Crisis Intervention in Rural Communities: A Cultural Catch-22
Susannah Bock and Clark D. Campbell
Distinctive features of rural communities create difficulties for mental health practitioners in providing adequate mental health care in the aftermath of a trauma. A “catch-22” is encountered in rural communities where there is a scarcity of psychological services available, yet residents in these communities may refuse services that come from outside the community. The authors describe a case example in which they were in a remote community and witnessed a traumatic event affecting many local residents. Even when mental health professionals were available, the residents tended to seek support for post-traumatic symptoms from traditional sources, such as the local church. Recommendations are made for local service personnel in rural communities to be trained in critical incident stress interventions, and for mental health practitioners to be sensitized to the cultural distinctives of rural communities .
INTRODUCTION AND LITERATURE REVIEW
In the aftermath of a traumatic event, rural communities face a two-fold challenge in the provision of adequate mental health services. Firstly, there is a well-documented scarcity of trained mental health practitioners in rural communities (Bergland, 1988; DeLeon, Wakefield, Schultz, Williams, & VandenBos, 1989; APA, 1999, 2000; Stamm, 2003). Secondly, recent studies suggest that cultural issues in rural communities may indicate the need for modification of traditional crisis intervention strategies for them to be relevant (Campbell, 2003). This situation presents a quandary to urban practitioners who seek to provide on-call crisis services to communities in need: while there is a desperate need for mental health services in these underserved communities, cultural factors in rural areas proscribe that the most effective interventions will be made by individuals who are already residents of the community. Just as for any intervention within a defined community, members of the community trust those within more than those outside the community. When it comes to crisis intervention within a defined community, it is more likely that resources will be overwhelmed quickly and thus trust issues will rise rapidly for the whole community.
In a small, isolated community, it is more likely that an event of any scale will affect the community as a whole, given the closer relational and societal ties between individuals in rural areas when compared with urban residents (Keller & Murray, 1982).
A literature review of the mental health needs of rural communities concluded that while certain kinds of psychopathology and deviant behavior are found at higher incidence rates (notably alcoholism, domestic violence, and depression amongst women), formal psychological services are often minimal or non-existent in these communities (Campbell, Gordon, & Chandler, 2002). Given this lack of services for chronic conditions, we are left to hypothesize about the response within these communities to traumatic events, both natural and human caused. What psychological resources are available for rural residents when a tornado rips through town, a teenager commits suicide, or a fire burns down a local residence? In the absence of trained mental health professionals, Fox, Merwin, & Blank (1995) suggest that residents turn to traditional sources of support, i.e., churches, schools, and general practitioner physicians.
Campbell (2003) and Campbell & Gordon (2003) suggest that mental health treatment in rural communities needs to be sensitive to the unique worldview that underpins rural cultures. He notes that there are “internalized value and attitudinal differences” between rural and urban communities. Keller and Murray (1982) write that these value differences include “an emphasis on hard work and mastery of the physical environment, an emphasis on the importance of family and community ties, an orientation toward traditional moral standards and conformity to group norms” (p. 8). These cultural distinctives may indicate the need for a modified approach to mental health treatment and crisis intervention in rural areas. Specifically, interventions that do not address a religious interpretation of a critical event, that are insensitive to the community-wide effects of the event, or are insensitive to group norms may be experienced by rural residents as “missing the point”.
Of course, it is a gross overgeneralization to posit that all rural communities are the same. However, while rural communities may be vastly different from one another, in general, there is likely greater homogeneity within specific rural communities than within urban ones. Therefore, while one rural area may struggle with high unemployment, and another with a proliferation of methamphetamine labs, these issues will tend to affect all individuals within each specific community at a higher level than in an urban community, where community problems tend to be more diffuse.
Hiley-Young & Gerrity (1994) make an important distinction between “critical incidents” and “community-wide disasters”. They note that a community-wide disaster (such as a hurricane that destroys entire city blocks) is fundamentally different from a more isolated critical incident. They write,
“Unlike most critical incidents (such as shootings, on the job accidents, etc.), community-wide disasters involve
the political, cultural, and economic past of an affected community. These historical factors converge with the
disaster itself (the number of deaths, physical and systemic destruction, relief and recovery efforts, etc.) to shape
the future of the community and the individuals who live there.” (p.3)
We propose that in small, rural communities, many events that would be isolated “critical incidents” in urban communities, are likely to have psychological and sociological effects more akin to the community-wide disasters described by Hiley-Young and Gerrity (1994). For example, in a metropolitan area, the effect of a homicide may be isolated to the victim and his or her immediate social circle, which may or may not be geographically centralized to the location of the incident. In contrast, in a small community where residents are more homogenous, with similar value systems and shared community ties (Keller & Murray, 1982) this event would have significant ripple effects throughout the community. This suggests that the response of mental health practitioners or those trained in crisis intervention in the rural community should address traumatic incidents in a manner that takes into consideration the greater community at large, while also addressing the immediate psychological symptoms related to the trauma. This raises a host of new issues related to the practice of rural psychology. Jambois-Rankin (2000) notes in a comparative study that in rural areas, first responders tend to have a greater knowledge of critical incident stress debriefing interventions than their urban counterparts, but that they are often at greater risk for vicarious traumatization by a traumatic event, given the higher likelihood that they will be caring for victims that they know personally. This also raises the concern about multiple relationships that is omnipresent when providing mental health services in rural communities. Hargrove (1986) describes this as yet another “double-bind” inherent to rural mental health work, in which multiple relationships can lead to tensions between service providers, in an area where such services are scarce and compatible relationships are most important.
Campbell and Gordon (2003) provide guidelines to consider when faced with multiple relationships in rural practice.
Given the need for crisis intervention in rural communities and the dearth of such specialists in these communities, it is likely that most crisis responders come from larger metropolitan areas to the rural communities. This creates a cultural catch-22. Described by novelist Joseph Heller (1961), a catch-22 has come to be defined as “a problematic situation for which the only solution is denied by a circumstance inherent in the problem” (Merriam-Webster, 2004). The rural communities need assistance and intervention beyond what they have at times of crisis, but these communities are served best by those who understand the community and preferably those who already live in the community. Thus, is it wise to focus on training specialists who are community outsiders to do this work, or is it more appropriate to provide specialty training to rural community leaders who can provide this service within their locale?
In light of the need for a more integrated community response in rural areas, local residents trained in appropriate interventions may in fact be the most qualified individuals to provide crisis intervention in these communities, as they can respond in a holistic manner to the larger concerns raised by the disruption of the social structure of the community. However, while rural teachers, pastors, and first responders can be trained in certain crisis interventions, trained mental health professionals from larger communities who are sensitive to the cultural distinctives of the rural community likely will be needed in the aftermath of a disaster or critical incident to provide ongoing care, and to identify those in need of further services.
Critical Incidents, PTSD and
Critical Incident Stress Debriefing
The psychological result of witnessing or experiencing a traumatic event is well documented. The National Center for Post Traumatic Stress Disorder (NCPTSD) fact sheet cites data that 8% of men and 20% of women will develop symptoms of PTSD following exposure to a traumatic event, and of these, approximately 30% will develop chronic symptoms that may affect them throughout their lives. Therefore, between 3% and 6% of individuals exposed to a traumatic event will suffer chronic symptoms of PTSD throughout their life. Lifetime incidence rates are estimated to be approximately 8% amongst the general population (NCPTSD, 2004). The current article addresses the potential development of acute and posttraumatic stress disorder as an after-effect of witnessing a traumatic event. However, other reactions to trauma, such as depression, anxiety, uncontrolled aggression, and substance abuse are common responses to trauma exposure that may also face the “catch-22” of mental health service provision in rural areas. It should be noted that while PTSD and other psychological disorders may result from involvement with a critical incident or traumatic event, studies suggest that more than 90% of all people who are involved in such an event do not develop symptoms of a psychological disorder (NCPTSD, 2004).
Nevertheless, psychological symptoms of trauma extend beyond the primary victims of an event, and are experienced by witnesses to the event, those who felt themselves vulnerable to the event, and vicariously by first responders to traumatic events. First-responders to traumatic events in most communities are often by-standers, co-workers, or family members, who arrive even before rescue crews and police (Lewis, 2002).
Critical Incident Stress Debriefing (CISD) models were first developed over two decades ago for application within the workplace for prevention of the vicarious traumatization experienced by first responders such as emergency room nurses and doctors, police officers, and firefighters (Mitchell, 1983). As conceptualized by Everly (1995), CISD is a seven stage process that occurs in a group setting with individuals who have been affected by the event. The first stage informs participants that CISD is “not psychotherapy”, but is an intervention for proactive reduction of posttraumatic symptomatology. The seven stages are designed to create a cognitive, behavioral, and emotional framework for the event, in a manner that normalizes and re-frames the event in a de-pathologized manner for the victim or witness. It also serves as a venue for the leaders of the intervention to identify individuals who display maladaptive coping strategies and symptomatology congruent with a need for follow-up services.
Since its development, the use of CISD has been expanded for use with primary victims of trauma for the amelioration of symptoms related to the development of PTSD. This expanded use of the treatment is highly disputed, with conflicting evidence of its effectiveness in this broader application (Dyegrov, 1999; vanEmmerick & Kamphuss, et.al., 2002). In general, it appears that recipients of a single session of CISD usually affirm that the intervention was helpful and cathartic in the aftermath of a traumatic event. However, epidemiological studies do not show significant reductions in the incidence of PTSD symptoms amongst recipients of CISD when they are compared with individuals exposed to similar traumatic events who did not receive CISD (Humphries & Carr, 2001).
A meta-analysis of studies related to psychological debriefing describes seven studies in which no effect was found, five studies in which a negative effect was found, and six studies in which a weak positive effect was found regarding the efficacy of psychological debriefing interventions in reducing acute and chronic post-traumatic stress reactions (Arendt & Elklit, 2001). The potentially negative impact of CISD interventions has also been documented by vanEmmerik, et.al., (2002). The negative effects of the debriefing intervention have been attributed to the hypothesis that the debriefing alters the natural process of recuperation, and that individuals who would otherwise have been able to metabolize the effects of traumatic exposure become sensitized to acute stressors (vanEmmerik, Kamphuis, Hulsbosch & Emmelkamp, 2002). Advocates of single-session CISD argue that the most effective response to trauma involves CISD as “one component of a comprehensive multicomponent crisis intervention program” (Lewis, 2002, p. 24).
Alternate interventions following exposure to traumatic incidents include brief (usually 4-6 sessions) cognitive behavioral therapy for individuals who are identified as displaying maladaptive coping strategies following a critical incident (Bryant, Sackville, Dang, Moulds, & Guthrie, 1999). Whatever the intervention might be, we argue that in a rural community, it will need to be implemented with sensitivity to the cultural distinctives of the community.
“Why Didn’t God Protect Us?” A Case Example
In September 2002, we participated in an event that vividly illustrates the various dimensions of psychological crisis intervention following a traumatic event in a rural community. We were invited to participate in a health fair in a remote coastal community in Northern California that was being held at a relatively large local church.
This health fair had been held annually for two years, was well-attended, and endorsed by the city counsel as an act of care for the city’s needy. The population of this town was underserved, and suffered from a high prevalence of alcoholism, domestic abuse, homelessness, and crime. Due to its isolation, the town offered limited venues for educational or occupational advancement. With recent decreases in local fishing and logging industries, the only major employers in the area were the service and tourist industries and a nearby maximum security prison. The health fair provided free services typically unavailable to many of the community’s residents. Services included brief medical examinations, dental checks, and hair-cuts, along with boxes of food and clothing. Our team, which was composed of graduate students in a doctoral program of clinical psychology, and one licensed clinical psychologist, was slated to provide psychoeducational training. We prepared brief training modules on such topics as parenting skills, anger management, substance abuse, etc.
On the morning of the event, hundreds of local residents were lined up at the gate of the fair anticipating its opening, and when the gates opened, the parking lot in which the event was being held was soon packed with people who streamed past the various booths. Within minutes of opening the gate, an SUV driven by an 85-year old woman lost control in the parking lot. She crashed her truck into multiple vehicles in the lot, and then when she was pointed towards the crowd, slammed on the accelerator mistaking it for the brake, and hurtled directly into the mass of people and booths, running over some twenty individuals, many of them children, before crashing into the side of the church. In the aftermath of the event, chaos reigned, as individuals frantically sought out their family members or loved ones, and as people tried to assess the extent of the injuries and damage. Bodies were strewn across a broad swath of pavement covered with pamphlets, supplies, and destroyed paraphernalia. Approximately sixteen people were hospitalized, and one woman died at the scene. Thankfully, no member of our team was injured.
Emergency first responders arrived within minutes to remove the wounded, and to impose a semblance of order. When the Red Cross was contacted so that they could send mental health counselors, organizers of the event were informed that there were no counselors available for this remote community at the time. It soon became clear that our team’s intended job at the health fair needed to change course. One advanced doctoral student amongst our team had recently returned from an intensive training in CISD, and after a brief check-in, she and the psychologist on our team quickly taught the other graduate students the essentials of providing crisis intervention to individuals at the fair. We faced the issue of attempting to transcend our own shock and fear in order to provide services to the community. We formed small groups, and residents of the local community were encouraged to participate in an informal de-briefing, and to return to the church the next day for follow-up processing of the emotion and trauma related to the event. It should be noted that we did not implement formal CISD interventions, although we did encourage people to talk about their experience of the event.
The residents of the community displayed multiple responses to this traumatic event, ranging from rage and panic to cynicism and fatalism. Some mentioned that they thought they had been purposely targeted in a hate crime against the town’s poor and homeless residents. Alternately, many individuals sought to explain the tragedy in terms of their religious faith. The event was interpreted by many as an “attack” by evil forces upon the efforts of the church to provide services to the poor. In addition to residents of the community who had come to the health fair in order to receive services, a large percentage of people who witnessed the event were local volunteers from the church where the event was held. These volunteers had invested hundreds of hours into planning and organizing the event, and to have their efforts of goodwill destroyed by a senseless and violent act placed the event in a highly negative emotional context. Many of these volunteers expressed feelings of rage, grief, disbelief and intense disappointment at the dramatic reversal of their intended plans.
Our team encouraged all victims and witnesses of the tragedy to talk about their experience, and we provided brief psychoeducational advice to parents dealing with children in the aftermath of trauma. We also attempted to flag individuals who seemed particularly disturbed by the event, and encouraged them to return for further services the next day. The next morning, hundreds of people converged upon the church, and small groups met again, led by members of our team. We sought to normalize expected symptomatology related to coming into close contact with a life-threatening event, and to encourage coping strategies such as sharing their experience with trusted confidantes.
We observed that many people seemed naturally resilient to the acute psychological effects of the event, while others were more obviously confused and distraught. Those with more limited coping strategies appeared to have more difficulty containing the event as an isolated incident. Instead, they tended to see it as evidence of the ultimate dangerousness and unpredictability of the world. While these are merely anecdotal observations, they speak to the potentiaL for many individuals to successfully cope with trauma without psychological debriefing.
As important as our own intervention in this community was, the spiritual interventions made by leaders of the church where the event occurred seemed to be most significant. It was clear that in the absence of formalized mental health services, residents of this rural community depended upon pastoral care for respite. This rural community probably is not unique in its dependence upon religious institutions to provide meaning in times of traumatic stress, but there are other cultural factors beyond spiritual ones that may be distinctive to specific communities that will best provide the context for giving meaning to events such as these. These cultural factors will be dependent upon the “character” of the community; it’s cohesiveness, homogeneity, dominant ethnic group, and local economy, to name a few. The ultimate goal of most crisis intervention strategies are threefold: 1) to combat feelings of helplessness and powerlessness amongst victims and witnesses, 2) to reduce feelings of responsibility for the event, and 3) to contain anxiety about the event within the confines of the debriefing process (Everly,1995). Our team of mental health professionals was effective in normalizing the stress and trauma that individuals were experiencing. I believe that we also served a purpose in helping the community members to feel some power over the event simply by talking with others and sharing similar thoughts and feelings. Although containment of anxiety over such a horrific experience occurs over time, the start of a containment process was initiated through our brief interventions.
The function of psychologists within a rural community should be seen in the broader cultural context of the local community, which in this case viewed the church as part of the de facto local mental health system. The majority of residents seemed to find the deepest solace and reduction of their anxiety by turning to explanations of the event offered by the church. Our team of graduate students modeled the structure of forming small groups to discuss the event. While the ultimate interpretations of the event that community members generated may have been spiritual in nature, the format of small, non-judgmental groups in which each individual was able to discuss his/her own experience without interruption was the contribution of our team.
This suggests that crisis intervention in rural communities, where incidence of traditional Christian belief systems are more prevalent (Campbell, Gordon & Chandler, 2002), may be significantly different than in metropolitan areas where events may be interpreted according to a non-religious worldview. Debriefing strategies may need to integrate spiritual features along with cultural sensitivity to community norms to achieve maximum efficacy.
Our team of psychological trainees left 36 hours after the critical incident, and while we were able to provide a meaningful service by addressing some of the immediate psychological symptoms that surfaced in the aftermath of this tragedy, in the days, weeks, and months afterward, those affected by this event turned to the church and other local resources (primary care physicians and family) for support.
The effects of trauma can have a profound impact on the functioning of entire communities. In a rural community, where the societal “root system” is closely intertwined, the malfunction of one piece of the community can affect the whole. Unprocessed trauma can result in greatly reduced functionality in individuals, particularly when PTSD symptoms lead to further issues such as substance abuse and domestic violence. Crisis intervention for psychological crises in rural communities is key to maintaining the healthy function of these communities as a whole. However, given the paucity of trained mental health professionals in rural areas, the provision of adequate services in underserved areas remains a challenge. In addition, given certain cultural distinctions of rural communities described above, any mental health practitioner who comes into a rural area to provide crisis intervention may find their work complicated by the rural worldview that may be loathe to seek services from “outsiders”. These barriers to treatment suggest several options for adequate treatment in rural communities.
Psychologists, mental health practitioners, and lay counselors who are called to provide crisis intervention in rural communities should consider the following:
Be aware of the broader cultural implications of any given event. They should seek to understand a crisis from a systemic approach, taking into consideration the web of individuals who are affected by a critical incident, and the historical context in which it occurs. This awareness could be facilitated by the creation of a standardized protocol for use by mental health professionals who go to rural communities to provide crisis intervention. This protocol could include a list of culturally-sensitive questions that could facilitate the professionals’ understanding of the distinctive character of the community they are entering to serve. For example, it could briefly list suggestions for sensitive ways to inquire about the potential religious or community-based factors that would be influential in understanding a traumatic event. Such a protocol could be distributed to the Red Cross and other bodies that would be involved in the provision of crisis intervention services in the case of an emergency in an underserved community.
Seek to understand the religious, economic, and political worldview of the communities in which they serve. This knowledge may profoundly affect the manner in which traumatic events are interpreted and understood by residents of the community affected by the event. Recent APA publications addressing the integration of spiritual resources in psychotherapeutic interventions may facilitate this understanding (cf., Miller, 1999; Sperry & Shafranske, 2004).
APA publications dealing with the cultural distinctives of rural provision of mental health care also are very helpful (cf., Stamm, 2003).
Psychologists need to gain an understanding of traditional sources of support within the community, such as schools, churches, community groups, family physicians, and family. Residents of rural communities may negatively stigmatize psychological services, therefore, referrals within the community should take these attitudes into consideration. Plante (1999) and McMinn, Meek, Canning, & Pozzi (2001) provide useful information regarding collaborative relationships between psychologists and clergy members and religious organizations.
To maintain minimal diffusion of services, certain key individuals within the existing infrastructure of rural communities (teachers, pastors, physicians, nurses, police, firefighters, paramedics) should be trained to recognize the need for intervention. Since these people form the mental healthcare infrastructure in rural communities (Fox, et al., 1995), they should be trained in the basic provision of these interventions. This could include training in CISD and basic lay counseling techniques. Since the controversy over the utility of CISD interventions is not yet settled, it is recommended that rural responders be taught the protocol with an emphasis on triage. It may be that most victims of trauma may respond best to a supportive gesture such as a comment or brief hug along with information about typical trauma responses and potential resources. Some individuals may need more specific interventions and follow-up assessment. Hopefully, further research will illuminate this triage function.
Training key figures in rural communities in basic CISD and lay counseling techniques addresses both sides of the catch-22 that rural communities present, through increasing psychologically trained leaders who are already aware of the cultural distinctions of the rural community. Rural residents who would refuse treatment or debriefing by a psychologist might be willing to speak with a pastor or medical doctor from their own community. As we learn more about the effects of trauma and the resilience of individuals, we will be able to address these concerns with more subtlety and efficacy. Until then, our interventions should be couched in a careful evaluation of the cultural and community factors that inform their context.
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