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126ПЕРЕКРЁСТОК КУЛЬТУР
ОРГАНИЗАЦИЯ ПОМОЩИ ДОБРОВОЛЬЦАМИ ОБЩИНЫ В УСЛОВИЯХ ЧРЕЗВЫЧАЙНОЙ СИТУАЦИИ И КРИЗИСА
Н. Агазаде
Клиника «Наргиз», Баку, Азербайджан
ORGANIZING COMMUNITY PEER SUPPORT AT TIMES OF CRISES AND EMERGENCIES
N. Agazade
Nargiz Clinic, Baku, Azerbaijan
The Need for Community Peer Support
The need for psychological support is extremely high in emergency and crisis settings. Frequently, due to a wide scale of problems, mental health services provided by professionals (counselors, psychologists, and psychiatrists) are not adequate to address the growing psychosocial needs of the affected population. Therefore, in order to address the needs of distressed and traumatized people, it is necessary to have community mental health volunteers and peer helpers trained in advance as additional resources. The benefits of having peer support systems collaborate with mental health professionals and emergency responders have been demonstrated by many authors (Katz R. et al., 2000; Ochocka J. et al., 2002; Campbell J., Leaver J., 2003; Grauwiler P. et al., 2008; Dowdall-Thomae C. et al., 2009; Jones N.S., Majied K., 2009).
Paraprofessional support has several advantages:
- Informal peer support already exists in many communities, teams, and organizations. Therefore, it makes sense to capitalize on
this phenomenon, and to further develop the community peer helper movement.
- Peer helpers usually act both as paraprofessionals and community representatives, and can provide not only psychological support but also practical help in addressing basic needs (shelter, water, food etc.) and resolving problems.
- Another advantage of community peer help is related to the fact that the helpers themselves are community members, and as such are much closer to the affected population both culturally and physically. They can actively reach out to isolated populations living in the most remote areas.
- Many of the affected persons frequently avoid mental health professionals due to the attached stigma, preferring instead to collaborate with paraprofessionals.
Paraprofessionals are selected from among volunteer community members. These volunteers, who provide psychosocial support and psychological first aid to affected people are generally known as community helpers, or community peer supporters, or community mental health activists. Similarly, at the institutional level, staff members who have been trained to provide paraprofessional support to coworkers and their family members are referred to as peer helpers or peer supporters. In the current article, the term "community helpers" is used in reference to all the aforementioned helper categories.
Responsibilities of Community Helpers
The general tasks and responsibilities of community helpers include the following:
1. Providing paraprofessional support under the supervision of local mental health professionals.
2. Assisting mental health professionals in assessing the needs for psychosocial interventions after traumatic events.
3. Identifying the most affected persons in crises and emergencies.
4. Initiating contact with those community members who demonstrate signs of severe distress.
5. Assisting the affected individuals to cope with traumatic experiences.
6. Providing psychosocial support as needed.
7. Referring, in coordination with the mental health professionals, the most affected persons to medical facilities, as needed.
8. Following up with the affected people in helping them resume and cope with everyday activity.
General Requirements for Community Helpers
The community helpers are expected to have the following characteristics:
- be a respected member of the local community;
- be trusted and viewed as reliable by other members of community;
- have a caring attitude and respect towards others;
- demonstrate overall proficiency and sensitivity in interpersonal communication;
- have excellent listening skills;
- show emotional integrity, maturity, and responsibility;
- have a forthright attitude;
- show motivation, patience, and interest in learning about human behavior;
- be able to maintain confidentiality;
- be aware of the requirement of working within personal limits.
Possible Challenges for Community Helper Networks
- Community helpers may begin working independently (as mental health professionals), while in fact they are unable to provide necessary professional assistance. The contributing factor is that the local government, community leaders, and emergency managers may have the unrealistic expectation of peer helpers acting not only as caring community members but also as mental health professionals.
- Community helpers may not be aware of the requirement of working within personal limits and may start intervening beyond the responsibilities of a helper.
- As is true for ordinary people, when confronted with difficult situations community helpers can also be affected emotionally. Their own expectations and the communities' expectations of them may be too high. The community helpers are in fact just resource persons and not actual problem solvers.
- The community helpers' activities may be blocked by community leaders or members, emergency workers, security officials, or medical personnel. This usually happens if collaborative relations with all stakeholders have not been established.
- Just like emergency professionals, community helpers who provide ongoing assistance to the traumatized population are a highrisk group for psychological effects. They can demonstrate signs of emotional fatigue or burnout, or can suffer from vicarious trauma as they internalize some of the actual consequences of a crisis situation.
All the aforementioned points should be addressed during the training period, and later on during an emergency response through mental health professionals' ongoing supervision of community helpers.
Training of Community Helpers
Community helpers should be trained and available as part of emergency services for community contingency planning, or for business continuity planning for various institutions. The purpose of the training is to provide the selected helpers with comprehensive knowledge and practical skills regarding their role in addressing stress and stress related situations, with special focus on attending to the psychosocial needs of the affected people during emergencies or crises.
The helpers, in teams or as part of a network, should be trained and supervised by mental health professionals, namely psychologists, psychiatrists, or stress counselors. The goal of supervision for these teams or networks of helpers is to guide and direct their interventions of psychological support and empowerment of the affected individuals in traumatic situations.
The helper network should act as a liaison between families, mental health services (both inpatient and outpatient), rescue teams, community leaders, security officers, and the local government. The network should also interact with various institutional bodies, such as local government, community based associations (e.g., women's groups, councils of elderly), staff unions, human resources, and local mental health services. During emergencies, community helpers should also operate as phone helpline operators.
The expected results of the training are as follows:
1. The establishment of a local network of mental health helpers in respective regions of the country. The network should consist of the trained helpers and one or two local mental health professionals (psychologist, psychiatrist, or stress counselor), who would lead the work of the overall network, as well as supervise the work of individual helpers.
2. The facilitation of immediate psychosocial interventions for affected people after traumatic events of emergencies or crises.
3. The establishment of a well-organized referral system for severely affected individuals.
It is recommended that communities within respective regions of the country propose several candidates for the selection process, while the final selection of helpers is made by local mental professionals in collaboration with community leaders. Medical staff, teachers, police personnel, emergency workers, human resource representatives, informal community leaders, representatives from women's groups and staff unions, and line managers are strongly encouraged to participate. Ideally, the community helpers should represent a diverse, demographic group.
Training Overview
A training workshop is generally organized for a select group of approximately 25-30 individuals. Based on a needs assessment or an identified requirement to train more volunteers, the communities can request additional workshops if necessary. The duration of the course is generally 8-10 days, but it can be condensed into 4-5 working days.
Pending availability of funds, the training should be conducted as part of the contingency planning in a pre-emergency period. However, if there is an unexpected onset of an emergency or crisis situation, then a brief orientation training rather than a full workshop should be conducted. In such cases, close supervision is required.
The following topics are generally covered during the training course:
- Community Helper Program Introduction.
- Stress Management: Basic Knowledge, Approaches and Techniques.
- The Impact of Trauma, ASD, and PTSD.
- Communication.
- Working with Diversity.
- Psychological First Aid.
- Harassment.
- Effective Helping Styles.
- Coping with Loss and Death.
- Interventions and Referrals.
- Phone Interventions.
- T aking Care of Y ourself.
- Community Helper Program Implementation.
Roles and Responsibilities of Community Helpers
Friends, neighbors, and other representatives from the community assist the affected people by providing psychological first aid, constructive mental health activities, or emotional support. They also help these individuals address particular problems or undertake specific actions. The responsibilities of community helpers can be very diverse and extensive. The type of interventions they provide will depend on the stage of the emergency or crisis, as indicated in the table below.
The Map of Community Peer Helpers' Activities in Emergencies
Before emergency During emergency After emergency
Assessment
Assisting in conducting the needs and resources assessment Updating the assessment In case of an unexpected emergency, assisting in conducting rapid assessment Involvement in the postemergency assessment Monitoring high risk groups Assisting mental health professional in determining delayed traumatic stress, cumulative stress, PTSD, or vicarious trauma behaviors among helpers Assisting in drawing from the lessons learned
Before emergency During emergency After emergency
Training
Training for community representatives, for 5-10 days Trained helpers participate in simulations Participating in brief training orientation for volunteers if no prior helper training has been done -
Information, Education, and Communication (IEC) campaign
Assisting mental health professionals in pretesting and educating/informing public (circulating information, leaflets, brochures etc.) Assisting in public education/information (circulation of leaflets, brochures etc.) Assisting in pretesting and educating/informing of updated or new information (circulation of leaflets, brochures etc.)
Coordination
Participating in periodic meetings Activation of the community helpers' network Regular meetings Community peer helper outreach on emergency sites Final meeting Assist in maintaining helpers' network in designated locations; use helpers as community based mental health paraprofessionals in non-emergency settings
Preparing for delivery of support and provision of direct support to the affected people
Preparing the community map for outreach Initiating the organization of a 24/7 phone helpline Helping mental health professionals compile a referral list Provision of psychological first aid Provision of emotional support Provision of support during relocation and evacuation Participating in 24/7 phone helpline Referral to professional services Helpers monitor high risk groups for delayed manifestation of psychiatric disorders among local population Community peer helper network is maintained in the designated locations as paraprofessional aid functioning in non-emergency settings
The role of mental health professionals is to provide guidance to community helpers to ensure that support to survivors of an emergency is provided in the most positive and effective way, and without any potential negative results. It should be noted that affected persons appreciate all significant, simple, and even minor supportive efforts from the helpers and friends, particularly during crisis times.
Community helpers, in conjunction with mental health paraprofessionals, are involved in both programmatic (organizational) activities and support delivery.
Community helpers' programmatic activities include:
- Participating in the needs and resources assessment at all stages (before, during, and after the emergency).
- Organizing and completing the helper training program.
- Assisting mental health professionals with IEC campaign -distribution of leaflets, brochures etc.
- Joining the community based trainings and simulations.
- Participating in the periodic coordination meetings.
- Activating the helpers' network.
- Reaching out to the emergency site.
- Organizing a 24/7 phone helpline.
- Monitoring high risk groups for delayed manifestation of psychiatric disorders among local population after an emergency.
- Participating in drawing from the lessons learned.
The main types of supportive interventions or psychosocial support delivery undertaken by colleagues and friends generally include:
- Providing psychological first aid.
- Providing emotional support.
- Delivering distant support through a 24/7 phone helpline.
- Providing practical assistance.
- Listening.
- Empowering the targeted person to undertake pro-active behaviors.
- Assisting the targeted people in clarifying their problems.
- Helping with addressing practical problems.
- Sharing technical advice, experience, and information with the affected people.
- Referring to professional resources.
These recommendations are clearly described in the specialized literature on providing general paraprofessional support. The recommendations below are adjusted to the context of emergency and crisis. As mentioned previously (Agazade & Martynova, 2010), the helpers' choice of interventions will depend on their capacity in terms of skill and experience in providing support in general, the level of their own emotional involvement, and their availability to provide assistance as required. It is also very important for the helpers to recognize their limits and accept that in some cases they will not be able to effect aid to others. Below are some outlines of helpers' supportive interventions.
Psychological First Aid
The issue of Psychological First Aid (PFA) has become particularly important in the last years, probably due to the increasing number of natural disasters, manmade emergencies, catastrophes, and crises (Crocq L., 2012; Ottenstein R.J., 2010; Crocq L. et al., 2009; Everly et al., 2006; VandePol B. et al., 2006; Lerner M.D., Shelton R.D., 2005; Herman J., 1997; Mitchell, J.T., Everly G.S., 2001; Crocq L., 1999).
The World Health Organization (WHO), jointly with the War Trauma Foundation and World Vision International have recently published guidelines for providing psychological first aid. The guidelines reflect several positive points. They introduce a comprehensive approach, incorporating disaster management and an emphasis on communication during PFA. Other positive points of the guidelines are the special focus on cultural diversity and the importance of selfcare. However, the guidelines also contain some technical inconsistencies. For example, in Chapter 1, page 3, Understanding PFA, Section 1.2 What is PFA, it is mentioned that "PFA involves the following themes: providing practical care and support which does not intrude... " Although a "non-intrusive" approach may be appropriate for some clients, it is totally inappropriate while delivering PFA to those persons who require immediate protective measures. This refers, for example, to individuals with suicidal intentions. If PFA is not provided to these individuals, even intrusively, such persons may follow through on their suicidal intentions.
Thus, it is important to remember that psychological first aid is normally provided when the affected person loses control over his or her behaviors and emotional reactions, which can jeopardize either his or her own wellbeing or that of others. If the affected individual's behavior is potentially dangerous in any direction and at any level, then psychological first aid should be provided regardless of the "intrusion" level.
Assisting the Affected People during Evacuation
Relocation within a home country and especially evacuation out of a home country is one of the most stressful events experienced by survivors of emergency or crisis situations. As a result, working with a displaced population is one of the most challenging tasks for relief workers and emergency responders. Therefore, in order to address the psychosocial needs of displaced people, it is recommended that community helpers (with the coordination of counselors and leadership of emergency responders) assist these people during the entire process of relocation or evacuation. Ideally, a team of community helpers should be present at the evacuation/relocation site, during the travel, and at the reception point. The presence of community helpers during the travel per se provides a comforting and reassuring effect on the distressed people.
Listening
Listening and thereby allowing the survivor of the emergency or crisis to openly and comfortably express himself or herself is the most common and practical way of supporting distressed people. Effective listening skills comprise the following most commonly used communication techniques. These are elaborated in detail in the peer supporter training course:
- Questioning - including the ability to ask open-ended, closed ended, and leading questions.
- Paraphrasing - that focuses on the content of the message, usually through brief, re-phrased feedback by the listener.
- Reflecting feelings and words back to the speaker, focusing on the emotional content of the information.
- Clarifying the events, with the objective of determining the accuracy of the information.
- Offering encouragement, with the purpose of eliciting additional information and a fuller account.
- Summarizing the discussion.
- Acknowledging the hardships of the survivor.
- Providing non-verbal support, such as an open and relaxed posture, leaning in towards the speaker, making appropriate eye contact, and using culturally acceptable gestures and body language.
These important techniques are widely discussed in books and articles on communication. However, it should be noted that in order to learn and incorporate these techniques, reading about them is not enough. Community helpers will need to have ongoing training sessions on building specific communication skills. Nevertheless, as a baseline even without such training, using common sense, personal tact, and the accepted cultural norms are good directives for guiding peer helpers to communicate effectively with distressed individuals.
One of the most important elements of active listening is the capacity of the listener to acknowledge the problems that the affected survivor encounters. However, there is also a trap - that is becoming partial to the affected person, and sometimes losing the ability to see a situation with unbiased clarity. While listening to distressed colleagues, we need to keep in mind that we have become informed about an issue through the eyes and reactions of one involved party. Sometimes, the real story can be quite different. Therefore, it is very important that the acknowledgement be provided impartially.
Providing Emotional Support
Support of the affected person can be provided in various forms, including verbally and nonverbally. Sometimes, all the peer helper needs to do is stand next to the distressed person, or be there as silent company during a difficult time without discussing any troublesome issues. Socializing with the victims can be as beneficial as listening. While providing emotional support, it is important to be aware of and follow cultural norms and practices, including gender specific issues. For example, if a community helper and a beneficiary are of different genders, in some cultures they would be discouraged from looking directly into the eyes or face of the other person, or of holding the other person's hand.
Empowering the Affected Person to Take Charge
One of most serious consequences of traumatic events is that the survivor's basic mental and emotional strength becomes compromised, as he or she frequently loses confidence, self-esteem, and self-assurance. In situations of continuous emergency, survivors often become passive, disempowered, and irresolute. They tend to avoid making judgments, make decisions reluctantly or carelessly, and seldom put in any effort to problem solving.
In such cases, positive interventions by helpers and friends can offer encouragement to the affected persons and empower them to take charge of their current and future actions. Community helpers can assist the harassed persons in reevaluating their capacities, rebuilding their self-esteem, and taking hold of fresh, new opportunities.
Assisting the Affected People in Clarifying Their Problems
One of the main challenges for the survivor is to determine the real nature of a problem. In many cases, the targeted persons are so confused and overwhelmed with the emergency situation that they are unaware of the actual nature of the problem. Many persons, particularly those in crisis, assume that a problem is much worse than it actually is. They dramatize and catastrophize what has happened to them, even though a situation may not be so bad and they may have enough potential to overcome the situation. This negative behavior frequently results in evoking the survivor's self-blame.
The role of the community helper in such cases is to assist the affected person in reviewing the situation and identifying the nature and source of the problem, without dramatizing the situation.
Helping with Problem Solving
Once the issue is clarified, a community helper can assist the affected person in finding possible solutions. There may be several options for these solutions, each one with its own advantages and disadvantages. The most important strategy for the community helper in such cases is to avoid giving advice. The helper's main role is to help the affected individuals recognize all the various choices and find the best possible strategy for the resolving the situation.
Sharing Technical Advice, Experience, and Information
In many cases, the affected persons need specific information or technical guidance, and need to benefit from other people's valuable experience as well. They may be unaware that certain information is required for a specific task, or, because of their emotional distress, they may be unable to recall or properly use that information. The role of the community helper in such situations is to provide guidance and inform the affected persons of the relevant resources and assistance available at the emergency site, direct the victim on how to access these, and be there to share his or her own experiences.
Providing Practical Assistance
There may be situations where community helpers are able to provide additional practical assistance to the affected people and can stand by them while this assistance is ongoing. This does not mean that helpers should actually undertake a specific action act instead of the affected individual doing so, but rather they should assist the persons to follow up on these actions themselves. Practical steps undertaken by helpers, regardless of the final outcome, are highly valued by the affected persons. Such support by community helpers can include assistance with routine minor activities and/or assistance in resolving serious problems. In many cases, emotionally overwhelmed individuals may simply require a helper's physical presence during those hard times, along with assistance in performing minor assignments.
Referrals
Community helpers can refer affected persons to relevant professional resources, such as mental health professionals, local government offices, emergency responders and their administrative offices, medical services etc. Referring the affected person to mental health professionals is a very important intervention. All individuals who present with acute stress disorders, post-traumatic stress disorders, or other psychiatric disorders, should be directed to mental health professionals immediately. The same directive applies for individuals with suicidal or homicidal tendencies, survivors of sexual assaults (especially rape cases), and those who demonstrate signs of vicarious trauma. In fact, for any advanced case of cumulative and
traumatic stress responses, the directive should be the same. Generally, whenever a community helper merely suspects a serious mental health disorder, it is better to be overly cautious and refer the affected person rather than overlook potential problems that might result in serious consequences. When referring suicidal or homicidal persons, or rape victims, it is necessary for a community helper (preferably more than one helper) to accompany these individuals at all times.
In other cases, affected persons may require emergency related technical advice regarding the management of their problems in the community. This service can be best provided by emergency management responders or community based governmental officials with the appropriate capacity to address those problems. Individuals with security related issues should be referred to the appropriate officials.
Some Don’ts in Community Support
The following don'ts are well described in the specialized literature on various peer support or self-help groups. Community helpers should be informed about these resources well in advance. It is a good idea to have a leaflet or flier with the pertinent content prepared for distribution. These don'ts should include the following:
Some Don’ts in Community Peer Support
Please keep in mind these simple rules when providing paraprofessional support to affected people in emergencies and crises:
Never breach confidentiality!
This is the most important and basic rule. We should never breach confidentiality unless it is a life-threatening situation, such as intention for suicide or homicide that will likely require intervention by another person. Even then, only the information related to the safety of the affected person should be shared with those people who could provide the necessary assistance.
Do not act as a counselor!
There might be expectations from the affected person or from some managers that peer supporters will act as counselors and thus provide recommendations that only a mental health professional can or should do. Remember that you are a supporter, not a service provider.
Do not advise!
Advising others, especially affected persons, is tempting for a caring community helper or friend. Yet, we have to remember and respect the dis-
tressed person's right to make his or her own decision, no matter what we think about the issue.
Do not overexpose the distressed person!
Do not force the person to share everything with you. We need to remember that when individuals are overwhelmed emotionally they may share some intimate facts that they would not share otherwise. We should remember that sharing too has its limits. The affected person may regret later that he or she has divulged confidential information. Therefore, it is better to create a safe rapport with the person from the very beginning: "Please feel free to share only as much as you are comfortable sharing".
Do not patronize the affected persons or minimize what they are
experiencing!
Avoid using phrases like "It is not as bad as you think!", "You can take care of that!" or "Come on, you can manage it!" The person will resent you treating him or her like a child. It is much more important and helpful to acknowledge the person's difficult experience.
Do not provide support if you are overwhelmed!
As a caring community supporter witnessing or listening to the dis-
tressed person, you may be seriously affected emotionally by what you are hearing or seeing. In turn, you may add further distress to the affected person by your own emotional reactions. Also, you may even become the next emotional victim through the mechanism of vicarious traumatization - that is, becoming psychologically traumatized simply by listening to the stories or witnessing dramatic events. The risk of vicarious traumatization can be higher if you have been exposed to similar and unaddressed traumatic experiences in the past. Therefore, whenever you feel that you are overwhelmed and thus unable to help, look for alternative resources or for a colleague to intervene so that you can postpone your own interaction with the distressed person.
Do not take sides!
Your judgment that is based on a one-sided view of the event may be skewed. The affected person may be wrong about his or her own perception of certain circumstances, especially in cases accompanied by conflicts during emergencies. By taking their side, you can further confuse the affected person, even if you have the best intentions.
Do not become a savior!
This role is very tempting and many helpers start with phrases like: "We will take care of that" or "I will do it for you!" Efforts to fix problems for the affected persons instead of empowering them to do so on their own can cause more harm than good. In some cases, the affected person can perceive such efforts as patronizing. Efforts at rescuing can make the affected person
even more disempowered, which is not the route an effective helper wants to take.
Do not become judgmental and do not blame the affected person or others for any actions!
Your role is not to judge, but to help. One of the temptations of the helper's role is to feel like an expert on the situation and become a judge. Your role is to stick to the evidence, assist the person in crisis, and support them in making their own choice.
Don’t overlook the quiet survivors!
Many individuals are stunned after a tragic event. They may appear quiet, unaffected, and fine. We need to remember that many people can be affected by a critical event. Don't overlook those "invisible" problem cases! When you suspect someone is affected by a tragic event, reach out with caring interest and persistence.
Conclusion
Assistance by community helpers can be defined in several strategic areas. These include: response to needs assessment, capacity building, conducting IEC campaigns, coordination of activities, and provision of direct support to the affected population.
Prior to an emergency situation, at the crisis anticipation stage, activities should include assistance to mental health professionals for the needs and resource assessments, with a particular focus on creating the availability of community peer helpers. Based on that, timely training of volunteers as community helpers is essential so that they will be available during crisis or emergency situations. The trained helpers should participate in all simulations activities, and should maintain ongoing education as paraprofessionals. Additionally, they should assist in public education by circulating leaflets, brochures, and other IEC materials. At this stage, preparation for anticipated interventions should be conducted as well. These should include preparing the community map for outreach, assisting in creation and management of a 24/7 phone helpline, and helping to compile a list of referral systems and resources.
During an emergency situation, the main focus should be on support delivery. However, if the emergency is completely unexpected, and no assessment was conducted prior to the event, community helpers should assist mental health professionals in conducting rapid assessment. Similarly, if no community helpers have been
trained, brief orientation trainings should be conducted for volunteers. Information on stress indicators and adaptive coping strategies is urgently needed; therefore, community helpers should be involved in the circulation of leaflets and brochures on these topics. If, however, the preparation was done well in advance, then the assigned mental health professionals need to activate the network of helpers and conduct regular meetings for coordination purposes.
Direct support will include community peer helper outreach at the emergency site, and provision of psychological first aid and emotional support, all as needed. Of special importance is the support provided by helpers to affected people during times of relocation and evacuation. If a 24/7 phone helpline is operational, community helpers should be directly involved as helpline operators. One of the critical activities is referral to professional services, especially mental health facilities and security personnel.
After the emergency phase, community helpers' activities are most valuable in determining delayed distress responses and postemergency assessment. For that purpose, community helpers should monitor high-risk groups and participate directly in drawing from the lessons learned. It is also beneficial for helpers to circulate leaflets and brochures. A final meeting should be organized to discuss the lessons learned, evaluate actions taken, and look ahead at growth and improvement.
In order to maintain the community helper network in many designated locations, mental health professionals should continue holding meetings and education sessions in non-emergency settings. They are the most helpful link between professional services, paraprofessionals, and the general population.
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