The injury and death associated with natural flood disasters makes an imprint on the person's mind, with that imprint taking the nature of guilt for not doing enough, or of fear and anxiety (Figley, 1985). Horowitz (1976) has pointed out that denial and anger are frequent concomitants of flood disasters. The denial is especially common where lost relatives are involved, and the anger seems to be directed towards public officials for not having prevented dislocation, for rescuers who did not react fast enough, or to insurance companies for not paying a claim.
There are several
guiding principles that can be distilled from
experiences in
rehabilitation activities:
–recovery planning
should be broad in scope and fully integrated.
–a balance must be
reached between conservatism and reform
–reconstruction
must not be delayed
–economic recovery
will stimulate physical recovery
–reconstruction
offers opportunities to introduce mitigation measures
–relocation of
entire communities usually fails
–recovery efforts
can be therapeutic for individuals as well as
communities
–effective recovery
depends on adequate cash and credit
–reconstruction is
closely linked to land tenure issues
–maximize use of
local resources
–physical recovery
is dependent on local institutions, training, and
leadership
–political
commitment is vital to recovery
As
can be seen from the preceding sections, planning and management of
rehabilitation
are highly complex processes that cover a
sequence
of actions from data collection to assessment of needs, planning,
implementation
and evaluation. Rehabilitation actions embrace numerous sectors
of
society and involve actions by individuals, communities, governments and
international
bodies. Although similarities exist between one rehabilitation
situation
and another, each case has unique characteristics, diverse patterns of
damage,
different needs, varied constraints and levels of resources. Therefore,
given
such variables, only very general principles can be established. The
following
list covers a range of critical issues. Principles one to seven are
processes
to recognize while numbers eight to twelve relate to essential tools
required
to manage the rehabilitation.
The planning of rehabilitation needs to be broad in
scope and
fully integrated.
Planning
has to be wide ranging because the impact of flood disaster
can
be felt on all sectors requiring very detailed co-ordination.
In
addition, planning has to be integrated because each situation is
complex,
involving various actors risking a fragmented response.
A balance has to be achieved between the conflicting yet
vital processes of reform and conservatism.
In
any major rehabilitation process two powerful forces will exist;
reformers, who
recognize the opportunity to change administrative
patterns,
introduce new laws, modify urban forms and conservationists,
who
resist all changes and want to return to what existed
before
the flood disaster. Wise officials will seek to balance these opposing
forces.
Both change and continuity are essential.
Rehabilitation should not be delayed to await political,
administrative or economic reform.
Following
major flood disasters there is a tendency for politicians to
introduce
reforms at various levels and in varied sectors. However,
it
is critically important that rehabilitation not be delayed until laws
are
enacted since this will lose vital momentum for action. New
legislation
is normally essential, and reforms may be necessary, but
they
can be implemented in parallel with rehabilitation to avoid
costly
delays.
Economic rehabilitation should be regarded as a
prerequisite
for rapid physical rehabilitation.
Officials
are faced with many options in rehabilitation management.
They
could invest in rebuilding the economy or rebuilding
structures.
If they devote initial resources for economic regeneration
this
can stimulate physical rehabilitation as well as addressing some of
the
root causes of vulnerability for the poor and the marginalized.
Rehabilitation should offers unique opportunities to
introduce a
range of measures to reduce future risks to persons and
property.
Rehabilitation
offers a unique opportunity for public officials
wanting
to improve the protection of people and property. This is
due
to the heightened public and political awareness following a
major
flood disaster, which stimulates a demand for safety.
The relocation of entire communities is usually not
effective
and is rarely feasible.
Despite
the risks of populations inhabiting dangerous sites, which
can
result in extensive casualties and property losses, relocation to
safe
sites is not normally feasible in social, cultural, developmental or
economic
terms.
Rehabilitation actions should be regarded as a therapeutic process
to assist individuals and their communities to rebuild
their
lives and livelihoods.
If
the victims of flood disaster become active participants in the rehabilitation
process
as opposed to being mere spectators, they can play a
valuable
role in their emotional rehabilitation. Psychological well being of
the
affected population and those who are engaged in helping them
should
be seen as an integral part of rehabilitation process.
The basis of effective rehabilitation is the
availability and
maintenance of an adequate flow of cash and credit
throughout the entire process of rehabilitation.
The
flow of finance through cash grants and loans is essential
throughout
the entire rehabilitation process. A particular problem is that
the
initial political support after a flood disaster inevitably unlocks
resources
which decline over time when extensive finances are
needed
for rehabilitation. Public, private and international funds
need
to be focused to support local level capacities for long lasting
and
sustainable impact.
Successful rehabilitation should be closely linked to
the resolution
of land ownership problems.
Within
urban areas suffering earthquake or floods there is often a
serious
pressure on available land, resulting in the occupation of
unsafe
sites. Governments will need to grasp the difficult issue of
making
safe land available with tenure for the occupants and
enforcing
land use planning controls within rehabilitation planning.
Although
land can sometimes be more readily available in rural
areas,
it may be controlled by the few. Reforms to improve
ownership
and tenure of agricultural land can be relatively more
feasible
after a flood disaster.
To aid rehabilitation it is preferable to maximize the
use of
local resources.
Before
planning for external support, it is vital for officials to check
whether
locally available expertise, labor and products are available
in
order to regenerate the local economy. It is preferable to use these
resources
rather than import skills and materials. Strengthening the
capacities
of affected people will increase self reliance, long-term
sustainability
of mitigation efforts as well as protect their dignity.
Physical rehabilitation should be dependent on the development
of
effective local institutions as well as training and
leadership
at all levels and in all sectors.
Frequently,
political leaders want to see rapid ‘action on the ground’
in
response to public pressure for rehabilitation. However, these actions
depend
on the development and maintenance of committed
leadership,
staff training and resilient institutions in each affected
locality.
Political commitment is vital to ensure effective
rehabilitation.
Political
support is needed from the very highest level of
government
and right through the political system to ensure that
integrated
planning, financing and implementation of rehabilitation and
rehabilitation
continue from inception to completion without
interruption.
It
is not a platitude to state that rehabilitation after flood disaster poses a
challenge.
It
can easily become a series of lost opportunities: minimal advances in
safety,
protracted years, even decades of unfinished projects and an economy
that
has failed to reach pre-flood disaster levels of productivity. But, with
careful
planning,
conscientious management and the full commitment of a society it
can
be regarded as a unique opportunity to bring many benefits which can
lead
to an improved natural and built environment.
In
rehabilitation counseling, two phases are apparent: the
relationship/exploration phase, and the teaching of new ways of adapting and
living. Ochberg (1993) discusses four categories of techniques which are
necessary to address when helping the person with post traumatic stress
disorder: a) educational (sharing of books and articles); b) holistic health (dealing with physical activity,
nutrition, spirituality, and humor); c) social support and integration (family
and group therapy, self-help and support groups, the reduction of irrational
fears, and the learning of new social skills); and d) therapeutic (working
through grief, extinguishing the fear response, stress debriefing, hypnotherapy and other psychotherapeutic
methods such as role playing, guided imagery, and so on). The rehabilitation
counselor must know about these techniques and the importance of addressing
each of the four categories. The counselor is directed to Ochberg (1993) for
more information on each technique.
The vocational rehabilitation of persons with posttraumatic stress disorders is based on four elements: a) a complete work evaluation of the person; b) a gradualized return-to-work approach; and c) the Stress Inoculation Technique of Donald Meichenbaum (1985). It is also based on the awareness that rehabilitation will also involve a team approach, since other persons will necessarily be involved in the person's life: employers, spouses and other family members, psychiatrists and psychologists, and other professionals.
A complete work evaluation attempts to preclude future occupational stressors as much as possible by attempting to identify the person's strengths, limitations, and preferences and taking these into account in the guidance of the person in his or her re-entry into employment. The need for this assessment is apparent from the already impaired coping abilities of the person with PTSD. When helping the person to make occupational choices, the issue of control in the occupation should be discussed. It is likely that the person with PTSD may have experienced frustration at the lack of his or her ability to control a situation of flood disaster, and his or her self-efficacy estimates may have diminished since that experience. Hence, occupations that require high levels of self-confidence, or occupations with considerable ambiguity, such as sales or management, should be considered with caution.
Insofar that work environments are critical, the rehabilitation counselor may provide an important service to the client by helping to assess a potential work environment. The work environment consists of three areas, all of which need to be analyzed: a) the cultural environment (rules, dress, attendance requirements, etc.); b) the physical environment (heat, light, humidity, cleanliness, etc); and c) the social environment (the attitude, values, interest of the company and of other people who work there, and the behavioral expression of others such as supervisors, co-workers, etc.).
Gradualized work should begin in as low-demand work-type situations as possible, and increase to the point at which the person seems to be able to function without symptoms, utilizing coping skills learned in therapy, such as relaxation, mental imagery, mental activity, and physical exercise. For example, volunteer work is a good place to start since the person can set their own hours and work at an activity which has reinforcement value for the person. The volunteer work may be replaced, or supplanted, at the appropriate time with part-time competitive work, taking into consideration the person's needs and abilities on the one hand, and the reinforcers in the work and demands of it on the other. As long as the rehabilitation team continues to meet with the person on a regular basis, the activity can become gradually increased until the person's coping capacity has been reached.
The guiding principle behind gradualized return to work is that of Meichenbaum's Stress Inoculation (1985). Here persons are provided with varying situations in which new coping skills, gained through cognitive-behavioral techniques (e.g. cognitive restructuring, relaxation, self-observation, self-monitoring), are applied. The situations are mildly stressful in the beginning, and increase in stress as the person successfully handles the milder stimuli. This program prepares persons for stressful situations, and helps convince them that they can indeed handle these situations through successful and reinforcing feedback (and hence is motivating). Stress-inoculation training (SIT) includes components of information-giving, discussion, cognitive restructuring, problem-solving, relaxation training, behavioral rehearsals, self-monitoring, self-instruction self-reinforcement, and modifying environmental situations. SIT has three phases: a) the conceptual phase, which involves analyzing and changing irrational beliefs; b) the skills-acquisition and rehearsal phase, which involves learning how to self-analyze beliefs and new coping skills which are incompatible with stress such as using imaging and relaxation; and c) the application and follow-through phase, in which debriefing and re-learning occur.
Summary
Rehabilitation counselors can expect to encounter more persons who acquire disabilities because of natural flood disasters. Some of these will have physical impairments such as heart attacks or permanent disability due to injury. Still others of these victims will suffer the effects of PTSD, the net result of which is to impair coping skills with other stressors, including those in jobs.
Rehabilitation counselors are finding themselves increasingly in non-traditional sectors, as noted by Lynch, Lynch and Beck (1992). Thus, with regard to natural flood disasters, rehabilitation counselors may find themselves utilizing counseling skills either in the acute stage of crisis intervention, or in the rehabilitation of the psychosocial and vocational sequelae of chronic conditions. These counselors must therefore be aware of the full range of needs which victims of natural flood disasters may have, and have the skills necessary to help these victims resolve these needs. This may involve crisis counseling during the crisis stage, or long-term rehabilitation in the chronic disability stage of the victim's experience. As in other disability experiences, the counselor will encounter persons with anxiety, depression, grief, loss, cognitive or social dysfunction, and almost certainly coping deficits. Because of the latter, rehabilitation counseling in the victim with PTSD may be of a different quality, perhaps a more gradualized and longer term than in persons with other kinds of disabilities. And perhaps as research continues in the area of PTSD, we will learn that some of the problems that we have ascribed to other disabilities, such as the emotional lability in brain injury, may overlap with the normal sequence of the traumatic event produced by the injury. In that event, it behooves us as professional rehabilitation counselors to educate ourselves in the social and personal costs of natural flood disasters, particularly those associated with PTSD.
References
Arnold. C. (1988). Coping with natural flood disasters. New York: Walker & Co.
Beck, R. & Fogarty, C. (1995). Vocational rehabilitation in post-traumatic stress disorders. In Beck, R. & Fogarty, C. Proceedings of Rehabilitation and Stress Disorders Conference, SIUC, April 19 and 20 1995. Available from the Rehabilitation Institute, Southern Illinois University at Carbondale, Carbondale, IL 62901.
Barnett-Queen, T., & Bergmann, L. (1988). Post-trauma response programs. Fire Engineering, 52-58.
Canino, G., Bravo, M., Rubio-Stipec, M. & Woodbury, M. (1990). The impact of flood disaster on mental health: Prospective and retrospective analyses. International Journal of Mental Health 19, 51-69.
Clark, D. (1988). Debriefing to defuse stress. Fire Command, pp. 33-35.
Comfort, L. (1988). Managing Flood disaster. Duke University Press. Figley, C. (1985). Trauma and its wake: The study and treatment of posttraumatic stress disorder. New York: Brunner/Mazel.
Gist, R. & Lubin, B. 1989). Psychosocial aspects of flood disaster. New York: John and Sons.
Herman, R. (1982). Flood disaster planning for local government. New York: Universe books.
Horowitz, M. (1976). Stress response syndromes. New York: Jason Aronson.
Laube, J. & Murphy, S. (1985). Perspectives on flood disaster recovery. Connecticut: Appleton-Century-Crofts.
Lynch, R.K., Lynch, R.T. & Beck, R. (1992). Rehabilitation counseling in the private sector. In Parker, R. & Szymanski, E. (1992). Rehabilitation counseling: Basics and beyond (2nd Edition). Austin: Pro-Ed.
Meichenbaum, D. (1985). Stress inoculation training. New York: Pergamon Press.
Mitchell, J. (1983). When flood disaster strikes ... The critical incident stress debriefing process. Journal of Emergency Medical Services, 8(1), 34-36.
The vocational rehabilitation of persons with posttraumatic stress disorders is based on four elements: a) a complete work evaluation of the person; b) a gradualized return-to-work approach; and c) the Stress Inoculation Technique of Donald Meichenbaum (1985). It is also based on the awareness that rehabilitation will also involve a team approach, since other persons will necessarily be involved in the person's life: employers, spouses and other family members, psychiatrists and psychologists, and other professionals.
A complete work evaluation attempts to preclude future occupational stressors as much as possible by attempting to identify the person's strengths, limitations, and preferences and taking these into account in the guidance of the person in his or her re-entry into employment. The need for this assessment is apparent from the already impaired coping abilities of the person with PTSD. When helping the person to make occupational choices, the issue of control in the occupation should be discussed. It is likely that the person with PTSD may have experienced frustration at the lack of his or her ability to control a situation of flood disaster, and his or her self-efficacy estimates may have diminished since that experience. Hence, occupations that require high levels of self-confidence, or occupations with considerable ambiguity, such as sales or management, should be considered with caution.
Insofar that work environments are critical, the rehabilitation counselor may provide an important service to the client by helping to assess a potential work environment. The work environment consists of three areas, all of which need to be analyzed: a) the cultural environment (rules, dress, attendance requirements, etc.); b) the physical environment (heat, light, humidity, cleanliness, etc); and c) the social environment (the attitude, values, interest of the company and of other people who work there, and the behavioral expression of others such as supervisors, co-workers, etc.).
Gradualized work should begin in as low-demand work-type situations as possible, and increase to the point at which the person seems to be able to function without symptoms, utilizing coping skills learned in therapy, such as relaxation, mental imagery, mental activity, and physical exercise. For example, volunteer work is a good place to start since the person can set their own hours and work at an activity which has reinforcement value for the person. The volunteer work may be replaced, or supplanted, at the appropriate time with part-time competitive work, taking into consideration the person's needs and abilities on the one hand, and the reinforcers in the work and demands of it on the other. As long as the rehabilitation team continues to meet with the person on a regular basis, the activity can become gradually increased until the person's coping capacity has been reached.
The guiding principle behind gradualized return to work is that of Meichenbaum's Stress Inoculation (1985). Here persons are provided with varying situations in which new coping skills, gained through cognitive-behavioral techniques (e.g. cognitive restructuring, relaxation, self-observation, self-monitoring), are applied. The situations are mildly stressful in the beginning, and increase in stress as the person successfully handles the milder stimuli. This program prepares persons for stressful situations, and helps convince them that they can indeed handle these situations through successful and reinforcing feedback (and hence is motivating). Stress-inoculation training (SIT) includes components of information-giving, discussion, cognitive restructuring, problem-solving, relaxation training, behavioral rehearsals, self-monitoring, self-instruction self-reinforcement, and modifying environmental situations. SIT has three phases: a) the conceptual phase, which involves analyzing and changing irrational beliefs; b) the skills-acquisition and rehearsal phase, which involves learning how to self-analyze beliefs and new coping skills which are incompatible with stress such as using imaging and relaxation; and c) the application and follow-through phase, in which debriefing and re-learning occur.
Summary
Rehabilitation counselors can expect to encounter more persons who acquire disabilities because of natural flood disasters. Some of these will have physical impairments such as heart attacks or permanent disability due to injury. Still others of these victims will suffer the effects of PTSD, the net result of which is to impair coping skills with other stressors, including those in jobs.
Rehabilitation counselors are finding themselves increasingly in non-traditional sectors, as noted by Lynch, Lynch and Beck (1992). Thus, with regard to natural flood disasters, rehabilitation counselors may find themselves utilizing counseling skills either in the acute stage of crisis intervention, or in the rehabilitation of the psychosocial and vocational sequelae of chronic conditions. These counselors must therefore be aware of the full range of needs which victims of natural flood disasters may have, and have the skills necessary to help these victims resolve these needs. This may involve crisis counseling during the crisis stage, or long-term rehabilitation in the chronic disability stage of the victim's experience. As in other disability experiences, the counselor will encounter persons with anxiety, depression, grief, loss, cognitive or social dysfunction, and almost certainly coping deficits. Because of the latter, rehabilitation counseling in the victim with PTSD may be of a different quality, perhaps a more gradualized and longer term than in persons with other kinds of disabilities. And perhaps as research continues in the area of PTSD, we will learn that some of the problems that we have ascribed to other disabilities, such as the emotional lability in brain injury, may overlap with the normal sequence of the traumatic event produced by the injury. In that event, it behooves us as professional rehabilitation counselors to educate ourselves in the social and personal costs of natural flood disasters, particularly those associated with PTSD.
References
Arnold. C. (1988). Coping with natural flood disasters. New York: Walker & Co.
Beck, R. & Fogarty, C. (1995). Vocational rehabilitation in post-traumatic stress disorders. In Beck, R. & Fogarty, C. Proceedings of Rehabilitation and Stress Disorders Conference, SIUC, April 19 and 20 1995. Available from the Rehabilitation Institute, Southern Illinois University at Carbondale, Carbondale, IL 62901.
Barnett-Queen, T., & Bergmann, L. (1988). Post-trauma response programs. Fire Engineering, 52-58.
Canino, G., Bravo, M., Rubio-Stipec, M. & Woodbury, M. (1990). The impact of flood disaster on mental health: Prospective and retrospective analyses. International Journal of Mental Health 19, 51-69.
Clark, D. (1988). Debriefing to defuse stress. Fire Command, pp. 33-35.
Comfort, L. (1988). Managing Flood disaster. Duke University Press. Figley, C. (1985). Trauma and its wake: The study and treatment of posttraumatic stress disorder. New York: Brunner/Mazel.
Gist, R. & Lubin, B. 1989). Psychosocial aspects of flood disaster. New York: John and Sons.
Herman, R. (1982). Flood disaster planning for local government. New York: Universe books.
Horowitz, M. (1976). Stress response syndromes. New York: Jason Aronson.
Laube, J. & Murphy, S. (1985). Perspectives on flood disaster recovery. Connecticut: Appleton-Century-Crofts.
Lynch, R.K., Lynch, R.T. & Beck, R. (1992). Rehabilitation counseling in the private sector. In Parker, R. & Szymanski, E. (1992). Rehabilitation counseling: Basics and beyond (2nd Edition). Austin: Pro-Ed.
Meichenbaum, D. (1985). Stress inoculation training. New York: Pergamon Press.
Mitchell, J. (1983). When flood disaster strikes ... The critical incident stress debriefing process. Journal of Emergency Medical Services, 8(1), 34-36.
