Community counselor

Community counselors provide counselling for traumatized communities in the aftermath of large-scale natural disasters. They are trained in basic psychological techniques but are not necessarily professional psychologists. While the concept of lay community counselors is not new, the most commonly known usage was implemented by Dr U. Gauthamadas in the immediate aftermath of the Super Tsunami of 2004. He organised a team to provide counselling for the thousands of survivors among coastal villages in the Cuddalore District of Tamil Nadu, India.

Introduction

The operations of the Academy for Disaster Management Education Planning and Training (ADEPT) in the aftermath of the Tsunami were focussed on fulfilling the needs felt for psychosocial intervention. Mindful of problems of entry into the ethnocentric fishing community, whose social fabric had been rendered fragile by the aftermath of the Tsunami, ADEPT was faced with the issue of dealing with the psychological trauma suffered by nearly 100,000 survivors in 51 hamlets and villages scattered across nearly 100 km of coastline. Counseling in emergency situations is a labor-intensive activity and at that time there was the dearth of trained personnel, especially at short notice.

The premise for the work undertaken by ADEPT in the aftermath of the Tsunami was that the human mind had been both the biggest victim and the strongest survivor and therefore trauma counseling was the greatest challenge.

While one may define trauma as a condition that overwhelms ordinary human life, we must also recognize the different psychological needs in cases of individual and collective trauma. The model of crisis intervention adopted by ADEPT includes the following:

• the need for developing an alternate model for dealing with the psychological trauma of survivors in the aftermath of the Tsunami.
• the model of lay community counselors that ADEPT has evolved with lessons learned in the field.

The Challenges

A community may be defined as a group of people with a sense of common history, language, race, mores, values, attitudes, knowledge structures, and purpose. However traumatic events, such as a natural disaster, spawn new “transitory communities” and establish new dynamics that transcend natural communities. In such transitory communities the blow is not just to the individual psyche, but to the tissues of social life and the bonds that bind these communities together.

The 51 Tsunami affected villages in Cuddalore District, Tamil Nadu, are geographically removed from urbanization. These villages had not been exposed to the effects of Globalisation before the Tsunami. The fishing community, in these villages, is a very “closed community” that does not broach interaction even with neighboring communities except for their trade. Therefore the biggest obstacle to any kind of psychosocial intervention was the community’s lack of openness to “outsiders”. This accentuated the role of ethnocentricism that has been recognized as the single most powerful impediment to trauma counselling and which probably represents the vestiges of an ancient avoidance of strangers (Chemtob,1997). Thus such “closed communities” tend to assume that their experience of the world “is the world”. An influx of the “outside world”, such as in the aftermath of a natural disaster, could be an impediment or an advantage. It could either make the community withdraw into itself, or develop a bond with the outside world that has seen and experienced a similar peril. According to the National Organization for Victim Assistance (NOVA), Washington, D.C, likelihood of defensiveness will be high, based on pre-exposure conditioning, due to the need for security and social resonance. The fishing community in Cuddalore district had been closed to differences for centuries. Their ethnic identification was an irreducible entity, central to how the people in that community organized experiences. They used a unique "cultural prism" (Parsons, 1985) in perception and evaluation of reality.

Ethnocentrism is central to understanding help-seeking behavior, what the people in the community define as a "problem," what the individual understands as the causes of psychological difficulties, and the unique, subjective experience of traumatic stress symptoms (Parsons, 1985). Cultures also create meaning systems that explain the causes of traumatic events (De Vries).

While the threats to life associated with psychological trauma are universal, the perception and interpretation of the threats varies across cultures including: the perception of what type of threat is traumatic, the interpretation of the threat's meaning, the nature of the expression (presentation) of symptoms in response to such threats, the cultural context of the responses of traumatized people, as well as the cultural responses by others to those who have been traumatized, and the culturally prescribed paths to recovery from experiencing life-threatening events. Finally, it is also useful to consider the process by which the exposure of individuals and groups to traumatic events is made useful for the entire culture (The National Organization for Victim Assistance, 2003). According to Chemtob (1997), all this is not possible to grasp for newcomers who enter the community for the first time in the aftermath of a disaster, and may not be possible even for those who are professionally trained, to understand in the emergency situation.

Another barrier to counseling in the aftermath of a disaster is language. Language differences and patterns among diverse cultures are common and complicated. The national languages, and even the nuances of local dialects spoken, weave into the delicacy of working with local communities, who are little exposed to the world outside. One can learn Spanish, English or Russian but not understand the synthesis of verbs, nouns, adjectives, adverbs and phrases that result in common understandings among those who are a part of the culture. Languages including regional dialects dictate how one forms ideas, translates sensory perceptions, and interprets the world. The phrasing, silences, speed of delivery, and pitch or tone of voice, even when using the same word or phrase, means different things to different people and form the crux of the counseling skills. (The National Organization for Victim Assistance, 2003).

While interpreters can be used, training is needed for speaking through an interpreter. Interpreters or translators contribute to the ambiance of any crisis setting. They become the interpreters not only of the survivor but also of the intervener. In some cultures it may be appropriate for them to translate with additional flair. In other cultures such interpretation may be offensive. In the counseling situation such differences alter the healing relationships (The National Organization for Victim Assistance, 2003) In any case such training was not possible in the immediate aftermath of the Tsunami.

In a post disaster setting the counselor, besides meeting the basic needs of the affected individuals, needs to understand the grieving process and psychological trauma, and the needs of the survivors in a culturally appropriate manner. Also counseling of disaster survivors may require to be undertaken in informal settings. A supportive conversation or a focused problem-solving session during a casual home visit could very well be a counseling session.

Last, but not the least, counseling has proved a challenge in India even to contemporary Indian families (Kashyap 2004). While the average Indian is ready to accept physical explanations for symptoms of psychological trauma, they are less likely to attribute psychological origins to them and therefore less amenable to formal counseling.

The Approach

Quick deliberation in the emergency context resulted in a decision to adopt a lay community counselor model to deal with these challenges. Lay counselors are members of the community who are trained to provide a specific service or to perform certain limited activities. The concept of lay / community counselors is not new.

A large number of agencies outside of India, particularly in the United States and United Kingdom depend on the volunteer sector for counseling services (Bond, 1993). Therefore the strategy adopted by ADEPT was of community based counseling using volunteer lay community counselors who share a significant aspect of their background–culture, language and experience primarily - with the affected community .

Members from the affected communities, and others closely interacting with the local population such as teachers, government personnel etc., can be highly effective to reach out as community counselors as they represent the groups they are serving, and can readily gain access to them. This model works by strengthening the existing social support networks.

Lay counselors have been used in counseling of drug addicts, people living with or at risk for HIV / AIDS etc. Experiences have showed that paraprofessional counselors, who would work effectively in their home-community, can be produced with short-term training. Gluckstern (1972) reported success of a 60 hour training of parents as lay counselors. The study evaluated the effect of the program on the trainees with regard to knowledge and attitudes, the effect of the training upon the trainees with regard to counseling skills acquisition, and the role the trainees played in the community seven months after training. The results of the study indicated that the trainees did in fact learn the skills taught and did maintain them over a period of time. Peer counselors have been found to be more effective than regular professional care (Malchodi et al., 2003)

ADEPT’s community counselor overcame the issues of entry into community, those related to ethnocentrism, and the shortage of resources, by training members from within the affected community. These same counselors were especially effective as they were involved in the relief and recovery operations after the disaster.

Keeping in mind the limitations of the organization and the available resources the goals of the training were simple

• To train local volunteer community counselors in immediate crisis response and basics of trauma counseling.
• To help the community counselors to support survivors in their efforts to respond to the effects of Tsunami.
• To assist the counselors plan their activities in the aftermath of the Tsunami.

The participants were trained in the psychological effects of disasters, and simple guidelines with sample techniques to handle them, including vignettes and an assignment to design sample action plans targeting different situations. Training methodology was short interactive lectures combined with interactive group work and participatory plenary sessions. Training duration was three days. The entire training was conducted in the vernacular using simple language and avoiding technical terms and jargon. The design of the program included the preparation of the training module, identification of the target group, planning duration of the training and its methodology and post training professional support. The module was formulated for purposes of exigency and the material adapted from several open source documents. Training commenced on 11 January 2006. The training team included a psychiatrist, a psychologist, a trained counselor from the Arcot Lutheran Church and an aid worker, of the National Lutheran Health and Medical Board, trained in trauma counseling in aftermath of Gujarat Earthquake

The participants of the program were several members associated with the local communities, and grass root level leaders, especially those who have already been providing supportive service to the affected community prior to the Tsunami such as:

• Village Health Nurses and Health Inspectors
• Teachers
• Self Help Group members
• Youth Leaders
• Leaders of faith based organizations
• Community leaders
• Disaster Response workers

The expected outcomes of the training included basic skills of counseling such as the capacity:

• To understand reactions to trauma,
• To listen and help survivors to ventilate,
• To help survivors find privacy for the expression of emotions
• To support survivors in their efforts to achieve a sense of emotional safety by reassuring them that their reactions are acceptable and not uncommon,
• To help survivors begin to take control of the events going on around them
• To assist survivors in handling the practical issues that will face them in the aftermath of the Tsunami.
• To identify survivors with severe psychological problems and refer them to qualified experts/professionals.

The Training was designed for a three-day period to quickly equip the volunteer community counselors with the basic skills of counseling. Thereafter additional support and hand-holding was provided through fortnightly follow up half-day sessions over a three-month period that was participatory and interactive.

The Community Counselors took the initiative to sit and talk with the survivors, listen to them and be a part of their loss and this was immensely helpful. The survivors needed someone to empathize with them and it was not always the monetary part that mattered. The community counselors provided counsel by

• handling the bereaved through supportive interaction,
• handling the children through play, and interactive and creative activities such as enacting plays, composing poems, singing songs, dancing and music etc. with the themes of “goodness of nature”, “tsunami is transient”, “we shall overcome” etc.
• public education and awareness of the nature of the tsunami
• problem solving and supportive activities

The follow-up meetings have shown that the training produces efficient and expeditious results. The referral pattern was good and it was observed that the community counselors developed culturally appropriate interventions that were effective and methodologically diverse for every group. These have been documented as case studies. The trained volunteer community counselors helped to provide structure and calm in the midst of the chaos in the aftermath of the Tsunami.

The methods used among the adult population were case specific, innovative and adaptive such as:

• the ten-year-old boy who was brought out of his grief (for the six-year-old sister snatched from his hands by the Tsunami) by being asked to mother a plant.
• systematic desensitization of the fear of the sea by regular visits to the backwaters for a bath
• diverting attention from the tragedy by engaging the affected person in activity to restore normalcy to life.

The examples of cases referred to professionals were also indicative of the confidence of the community counsellors–both in the counselling process and in realizing their own limitations

The design of the program and the associated advantages of the model were many including:

• Less dependence on experts
• Cost effectiveness
• Ensured local community participation
• Ready entry points with the additional benefits of shorter time frames, easier
• Identification of needs, easy rapport, and effective communication,
• Enhanced stature of the community counselors in the affected communities due to their continued presence and participation in recovery and reconstruction activities.

Effectiveness

Focus group evaluations were conducted 8 months and 16 months after the training. The study elicited the long-term effects of the training from core groups of community counselors, including the knowledge and attitudes, the effect of the training upon the trainees with regard to counseling skills acquisition, and the role the trainees played in the community immediately after the training and at the time of evaluation. The core groups consisted of teachers, health inspectors, youth leaders, and nursing personnel from the education and health departments at the district level. They included those who had undergone ADEPT’s community counselor training as well as those who did not.

Several post training benefits of the training were elicited. All those who had undergone training felt that the training had a positive impact on the quality of ameliorative assistance provided by them immediately after the tsunami, when compared to the assistance given by their colleagues and peers who had not been trained.. Many felt they could cope better both personally and professionally. They felt that the training enhanced their skills in interpersonal relationships and helped them to be more insightful in their work. The major points that were repeatedly mentioned by the majority of participants of the training include the following:

• A capacity to reach out to communities better than in the past.
• The confidence that they could translate learning into practice.
• A distinct difference between those who had been trained and those who had not. While those who had been trained coped well with post tsunami daily life crisis, those who had not floundered.
• Personal benefit as they ventilated during the training, rendering their own healing process much faster.
• The internal transformation produced by engaging the adults in re constructive activities.
• The acquired ability to train co-workers on psycho-social intervention
• The benefits of “venting” their feelings and sharing their experience with other community counselors during the post training contact programs, that helped them cope with the stress that came with handling grief-stricken survivors.
• The perceptible sharpening of innate qualities that are a natural part of any individual such as listening skills, use of questions, even reflective silences

All participants felt that the duration of the training in the opinion was adequate for the work done. The study also indicated that even 16 months after the Tsunami those who had not undergone ADEPT’s training were unable to cope with crises that they were faced with such as the Tamil Nadu floods, the bird flu scare etc., while those who were trained could narrate in depth how they handled those affected. More than half of the trainees felt competent to identify and refer cases they were unable to handle to experts and several who were from the Public health department were aware of the services available and frequently referred them to experts.

The participants felt that while the training provided guidelines without in-depth training in techniques, this helped them innovate and develop their own tools of practice as they went along. One recurring comment that came from the focus groups was that healing and transformation for adults was helped immensely and in some cases expedited by their continued involvement in physical aspects of reconstruction. The respondents requested reading material or training in areas not covered by the contents of training such as techniques to handle the guilt of survivors. The depth of the grief experienced by the older person who survived while younger members of the family perished was something most of them felt unable to cope with. They also expressed the need for further refresher courses which would incorporate more depth knowledge in areas related to child psychology, grief counseling, counseling the elderly etc. This indicates a recognition of the value of training by the participants.

Dr. Gauthamadas followed through by bring out a manual for Community Counselors in March 2005 which has been well received. There have been requests by several organizations (including the UNDP) for their reference and use in the field. ADEPT has gone in for a third reprint of the manual to meet the growing demand for the manual.

The contents’ of ADEPT’s training can be said to have been validated by the manual distributed to the schools by the Department of Education in April 2005 which laid out guidelines that were in keeping with the framework laid out in ADEPT’s training sessions. Conclusion

Dr. Gautham’s model has been to train volunteers from within the community in psycho social care through individuals who have been care workers for their community. In doing so, ADEPT successfully utilized the strong interconnectedness of individuals within the affected community.

References

• Bond, Tim (1993). Standards and Ethics for Counselling in Action. (Sage, London.)
• Chemtob, C.M., "Posttraumatic Stress Disorder, Trauma, and Culture", International Review of Psychiatry, Volume 2, Chapter 11
• Community Crisis Response Team Training Manual, The National Organization for Victim Assistance, 2003
• De Vries, M.W., "Trauma in Cultural Perspective", in van der Kolk, B.A., McFarlane, A.C. and Weisreth, L., Traumatic Stress.
• DeWolfe, Deborrah J, Training Manual for Mental Health and Human Services Workers in Major Disasters, Ed: Nordboe, Diana, Substance Abuse and Mental Health Services Administration, USA, 2000.
• Ehrenreich, John H. and McQuaide Sharon, Coping with disasters: A guidebook to psychosocial intervention, Revised edition, Center for psychology, State University of New York, 2001
• Gluckstern, Norma B. Parents as Lay Counselors: The Development of a Systematic Community Program for Drug Counseling, Education Reources Information Center, 1972
• Kashyap, Lina, Introduction to this Special Issue, International Journal of Advancement of Counselling, 26:4, 2004
• New South Wales Institute of Psychiatry, Disaster Mental Health Response Handbook, 2000
• Malchodi Carolyn S., Oncken, Cheryl, Dornelas; Ellen A.; Caramanica, Laura, Gregonis, Elizabeth; Curry, Stephen L., The Effects of Peer Counseling on Smoking Cessation and Reduction, Obstetrics & Gynecology 2003;101:504-510
• Parsons, E.R., Ethnicity and Traumatic Stress: The Intersecting Point in Psychotherapy, in Trauma and Its Wake, ed. Figley, C.R., Brunner/Mazel: New York, 1985.
• Rocky Mountain Disaster Mental Health Institute, Crisis Intervention Training for Disaster workers