisis worker enters the “turf” of the client. “Outsider” could mean from a different geographic region, state, county, or even town. Crisis workers need to be aware of the cultural subtleties. More Obstacles ©2017 Cengage Learning Local leaders know the infrastructure of the community. Using local leaders may provide a model of cooperation for community members. Local leaders may have their own agendas rather than maintaining objectivity. Non-local crisis workers should not attempt to address social injustices ingrained in the community. The Dilemma of Local Consultation ©2017 Cengage Learning People most likely to receive services are: YAVIS Young Attractive Verbal Intelligent Socially well connected People most likely NOT to receive services are: Low-income, elderly, limited-education, and ethnic minorities Who Receives Services? ©2017 Cengage Learning G U I D I N G P R I N C I P L E S A N D R E C O M M E N D A T I O N S Developing Cultural Competence in Disaster Mental Health Programs 2 0 0 3 Developing Cultural Competence in Disaster Mental Health Programs: Guiding Principles and Recommendations Acknowledgments The document was written by Jean Athey, Ph.D., and Jean Moody-Williams, Ph.D., under Contract No. 99M00619401D with the Center for Mental Health Services (CMHS), Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (DHHS). Portland Ridley was a contributing author and also served as the Government Project Officer. Susan R. Farrer, M.A., was the content editor of the guide. The SAMHSA Disaster Technical Assistance Center operated by ESI, under contract with the Emergency Mental Health and Traumatic Stress Services Branch (EMHTSSB)/CMHS, edited the document and designed the cover and layout for the publication. Numerous people contributed to the development of this document. (See the textbox at the end of this page.) Disclaimer The views, opinions, and content of this publication are those of the authors and do not necessarily reflect the views, opinions, or policies of SAMHSA or DHHS. The authors and the staff of CMHS acknowledge, appreciate, and respect the diverse terminology associated with cultural competence and related issues, and regret any inadvertent omission of information or inclusion of statements that may be unfamiliar to our readers. Public Domain Notice All material appearing in this report is in the public domain and may be reproduced or copied without permission from SAMHSA or CMHS. Citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization of the Office of Communications, SAMHSA, DHHS. Electronic Access and Copies of Publication This publication may be accessed electronically through the following Internet World Wide Web connection: www.samhsa.gov. For additional free copies of this document, please contact SAMHSA’s National Mental Health Information Center at 1-800-789-2647 or 1-866-889-2647 (TDD). Recommended Citation U.S. Department of Health and Human Services. Developing Cultural Competence in Disaster Mental Health Programs: Guiding Principles and Recommendations. DHHS Pub. No. SMA 3828. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 2003. Originating Office Substance Abuse and Mental Health Services Administration 5600 Fishers Lane, Rockville, Maryland 20857 DHHS Publication No. SMA 3828 Printed 2003 Contributors and Reviewers: Lourdes Arellano-Carandang, Ph.D.; Robert Benedetto, D.P.A., L.C.S.W.; Marisa Brown, M.S.N., R.N.; Nan Carle, Ph.D.; Deborah DeWolfe, Ph.D., M.S.P.H.; Kana Enomoto, M.A.; Linda Fain; Renee Georg; Elzbieta Gozdziak, Ph.D.; Rachel Guerrero, L.C.S.W.; Robert Hammaker, Ed.D.; Angelia Hill; Joseph Hill; Carol Kardos, M.S.S.W.; E’layne Koenigsberg; Harriet McCombs, Ph.D.; Patricia Mendoza, Ph.D.; Mary Elizabeth Nelson, M.S.W.; Wanetta Noconie; Gladys Padro, M.S.W.; Constance Peters, M.S.P.A.; Steven Shon, M.D.; Anthony Simms, Ph.D.; Karen Stengle; Suganya Sockalingam, Ph.D.; Cecilia Rivera-Casale, Ph.D.; and Katherine White, M.Div., R.N., C.C.C. i i http:www.samhsa.gov Table of Contents FOREWORD ........................................................................................................................................ 1 INTRODUCTION................................................................................................................................ 4 Background and Overview ......................................................................................................... 4 ORGANIZATION OF THIS GUIDE ................................................................................................... 7 SECTION ONE: CULTURE AND DISASTER ..................................................................................... 8 Understanding Culture ............................................................................................................... 8 Diversity Among and Within Racial and Ethnic Minority Groups........................................ 10 Cultural Competence: Scope and Terminology...................................................................... 11 The Cultural Competence Continuum ................................................................................... 12 Cultural Competence and Disaster Mental Health Services ................................................. 14 Disaster Phases and Responses ............................................................................................... 17 Cultural Competence and Disaster Mental Health Planning................................................ 19 SECTION TWO: GUIDING PRINCIPLES AND RECOMMENDATIONS ....................................... 22 Guiding Principles for Cultural Competence in Disaster Mental Health Programs ........... 22 Principle 1: Recognize the Importance of Culture and Respect Diversity .......................... 23 Principle 2: Maintain a Current Profile of the Cultural Composition of the Community ..................................................................................................................... 24 Principle 3: Recruit Disaster Workers Who Are Representative of the Community or Service Area........................................................................................... 26 Principle 4: Provide Ongoing Cultural Competence Training to Disaster Mental Health Staff ................................................................................................ 27 Principle 5: Ensure That Services Are Accessible, Appropriate, and Equitable ................... 28 Principle 6: Recognize the Role of Help-Seeking Behaviors, Customs and Traditions, and Natural Support Networks...................................................................... 29 Principle 7: Involve as “Cultural Brokers” Community Leaders and Organizations Representing Diverse Cultural Groups .................................................................................. 33 Principle 8: Ensure That Services and Information Are Culturally and Linguistically Competent .................................................................................................. 34 Principle 9: Assess and Evaluate the Program’s Level of Cultural Competence .................. 37 i i i Table of Contents CONTINUED REFERENCES.................................................................................................................................... 40 Appendix B: Disaster Mental Health Resources from the Center Appendix F: Cultural Competence Checklist FIGURE TABLES Table 2-2: Important Considerations When Interacting Table 2-3: Staff Attributes, Knowledge, and Skills Essential Table 2-6: A Cultural Competence Self-Assessment APPENDICES .................................................................................................................................... 45 Appendix A: Cultural Competence Resources and Tools....................................................... 46 for Mental Health Services ....................................................................................................... 48 Appendix C: Sources of Demographic and Statistical Information...................................... 49 Appendix D: Sources of Assistance and Information ............................................................ 50 Appendix E: Glossary ................................................................................................................ 54 for Disaster Crisis Counseling Programs................................................................................. 57 Figure 1-1: Cultural Competence Continuum........................................................................ 13 Table 1-1: Percentage Distribution of the Population by Race and Hispanic Origin ............ 9 Table 1-2: Federal Government Categories for Race and Ethnicity ...................................... 11 Table 1-3: Characteristics of Disasters .................................................................................... 18 Table 1-4: Questions to Address in a Disaster Mental Health Plan....................................... 21 Table 2-1: Key Concepts of Disaster Mental Health ............................................................... 23 with People of Other Cultures .................................................................................................. 25 to Development of Cultural Competence ............................................................................... 27 Table 2-4: Special Considerations When Working with Refugees ......................................... 30 Table 2-5: Guidelines for Using Interpreters........................................................................... 37 for Disaster Crisis Counseling Programs................................................................................. 38 i v Foreword Disasters—earthquakes, hurricanes, chemical explosions, wars, school shootings, mass casualty accidents, and acts of terrorism—can strike anyone, regardless of culture, ethnicity, or race. No one who experiences or witnesses a disaster is untouched by it. Peoples’ reactions to disaster and their coping skills, as well as their receptivity to crisis counseling, differ significantly because of their individual beliefs, cultural traditions, and economic and social status in the community. For this reason, workers in our Nation’s public health and human services systems increasingly recognize the importance of cultural competence in the development, planning, and delivery of effective disaster mental health services. The increased focus on cultural competence also stems from the desire to better serve a U.S. population that is rapidly becoming more ethnically and culturally diverse. To respond effectively to the mental health needs of all disaster survivors, crisis counseling programs must be sensitive to the unique experiences, beliefs, norms, values, traditions, customs, and language of each individual, regardless of his or her racial, ethnic, or cultural background. Disaster mental health services must be provided in a manner that recognizes, respects, and builds on the strengths and resources of survivors and their communities. The Crisis Counseling Assistance and Training Program (CCP) is one of the Federal Government’s major efforts to provide mental health services to people affected by disasters. Created in 1974, this program is currently administered by the Center for Mental Health Services (CMHS), Substance Abuse and Mental Health Services Administration (SAMSHA), and the Federal Emergency Management Agency (FEMA). The Program provides supplemental funding to States for short-term crisis counseling services to survivors of federally declared disasters. Crisis counseling services provided through the Program include outreach, education, community networking and consultation, public information and referral, and individual and group counseling. The CCP emphasizes specialized interventions and strategies that meet the needs of special populations such as racial and ethnic minority groups. The purpose of this guide is to assist States and communities in planning, designing, and implementing culturally competent disaster mental health services for survivors of natural and human-caused disasters of all scales. It complements information previously published by FEMA and CMHS on disaster mental health response and recovery. FEMA provided the funding for this guide as part of the agencies’ ongoing effort to address the needs of special 1 N o o n e w h o e x p e r i e n c e s populations in disaster mental health response and o r w i t n e s s e s a d i s a s t e r recovery. Developing Cultural Competence in Disaster i s u n t o u c h e d b y i t . Mental Health Programs: Guiding Principles and Recommendations is part of a series of publications developed by CMHS. In developing this guide, CMHS recognized that cultural competence is a complex subject— one that has varying terminologies, opinions, expectations, models, and paradigms. The authors sought to identify common concepts and to suggest guiding principles and recommendations for primary and behavioral health care providers working with disaster survivors in multicultural communities. Although it is the hope of CMHS that readers will find the guide useful, the authors also recognize that it is by no means intended to provide comprehensive information on cultural competence. The guiding principles are based on standards, guidelines, and recommendations established by SAMHSA, the Office of Minority Health, and the Health Resources and Services Administration in the U.S. Department of Health and Human Services (DHHS), although the guiding principles do not necessarily represent these agencies’ specific views. Mental Health: Culture, Race, and Ethnicity—A Supplement to Mental Health: A Report of the Surgeon General (DHHS, 2001) informed our efforts to ensure consistency with fundamental practice and theory. To produce this guide, the authors invited input from State and local disaster mental health coordinators and consultants as well as from reviewers at the national, State, and community levels. The publication also incorporates information gathered through an extensive literature review. Vignettes from CMHS grant applications and grantee reports illustrate the range of promising practices, experiences, and challenges of State and local disaster mental health programs nationwide. As work on the guide continued, CMHS became increasingly aware that the principles and values underlying cultural competence parallel those historically espoused by disaster mental health service providers. This publication is a first step toward developing a framework for the design of culturally competent disaster mental health programs. It also is the hope of CMHS that the information it provides will improve understanding and increase the ability of State, local, and community mental health and human service administrators, planners, trainers, and other staff to respond sensitively and effectively to the needs of all disaster survivors. 2 Introduction B A C K G R O U N D A N D O V E R V I E W Disasters affect hundreds of thousands of people in the United States annually. Between 1993 and 1998, the American Red Cross responded to more than 322,000 disaster incidents in the United States and provided financial assistance to more than 600,000 families (American Red Cross, 2000). In 1997 alone, the Federal Emergency Management Agency (FEMA) responded to 43 major disasters in 27 States and three western Pacific Island territories (FEMA, 2000). In recent years, human-caused disasters have been a major challenge. Such events include the 1992 civil unrest in Los Angeles, the 1995 bombing of the Alfred P. Murrah Federal Building in Oklahoma City, and the September 2001 terrorist attacks on the World Trade Center in New York and the Pentagon in Arlington. Disaster crisis counseling is a specialized service that involves 4 B e c a u s e o f h i g h e r b i r t h a n d i m m i g r a t i o n r a t e s , t h e H i s p a n i c p o p u l a t i o n i s g r o w i n g f a s t e r t h a n a n y rapid assignment and temporary deployment of staff who must meet multiple demands and work in marginal conditions and in unfamiliar settings such as shelters, recovery service centers, and mass care facilities. The major objective of disaster mental health operations is to mobilize staff to disaster sites so that they can attend to the emotional needs of survivors. In the past, these responses tended to be generic; little or no effort was made to tailor resources to the characteristics of a specific population. With time and experience, however, service providers and funding organizations have become increasingly aware that race, ethnicity, and culture may have a profound effect on the way in which an individual responds to and copes with disaster. Today, those in the field of disaster mental health recognize that sensitivity to cultural differences is essential in providing mental health services to disaster survivors. Integrating cultural competence in the temporary structure and high- intensity work environment of a disaster relief operation is a challenge. Increasing cultural competence, not a one-time activity, is a long-term process that requires fundamental changes at the institutional level. Because both culture and the nature of disasters are dynamic, these changes must be followed by ongoing efforts to ensure that the needs of those affected by disaster are met. The primary purpose of this guide is to provide background information, guiding principles, recommendations, and resources for developing culturally competent disaster mental health services. Disaster mental health providers and workers can use and adapt the guidelines set forth in this document to meet the unique o t h e r e t h n i c m i n o r i t y g r o u p . characteristics of individuals and communities affected directly or indirectly by a full range of natural and human-made disasters. Designed to supplement information already available through CMHS, SAMHSA, and other sources, Developing Cultural Competence in Disaster Mental Health Programs highlights important common issues relating to cultural competence and to disaster mental health. It provides guidance for improving cultural competence in support of disaster mental health services. The following issues are key to the recommendations set forth in this guide: ■ Cultural competence requires system-wide change. It must be manifested at every level of an organization, including policy making, administration, and direct service provision. Therefore, for disaster mental health services to 5 P r e c i s e d e f i n i t i o n s o f t h e t e r m s “ r a c e , ” “ e t h n i c i t y , ” a n d “ c u l t u r e ” a r e e l u s i v e . be effective, cultural competence and health profiles of individual must be reflected in disaster mental cultural groups, readers may wish health plans. For additional to refer to Mental Health: Culture, information on building mental Race, and Ethnicity—A Supplement health systems capacity for disaster to Mental Health: A Report of the mental health response and Surgeon General (DHHS, 2001) and recovery, readers may wish to to Cultural Competence Standards review Disaster Response and in Managed Care Mental Health Recovery: A Strategic Guide (DHHS, Services: Four Underserved/ Rev. ed, in press). Underrepresented Racial/Ethnic ■ Cultural competence requires Groups (DHHS, 2000b). an understanding of the historical, ■ Precise definitions of the terms social, and political events that “race,” “ethnicity,” and “culture” are affect the physical and mental elusive. As social concepts, these health of culturally diverse groups. terms have many meanings, and Issues such as racism, those meanings evolve over time discrimination, war, trauma, (DHHS, 2001). This guide espouses immigration patterns, and poverty— a broad definition of culture that which reinforce cultural differences includes not only race and ethnicity and distinguish one cultural group but also gender, age, language, from another—must be considered socioeconomic status, sexual (Hernandez and Isaacs, 1998). For orientation, disability, literacy level, a descriptive summary of historical spiritual and religious practices, background, patterns, and events, individual values and experiences, as well as detailed demographic and other factors. This guide uses the phrases “cultural groups” and “racial and ethnic minority groups”1 to refer to the Nation’s diverse, multicultural groups and individuals. ■ The operational definition of cultural competence provided in this guide is based on the principles of cultural competence described in Towards a Culturally Competent System of Care (Cross et al., 1989). Many Federal, State, and local public mental health systems, as well as organizations in the private sector, have adopted the principles presented in this document. 1 The major racial and ethnic minority groups referred to in this publication are African Americans (blacks), American Indians and Alaska Natives, Asian Americans, Native Hawaiian and Other Pacific Islanders, and Hispanic Americans (Latinos). The authors recognize that opinions about which labels are appropriate differ and acknowledge that heterogeneous subpopulations exist within each of these populations. These categories, which were established by the Office of Management and Budget in 1997, are used because they are widely accepted and used by service providers in the public and private sectors. 6 Organization of This Guide T h i s g u i d e i n c l u d e s t w o s e c t i o n s a n d s i x a p p e n d i c e s . SECTION ONE explores the nature of culture and disaster. It begins by defining culturally related terms, discussing diversity within racial and ethnic minority groups, and describing cultural competence. It then discusses cultural competence in the context of disaster mental health services. Section One also presents the Cultural Competence Continuum and a list of questions to address in a disaster mental health plan. Readers seeking more detail about crisis counseling or disaster response and recovery may refer to other CMHS/FEMA publications. For example, the Training Manual for Mental Health and Human Service Workers in Major Disasters (DHHS, 2000e) provides a comprehensive overview of and essential information on training concepts on crisis counseling, including a training curriculum. Disaster Response and Recovery: A Strategic Guide (DHHS, Rev. ed., in press) also is a useful resource. SECTION TWO sets forth nine guiding principles for culturally competent disaster mental health services and related recommendations for developing these services. It also presents the key concepts of disaster mental health; important considerations when working with people of other cultures; staff attributes, knowledge, and skills essential to the development of cultural competence; and a cultural competence self-assessment for disaster crisis counseling programs. In addition, Section Two provides suggestions for working with refugees and guidelines for using interpreters. The appendices provide additional information that may be useful in developing cultural competence in disaster mental health. APPENDIX A is an annotated bibliography of cultural competence resources and tools. Many of these resources provide detailed information about individual populations’ histories, immigration patterns, and experiences with stress and trauma. APPENDIX B lists disaster mental health technical assistance resources and publications available through CMHS. Some of these materials discuss the needs and provision of services for special populations. APPENDIX C lists online resources that provide community-specific demographic and statistical information. APPENDIX D lists Federal, private-sector, professional, and other organizations with cultural competence expertise. APPENDIX E is a glossary of terms associated with disaster mental health and cultural competence. APPENDIX F is a Cultural Competence Checklist for Disaster Crisis Counseling Programs. Based on concepts discussed throughout this guide, the checklist covers essential principles for ensuring a culturally competent disaster mental health program. 7 S E C T I O N O N E S ince its founding, the United States has human service providers— Culture and Disaster been a nation of diversity. In the years to come, fertility and mortality rates, immigration patterns, and age distributions within subgroups of the population will contribute to an increasingly diverse national population (Day, 1996). Data from the 2000 U.S. Census reveal that Hispanics have replaced African Americans as the second largest ethnic group after whites.2 Because of higher birth and immigration rates, the Hispanic population is growing faster than any other ethnic minority group (DHHS, 2001). The population of Asian Americans is also growing and is projected to continue growth throughout the first half of the 21st century, primarily because of immigration (DHHS, 2001). As shown in Table 1-1, by 2010, Hispanic Americans will comprise 14.6 percent of the U.S. population, African Americans will comprise 12.5 percent, Asian Americans will comprise 4.8 percent, and Native Americans will comprise less than 1 percent (U.S. Department of Commerce, 2000). These demographic changes have given the United States the benefits and richness of many cultures, languages, and histories. At the same time, the Nation’s growing diversity has made it more important than ever for health and including disaster mental health service providers—to recognize, understand, and respect the diversity found among cultural groups and subgroups. Service providers must find ways to tailor their services to individuals’ and communities’ cultural identities, languages, customs, traditions, beliefs, values, and social support systems. This recognition, under­ standing, respect, and tailoring of services to various cultures is the foundation of cultural competence. U N D E R S T A N D I N G C U L T U R E Culture influences many aspects of our lives—from how we communicate and celebrate to how we perceive the world around us. Culture involves shared customs, values, social rules of behavior, rituals and traditions, and perceptions of human nature and natural events. Elements of culture are learned from others and may be passed down from generation to generation. Many people equate race and ethnicity with culture; however, the terms “race” and “ethnicity” do not fully define the scope and breadth of culture. Race and ethnicity are indeed prominent elements of culture, but there are important distinctions between 2 This publication uses the term “whites” to denote non-Hispanic white Americans. 8 T A B L E 1 - 1 these terms. For example, many people think of “race” as a biological category and associate it with visible physical characteristics such as hair and skin color. Physical features, however, do not reliably differentiate people of different races (DHHS, 2001). For this reason, race is widely used as a social category. Different cultures classify people into racial groups on the basis of a set of characteristics that are socially important (DHHS, 2001). Often, members of certain social or racial groups are treated as inferior or superior or given unequal access to power and other resources (DHHS, 2001). “Ethnicity” refers to a common heritage of a particular group. Elements of this shared heritage include history, language, rituals, and preferences for music and foods. Ethnicity may overlap with race when race is defined as a social category. For example, because Hispanics are an ethnicity, not a race, ethnic subgroups such as Cubans and Peruvians include people of different races (DHHS, 2001). “Culture” refers to the shared attributes of a group of people. It is broadly defined as a common heritage or learned set of beliefs, norms, and values (DHHS, 2001). Culture is as applicable to groups of whites, such as Irish Americans or German Americans, as it is to P e r c e n t a g e D i s t r i b u t i o n o f t h e P o p u l a t i o n B y R a c e a n d H i s p a n i c O r i g i n ( I n c l u d e s f o r e i g n a n d n a t i v e - b o r n p o p u l a t i o n s ) Hispanic/ Latino Origin* Race Black/ American Indian/ Asian and Year White African Alaska Pacific American Native** Islander 1995 73.6 12.0 0.7 3.3 10.2 2000 71.4 12.2 0.7 3.9 11.8 2010 67.3 12.5 0.8 4.8 14.6 2050 52.8 13.2 0.8 8.9 24.3 2100 40.3 13.0 0.7 12.6 33.3 * Persons of Hispanic/Latino origin may be of any race. Groups listed under “Race” are not of Hispanic origin. ** Includes American Indians, Alaska Natives, and Aleuts. Source: U.S. Department of Commerce, Bureau of the Census. (2000). Projections of the resident population by race, Hispanic origin, and nativity: Middle series, 1999 to 2100. Washington, DC: U.S. Department of Commerce. racial and ethnic minorities (DHHS, …