Brief Treatment and Crisis Intervention Advance Access originally published online on August 28, 2006
Brief Treatment and Crisis Intervention 2006 6[4]:337-348; doi:10.1093/brief-treatment/mhl009
© The
Author 2006. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: .
Monica M. Matthieu, PhD, LCSW
André Ivanoff, PhD
From the Center for the Study and Prevention of Suicide, Department of Psychiatry, University of Rochester Medical Center [Matthieu] and the Columbia University School of Social Work [Ivanoff]
Contact author: Monica M. Matthieu, Senior Instructor and National Research Service Award Fellow, Center for the Study and Prevention of Suicide, Department of Psychiatry, University of Rochester Medical Center, 300 Crittenden Boulevard, Box PSYCH, Rochester, NY 14642. E-mail: monica_matthieu{at}urmc.rochester.edu.
This conceptual article describes transactional theory [R. S.Lazarus, 1999; R. S. Lazarus & S. Folkman, 1984], a frameworkthat integrates stress, appraisal, and coping theories as theyrelate to how individuals react to psychologically stressfulsituations and/or environments. In clinical practice, this theoreticalframework can be effectively utilized in the assessment, intervention,and evaluation of an individual's psychological stress and copingresponses. This paper also discusses the role that theory can play in facilitating clinicians' assessment of the coping strategiestheir clients use to decrease distress in the aftermath of adisaster. Illustrative examples are drawn from studies on socialworkers who experienced the World Trade Center disaster in NewYork City. Theoretical knowledge about stress, more specificallycoping with the impact of psychological stress, will provideinformation that can help clinical professionals more effectivelyassist clients in resuming positive functioning and well-beingafter a disaster.
KEY WORDS: disaster, theory, coping, September 11, mental health professionals, graduate students
Increased Stress Is Common Social Problem
Stress has become a common denominator in our fast-paced, complexsociety. Work stress, family stress, financial stress, chronicstress, and, for some, posttraumatic stress are
no longer isolatedexperiences but common refrains shared by people from variedbackgrounds and in differing social circumstances. As a result,clinical practitioners increasingly need more sophisticatedmodels defining disaster-related psychological stress responsesand methods that their clients can use to effectively cope withit. Understanding how people assess events and react to theseevents is one key to helping them
move through taxing situationsresourcefully.
An important aspect to developing effective treatments for psychologicalstress reactions following a natural or human-caused disasteris studying why some individuals adapt following these demandingsituations and why others do not [Norris, Friedman, & Watson, 2002;Norris, Friedman, Watson, Byrne, et al., 2002; Rubonis & Bickman, 1991].Science has yet to provide a definitive answer to this questionabout coping after extreme situations [Linley & Joseph, 2004].
We do know that developmentally, disasters affect people differentlyat various ages and stages [Weisaeth, 1993]. For example, children, adolescents, the disabled, and the elderly are vulnerable populationsthat require special attention [Hoven, Duarte, & Mandell, 2003;Rubonis & Bickman, 1991]. Consequently, mental health professionalscontinue to develop clinical programs [Marshall & Suh, 2003]and public health services [Felton, 2002; Klitzman & Freudenberg, 2003]to address the unique needs of particularly vulnerable populations.However, even among less vulnerable populations, there are widevariances in how individuals cope over time with disaster, potentiallytraumatic events, or terrorism-related stressful experiences [Bonanno, 2004; Lating, Sherman, & Peragine, 2006; Linley & Joseph, 2004;Pfefferbaum et al., 2006; Walker & Chestnut, 2003]. In orderto better serve all demographic groups, more specific knowledgeabout coping with the psychological impact of stressful eventsis necessary. This knowledge will help clinical professionalsmore effectively treat clients and ultimately help them mitigatenegative effects on health, functioning patterns, and overallwell-being.
Using Stress Theory in Clinical Assessments After a Disaster
The purpose of this theoretical paper is to describe the transactionaltheoretical framework of stress, appraisal, and
coping theories.The concepts that make up this framework can be utilized inthe assessment, intervention, and evaluation of the human stressresponse and the coping processes used following a disasteror other crisis situation. An understanding of the completehuman stress response process allows the clinician to appreciatethe nature of stress and its physiological and psychologicaleffects and to view it more holistically
as an interaction ofthe mind and the body [Everly & Lating, 2002].
In addition, this paper will examine coping styles and processes,how people cope and what strategies they use to cope with agiven stressor or an acute event defined by many as taxing.Coping processes are distinguished from coping styles as currentstates exhibiting a dynamic interplay of person and environment,whereas coping styles are traits suggesting inherent personalitycharacteristics [Lazarus & Folkman, 1984].
Finally, examples of specific strategies that were used to decreasedistress when coping with a disaster of national proportionswill be used to illustrate the theoretical concepts presentedherein. With an understanding of this framework, the assessmentof cognitive and behavioral coping strategies can greatly assistmental health professionals in making clinical assessments regardingthe type of coping strategies utilized following a disaster,how effective these coping strategies are in relieving distress,and what interventions may be beneficial in aiding individuals,families, as well as the larger community to restore positivefunctioning postdisaster.
Stress and Coping After 9/11
On September 11, 2001, the terrorist attacks on America foreverimprinted the memory of death and destruction on people, youngand old, rich and poor, from urban New York City [NYC] to ruralPennsylvania, and broadly across the United
States. For somemental health professionals, the events may have created pressingand sometimes disturbing clinical questions. What long-termeffect will exposure to this disaster have on people? Who willbe most affected? How do we as mental health professionals,best serve the affected populations following the next disasterevent or crisis situation? Can there be a positive gain aftersuch adversity?
Viewing disasters from a public health or population-based perspectivemight help answer the questions about what groups or segmentsof the population might be affected, but commonly, clinicianswant answers to assist them in providing clinical therapeuticsto disaster-affected individuals presenting for care. Accordingto Lewis and Roberts [2001], crisis assessment by behavioralhealth practitioners should focus on the individual-level crisisfactors: the stimulus of the crisis, the individuals' perceptionof the stressor, their coping efficacy, as well as an assessmentof the individuals' appraisal of psychosocial variables, generalresource availability, and cultural norms [Lewis & Roberts, 2001].Using this as an assessment framework provides clinicians withthe needed information with which to apply appropriate crisisinterventions or provide brief supportive therapeutic encountersto potential at-risk groups or individuals who are already presentingwith acute distress symptoms specifically in the aftermath ofa disaster. Yet, clinical professionals may also benefit ifthey were to take into consideration the larger public healthimpact of disasters as well as attending to the clinical presentationof the individual experiencing a disaster in his or her localenvironment.
Research provides other information that guides clinical practiceby describing the evidence for a range of individual-level effectsresulting from disaster experiences. Studies from the WorldTrade Center [WTC] disaster in NYC indicated that initial copingreactions predicted the onset of psychological distress [Silver, Holman, McIntosh, Poulin, & Gil-Rivas, 2002]and, in some, depression and posttraumatic stress disorder [Galea et al., 2002].A national event of terrorism and disaster not only affectsthe obvious survivors who experienced personal injury, resourceloss, or death of a loved one but also has an impact on othersin the community in their perception or psychological evaluationof the event's crisis magnitude [Rubonis & Bickman, 1991].
In another study, cognitive resources, such as the ability touse emotions flexibly after September 11, 2001, has been linkedto decreased distress [Bonanno, Papa, Lalande, Westphal, & Coifman, 2004].Increased distress, however, is not indicative of psychopathology;therefore, caution is warranted when attributing mental distressexclusively to the effects of a disaster [Wilson & Rosenthal, 2004].In sum, a thorough clinical assessment guided by theory andclinical research is of great importance.
It is also critical for mental health providers to acknowledgethat there are competing demands, personal and professional,that are related to their ability to provide clinical servicesduring a disaster in their own local community. A form of disaster-relatedrole strain was noted in studies on social workers after September11, 2001. In one study focusing on the experiences of 286 socialwork graduate students surveyed at 1 and 6 months after 9/11,MSW interns expressed concern about their professional abilityto attend to clients in the immediate aftermath while managingtheir own emotional distress about the disaster, their academicresponsibilities, ongoing threats to their personal safety,and impaired communication with family and friends [Matthieu, Conroy, Lewis, Ivanoff, & Robertson-Blackmore, 2006].After 6 months, the students in this study reported continuingprofessional needs for training and education in disaster-relatedclinical service delivery, particularly with youth, with bereavement,and with the community, as well as personal needs for supportand connectivity with others via counseling, volunteer work,academic planning, and fieldwork supervision.
In another study, 206 agency-based social work field instructorsin the New York area surveyed at 1 month postdisaster reportedthat their agency demands and responsibilities for students,staff, and clients took priority over their own personal coping,which delayed their ability for self-care and connection withtheir social support network [Matthieu, Ivanoff, Conroy, & Lewis, 2006].Additionally, these field instructors and students reportedin a final study that flexibility and support from the academicinstitution, time devoted to on-campus disaster-related discussions,and active dissemination of community resources and evidence-basedinformation were helpful in reducing disaster-related distress[Matthieu, Lewis, Ivanoff, & Conroy, 2006]. The insightgained from these novice and experienced social workers regardingtheir own coping provides another vantage point to examine thequestion of how best to equip mental health professional withthe requisite theoretical knowledge, professional skill, andpersonal abilities to effectively serve disaster-affected individualsand communities.
Hence, it is therefore proposed that clinicians need to be ableto identify the concrete thoughts and behaviors that some disaster-affectedindividuals use to decrease distress in the immediate aftermathof a disaster, crisis event, or stressful situation using atheoretical framework as a guide. This clinical assessment ofan individuals' coping reaction may facilitate enhanced clinicaldecision making on how best to intervene as well as provideone possible clinical indication of who will engage in maladaptiveor adaptive coping [Folkman & Moskowitz, 2000]. In sum,resilience after adversity may be more common than once thought[Bonanno, 2004].
| Stress in Theory |
The concept of stress has evolved over the centuries from aninitial physiological definition [Selye, 1956] as the most commonlyaccepted description. Selye [1956], the forefather of stressresearch, presents a widely accepted, fundamental stress theorythat states that stressful life events are linked to the onsetof distress or disorders.
The stress response begins with a stressor, which is definedas any real or imagined event, condition, situation, or stimulusthat instigates the onset of the human stress response processwithin an individual [Everly & Lating, 2002]. Further, Everly and Lating [2002]report that there are two types of stressors: psychosocial andbiogenic. A psychosocial stressor occurs when the individualreacts to an event, condition, or stimulus based on the attributedperception of that stressor as a threat [Everly & Lating, 2002].The psychosocial stressor is cognitively interpreted along acontinuum ranging from no harm to adversely affecting the individual'swell-being [Lazarus & Folkman, 1984]. Everly and Lating[2002] also report that stressors can be biogenic, where thoughts,cognitions, or an appraisal of a situation or event is not neededin order to produce the same physiological stress reaction.They report that this can occur in instances where stress occursin the body when it reacts to substances such as caffeine orenvironmental conditions such as extreme temperatures.
Physiological response to stress is fundamental in stress theory[Selye, 1956], yet our inability to determine which events arepsychologically stressful, to whom, and in what ways is problematic [Lazarus, 1999]. A stressful event becomes a psychological stressorwhen the individual reacts to the stressful event or conditionbased on cognitions that the event will adversely affect hisor her personal well-being. This perception of the event aspsychologically stressful is the vital component necessary todefine the event as a psychosocial stressor in the human stressresponse [Everly & Lating, 2002].
Over time, the strain of responding to stressful situations,whether mentally or physically, can be cumulatively detrimental.The result of this stress process in the mind and body may be the occurrence of eventual disease states [Everly & Lating, 2002].Thus, a clinical understanding of the concept of stress andthe effects of excessive psychophysiological arousal enablesmental health practitioners to assess clients' presenting problemsfrom the vantage point of mind–body interactions. It alsoassists in targeting the most effective place within the stressresponse process to intervene: [a] in the environment with thestressful event, [b] with the individuals in their thoughtsabout this event, [c] their physical responses within theirbody, or [d] to their cognitive or behavioral coping strategiesused to mitigate the stressful event.
Cognitive Perspectives on Stress and the Transactional
Framework
Stress has traditionally been viewed as a response, a stimulus,and, most recently, as a transaction. Stress, specifically mentalstress, is defined as a transaction [Lazarus, 1999;
Lazarus & Folkman, 1984]when the cognitive focus is on the relationship between theperson and the environment, such as thinking about events inone's life and deciding if one has the personal resources tohandle those events. This transactional, or interactional, orientationfocuses on thoughts and
awareness that impact the overall individualstress response an individual can have in his or her mind andbody. As such, the transactional framework focuses on cognitionsand perceptions, or appraisals, that mediate the response tostressful events [Lazarus, 1999].
This transactional approach also emphasizes the importance ofthe individuals' analysis or subjective appraisal of the stressfulevents that occur within their environment. Taken together,the importance of their interpretation of the psychosocial stressor'smagnitude, the emotions that are generated, and the resultingstress response is called the cognitive primacy perspective [Everly & Lating, 2002; Lazarus, 1999]. Everly and Lating [2002]further describe the cognitive primacy perspective as when "theindividual's interpretation of the environment is the primarydeterminant in the elicitation of the stress response in reactionto a psychosocial stressor" [p. 164]. Many stress researchersand theorists subscribe to the cognitive primacy perspectivedue to its rich empirical base [Lazarus, 1999].
Appraisal Theory
In addition to stress theory, one of the cornerstones of thetransactional framework is appraisal theory. Within this theory,
Lazarus and Folkman [1984] state that a specific event or stressorinfluences individual cognitions of an event, termed appraisal.Appraisal theory examines the process by which emotions areelicited as a result of an individual's subjective interpretationor evaluation of important events or situations; hence,
it isthe evaluation of events to determine one's safety in relationto his or her place in the environment [Lazarus, 1999]. Therefore,an event, irrespective of its importance, may or may not beperceived as stressful or harmful by an individual
[Regehr & Bober, 2005].
Appraisal theory posits that there are two types of appraisal,primary appraisal and secondary appraisal [Lazarus & Folkman, 1984]. Primary appraisal is the individual's evaluation of an eventor situation as a potential hazard to his or her well-being.Primary appraisal is also defined as when an individual concentrateson the magnitude of an event or situation possibly for harm[Lewis, 2001]. As one example, following the WTC disaster inNYC, the study of 286 MSW students, who were just beginningtheir agency-based field placement when the attack occurred,reported that the students immediately became aware of the urgentneed to attend to personal safety, that of self and others,with particular attention placed on the clients their fieldplacement served [Matthieu et al., 2006].
Secondary appraisal is the individual's evaluation of his orher ability to handle the event or situation. This estimationof the range of coping skills in the individuals' repertoireoccurs in relation to, not necessarily after, a primary appraisalof a situation [Lazarus, 1999]. Thus, the evaluation is dependenton the subjective interpretation of whether or not the eventposes a threat to the individual [i.e., primary appraisal] andwhether or not the individuals perceive they have the resources[inner and outer] to cope with it [i.e., secondary appraisal] [Regehr & Bober, 2005]. In addition to assessing safetyfollowing the news of the WTC disaster, the social work internsin the aforementioned study also began to worry that they werenot prepared or skilled enough to handle the demands of theirnewfound client population while they too were struggling toidentify their own coping resources [Matthieu et al., 2006].
According to Lazarus and Folkman [1984], there are also threetypes of primary appraisal: [a] irrelevant, where the individualhas no vested interest in the transaction or results; [b] benignpositive, in which the individual assumes that the situationis positive with no potential negative results to his or herwell-being; and [c] stressful, where the individual only perceivesnegative results or that the circumstances are detrimental tohis or her well-being. In order to determine the magnitude ofan event or situation using secondary appraisal [Lazarus & Folkman, 1984],an individual focuses on one of three perceptions: harm or loss,threat, or challenge [Lewis, 2001]. Harm or loss is the beliefthat one has endured a physical or emotional loss with the temporalnature of the loss in the past. Threat is an anticipation offuture harm or loss. Lastly, challenge is marked by positiveevents that have a risk of future negative outcomes that arelaced with mastery [of event] and risk [from the challenge][Lazarus & Folkman, 1984]. Challenge also can be definedas the potential for positive personal growth by applying copingskills to mitigate the stressful event or encounter [Lazarus & Folkman, 1984].
Because secondary appraisal is purely a cognitive process, copingefforts have not been instituted at this point. Depending onthe nature of the primary appraisal, the secondary appraisalcan be influenced by contextual-level factors such as demands,constraints, and opportunities [Lazarus, 1999]. The resultingappraisal then generates an emotion, or meaning, attributedto the particular event or situation. The individual is nowable to move from thinking to action [Lazarus, 1999].
After the acute event has been appraised by the individual,meaning and emotions are generated. Then a behavior called copingensues. Coping involves the decision of which behaviors to utilizeto handle the event [Lazarus & Folkman, 1984]. Coping isan interaction between the person's internal resources and externalenvironmental demands [Lazarus & Folkman, 1984]. It is alsodefined as constantly changing cognitive and behavioral effortsto manage specific demands that are appraised as potentiallytaxing or exceeding a person's resources. Coping includes attemptsto reduce the perceived discrepancy between situational demandsand personal resources [Lazarus, 1993]. A study of social work students and their field instructors' perceptions of their academicinstitutions' response to the WTC disaster in New York describedtheir reactions to a variety of additional academic supports,ranging from extra check-in meetings to support groups, institutedby their school to bolster student coping. This study foundthat personal time specifically devoted to processing the eventsand their coping reactions, whether alone, with peers, in agroup, or with their field instructor, was important to thesestudents [Matthieu et al., 2006].
Lastly, an individual employs coping strategies in one of twoways, by problem-focused coping, which is actively or behaviorallyaltering the external person–environment relationship,or emotion-focused coping, which is altering the personal orinternal meaning or relationships [Lazarus, 1999]. Problem-focusedcoping is also defined as channeling efforts to behaviorallyhandle distressing situations, gathering information, decisionmaking, conflict resolution, resource acquisition [knowledge,skills, and abilities], and instrumental, situation-specific,or task-oriented actions [Folkman & Moskowitz, 2000]. Thistype of coping allows the individual to focus attention on situation-specificgoals and allows for a sense of mastery and control in workingtoward attaining that specific goal. Alternatively, emotion-focusedcoping involves positive reappraisal. This process of cognitivelyreframing typically difficult thoughts in a positive mannerimpacts deeply held values that become apparent when certainconditions occur and are needed to assist in coping [Lazarus, 1999].
It is important for clinical practitioners to understand theoreticalresearch concerning human stress responses, appraisal, and copingin order to apply knowledge in practice when dealing with aclient who has experienced a crisis, stressful event, or evena disaster. A fundamental understanding of these concepts andprinciples will make it easier for mental health professionalsto guide their clients through the cognitive process towarda favorable result. In addition, the theoretical knowledge ofthis stress process can also be beneficial for clinicians touse as a basis for psychoeducational presentations when workingwith diverse client groups.
Coping and Positive Outcomes
Why and how is it that some people adapt, grow, or find personalbenefit from adversity, stressful life events, or traumatic
experiences? The literature on transformational coping afteradversity reflects increased attention in answering this question[Aldwin, 1994; Linley & Joseph, 2004]. In one review,
theauthors [Linley & Joseph, 2004] determined that growth aftertrauma or suffering [Tedeschi & Calhoun, 1995], positivepsychology
[Seligman, 2000], and other related terms are allfocused on the study of adversarial growth, that is, findingpositive impacts to dealing with potentially traumatic eventsor adversity in life.
Cognitive theorists are particularly interested in coping strategiesthat individuals use in specific situations to determine ifone way of coping under a given set of circumstances influenceswhether someone adapts in a functional or dysfunctional manner[Aldwin, 1994]. At present, there is a vast literature, whichdemonstrates the negative aspect of stress on physical and mentalhealth outcomes [Aldwin, 1994].
However, in many situations, there is no need to elicit copingstrategies to deal with a distressing event or situation. Stresscan be appraised as "healthy," especially when the stressoris perceived as a challenge, which can thereby influence individualsto be more flexible and adaptive in their response to stressors[Esch, 2002]. The positive nature of coping, the constructive,adaptive, and functional aspects, will now be discussed.
In Selye's [1956] stress model, he delineates that stress canbe helpful, as in the case of an event or situation being usedas a motivating force for an individual toward goal attainmentor life enrichment [Everly & Lating, 2002]. Helpful stress,or eustress, and destructive stress, or distress, are consideredby Selye to increase in relation to one another in order toattain greater human performance or well-being [Everly & Lating, 2002].When increasing stress reactivity reaches an optimal level [whichis different for each individual], then any additional stressoror stressful life event can promote the onset of a physiologicalprocess that can lead to disorder or disease [Everly & Lating, 2002;Selye, 1956]. From these early designations, it is seen thateach individual has the potential for events or situations tobe beneficial as well as harmful.
Differing terms are used in the literature to describe a favorableview of coping. Positive affect, as contrasted by negative affect,is defined as the ability to find the positive side of coping[Folkman & Moskowitz, 2000]. Reappraisals or reinterpretationsare appraisals with the resolution of an event as successful[Lazarus & Folkman, 1984], and positive effects are denotedas a positive outcome after a particularly difficult encounter [Aldwin, 1994].
According to Folkman and Moskowitz [2000], who posit three observationsregarding the study of chronic stress, "positive affect canco-occur with distress during a given period, positive affectin the context of stress has important adaptational significanceof its own and coping processes that generate and sustain positiveaffect in the context of chronic stress involve meaning" [p.648]. These compelling points note the relevance of positiveaffect in the coping process in studies with individuals inchronically stressful situations, yet the present examinationfocuses on a specific acute stressor, which is conceptuallydifferent in many ways and must therefore be defined.
The most defining aspect of the stressor that influences anindividual's coping is the temporal nature of these events orthe conditions under study. A particular encounter or eventcan be described as acute, whereas an ongoing demanding conditioncan be described as chronic. An acutely stressful event or stressoris therefore distinguished from chronically stressful eventsor stressors in that an acute event is defined by its time-limitednature. Hence, it is a specific event, at a specific time [Lazarus, 1999].Chronic stress is defined as an ongoing threatening condition,event, or role that impacts an individual and his or her lifecontinuously [Lazarus, 1999; Pearlin, Menaghan, Lieberman, &Mullan, 1981]. The empirical literature has focused heavilyon coping with chronic stressors [Aldwin, 1994; Folkman & Moskowitz, 2000;Pearlin et al., 1981], yet the study of coping with acute stressorsand early interventions following major stressful life eventshas increasing relevance for current mental health researchand practice today [Bonanno, 2004; Litz & Gray, 2002].
Returning to the significance of positive side effects of copingwith psychological stress, there is a great need for mentalhealth professionals to assess an individual's level of copingstrategies and the potential for positive growth in times ofgreat turmoil. A review of adversarial growth [Linley & Joseph, 2004]revealed that a number of cognitive appraisal variables, aswell as other coping variables [e.g., positive affect, problemfocused coping], were consistently associated with adversarialgrowth. Therefore, professionals that work with traumatizedpopulations or those suffering acute stress reactions from psychosocialstressors such as disasters may want to consider incorporatingan awareness of the perceived benefits that can result fromextreme distress [Tedeschi & Calhoun, 1995].
In community work and in many other therapeutic situations,individuals are in great need for preventive services [specificallysecondary prevention in the immediate aftermath of a crisis],both physical and psychological, in which to [a] encourage theuse of self-care strategies, [b] seek a midpoint between stressorsand stress reactions, [c] increase health promotion activities,and [d] promote disease prevention as the overall goal [Esch, 2002].In summary, crisis intervention and secondary prevention programs,trauma treatment, and clinical research can all benefit fromemphasizing the positive side of stressful events with a carefuleye toward the overall design and development of mental healthprograms and services for those affected by stressful life events,crises, disasters, or traumatic situations.
| Putting the Theoretical Pieces Together: Transactional Framework for Coping with Acute Stress Responses Following a Disaster |
The WTC disaster in NYC, Washington, DC, and Pennsylvania presentedus with a disturbing new way to conceptualize ongoing psychosocialstressors with personal implications—heightened vigilanceto possible terrorist attacks, generalized angst, and fear ofpotential threats to our personal and national safety.
In order to fully understand the implications that stress theorycan have on clinical practice, it is important to thoroughlyreview the theoretical concepts and how they specifically canrelate to actual stressful situations. How individuals appraiseand cope with a disaster offers a unique opportunity to studythis interaction of theory and practice.
This paper has reviewed the theoretical contributions of stress,appraisal, and coping theories and outlined the person–environmenttransactional framework while providing insight on the followingquestions: [a] Why do we need to assess individuals after adisaster? [b] Using theory, what do we assess for after a disaster?[c] Is there potential for a positive outcome following a disaster?
In reviewing the different approaches to stress theory, thetransactional framework appears to give the most comprehensiveguidelines to assist clinical professionals in working withindividuals experiencing acute stress following a disaster inthe community. As this theory outlines the ways in which individualsassess events or situations as psychologically stressful, itenables clinicians to develop therapeutic approaches and perhapseven design programs that take a client's thought processesand emotional responses into account. It also factors in theindividual's coping skills and overall coping mechanisms sothat mental health practitioners can help augment and effectivelywork with the individual's existing, but perhaps little used, coping methods.
In assessing the best approach to treating a client, it is alsobeneficial to understand the types of stressors and how it isdefined within the transactional framework. The understandingof whether a stressor is acute or chronic lends itself to amore thorough recognition of the responses and behaviors theclinician witnesses in the client. Once it is determined thatthe stressor can be categorized as acute, an understanding ofthe transactional interplay between person and his or her environmentcan help lead the practitioner to an appropriate interventionpoint.
Additionally, understanding the nature of appraisal allows clinicalprofessionals to also consider an individual's perceptions andhis or her preferred coping strategies as part of an overalltreatment strategy. An in-depth knowledge of the research findingson the significance of coping with various disasters greatlyenhances the chances that a treatment approach will be designedfor maximum effectiveness for the individual functioning withinthe disaster-affected community.
Building and executing appropriate treatment programs to helpclients manage acute stress will continue to grow in importanceas additional stressors are identified. Stress has become oneof the major factors impacting the quality of life today. Withthe rate of change accelerating in the face of advanced technology,unstable economic and social factors, and volatile global issues,clinical professionals will be called upon to step into moreprominent roles. Effectively handling events perceived as stressfulmay become one of the greatest tools in maintaining highly functioninglives. Consequently, knowledge on the topic will become increasinglymore valuable and indispensable.
| Implications for Clinical Practice, Administration, and Community Outreach: Assessment During Disasters |
"Start where the client is" is a challenge for mental healthprofessionals in times of disaster. Especially when the disaster victim may be calmly spray painting his or her name and contactinformation on plywood, staring wistfully at the scarred rollinghills where his or her trailer home used to be, or pleadingwith tear-swollen eyes at the lack of information released onthe missing or dead from authorities. The initial contact withcommunity members affected by a disaster requires interviewing,assessment, and problem-solving skills that are grounded instress, appraisal, and coping theories. This initial contactis of utmost importance as many people will only be seen inpassing conversations, moments of respite, or brief clinicalinteractions.
The ability to tap into the theoretical basis of one's clinicalpractice allows for an increased ability to consider variousoptions, quickly formulate solutions, and appropriately respondto client requests for assistance. Using the theoretical frameworkpresented here, clinicians should assess the physiological,psychological, and social stressors as well as strengths andresources that impinge on the individuals and their potentialfor continued functioning and well-being within the disaster-affectedcommunity.
Postdisaster, the coping strategies, skills, and repertoiresused to decrease distress assist in clinical assessment andintervention as well as in the design of prevention and crisisintervention services for the community. The use of theory inprogram planning and organizing by assessing the community-feltneeds can also guide decision making on the appropriate leveland type of services provided to the communities affected bya disaster. The location of crisis intervention services intraditional clinical settings shelters, visits by disaster mentalhealth workers or community outreach, require an assessmentof the local norms, culture, and stigma surrounding mental healthservices within the diverse populations in the impacted community.Knowledge of the macro- as well as microlevel issues is a necessaryfoundation to building the repertoire of skills clinical professionalsengaging in disaster mental health service delivery need.
Stress from disasters is not a new phenomenon, but with themedia's ability to bring current events into homes on a massivescale and a more complex, fast-changing culture, disasters andthe ensuing calamity have become a more common social issue.More pressure will be placed on clinical practitioners to designand implement result-oriented and evidence-based treatment methods.By combining an in-depth understanding of research and theorieswith practical knowledge about the client, mental health professionalscan create and effectively mobilize the environmental and individualresources for healing and treatment after disasters.
With a focus toward positive outcomes from adversity and howto move individuals from negative states of distress to resourcefulstates of coping, clinicians can establish more salient treatmentmodels for their client population. Stress is an underlyingreality to modern life. Learning as a society how to diminishits negative effects will have far-reaching implications fora healthier, stronger, and more productive collective future.
| Acknowledgments |
The authors would like to thank Keri Thomas for her assistancein editing the manuscript. Dr. Matthieu is currently receivingsupport from National Institute of Mental Health through aninstitutional National Research Service Award to the Universityof Rochester, Center for the Study and Prevention of Suicide[T32MH020061]. Conflict of Interest: None declared.
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