Post-Disaster Counselling — Help or Well-Meaning Abuse?

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There is some evidence to suggest that ‘stress debriefing’ after disasters may actually increase the incidence of post-traumatic stress disorder. Are counsellors flying in from different cultures to those who have survived the disaster able to understand other kinds of coping strategies, or are they imposing their own models of psychological distress?

The scale of the present catastrophe in Japan is hard to grasp. The immediate needs of thousands of people are basic ones: safety, shelter, food, to know where their loved ones are, to bury the dead and rebuild their lives. While the critical situation shows no signs of letting up, and the nuclear threat at the time of writing seems to be increasing, the fundamental need for safety, for the crisis to actually be over, is not being met. For those of us watching the scene unfold in relative comfort, maybe feeling emotionally overwhelmed just at the images, the question arises, how are people to cope?

Critical incident stress debriefing is often used by counsellors who fly in to disaster sites to help survivors to cope psychologically. Interviewed in Time, Scott Lilienfeld, a professor of psychology at Emory University and expert on the research evidence on the risks and benefits of debriefing techniques, states that such debriefings should be used with caution, as some research shows that they can actually increase the incidence of post-traumatic stress disorder (PTSD).

According to Lilienfeld, putting people into groups in order to go ‘get their feelings out’ just after a traumatic event may actually cause the initial anxiety to rise and rise, without the opportunity to actually process it. In general, in working therapeutically with anxiety and trauma, it is accepted that anxiety has to peak, then pass and settle to a degree in order to be processed. In such hot-house situations, the peak anxiety may have no time or space to pass, leaving the person further traumatised. The second point he makes is that counsellors may cause self-fulfilling prophecies, by suggesting symptoms and giving people a framework for the possible development of PTSD.

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Suggesting that PTSD is a normal, logical consequence of experiencing a crisis is not only risky but downright inaccurate. To quote Lilienfeld, “most studies show that even after a horrific disaster about 70% [of survivors] are resilient and don’t show significant symptoms of PTSD.”

PTSD is a debilitating, ongoing condition, lasting over time and causing significant disturbance and distress well after the event. Anxiety, sleep problems, flashbacks, nightmares, startle responses, etc. are absolutely normal responses in the immediate aftermath of a disaster, and can go on for varying amounts of time without becoming an actual disorder.

So it is probably not a good idea to rush into a disaster zone, providing shocked and dazed people a meaningful framework to the chaos and leading them to fear, or expect that they will fall into a chronic condition, or even find a kind of welcome sense in that.

Other reasons for well-meaning counsellors not to rush into cultures very different from their own should be obvious. Individual coping styles vary considerably both between and within cultures. Even within a culture similar to the average debriefing counsellor’s own, in which “letting it all out” is presented as a self-evidently good idea, there are people who prefer not to express or explore their feelings, who cope in very different ways, and are not necessarily traumatising themselves by doing so.

Between cultures, however, there are huge differences in social norms as far as sharing details of emotional experiences with strangers are concerned, and huge differences in ways of coping with difficult times. In more collective cultures (such as Japan) there is likely to be more social support, which is (according to Lilienfeld and my own understanding) a consistent predictor of better outcomes for people who have suffered from potentially traumatic experiences. People in strong social networks have repeatedly been shown to be more resilient to stress. Counsellors flying in from more individualistic cultures may well be coming to staunch a wound that does not exist (thereby either wasting time and resources, or inadvertently creating psychological problems). In an individualistic culture, a survivor is more likely to suffer the consequences of isolation, both in practical senses and in terms of the distress of having to cope with overwhelming anxiety and other feelings alone.

While it is important for people caught up in disasters to have people around who are ready to listen, it seems that practical concerns have to come first, to enable enough safety for people to begin to deal with their wounds, and it seems to me that encouraging a focus on feelings before that safety has been established can disturb basic coping mechanisms which allow us to carry on and do what needs to be done on some kind of automatic pilot. It also seems to me that treating people as if they ‘should’ open up, specifically in front of strangers who, in so many ways (language, culture, context, experience of the trauma concerned) cannot understand, could even be seen as a kind of well-meaning abuse.

What do you think?

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