Normal reactions to traumatic situations
In a frightening, traumatic situation, everyone reacts. It is necessary and protective that we react to danger. Traumatic situations, whether they’re natural events such as a flood or manmade such as conflict, are the type of dangerous situations that normal healthy people react to. However, the ways in which people react, the things that they react to and the aftermath of these reactions vary from person to person and culture to culture. During a traumatic event or situation a person or their loved one is in danger of serious harm or death. The person doesn’t have the power to control or to stop the event – it’s beyond the person’s normal experience, so the event is terrifying.
People react to traumatic events in different ways, depending on a number of circumstances. Resources allow some people to flee or ask for help while others are more powerless. Having a phone, transportation, friends and family and money to pay for food and shelter all help manage traumatic experiences. Some people have previously managed very difficult situations, which helps them to manage the present situation. A person’s health, both physical and mental, influences how they respond to traumatic situations. All of these factors shape how a person responds to the situation.
People also have different reactions in the days and weeks following a disaster. Though all people react to danger, the severity of their reaction differs. Some people react only briefly and then return to normal functioning. Others have a delayed reaction to the events. Still others have ongoing reactions (Norris, F. 2009). For as many as 70% of people, all reactions will subside without the help of anyone other than family and friends.
The kind of reactions that people have varies from one person to another and from one culture to another. Different cultures have different ways of expressing stress, fear and grief. In the following, there is a chart that shows many different reactions to traumatic events. There is no right or wrong, brave or afraid, good or bad in these responses. They are simply reactions that have been described by people who have had traumatic experiences.
Families and communities moderate the effects of traumatic situations
People live in networks composed of families, communities and cultures. Families protect, comfort and sustain each other. The importance of family in the lives of individuals is paramount. Communities and cultures support the function of families by providing for common needs such as education. They encourage the formation of new families through traditions of marriage, land ownership and economic systems. Families, communities and cultures are the means through which human relationships are organised. When a crisis occurs, the family is the first resource for the affected population. The familiarity of family relationships provides great comfort in the face of danger. Children who remain within their families show fewer symptoms of stress and trauma than children who are separated from their families. Families are better able to care for their elderly and disabled members than a programme created by strangers.
Communities and cultures support the families in their midst. In crises, cultural understanding helps people make sense of what’s happening. Culture also provides a sense of belonging to a particular group, linking families and individuals to a larger whole. There is a common language, history and beliefs. When everything is in chaos, people still have their identity. Communities and culture provide a framework that helps people support each other in times of need. Community leaders represent families and individuals to acquire help and supplies. Together, community members provide help for each other until families recover and the infrastructure is re-established. The very process of helping a neighbour heals some of the helplessness that is common in disasters.
When disasters strike, families and communities are disrupted
Disasters wreak havoc in the lives of people. Normal family routines are disrupted. Markets do not provide basic supplies we depend on. Work is interrupted. Community activities such as education, health care and protection for residents stop functioning. At times, the problems are local, such as flooding. Other times, the problems are at a distance, but an influx of displaced people disrupts the local community. Infrastructure such as roads, communication networks, hospitals, police and schools are overburdened or damaged, making them ineffective.
The community and family networks that provide support and care for people are unable to function properly. Family members are separated, increasing fear and stress for all. The essential roles that people play in the family, such as caregiver or wage earner, are suddenly lost. Extended family and neighbours who help fill in during times of stress are themselves stressed. Children, adults and those with disabilities who were previously supported and protected, now become vulnerable. They are stretched at times beyond their ability to care for themselves in a way they haven’t experienced before.
As these disruptions spread to the wider community, there is a disruption that is often overlooked. When communities and cultural groups are displaced, there is a chance that they will begin to lose the characteristics that provide order and meaning to life. Burial, grief and mourning practices that support and comfort the living cannot be implemented. Spiritual practices that comfort and give meaning to irrational events are lost in the confusion and disruption. Even the place – the location of the family, the culture’s home for generations – can be lost, causing a sense of disconnection. Responding to traumatic experiences always begins with the community. Each person is part of a network of relationships that have provided comfort, support, and education and given him or her a place in life. Family and community are the most powerful tools for helping a person deal with traumatic events.
The community knows better than any outsider what needs to be done and how to do it. They know who among them are the most vulnerable. Everyone in the community has something to contribute. When approaching the chaos of a disastrous situation, the first step is always to listen and assess what has happened. Ask numerous people, coordinate and take a quick inventory of the needs, resources and gaps in the community. Mobilise the community to gather information, locate people with skills and those who need assistance. Normalising people’s reactions to disastrous events helps them to move on with constructive responses rather than creating a greater sense of helplessness.
Work with the community to make plans and implement them. Participatory decision making strengthens the community. Working together builds the ability to support families and individuals, and this can even be guided to include those who may have been marginalised in the past. Build opportunities into the planning to listen to the recipients, monitor and evaluate the effectiveness of the programmes and leave open the possibility to adjust for a better fit.
What is trauma?
Trauma is a word used for an event that causes major distress to a person. Trauma can be physical, such as a wound, or it can be emotional, such as grieving for a death or fearing acute danger. It is a situation that goes beyond ordinary experience. The situation is a threat towards physical or psychological integrity. A person’s spiritual life can be impacted by a traumatic event. For some people, a disaster brings them closer than ever to God, others pray for a reality that’s different from their present situation and others question why God is punishing them, or if he really cares about their plight?
Trauma can undermine your
• sense of reality (find meaning);
• autonomy/ self-governing;
Consequences of trauma are a
• lack of self-worth and respect,
• distrust in others,
• overwhelming feelings, and a
• lack of continuity.
Traumatic experiences can cause painful reactions. People are always alert for the next wave or tremor or explosion (hyper-vigilant). People feel helpless or hopeless, or even disoriented. People avoid reminders, but the trauma continues to invade their thoughts (flashbacks). Emotions are intense and sometimes overwhelming.
Post-Traumatic Stress Disorder (PTSD)
It is normal and healthy to react emotionally to terrible events, and most people who experience a traumatic event do not develop PTSD. Some people have intense reactions to events, which last days and sometimes months. However, that is not PTSD, that is an intense reaction to an overwhelming event that will subside over time with the support of family and community. These people’s symptoms can be helped by culturally appropriate comfort, support with grieving, listening and re-establishing normal routines.
A small percentage of people (less than 4%) do develop PTSD, and it is important to be aware of the symptoms to ensure that it’s recognised and appropriate help is found. PTSD is a severe and ongoing emotional reaction to extreme psychological trauma. PTSD is a delayed reaction that does not surface until months after the event occurs, and does not go away with normal support. Healing PTSD is beyond the capacity of psychosocial programmes alone, though it is often helpful for people with PTSD to participate in programmes with others in their community. PTSD requires professional treatment like any other mental disorder.
The internationally recognised guidelines for the diagnosis of PTSD are as follows:
Exposure to a traumatic event: the person experienced, saw, or learned of an event in which they felt a real or perceived threat of serious injury, death, or other violation of integrity to themselves or someone else.
Re-living some part of the traumatic event (one or more). Intrusive thoughts, perceptions, images, etc.,
Recurrent dreams of the event
Belief that the event is happening again, hallucinations, or flashbacks (children might re-enact the trauma).
Intense distress when exposed to reminders of the traumatic event.
Physical reactions when exposed to the reminders.
Attempting to avoid reminders of the traumatic event (three or more)
• Avoiding thoughts, feelings or discussions of reminders;
• Avoiding activities, places, or individuals that are reminders;
• An inability to recall an important part of the trauma;
• No longer having interest in or taking part in activities of daily living;
• Feeling detachment from others;
• Difficulty expressing feelings;
• Having a sense that nothing will last.
Demonstrating hyper-alertness/agitation about traumatic event (two or more)
The above symptoms must also meet the following criteria
Duration must be more than one month;
The symptoms must be causing significant distress with relationships, work, and other important areas of functioning;
The symptoms can occur at any time after the event.
Loss, grief and mourning.
All who survive a disaster suffer loss. Disasters change the nature of daily life, of relationships and our understanding of the meaning of life events.
Loss or bereavement describes the changes that occur – things are no longer the way they were. A person’s former life is gone. A friend or loved one is lost. Loss can be acutely painful. An emotional reaction to loss is normal. Most often, disaster is accompanied by sadness, fear, insecurity, pain, disorientation, anger, surprise, emptiness, and depression. Sometimes, however, the outcome can be positive, such as when a repressive leader is overthrown.
Grief is the name for the reaction to loss.
Mourning is the process or time period during which we attend to the losses we have experienced. During this time, a person may attend funerals or participate in other acts of remembrance. They may wear specific clothing to recognise the loss. These public displays of mourning allow people around the grieving person to offer their company and support, and to honour that which is gone.
Grief and mourning
In a disaster all survivors suffer from different kinds of bereavement. They suffer loss of safety and security, loss of property, loss of community, loss of status, loss of health and possible loss of loved one(s). Following a disaster, all individuals begin a natural recovery process through mourning and grief. The loss of a person close to us is the most common reason for mourning. However, mourning can also be caused by the loss of a familiar animal, a beloved object, a cherished place or a value that we held dear. In mourning, the connection with what we lost is more important than the nature of the lost object itself.
All cultures and religions have rituals and traditions regarding the care of the deceased and the transition time for family and friends. These rituals and traditions often have lifelong implications for those who celebrate them and thus recognition and adoption of these rituals are of major importance for ongoing psychosocial well being. Specific information about care of the bodies of the deceased can be found at the WHO website. Every effort should be made to accommodate to the local religious and cultural customs regarding the care of bodies following death. Families should be contacted about the death of their loved one. If this is not possible, then photos and other identifying information about the deceased should be gathered with the location of the burial site to allow the family to follow appropriate customs at a later date.
Funerals are the community recognition of death, and a time to mourn. Funerals or some other community recognition of loss is an important part of the mourning and bereavement process. It connects the immediate family and friends with those who are more distant. This public recognition of loss confirms the reality, recognises the pain and acknowledges the importance of the loss. The goal of public recognition is to recognise the importance of the deceased in the lives of people and to support the survivors as they work through the transition to a new reality.
Stages of grief
There are several common stages of grief that many people experience. They come in no fixed sequence – sometimes the stages are repeated and some may be skipped. They have been named denial, anger, bargaining, depression and acceptance. Each person grieves in their own time and their own way. Many people have few visible reactions other than sadness and thoughts of the deceased. They reorganise their lives and move on. However, some within a community may have trouble recovering emotionally and may have difficulty moving through the mourning process. They may become “paralysed by grief”.
This can result in painful emotional side-effects that may not appear until sometime after the event, possibly at an anniversary or remembrance service, or when another crisis brings the emotions into the open. Community-based counselling assists survivors on their journey through grief and mourning, thus avoiding emotional paralysis later.
Some exampes of extreme reactions might include:
- People who say they are drained of energy, purpose and faith. They feel like they are dead.
- Survivors who insist they do not have time to work through the grief with “all the other things that have to be done” and ignore their grief.
- People who insist, “they have recovered” in only a few weeks, and who are probably mistaking denial for recovery.
- Survivors who focus on the loss and are unable to take any action towards their own recovery.
Loss and grief in children
Children, like adults, experience grief and loss. Their emotional connection to parents and friends is very strong and more so because children are dependent on the adults in their lives for their basic needs. Children suffer from the loss of those who care for them. They may be sad, frightened or angry.
Children also struggle to understand what is happening. It is common that children are left out of adult conversations about what is happening. They may not have basic information about what happens when a person dies, what will happen to their body and what ceremonies will take place.
Most importantly, children may not know what will happen to them in the coming days and weeks. Will they move to a new household? Who will care for them? Will they continue in school and see their friends? It is important that caring adults take the time to listen to children, answer their questions as clearly and honestly as possible and provide support, protection and basic needs. Children also need the time to mourn their losses at their own speed and in their own way.
Nader, K., Dubrow, N., and Stamm, B. Hudnall; Honouring Differences: Cultural Issues in the Treatment of Trauma and Loss, New York: Taylor & Francis Ltd., (1999)
Social and systemic causes of stress
Inequality exists in every country and community. There are many reasons for this. Some people receive a better education, they have more money, resources and can secure better access to services, such as medical care. Unfortuately, pre-existing inequalities are, also often, exaggerated during times of emergencies.
There are those whose lives are more difficult. They are often poor. Their access to schools and medical care is not as good. The neighbourhoods they live in are often in geographically low areas, so their homes flood with heavy rains. Often sanitation is not as good in these neighbourhoods, leading to more communicable diseases. People in this group may have enough food or clothes to get by, but often do not have enough to save, or are in real trouble if they lose work for a day, or if their house catches fire. There is simply no flexibility in their budget to cover such losses. There are others who do not even have enough to eat on a regular basis much less when a catastrophe hits.
The reasons for differences between the ‘haves’ and the ‘have nots’ are often complex and have developed over generations. At times, differences can be traced to ethnicity. Sometimes, one group is in power and others are considered lower class, filling service jobs. At other times, gender is a major factor. In some countries, women have the equal rights to own land, purchase a car, study and vote. In other countries, these rights are restricted, regardless of who is head of the household. There are many other divisions and structures that make life more difficult for some than others.
In an emergency, the people who are poor or in difficult situations are affected to a greater degree. The people living near the river get flooded first. Houses made of cheap materials blow down and fires spread very quickly in shanty towns. People whose legal rights are not clear such as widows, women, child-headed households and minorities have a much harder time getting services they need to survive disasters. It is also common that people who care for children, the elderly and the handicapped cannot move as quickly to avoid danger and are, therefore, more vulnerable.
Separation and displacement
In addition to these pre-existing vulnerabilities, there are problems that are created by the emergency. When people flee, it is common for families to be accidentally separated. Some people move more quickly than others. Children and the elderly often get separated when fleeing. Separation causes great distress for all concerned, reducing people’s ability to cope with the daily stresses of the emergency. Among strangers, it may be harder to get informal help from neighbours.
Emergencies also disrupt local social institutions that support families and individuals. Churches and places of worship, often a place of support and comfort, may be destroyed or the congregation dispersed. Village chiefs or mayors may lose contact with community members or may not be recognised by relief workers from the outside. The loss of these familiar support systems increases risks and makes life more difficult.
People who are displaced, especially women and girls, are more vulnerable to interpersonal violence. Sexual and gender based violence (SGBV) can be a serious problem when normal protective structures within the community are disrupted. Stress can increase violence within the family. Separated children and women are also vulnerable to predators who may want to sell them or simply abuse them. Young boys are also very vulnerable to exploitation as soldiers or sexual partners.
The added burden of aid
Unfortunately, humanitarian aid can also create problems for the surviving population. In the rush to get food and supplies to people, sometimes community leadership is bypassed. Workers listen to the people they meet first, missing out on the voices of the most vulnerable, who cannot rush to meet the relief truck. Sometimes, the aid delivered does not comply with traditions or customs of the survivors. This leaves people the terrible choice between accepting necessary food or supplies or following their traditions. The most painful example of this is when the traditions and family wishes are not respected in the disposal of the bodies of the dead.
Psychosocial workers must often be the people who advocate for the surviving population. As people who attend closely to both the social and psychological needs of the community, psychosocial workers must speak up to ensure that local community connections are respected and families are reunited. Where injustice has made people more vulnerable, protection and equal access to necessary assistance must be offered. At the same time, it is critical to encourage people to do what they can for themselves, recognising their competence and dignity.
Wessells, M., ‘Culture, Power and Community: Intercultural Approaches to Psychosocial Assistance and Healing’. In Nader, Dubrow and Stamm, Honoring Differences, (1999)
Why some people recover more quickly than others?
It is an observable phenomenon that after an extremely stressful experience, some people begin to function normally more quickly than others. Recently, research has been done about this observation, looking at people’s reactions soon after a disaster and then watching over time to see how quickly they return to a normal functional level. Norris, Tracy and Galea (2009) published a report in the journal Social Science and Medicine proposing that there are a number of different trajectories of response to a disaster. They first examined the concept of resilience. The literature showed that “there is a growing consensus that resilience is better characterized as adaptability than as stability”. They further concluded that there are different patterns of response in different populations that can be diagrammed. These patterns take different courses over the weeks and months after the disaster. The information that these patterns offer helps us recognise from our own experience in the field the way recovery time varies.
(1) Norris et al. note first that there are some people who seem to have little reaction at all to the impact of a disaster. This group they named resistant. Their reactions do not increase when a disaster happens, and they continue to go on after the disaster without significant change.
(2) A second group was recognised as resilient. This group would have a reaction to the disaster, perhaps a rise in emotions or increased heart rate and alertness. This increased response is temporary and within a fairly short period of time, the reactions would return to their pre-disaster level, allowing the person to continue functioning as normal.
(3) The pattern of the third group was called recovery. This group had a reaction to a disaster. Their reactions would shoot up immediately following the impact and then gradually diminish. This group is different than the resilient group in that it takes them longer to return to their previous level of functioning. However, they too return to full function.
(4) A fourth pattern of response followed an irregular path. Titled relapsing or remitting, this group reacts to the disaster and then recovers somewhat. However, unlike previous groups, this group does not recover previous functioning and stabilize. This group has intermittent episodes of further reactions, then they return to normal again.
(5) A fifth pattern of response was that of delayed response or delayed dysfunction. This group may have only a mild reaction immediately, but the impact increases over time.
(6) The sixth and final group described was that of chronic dysfunction. This group does not recover from the impact of the disaster but maintains a high level of reaction over time.
These six different patterns or trajectories explain the very different responses to crises and disaster that we observe. In any given community, the largest number of people will be resistant, resilient or recover.
Resilience factors: In physics, where the term resilience was originally coined, it is defined as the ability to bounce back to the previous shape or form. In the emotional world of people, resilience refers to the ability to return to normal emotional and social stability after a period of extreme stress. Studies of people who are resilient have identified a number of common characteristics.
First are innate characteristics.
Inborn resources, which are part of the individual’s nature. They may be physical, emotional and intellectual.
Social ability, having an easy temperament.
Next are things that are learned through a close, supportive family and community environment.
The feeling of being valuable, self-worth,
Competence and confidence,
The ability to help others.
Finally, other skills are learned through experiences in life
The ability to master and cope with difficult challenges,
Experience of meaning and continuity, a sense of coherence,
Hobbies and interests,
Internal locus of control; self-confidence, self-worth, safety, awareness of self.
Many people will demonstrate signs of distress but will recover with appropriate support. Programmes should focus on people’s ability to overcome difficult events, and not assume vulnerability. Only a small percentage of the population will require more specialised clinical psychological and psychiatric services.
Urban refugees often exhibit great resiliency, demonstrating personal strength and resourcefulness, and increased solidarity, social support and generosity. However, resiliency and solidarity are under increasing pressure when crises become protracted (such as Somali refugees in Nairobi, and Iraqi refugees in Amman) and social resources become exhausted. Despite great distress, with the correct support, people and communities are often able to overcome the mental health and psychosocial risks of living in extremely difficult circumstances.
Children show the same resilience pathways as adults, depending on their innate characteristics and support system. They often show great adaptability and flexibility in adjusting to a new situation and new relationships. This adaptability is most obvious in children who have had strong, nurturing family relationships that have allowed them to develop their skills and independence.
N Norris, F., Tracy, M., & Galea, S. (2009) Looking for resilience: Understanding the longitudinal trajectories of responses to stress. Social Science & Medicine 68 (2009) 2190-2198
Reactions to traumatic events over time
Emotional effects from trauma often persist well after the event. New reactions may show up weeks later, just as life is seemingly returning to normal. Research shows that after several months as many as 50% of people still show emotional effects related to the emergency. These effects gradually subside. But even after one to two years, many people still suffer from emergency-related distress. Reactions may also occur at key dates such as anniversaries of the emergency or when a separate event triggers an emergency-related memory. Some distressing memories can reoccur ten or more years after the event. This is particularly the case for war-related emergencies.
The frequency with which people report emotional distress well after traumatic events shows that these are normal human reactions to crises, regardless of culture. Psychosocial caregivers should remind people of this, since people may otherwise feel something is wrong with them.
First few months
Emotional reactions after a traumatic event include depression, chronic grief, anxiety and guilt. Nightmares or waking flashbacks make it feel as if the event is happening again. Irritability, hostility, suspicion and anger are a challenge for some. Difficulty in trusting people or God, disruptions in social relationships, and a feeling of being different causes distress for many people. A common complaint is that life will never be the same again.
Traumatic experiences can open a floodgate of questions as people search for meaning: Should we trust that things will be okay, that there will be a tomorrow? Is it worth loving people and getting attached if it will hurt this much when we lose them? Is there really a God who cares about our welfare? Is it Allah’s will that we should suffer? Does evil win over good? These fundamental questions are often triggered by tragedies and must be resolved for healing.
Survivors often struggle with trust and intimacy. The intensity of the pain tends to make the survivor feel that no one else can really understand. The depth of their pain and suffering is often hard to articulate in words, or it may be too painful to discuss their emotions and fears. The perceived isolation around a survivor can lead to marriage difficulties and may contribute to a high degree of divorce. Sexuality is often impacted during the months following a tragedy.
Survivors of prolonged distress have some particular difficulties in recovery. These may include difficulties in regulating feelings or the feeling of being overwhelmed. Their sense of identity may be changed. Survivors may feel that they no longer have the same value or are not the same person. There may be disturbing states of consciousness like periods of amnesia or intrusive thoughts. These symptoms may disturb people’s relationships with close friends and family.
Some people express their distress through physical (somatic) complaints: head-, stomach-, or backaches, heart problems, faintness, feeling hot or cold. It is important not to minimise these complaints, as they can reflect much deeper problems. Family relationships often suffer because of emotional distress. People may feel distant from their spouses – and domestic violence may increase as stress is played out through aggressive behaviour. People may turn to alcohol or drugs to dull feelings. Families that work out safe ways to express their distress increase the speed of healing.
Likewise, communities often have difficulties as a result of traumatic events. Besides physical destruction, loss of leadership and of structure can hurt the functioning of the community. Pain and distress can cause conflicts not only within the family but more broadly. People can be more suspicious, especially if the emergency included civil unrest. At this time, there is potential for new people to rise to leadership and to provide assistance. These can be healing actions for the whole community.
Responses to reactions: Psychological First Aid
Psychological First Aid (PFA) is designed to reduce the initial distress from traumatic events or disaster and to prepare for short and long-term adjustment to a new reality. PFA does not assume that all people will develop severe mental health problems or long-term difficulties in recovery. Survivors and affected people will experience a broad range of early reactions (physical, psychological, behavioural and spiritual). Some of these reactions will cause significant stress; encouraging adaptive coping, and offering immediate caring and compassionate responses will reduce further maladaptive behaviour and help the survivor recover.
The steps involved in psychological first aid are relatively simple. They can be summarised as follows:
- Comfort and console affected people.
- Protect people from further threats.
- Care for immediate physical needs such as food, drink, shelter, rest and medical care.
- Assist and encourage short-term planning.
- Reunite people with loved ones and community.
- Offer opportunities for people to tell their story without pressuring them.
- Assist in developing long-term systems of support.
- Provide opportunities to be competent, to master experiences.
- Identify further needs and refer people to appropriate resources.
A wide range of people in the community can offer this support, leading to local ownership of the response to survivors of stressful situations. At the same time, these simple steps are designed to help position survivors to take the next steps in their own lives. This is an important goal as one of the great dangers for people is being stuck in hopelessness or helplessness. If a person feels hopeless they may spiral downward emotionally, instead of bouncing back from adversity.
Working with children and adolescents
- Sit or squat to speak to children at eye level.
- Help school-age children verbalise their feelings, concerns and questions; help provide simple labels for common emotional reactions (for example sad, mad, scared, worried). Do not use extreme words like ‘terrified’ or ‘horrified’ because this may increase distress.
- Listen carefully and check in with the child to make sure you understand her or him.
- Be aware that children may show signs of developmental regression in their behaviour and use of language.
- Match your language to the child’s developmental language. Younger children typically have less understanding of abstract concepts like ’death’. Use direct and simple language as much as possible.
- Talk to adolescents ‘adult to adult’ so you give the message that you respect their feelings, concerns and questions.
- Reinforce these techniques with the child’s parents and caregivers to help them provide appropriate emotional support to their child.
Brymer, M., Jacobs, A., Layne, C., Pynoos, R., Ruzex, J., Steinberg, A., Vernberg, E., Watson,P. (2006). Psychological First Aid: Medical Reserve Corps Field Operation Guideline. National Child Traumatic Stress Network (NCTSN) and National Center for PTSD.
In response to people’s distressed reactions following a disaster, it is helpful to look at the aspects of well-being. Disruption of any of the domains will cause distress. However, awareness of these domains helps us see how distress is a normal response to the loss of a basic component of well-being. Support in the restoration of these basic components helps to restore well-being in the population.
The domains of well-being
Within the sphere of well-being are 7 interrelated apects. It would be difficult to place them in a hierarchical order.
Biological aspects of well-being can include respiration, hydration, nutritional intake and the overall functioning of the body. Emergency responses might include water and sanitation, nutrition, public health, and medical services.
Material aspects can include roads, vehicles, tools, equipment and the structures in which people live and work. Emergency responses include shelter and transport.
Social aspects may concern membership and participation in a social or cultural group is integral to the identity and daily functioning of most people. The disruption of social functioning typically undermines well-being. Enabling an affected population to regain, as much as possible, their normal social functioning can improve well-being. Emergency responses might include social activities, gatherings, facilitating communication between people etc.
Spiritual aspects are important for an aid worker. We must have some level of understanding of a population’s spiritual beliefs and religious practices because these relate directly to emotional well-being, normal social functioning and the restoration of cultural integrity. Enabling a population to resume its traditional religious practices can be an important part of their recovery. In relation to cultural aspects of well-being, the following things should be considered. How do the spiritual beliefs of the population influence their ability to cope with loss and distress? To what extent are people able to carry out their normal religious practices? What role, if any, has religion played in creating or mitigating conflict? Emergency responses might include facilitating spiritual practice and appropriate rituals for deaths, births and marriages.
Cultural aspects involve learned patterns of belief, thought and behaviour. It defines how things are supposed to be for us. Culture makes life and its stages more predictable, and enables a society to maintain itself. A culture also develops, adopts, or adapts the tools, types of shelter, transportation, and other physical items needed to maintain itself. It defines standards of beauty for both things and people and prescribes acceptable and unacceptable ways to express emotion. It defines what behaviour is considered normal or abnormal. A culture evolves and changes over time, but not always easily or smoothly.
Cultural patterns of belief and behaviour may generate conflict, for example within a society or between societies as competition for limited resources becomes more intense. Those who work with an emergency-affected population need a working knowledge of its culture(s). They need some understanding from the population’s perspective of what the norm was and what is now current practice. Those who intervene need to consider the cultural norms in relation to the current context and its opportunities and constraints. The changes in cultures that come as a result of an emergency may not always be bad. In some cases there are opportunities to help a population change traditional practices that are harmful to some members of the population, particularly ones that can violate the rights and well-being of women and children. Emergency responses might include cultural activities, music, dance etc.
Emotional aspects include feeling well in order to truly be well. Family and friends create the social structures that provide emotional well-being. Emergency responses could include family reunification, support groups, support for those in bereavement, child-friendly spaces, gatherings for mothers of young children, social events for the elderly, recreation for all ages and activities for youth.
Mental aspects covers the functions of the mind, which includes learning how to learn, how to acquire information, and how to use it. Emergency responses: Providing access to education (school) and access to relevant information regarding the affected populations’ circumstances, survival and safety.
N.B: Safety, participation, and development are three issues that must be addressed in promoting the well-being of a population. These factors should always be observed when supporting the population in any aspect of well-being.
Williamson, J. & Robinson, M., 'Psychosocial interventions or integrated programming for well-being?' Intervention, 4:1, (2006), pp4-25
Creating a new "normal"
Things are never the same after a disaster. This may be an obvious statement, but for survivors, the desire to move beyond the tragedies and demands of the disaster can be intense. Often they just want life to return to ‘normal’. Psychosocial support can help in providing comfort and some structure in an otherwise overwhelming situation.
When things all around you are chaotic, simple routines become comforting. Meals, school for children, regular gatherings and religious practice become calming. These simple things can be restored very early in an emergency response to provide comfort and a platform for the family so they can move forward with the next important steps.
Family-centred meals can help to bring a family together for company and support. Allowing families to cook for themselves means that meals are culturally appropriate and meet the needs of the family’s members. Eating familiar foods and having time each day to talk about recent events encourages family support and problem solving. These all contribute to the appropriate centre of control moving back to the family, allowing them to make decisions on their own behalf.
School provides much-needed structure, education, diversion, and protection for children. Children who are kept with their families have significantly fewer long-term reactions to disaster than children who are separated. This is the foundation of all work with children in emergencies. Parents have a lot of work to do after a disaster and do not always have the time or energy to focus on children. School provides education necessary for a child’s future – but school also provides protection. Children who are in school are observed for signs of distress, safe from street dangers, and are often fed. School is the most effective protection mechanism for children in an emergency.
For some people, religious practice is comforting. Religion provides the practice of spirituality in a structured and communal way. The gathering of people for prayer and ritual provides community even when the former community was disrupted or lost. Finding meaning in disasters is also important. Conversation with others of the same faith helps in this struggle to find meaning in chaos.
Regular gatherings of people with commonalities can be of great support. Mothers of young children and the elderly are two obvious groups. Bringing people who are struggling with legal questions following the disaster together to problem solve and share information can also be helpful. Groups for education are another possibility. Groups help people discover that they are not alone in their struggles, and this support has a stabilising effect.
Strengthening and building social networks
Two authors, Landau and Saul have found that community resilience encompasses the following four themes:
- Build community and enhance social connectedness as a foundation for recovery by strengthening the system of social support, coalition building and information and resource sharing.
- Participate in collective storytelling and validation of the trauma and response, with the emerging story broad enough to encompass the many varying experiences.
- Re-establish the rhythms and routines of life and engage in collective healing rituals.
- Arrive at a positive vision of the futre with reewed hope.
Rebuilding community and family networks following a disaster strengthens the resilience of all its members. There are suggestions for strengthening families in many areas of this website. Supporting parents in caring for their children, allowing families to cook and eat together, supporting mothers of young children through well-baby centres and child-friendly spaces are just a few of the ideas. Making it possible for families to keep their elder members with them lets families benefit from the experience and wisdom of an older generation. Providing help with mobility and housing often makes unity possible.
Locating and involving recognised community leadership helps to strengthen damaged community structures. Like everyone else affected by a disaster, mayors, chiefs, committee members and religious leaders have been shaken by the events. However, when the existing leaders can be located and involved in the assessment and planning for recovery, the whole community will benefit. Existing leadership provides information and consistency. At times, existing leaders may have been part of the problem and should be considered carefully by the standard of ‘Do No Harm’. However, the recovery of the community will be hastened by re-establishing some sort of familiar community structure with leadership that knows the population and the resources available in the community.
Religious leaders can be helpful in community recovery if they are engaged in a constructive way. Involving them in providing services for the dead and providing comfort for the grieving is important. Helping people find new hope for the future encourages them to go on. At times religious leaders become ‘dividers’ in the community, accentuating differences between people. Engaging them in ‘acts of compassion’ helps to turn the behaviour in a more unifying direction. Evangelism can be a problem at times, especially when aid is tied to attending rituals or teachings. Using the guidelines in the Code of Conduct may help.
Empowerment: Moving from powerless to powerful
A normal reaction to disaster is based in the understanding that the disaster is beyond the capacity of anyone to stop it. This can lead to a sense of powerlessness in individuals. Powerlessness can be debilitating.
Regaining the power to do something to help others, especially those you love is a strong antidote. Being part of a group that is involved in the recovery, whether it is caring for a neighbour, providing meals for the elderly or distributing supplies helps people feel useful. Planning for the future by learning a new job skill helps a person become more powerful.
Walsh, F., Family Process, Vol 46, June 2007. Landau, J., & Saul, J. (2004) Family and community resilience in response to major disaster. In F. Walsh & M. McGoldrick (Eds) Living beyond loss: Death in the family (2nd ed.. pp. 285-309). New York: Norton
Assisting psychologically and medically vulnerable people
In every population, there are people who are more vulnerable due to psychological or medical problems. These people are in need of special protection and support during emergencies.
- Provide training to increase the understanding of the emergency and its impact on this group.
- Encourage self-care skills and self-management of condition symptoms.
- Establish regular routines for meetings between doctors and caregivers.
- Establish assisted living arrangements (community volunteers).
- Establish daily routines and safe spaces.
- Establish stable caregiving personnel and provide familiar foods, places and routines.
Returning to normal
- Explore relocation to longer-term facilities as soon as possible.
- Increase the degree of self-care as appropriate.
- Include the vulnerable in community activities whenever possible (movie night).
- Keep the vulnerable in their own families when possible or within a stable community group.
- Provide access to spiritual leaders who represent their beliefs.
- This is important so questions can be addressed.Respect the rituals from each tradition.
- Provide regular medical and psychiatric services. If no services are available, move people with their families to reduce trauma.
- Monitor and evaluate quality of services.
- Access to UNHCR and WHO should be made available.
- Explore medical evacuation through UNHCR when appropriate.
HIV and AIDS
- Integrate HIV and AIDS information with programme activities, whenever possible.
- Establish programmes for living with AIDS, support voluntary caregivers and home based care.
Special care for rape survivors
Some groups in society require special attention during emergencies because they are at particular risk of human rights violations, physical attacks and other protection problems. These groups are: children – especially unaccompanied minors, women – especially pregnant women, mothers with young children, female heads of households; persons with disabilities and elderly people. These groups are especially at risk during complex emergencies, domestic conflicts, war and natural disasters.
Rape and torture are, unfortunately, common during warfare. Trafficking and prostitution, often as a consequence of rape, are growing problems for women, young girls and boys. Trafficking and prostitution often follow war and disasters and are present when large groups of people are forced together in abnormal situations and when accessing relief supplies. Thus, it is important to be aware of the Code of Conduct principles and the core principle to Do No Harm. Men are also at risk of being raped, and tend to face a stigma that is different from women and children. The fact that a man was unable to defend himself can make it very difficult (if not impossible) to admit that he has been raped in some societies. The effects of being raped are devastating for the survivor, especially as in many societies they are often abandoned and stigmatised. In some cultures rape survivors are banned from their society and community and are forced to live the life of an outcast. This isolation and alienation can cause additional trauma and psychological problems for the affected person. People who have been exposed to torture or rape are often in need of special care, physical therapy, and protection from others. People who are abandoned by their families need new forms of family, social and community support. It is important to help these people understand that their reactions are normal for someone who has been exposed to this particular type of acute trauma. These people are in need of help, in some cases from medical professionals including gynaecologists and psychologists, in addition to possibly needing spiritual support.
Some typical reactions to rape might be:
- feelings of shame and disgrace;
- guilt because of the disgrace they have brought on their family;
- fear of bearing a child because of the incident (for females);
- fear of strangers;
- feelings of resignation to fate or destiny;
- feeling of being dirty, soiled and ‘infected’;
- risk of suicide.
How can we help and support rape survivors?
It is important to approach survivors with sensitivity and an awareness of the cultural effects of their trauma. Provide these people with a place where they can feel safe, and encourage them to meet with others who share the same experiences – this can make it easier to reveal what has happened to them. Any counsellor should be a trained professional selected from within the community, who understands the cultural heritage, language and customs. Depending on the community, some people may prefer a counsellor of the same sex (this is usually true for females), whereas in other societies, men who have been raped may only feel confident talking about their experience with a trained female. Try to pay special attention to physical injuries, sexually transmitted diseases, pregnancy, and the loss of virginity, which can have a profound effect in some cultures. It is important to maintain strict confidentiality at all times and any documentation must be kept safe to prevent retaliation against those who report such matters.
Some basic advice on how to support rape survivors:
- Confidentiality is of vital importance.
- Recognise that it is common for an abused person to feel ashamed.
- Encourage medical examinations for pregnancy and for sexually transmitted diseases. These should be voluntary but encouraged.
- Give support. Listen; do not make any moral judgments or criticisms.
- Allow the victim to talk when she or he is ready; don’t push or force them.
- Do not make the survivor repeat the story many times
- Find ways to end the social isolation of the abused; try to get the community and family involved.
- Organise support groups for rape survivors.
- Provide support for staff working with these traumatised patients. Using support groups and loosely based ‘group-therapy’ is one way to meet this need.
- Collaborate with local, national and international organisations and institutions to distribute advocacy information within communities.
Haeri, S., ‘Resilience and Post Traumatic Recovery in Cultural and Political Context’, Journal of Aggression, Maltreatment and Trauma:14 (1/2), (2009)
Special care for survivors of torture
Torture occurs in one third of all countries in the world. In armed conflict and at times of great instability within a country the number of torture victims is likely to increase. The signs and symptoms of being exposed to torture are the same as those for disasters, although they are often more severe. Torture survivors often have a mistrust of others, difficulty relating to their peers and they may struggle to form new social bonds after the event.
It can be useful in some communities to bring torture survivors together in small groups of 6-10 people to discuss and share their experiences and emotions. Torture survivors in other communities or cultures might find the idea of talking about what happened horrible. In their culture, there are other ways of supporting those who have been abused. These ways must be learned and respected. It does seem, however, that the support of trusted people helps to repair some of the damage. The network and support of helpers that interact with tortured people within these groups is essential. The helpers need to be trained to cope with what they are hearing from the torture survivors, to provide support and guidance, in addition to facilitating the group process.
Supporting victims of torture can be a long process. It is a matter of relationship building and trust. Due to possible physical injuries and complications, any assistance often depends on the cooperation with medical teams, doctors and physicians.
Some basic advice to help victims of torture
Feeling safe is essential. Create a secure, safe and private meeting venue.
Help the victim address the medical, physical and existential issues, while being aware of the fact that they are all intimately connected.
Be aware of the need for victims to assume control. If they need assistance in this, find ways to support them.
Be aware of environmental triggers. Relaxation exercises, such as deep breathing or gentle exercise can sometimes help.
Head injuries can interfere with cognitive processing, emotional expression and coping. Support the need for justice.
Give opportunities for people to tell their story, in whatever format they feel comfortable – pictures, theatre, dance, verbally or in written format.
Experience with people who have survived incidences of torture and received the necessary help and support
Survivors respond better to interventions that restore self-respect and trust in their surroundings, along with psychological and social support.
Further reading:Healing the Hurt: 'A guide for developing services for torture victims'
. Centre for Victims of Torture: www.ctv.org RCT Field Manual on Rehabilitation, Rehabilitation and Research Centre for Torture Victims, Copenhagen, (2007)
Suggested content of training workshops and seminars
Training of Trainers' workshops should include:
Basic communication and teaching skills to create awareness of how messages are transmitted and received.
Basic skills on how to organise workshops, including presentation of participants, curriculum development, ice-breaking activities, expectations, timetables, and creating a safe atmosphere.
How to prepare and introduce group activities. (The best method of teaching these skills is to demonstrate them in practice - learning by doing).
Continuous training: In most cases, trainers and trainees will feel that more than three days of training is needed. One solution is to let the participants start to practice in the field under guidance of an experienced aid worker and to organise regular debriefing sessions with the group. Training should always be followed up by field-based support, mentoring and supervision. Supervision and mentoring are the most effective ways of extending training into real-life and they cannot be emphasised enough.
Training of providers: Below is a comprehensive list of topics to be covered during the training of community-based psychosocial support workers/ providers. However, it is impossible to cover all of the topics in one training session. It is advisable to select your topics and keep the content as simple as possible. Basic principles of community based psychosocial support.
Code of Conduct
Individual human beings have dignity and worth.
Everybody has the right to life with dignity.
Everybody has the right to receive help (rights-based assistance).
Trauma is a fact of life and reactions to trauma are natural. Resilience, can help people heal after a traumatic event as it is the capacity and strength everybody has for recovery no matter how desperate her/ his situation. Help the community cope by detecting the creativity of the community, gathering suggestions for income generation and planning for appropriate guidance and training materials.
Children’s situations must be addressed, including the handling of critical issues like separated children, child-headed households, child soldiers, and basic education. Vulnerable and marginalised people need special consideration, sp analyse their situation and try to seek solutions to their problems. Explore attitudes and ways of assisting disabled persons, especially children and elderly people. Explore attitudes and ways of addressing sexual abuse and exploitation.
Self-help activities should be promoted and supported. Practical measures should be taken to ensure access to services through mediation and advocacy at the local level and through the NGO community. Peace and reconciliation for the normalisation of societies and communities should be encouraged.Cooperation should be established with those who are responsible in the health sector for referral of mentally ill individuals (in particular, coordinate with the World Health Organisation and Medicins Sans Frontier).
Topics for group activities:
Trauma reactions and interventions, exchange of personal experiences.
Resilience factors: make associative descriptions of individuals based on photos or drawings. The drawing of personal experiences rather than describing them in words can be very powerful and illustrate points that are otherwise difficult to get across. People become much more involved in a drawing than in a verbal presentation, which can have its own terrors for some.
Trauma and resilience in the specific cultural and religious context: share stories (can be fairy tales) that are more or less known by everybody, and comment on them.
Role-playing and charades: a tool to express personal problems.
Training in the skill of active listening and psychological first aid.