This paper is in response to the work being carried out in China by counsellors in the field. China on May 12th suffered its worse earthquake for 30 years measuring 8 on the Richter scale, causing at this time over 70,000 deaths and millions of people homeless and injured. The Chinese government’s response was mostly organized by the Party centrally from Beijing in servicing the immediate needs in the aftermath such as, temporary housing, warmth, food, water and rescue services. The central government sent some academic psychologists to the area who were ill equipped to understand the conditions there and certainly not trained in Critical Incidence Response. Most of the counsellors were volunteers many with less than one years training and most with no experience of Grief Counselling or Disaster Counselling techniques. The real time for counselling however will be in 6 to 12 months time when Post Traumatic Stress Disorder amongst survivors, rescuers and professionals will start to appear. The purpose of this paper is to help brief those counsellors who have no training or support before being sent to the disaster area.
All over China many counsellors want to go and show their patriotic duty and help the victims and survivors of the earthquake in Sichuan Province in the South of China. However most of these counsellors are ill-trained and ill-equipped to understand the nature of the disaster or their role in treating those caught up in the disaster area. In response to this in Shanghai I have been briefing groups of counsellors in Grief Counselling adapted to this special situation. In addition to this I am teaching immediate first-aid counselling for professionals. Little or no supervision is available to them in the area and so the only solution to this is peer group support by having regular meetings to relieve personal stress and anxiety. In the following passages I will talk about what we are telling the counsellors before they go to the area – often we only have two hours or less to prepare them.
Grief Counselling as adapted to the Earthquake:
* Grief is the physical, emotional, somatic, cognitive and spiritual response to actual or threatened loss of a person, thing or place to which we are emotionally attached. We grieve because we are biologically willed to attach. (John Bowlby, Father of Attachment Theory)
This quote from Bowlby, sums up the effect of grief in a general setting, however in a disaster where death is everywhere some special thoughts have to be added to the experience of survivors. We can in turn look at the stages of grief and see how they might apply to earthquake victims.
Stage 1: Numbness
At the moment the earthquake happened peoples initial stress reaction is to process the personal threat to one-self. Once survival is achieved the scale of death and destruction is apparent. Most people will at first just feel nothing, they cannot comprehend what is happening. Their immediate concern in the aftermath is their close relatives, many who did not survive. For children especially those born under the one baby policy – the death of classmates is as effective to their cognition as any other close relative as these relationships often replaced the normal sibling feelings that are absent in much of Chinese society. Most are standing around dazed and bewildered at this time not really processing any rational thoughts. There were so many after-shocks in the region that some remained in this state for some time vaguely wondering if after surviving the main quake they would be killed in the next one. Despite the numbness of feelings they never-the-less become highly sensitive to noise and sudden movement causing panic attacks to happen at the slightest changes.
Stage 2: Shock
Once they move out of numbness their cognitive abilities return and they start to realize the enormity of the event that has occurred. They go through the motions of action but with little purposeful use. Disbelief is the most common reaction in which they are questioning the reality of the situation and want to blank out the sights of death and destruction which is all around them. The may ask rescue workers what has happened even though it seems obvious – but they need a verbal conformation of the event. Physically they will be shaking, have labored breathing and an inability to work out even the simplest tasks asked of them such as their name and where they come from.
Stage 3: Anger
As they move out of the shocked state they start to become angry, counsellors are often unprepared for this as they find it hard to understand why someone they are trying to assist should shout and blame them for their situation or loss. The survivors need someone to blame, they often talk about God abandoning them, governments not warning them of the danger in time, rescue workers for not saving their loved ones, and the counsellors for trying to understand something the survivor believes is impossible for them to have empathy with, when they were not there and lost no-one.
Stage 4: Anxiety
Here the fear of personal survival may make the survivors overly-sensitive to noise, sudden movement and fear of their own death may still be imminent. Each after-shock brings fresh panic attacks and a fear response of personal survival. This sense of sensitivity can be seen even in areas unaffected by the earthquake as far away as Shanghai. For example a shop window shattered in down-town Shanghai a week after the event and all the people close to the incident went into a state of panic. In normal circumstances most people would have only been mildly curious to see the broken window fall into the street.
Stage 5: Loneliness
Once the initial sense of personal survival has passed then the realization that many are alone without their loved ones hits them very hard. Knowing your wife, husband or child has been killed and you survived brings a yearning for their return. Survivors are at a loss to know what to do next. How will they rebuild their lives, family and home when they are alone now and feelings of abandonment by their loved ones who died oppresses their thinking. Counsellors have to be very comforting to those at this stage and listen carefully to their grief, but to be careful not to let the victim become dependent on the counsellor as a substitute for those lost. Counsellors will at some point leave and may inadvertently make the sense of loss and abandonment even worse.
Stage 6: Fatigue
With only temporary shelter, basic food and water most survivors will be feeling emotionally drained and physically beaten. The search for the dead, the realization of permanent loss will all bring the person to feelings of utter despair in which the slightest exertion will defeat their reserves of energy. They will feel and act listless and unable to concentrate, they will have a lack of appetite or eat in a robotic style, and they will also suffer insomnia, troubled, disturbed sleep and nightmares. Their heightened sensitivity means they are constantly scanning the environment for danger and searching for the lost loved ones, even though they know they are now dead.
Stage 7: Yearning
At this time the survivors just want everything back to the way it was prior to the disaster. They find themselves wishing this had not happened and why can it not go back to the way it was. They will convince themselves that dead relatives or friends had somehow survived and will walk around the corner and tell them it was all a big mistake and they are alive after-all. This may happen despite overwhelming evidence to the contrary that their nearest are in fact dead.
Stage 8: Relief (Acceptance)
This stage will take sometime to achieve even in the strongest mentally of survivors. To feel some relief that it is all over and they have survived where others did not. Guilt may have to be worked through here as they feel that why did they survive when the young, the successful, the good person did not. They may question their own value and self-worth. This is the time for long-term mental healing as the victim accepts the situation and that the reality of the here and now exist and you have to move forward and live again. At this stage ritual is very important – to grieve again at anniversaries, birthdays, holiday times where the grief returns for a moment and recedes again after the event. The central government may have to initially dig mass graves to handle the dead, however in modern times they will be numbered and DNA tagged so that in time as relatives can give DNA samples they can identify the remains of their own dead and so rebury them in the traditional way and so as to start the acceptance stage of the grief processes. These rituals are of great importance to survivors to move on. National days of mourning, events in recognition and other rituals all help the nation to heal and move forward. As this is the year of the Olympics the opening ceremony should be radically changed to honor the dead from the earthquake and treat the events as a sense of respect for the dead and a sign of renewal.
Many of the survivors are children who are now homeless, orphans and have witnessed death and destruction for the first time in their lives. Psychologically they too experience the same stages of grief as any adult but unlike grown ups they cannot verbalize or express their shock and feelings directly. Counsellors here should try to engage the children in meaningful activities to help them express themselves through art, drawing and play. To listen carefully but not interpret directly to the child their adult comprehension of the event. Under no circumstance should you lie to them. If their parents are dead, tell them directly. Children in some cases can be far more resilient than the adult survivors who can cognitively assess their feelings and sense of loss. Children need to express this in more simple ways in a caring atmosphere with warmth and attentiveness but not with attachment from the counsellor. Counsellors must be aware at all times they will leave the child at some point and return to their own normal lives. The best situation for children is not therapy but routine. Routine involves regular sleep and rising times, meals at the same time everyday. They should sleep in small groups of no more than four if possible. They in this way will bond with the other children and not the adults around them. Children can be self-supportive in small groups and can assist each other in coping with the aftermath. In addition to this routine is a return to schooling – even if this is make-shift in tents – the sense of the familiar will help them to feel some normality. Activities such as art expression and paper tearing games can help children of all ages to express their stages of grief to the counsellors and teachers present. Many people around China are offering to adopt children whose parents have been killed but this should be approached with caution as many of these would-be parents are ill equipped to deal with traumatized children who later may develop Post-Traumatic-Stress-Disorder. (I will deal with this is a separate paper).
This group consists of those who have found that for the first time they are dealing with mass destruction and death. The soldiers in China have never seen combat, have no experience of real action in service or death. They are an army at peace and most of their time is taken up with civil duties and training. Now in the aftermath of the earthquake they are in the front line service in rescuing the victims buried in the remains of apartments, shops, schools and road landslides. Many for the first time are seeing crushed dead people and with horrific injuries in survivors. The initial reaction of the soldiers is fortitude, they are there to do a job, it is their duty to help and assist the professional rescue services and health professionals. In addition to the soldiers there are armed police, doctors, nurses, teachers, firemen, infrastructure workers such as electricians, gas workers, and other emergency personnel. Just like the soldiers they are busy doing their duty and carrying out the tasks assigned to them as efficiently as possible. However there is a price to pay for the diligence and holding in their feelings during the immediate crisis. In 6 months to 12 months time the fall-out from these helpers will become apparent. Many will suffer flashbacks in which in the daytime they suddenly imagine themselves back in the disaster area and re-living the horrors that at the time they coped with so well. Now however they are starting to fall-apart and find they are suffering from lack of sleep, appetite and concentration. They are now the victims of the earthquake in quite another manner – PTSD. After 9/11 in the United States many of the original emergency workers suffered stress reactions months and months, after their initial involvement in the disaster, in that day of terrorism. However the United States has well organized Employee Assistance Programmes in place to assist in the aftermath of critical incidences such as 9/11. This support actually forestalled many of the cases of PTSD in the USA. However here in China the EAP service is in its infancy and most government departments have no such support or plans to budget for them. This means in a few months time their will be no real support other than the under-staffed mental hospitals to cope with the many cases of PTSD that will certainly occur. Mental health problems are seen as shameful in China and many families hide the victims of mental breakdown and rarely seek help for them in case the neighbors discover their shameful secret. One indirect bonus of the earthquake may in fact be an increase in awareness of psychological services that can be accessed by ordinary people, although the costs in China still prevent most people from seeking help.
As I said in the beginning most counsellors in China are poorly trained and have little or no real long term experience of this type of event. In fairness although Western training is longer and more arduous many in the USA were also not prepared for the fall-out of 9/11. However British counsellors were more likely to have direct experience as terrorist bombings and constant overseas military action presents many clients with a variety of critical incidence events. In China the counsellors particularly need briefing before they go to understand the stages of grief, how they apply to this disaster and how to act with survivors. This can only be achieved if government supports the training both in monetary terms and the political will to support such activities. Sending unprepared counsellors may in fact cause more long term harm than good. Also counsellors need to understand the process of critical incidence response procedures in debriefing and defusing techniques to help indirect people affected by the quake. While much of this expertise is available from foreign experts very few University professors in China would have this knowledge and understanding except second-hand from Western texts. In China most professors in psychology and counselling are theorists with little or no practical experience in the field. So while they may give TV interviews and parrot book passages they are of little practical use to counsellors who need real hands on advice and supervision. Counsellors in the earthquake area should have daily peer support as supervision by experienced professionals is unlikely to be available. So they should group together each day and discuss worries and cases they have dealt with – seeking advice and support from each other. This is the best they can achieve here and in addition they must eat regularly, sleep when they can and take some light exercise every night after they have finished counselling for the day. A counsellor is of no use if they try to act the hero and work long hours with little rest. Fatigue sets in very quickly for some counsellors particularly emotionally. They should then withdraw for a time or leave all together as they may then be causing harm through a lack of concentration. Some counsellors are mentally ill-equipped to deal with this scale of loss and should withdraw quickly and realize there is no shame in not doing the work if you are not mentally strong enough.
I hope this paper will help those in China who are embarking on counselling but have no support or training and to give then some in-sight into the possible problems and difficulties they may encounter along the way. Many counsellors feel it is their patriotic duty to volunteer their services and feel a sense of duty to their countrymen who at this moment need them. However not every counsellor is strong enough or competent in this tough area of counselling and should think very carefully about going to the earthquake area and perhaps breaking down under pressure or simply by lack of understanding make matters worse for the survivors than no counselling at all. For most counsellors the work is still to come, as the grief process proceeds for survivors and professionals alike then they will be seeking counsellors to support and treat them in the future as PTSD takes hold of those who could not grieve or survive mentally the after-math of China’s huge earthquake which led to such a huge loss of life and property.