SECTION III:International Disasters
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International Disasters Section Introduction
Disasters shatter assumptions about the nature of the world and one’s place in it. Thus, the reactions that individuals and communities experience after a disaster are not just a result of the event itself, but also of the world around them. Culture, context, and history shape all aspects of a disaster, including the attributions that individuals and communities make about its causes, how they express distress, and how healing and recovery occur, including how, and from whom, help is typically sought. As described by Miller (2012), “What is most salient for disaster responders is having an understanding, within a sociocultural context, of the subjective experiences of individuals, groups, and collectivities that have lived through disaster and recognizing the many stories, meanings, reactions, and needs engendered by a specific disaster” (p. 7). Some concepts to consider in developing such an understanding include sociopolitical history and climate, worldview and communication patterns, and traditional and indigenous healing practices, among others.
The authors of the case studies in this section include two who were responding to a disaster within their own cultural context, two who were from outside the culture and were deployed to the disaster setting with an international response organization, and one who responded to a disaster that took place locally, but which involved survivors and responders from multiple countries and cultural backgrounds. They highlight key lessons learned from within those different perspectives, and together offer a range of cultural considerations for effective disaster mental health work.
Sociopolitical History and Climate
Community reactions to tragedy reflect and are shaped by the social and political forces around them. Pre-existing social inequities continue to play out in the aftermath of a disaster. Because traumatic experiences induce a sense of powerlessness and loss of control (both real and perceived), an individual’s understanding of a traumatic event will be shaped by their experiences of privilege, oppression, colonization, and other social factors.
At a broader level, any specific event is situated in the in-group/out-group divisions, and other racial, ethnic, religious, or social tensions that exist in a place. Understanding these complexities is crucial to understanding the event itself, as well as the reactions and needs of survivors, and to developing a plan for responding in culturally appropriate ways.
A number of the case studies in this section highlight the significant influence of sociopolitical context on disaster response. The massacre at Raba’a in Cairo, Egypt (Abdelaziz, Chapter 20) was embedded in a deep and complex set of historical, political, religious, and ideological differences within the country. Likewise, the multiple social and political contexts that converged on the island of Nauru (Brooker, Chapter 19) played a direct role in sparking the riots there. To fully understand that event, one must consider the political history and climate in Australia that led to the asylum seekers being held on Nauru, as well as the social and political climates of the countries from which the asylum seekers fled.
Postcolonial countries, and/or countries such as Haiti with a history of being invaded by Western nations, are likely to have a historical mistrust of outsiders that carries over to any influx of outside responders following a disaster. There is potential harm associated with working in these settings without an understanding of the history and modern-day consequences of colonialism, invasion, or occupation. This may occur through power dynamics in relationships between Western agencies and responders and their international clients or colleagues. For example, Jean-Charles (Chapter 18) notes that the arrival of overwhelming numbers of outside responders following the 2010 Haiti earthquake, many of whom were inexperienced and had an insufficient understanding of the Haitian culture and context (including its history of invasion and occupation by the United States), resulted in additional and unnecessary suffering.
Worldview and Communication Style
Worldview shapes how people make meaning of their experience - how they conceptualize and solve their problems. Many psychological theories and the intervention models on which they are built are based on a Western worldview of individualism. The underlying assumptions in many of these models about the primacy of individual wants, needs, and goals, and the importance of self-determination, self-reliance, and an internal locus of control, may all be incompatible with a collectivist worldview. Yet approximately 70 percent of the world's population comes from collectivist societies (Chung & Bemak, 2012). When not carefully taken into account by responders, worldview differences can create mismatches that impede their best efforts at helping.
Communication patterns are often a reflection of worldview, and are another crucial consideration in the provision of DMH services. As described by Brown (2008) "... the ways in which humans translate their inner biological states of disequilibrium into outward expressions of distress are strongly affected by culture and context” (p. 7). The construct of low- and high-context communication patterns, which are linked to individualist and collectivist worldviews, has particular relevance to responders. In the low-context communication patterns common among Western individualist cultures, the verbal code is the primary source of information; intended messages are conveyed using the words themselves. Communication is done directly and explicitly, and is done in ways that are consistent with one’s feelings. These patterns may be a mismatch when working within a culture with high-context communication patterns characterized by a more restricted code system, in which words are less necessary to convey meaning as messages are interpreted through social cues and an accumulation of shared experiences and expectations. High-context communication is less direct, and is typified by politeness, discretion, and the importance of “saving face” - an important concept in collectivist cultures. Notably, putting feelings into words is not seen as an important goal, as it may be seen as lowering or spoiling their value.
In situations such as these, the concept of providing a compassionate presence when there are few words that can offer much comfort - a theme that runs throughout this book - takes on even greater significance. Whether it is being done at an Ebola patient’s bedside while dressed in a complete set of personal protective equipment, or while maintaining a physical presence in a prison to help ensure that imprisoned asylum seekers are not physically assaulted, the authors in this section found ways to connect with those they were helping. Addressing survivors' interrelated physical and practical needs along with their psychological and spiritual needs also takes on a unique importance in such settings. Examples from the authors in this section include ensuring that an Ebola patient was able to receive her favorite beef feet bouillon soup, and handing out pain-relieving medication to suffering asylum seekers as they sat in the rain. These moments of human connection and support can transcend cultural differences.
Traditional Beliefs and Practices
A related consideration is the question of how and from whom help for personal and social problems is typically sought. Natural help-giving networks can be disrupted or delegitimized when traditional beliefs and practices are overlooked. At its worst, Western mental health providers “parachuting in” to an international disaster setting and providing Wes-tern-based interventions, without regard for the local traditions that shape a community’s response and needs, can become what has been referred to by Bemak and Chung (2011) as psychological colonialism. The picture portrayed by Watters (2010) of the “invasion” of Western mental health professionals after the 2004 Asian tsunami, utilizing Western interventions that made little sense to survivors and disregarding their healing and helpseeking practices, is a cautionary tale in this regard.
Working to build trust with local experts and authorities and seeking their guidance and input on intervention strategies not only helps to ensure the cultural appropriateness of those strategies, but also helps to establish the local credibility of the overall response effort. In her experiences during the Ebola outbreak in Guinea, Lebel (Chapter 21) describes the mistrust and stigma that the Western response team, and infected patients, faced from the communities in the area. Her team worked to establish trust with the local communities by making visits to these communities to meet with village elders, chiefs, and traditional healers to discuss their concerns; they also invited these leaders to visit the treatment center to demystify the process and counter the many rumors that were being spread among the population. The team’s efforts to incorporate traditional funeral practices into the sanitary burial procedures that were necessary to prevent contamination played an important role in their efforts to promote healing and recovery. In his response in Nicaragua, one of Diaz’s (Chapter 17) first orders of business was to identify and meet with local elders and other religious leaders to learn about the needs of their communities; he built on these relationships later to plan support activities and coordinate service delivery.
Building Local Capacity through Training
In low-resource settings or settings without an existing infrastructure of mental health providers, a DMH response must support and build up local capacity without undermining existing community structures and support mechanisms. Training local people, including those without previous formal mental health training, to provide basic supportive services in a culturally appropriate manner as well as to provide additional training to others, is an important component of disaster response in such settings. Sometimes referred to as “task sharing” (Eaton, De Silva. Rojas. & Patel, 2014), training non-specialists to provide basic mental health interventions has been demonstrated to be successful in a number of settings including Pakistan, India, and Uganda (Eaton et al.). An emphasis on this type of sustainable approach is consistent with the Guidelines for Mental Health and Psychosocial Support in Emergency Settings established by the Interagency Standing Committee (1ASC, 2007) which emphasize maximizing the participation of local affected populations in the response, including working to “identify, mobilize and strengthen the skills and capacities of individuals, families, communities and society” (p. 136). Similarly, Miller (2012) has detailed an approach called “psychosocial capacity building” which emphasizes building on existing community resources to create sustainable local capacity for recover.
These approaches can be contrasted with the numerous problems associated with outside mental health volunteers rushing in to provide direct services for a limited time, and then leaving. In Chapter 18, Jean-Charles highlights the challenges posed by the overwhelming number of outsiders seeking to provide assistance and describes the approach he and his colleagues (both Haitian and American) took to establishing a sustainable local mental health response by training local responders using the 1ASC guidelines. Similarly, Diaz describes a training program for local personnel that created a tiered system of community-based responders. Developed in collaboration with village elders, this program created capacity for community outreach, psychoeducation, assessment, and the provision of Psychological First Aid.