Abstract
Subsequent to the events of September 11th, there has been an increased interest among mental health professionals to develop strategies that address psychological and social manifestations of disasters. One understudied area relates to the ways in which professionals sort out inner conflict among personal and professional interests and obligations following a disaster. In this article, we highlight the results of an international qualitative study, which explored the dialectical tensions that arise when professionals confront the task of serving clients during a disaster while concomitantly assimilating postdisaster reactions within themselves. The study was conducted with focus groups of social workers in health care and social service settings in the United States, Canada, and Israel. Respondents were asked to reflect on their disaster response experiences, both professionally and personally. Specific focus was placed on understanding postdisaster cognitive, affective, and behavioral patterns, perceptions, and motives.
An average of 300 million people are affected emotionally, physically, and socially by man-made and natural disasters each year (United Nations, 2008). Significant challenges face those who are deployed to the disaster, including social workers, who are among the experts and professionals that provide vital care during and after the emergency. There is a wide and varied range of stressors and tensions that individuals may experience following a disaster such as feelings of fear, shock, confusion, disbelief, and helplessness (Norwood, Ursano, & Fullerton, 2000). These stressors may cause a variety of cognitive, affective, and behavioral manifestations that could undermine the ability of disaster responders to render effective services.
Subsequent to the events of September 11, there has been an increased interest among mental health professionals to develop strategies which address psychological and social manifestations of disasters (McCarthy & Butler, 2003; Schechter & Cotes, 2006). One understudied area relates to the ways in which professionals sort out cognitive, affective and behavioral dimensions of disaster response.
Authors explain that social workers are among the key allied professionals providing care in the aftermath of disasters (Dominelli, 2007; Newburn, 1998). In the midst of the disaster, social workers are expected to provide the best possible support and services while concomitantly sorting out personal reactions and other challenges caused by the disaster. The general public expects professionals to respond during a disaster with skill and confidence. Investigators suggest that there is a culture among helping professionals which emphasizes emotional control, the displacement of personal concerns, and the strong inclination to focus on others prior to taking care of oneself; this allows professionals to be focused and to contend with the crisis at hand (Jordan, 2007; Madrid & Schacher, 2006). The literature does suggest, however, that these outcomes may be compromised if the responder experiences emotional, cognitive, and/or behavioral disturbances (Centers for Disease Control and Prevention [CDC], 2010). Planning for disaster preparedness ought to be based on knowledge of how individuals act during the disaster (Veenema, 2007). This knowledge can be particularly valuable in understanding and analyzing preparedness and response activities, refining existing protocols and infrastructure, and further advancing the study of disaster-response related issues.
For this study, the term social worker is defined as a graduate of a social work program at the bachelors or masters level who uses knowledge and skill to provide social services to clients (Barker, 2003). The terms vicarious trauma, and secondary traumatic stress are used to describe disruptive and distressful psycho-emotional reactions experienced by professionals exposed to traumatic stories and content from clients. In some cases the literature defines these two terms slightly differently; for many researchers and practitioners however, the terms carry the same meaning (Hesse, 2002). For the purposes of this paper, the terms are used interchangeably.
Disasters are defined as natural or man-made events of an extreme magnitude that pose a substantial threat to life, property, society, and/or the environment. Two components interact to create a disaster: a triggering agent and vulnerability (McEntire, 2006; Ural, 2007). A triggering agent can be naturally occurring like an earthquake, hurricane or volcanic eruption, or may be in the form of a man-made event like terrorism. Disaster-based vulnerability can be viewed as a self-assessed level of susceptibility prior to, during, and after a disaster event. In effect, an individual’s response to a disaster, in part, parallels his or her assessed level of vulnerability (Myers & Wee, 2005). The literature also suggests that there are psychological, sociological and biological factors which drive perceptions and behavior during and after a disaster (Chopko & Schwartz, 2009; Walter, 2009).
In this article, we highlight the results of an international qualitative study, which explored the dialectical tensions that arise when professionals confront the task of serving clients during a disaster while concomitantly assimilating postdisaster reactions within themselves. The study was conducted with focus groups of social workers in health care and social service settings in the United States, Canada, and Israel. Respondents were asked to reflect on their disaster-response experiences, both professionally and personally.
Method
Instrumentation
A qualitative inquiry was conducted using a semistructured focus group protocol developed by the researchers. The questions were intended to elicit personal stories from participants regarding the behavioral patterns, motives, and perceptions of those affected by catastrophic events. Respondents shared their own experiences and impressions while reacting to the experiences and impressions of others in the group. This interaction was helpful in eliciting memories and personal stories. The dynamic interplay inherent in focus groups methodology allowed respondents to offer rich and meaningful feedback (Krueger & Casey, 2000).
Focus groups lasted between 60 and 90 minutes. Demographic information was collected from a paper survey prior to the start of each focus group. All focus groups and individual interviews were audio recorded with permission from respondents. Focus group questions targeted areas such as (a) how/if the respondent’s personal life has been affected by a catastrophic event; (b) how/if the respondent’s professional practice has been impacted by the disaster; (c) the respondent’s feedback about any struggles or dilemmas experienced as a result of the disaster; (d) examples of specific cases.
Settings
Following Internal Review Board (IRB) approval, recruitment letters were sent to executive directors of a convenience sample of field placement agencies of varying sizes, located in urban, suburban and rural areas. The settings included hospitals, family service agencies, and community based mental health agencies. In general, the agencies provided comprehensive community-based health and mental health, preventive and supportive services.
Data analysis
Names of focus group participants did not appear in the transcripts which were transcribed verbatim. Grounded theory guided the analysis (Glaser & Strauss, 1967). The transcripts were reviewed by each researcher separately and coded for themes (Glaser, 1978). The research team then met to discuss themes for the purpose of consolidating categories and achieving consensus. The transcripts were organized based on general themes; tables were used to organize and compare themes. See Figure 1 for an example.
Example of themes derived from focus group question: Group 1, Question 1
Members of the research team then recoded the transcripts, this time focusing on theoretical constructs and logical groupings of categories within preliminary themes. Codes were further delineated and consensus and consolidation was achieved. Finally, after a third set of transcripts, categories were linked to larger theoretical constructs, thereby creating families of codes, and interrelationships among categories. The team then met to achieve final consensus on the theoretical underpinnings of themes to make links to broader theoretical constructs. Several passages were coded in several categories as they had multiple layers of meanings. This was helpful in achieving consensus among the researchers. The data were then entered into the computer software package Atlas TI.
Verbatim quotes were used to pull together theoretical constructs and to identify important issues discussed by participants. Demographic information was used to provide context about the sample. While the generalizability of the findings may be limited due to the sites not being broadly representative, the insights generated by qualitative studies such as this, have meaning in their own right (Myers, 2000).
Results
Demographic Description of Sample
Fourteen focus groups were held, each with 7 to 10 participants; 12 were conducted in person and two over the telephone to allow respondents from geographically dispersed areas to participate without incurring transportation costs (Krueger, 1994). The final sample included 102 of 109 social workers approached to participate in the study. Eighty two percent of the participants were female; this ratio is consistent with other data on the human services labor force which reflects a growing trend of feminization (Bureau of Labor Statistics, 2003; Gibelman & Schervish, 1997). The age of respondents ranged from 26 to 67.
With regard to professional characteristics, 8% of respondents received their MSW degree less than 2 years before the study, 18% had the degree for 3 to 5 years, 15% for 6 to 10 years, 11% had their MSW for 11 to 15 years, 11% for 16 to 20 years, and just over a third had an MSW for more than 20 years. Just over two thirds of the respondents had prior experience in the field, either volunteer or paid; 57% were working in direct practice, while 43% were in administrative or supervisory positions.
Postdisaster Responses
The data revealed an array of responses, perceptions, and reactions during the aftermath of a disaster; these were classified along two major gradients: Cognitive/affective (internal expressions, such as critical thinking, ethical reasoning, physical well-being, cognitive distortion) and behavioral (external expressions, characterized by actions and practices). Descriptions of each dimension as well as verbatim quotations from respondents that relate to these domains are provided below. For each quotation, an identifying focus group (FG 1-12) and social worker (SW 1-10) code is offered to identify the speaker.
Cognitive and Affective Expressions & Reactions (Internal)
Client responses judged as self-absorbed
Some respondents (n = 18) noted difficulty reconciling the behavior and emotional responses of others in light of the disaster. These respondents indicated having strong feelings about clients/others who did not react to the disaster in an “expected” way. One respondent stated,
We were all affected emotionally by what had happened. It amazed me and angered me that clients came in, and they kept wanting their needs met. They knew what was going on, but were far removed because of their focus on their own survival. I couldn’t fathom how they continued to go about their daily living when all of this stuff was going on. (FG3, SW6)
Another respondent stated, “There was an attack on a bus in the same city that my client lived, but she wanted to talk about problems with her boyfriend, or her children, and that’s that” (FG2, SW3). Another stated,
She was crying and upset that it was her birthday
I knew she understood the impact of what had happened, and she still didn’t get it. I recall that it made me so angry, I thought “look what happened, and you are concerned about a birthday.” (FG3, SW1)
These respondents noted dismay about clients/patients who were more focused on their own needs, than on the impact of the disaster on others, and this appeared to evoke consternation from the respondents toward these clients/patients.
Client responses judged as selfless
Some respondents (n = 22) expressed that they felt inspired by the behavioral and emotional responses of others in light of the disaster. These respondents indicated having strong feelings about clients and others who reacted to the disaster in an overly benevolent and selfless way. One respondent stated, “Somehow they (clients) feel as if they don’t have the right to complain when such momentous events are taking place” (FG6, SW6). Another stated,
I remember this teenage girl walked up to me outside of the emergency room and said that she needed help. I asked if she was a victim of the World Trade Center, and she said, no, my friend’s father just raped me. She said everyone was watching the Trade Center collapse, and he pushed me into a room and raped me. It shouldn’t have been something that anybody had to deal with on that day—and she was sitting there and apologizing saying . . . I know people are dying and I shouldn’t be taking up your time. (FG1, SW4)
Another respondent, who was working in an Israeli hospital during a series of terrorist attacks, stated,
there was a young man who was just brought in after being hurt in a terrorist attack. The man on the bed next to him said—excuse me, when you have a chance . . ., I was hurt in the earlier attack . . . I got all choked up. (FG2, SW1)
The aforementioned quotes highlight that some respondents viewed clients/patients as possessing a high degree of selflessness and concern for others during disasters, even to the neglect of their own needs. This appeared to evoke admiration from these respondents toward their clients/patients.
Administrators/bureaucrats viewed as too narrowly focused on disaster victims
Some respondents (n = 12) suggested that when a disaster occurs, all resources and efforts tend to be too overly concentrated on the disaster, which is not as obvious a necessity as it may appear. For example, one respondent explained that her regular patients who were suffering from terminal illnesses seemed to be tossed aside during and after the disaster; “I remember feeling, what about them” (FG2, SW1). Another respondent explained that victims of terror tend to receive everything they need, while others, with perhaps even greater needs, wait; “a lot of money goes to the victims of terror, but we try to get a wheelchair for someone with a neurological disorder and we can’t” (FG3, SW6). One respondent explained that during SARS, her regular mental health patients were told to stay home, despite needing treatment: “it all takes a backseat to the logistics of public safety. People really suffered from that” (FG4, SW5). Another stated, “people could not access services at a time when they most needed them.” (FG1, SW2). These respondents complained about the high priority given to services for disaster victims to the neglect of other, perhaps more needy victims.
Behavioral Expressions and Reactions (External)
Professional duties displaced personal proclivities
The transcripts revealed an array of postdisaster responses along behavioral gradients. Some respondents (n = 26) discussed their ability to maintain professional standards and practices despite being anxious and overwhelmed. These respondents appeared to act in a confident and self assured manner, demonstrating little professional ambiguity. One stated, “As a professional, you came in, you were focused on what you had to do, and you disassociated with everything around you” (FG3, SW1). Another stated,
I believe that this is a technique that we’ve polished and improved, each one of us on our own . . . we’ve become increasingly calmer, it’s kind of a trick that we use, we get to our professional business without thinking about it. (FG2, SW3)
Another pointed out that when you put on your professional hat, it’s
like turning off a switch. I tell myself that I’m a social worker, and suddenly you act completely differently. That feeling of professional responsibility might help us overcome the sense of helplessness that we feel when we’re at home. If I manage to be there and help people, it helps me regain a sense of peace. (FG11, SW1)
One respondent explained that when she hears about an attack, she does not call her family; this allows her to leave them out of what happened so she can take care of people; “I put on my white coat and treat the people who are being hospitalized. My family is not part of this picture, they’re not here, they have nothing to do with this” (FG7, SW9). One respondent explained that social workers can not think about themselves; she stated, “I am going to do my job” (FG7, SW3). Another stated,
There is no room for the personal. Our jobs are very measured. I think that very few of us let our feelings take over while we’re doing our jobs. We are strengthened by our colleagues, and we strengthen them in return. (FG11, SW6).
Another explained that she does not experience any professional difficulty when there is a disaster; she stated, “I get here as soon as I can so I can get to work” (FG3, SW3).
Personal proclivities superseded professional duties
Some respondents (n = 16) indicated that they experienced difficulty prioritizing professional duty over personal responsibility. The actions of these respondents appeared to be textured by personal concerns or emotions, which caused some degree of professional ambiguity. One respondent stated, “I have become much more cautious and anxiety ridden about everything. I am sure it affects on the work that I do. I say it doesn’t, but I’m sure that on some level it must” (FG3, SW1). Another stated, “You have to focus on the needs of your clients and put your own personal thoughts aside, but that is not all that easy” (FG10, SW5). Another stated,
I once called and found out that my niece might have been in the area of the attack. It made it very hard for me to function. I need to keep the two separate, I can’t mix the two. When something that affects you personally comes into play in your place of work, that makes it very very difficult. (FG2, SW2)
Another explained that “When there is a terrorist attack, I am not entirely with the client, because I am thinking about what happened” (FG7, SW2). Another stated,
if there is an emergency, I am here—that has never been a problem for me. If there was a concern in my mind, like not being able to find a family member, and someone here expected me to stay, I would be shocked, and would be like—you have to be kidding. At the end of the day, the only thing that really matters is family, I hope someone else would be there to do what I could not do. (FG2, SW3)
Another stated,
after I knew all of my family was safe, I got into a car and came to work. I said to myself, why am I doing that? Why am I going to work? I should stay home. But something took me here, maybe I’m needed. (FG4, SW4)
Another stated,
I felt conflicted; on the one hand there was the aspect of personal safety and feelings of vulnerability, and on the other hand, I felt as if I needed to stay and help out other people; everyone else left however, so I left as well. (FG1, SW3)
Another spoke about her colleagues wanting to go home. She stated, “someone on our staff then said, what are we doing here, we have to close and go home” (FG6, SW4). Another stated,
I felt very emotionally tired when I showed up for regular appointments. My clients saw it. Some told me that I didn’t have to see them during that time. There was a great deal of concern for me, which touched me very much. (FG10, SW4)
Another explained that during a disaster, her first instinct is to check with family to make sure they’re all right; “The goal is to finish your responsibilities as quickly as you can so you can be home with your family” (FG2, SW1). One respondent stated, “I was happy that I didn’t have to run to the hospital and work. I know that is terrible, but that is what I felt in that split second” (FG11, SW3).
On the behavioral level, the aforementioned quotes highlight a variety of responses. There were some who kept their personal and familial concerns out of the professional arena and were totally dedicated to the tasks at hand; whereas, others could not make this separation. They felt confused and conflicted over the intrusion of personal needs into their professional function.
When the data were analyzed separately by country of origin, we found that the Israeli subset felt less confused and conflicted over personal/professional boundaries and experienced less ambivalence about other scope of practice issues. Respondents generally attributed this to the degree of frequency that terror attacks occur in Israel, suggesting that disaster preparedness and response is part of the culture in Israel, whereas in the United States and Canada, disasters are much less frequent and less pervasive. One respondent stated,
here it is a sober reality. In the US it still seems unreal, because something happened that was terribly dramatic and then escalated into a war. It seemed just a little like a Hollywood movie. But here it is a routine part of everyday life, of real life. (FG2, SW2)
Limitations
It is important to be aware that the results of this study are generated from a convenience sample of 14 focus groups with 102 social workers from three countries. The findings are based on a qualitative inquiry. The goal was to understand some of the ways in which social work practice is impacted by catastrophic events and to gain a better understanding of the ways social workers view clients and themselves when there is a shared traumatic event. The study findings may have been different had the study included other countries, and we caution against generalization from these results.
This is a qualitative study. We quantified a selection of themes for the purpose of better describing the data, and understanding the experience of the sample in our study, however, it is important to clarify that generalization is not the purpose of qualitative research. Much of the literature clearly frowns on attempts to generalize focus group data, characterizing this as a severe limitation (Fern, 2001; Harrell & Bradley, 2009).
Discussion
When disaster strikes, social workers and clients alike face a complex web of emotional, behavioral, and psychological reactions (Landau, 1997; Yanay & Benjamin, 2002). Widespread disasters like terrorism, hurricanes, and SARS affect the whole of society. Social workers and other helping professionals are not immune.
Respondents of this study shared examples from their professional experience of how they were affected by natural and man-made disasters. Many noted that they experienced confusing cognitive, affective, and behavioral reactions, which, in many ways, were rooted in the self—other dialectic. In effect, many of the respondents experienced dynamic tension between grasping the disaster from a professional perspective, while attempting to assimilate the disaster within themselves (Schroeter, 2008). Some respondents experienced the dialectic in full force, expressing difficulty in reconciling their own personal and professional cognitions, emotions and behaviors, and maintaining professionally focused feelings/thoughts/composure, while other expressed little difficulty.
With regard to cognitive reactions, respondents appeared to experience both positive and negative reactions about the postdisaster behaviors of clients/patients. Some felt consternation toward clients/patients when it was felt they were being selfish; other respondents felt admiration toward clients/patients when it was felt they were being selfless. Some respondents noted that they were able to mask their feelings, and others were unable to maintain professional objectivity.
With regard to behavioral reactions, three groups of respondents emerged from the data. One group is able to suppress their personal concerns in favor of their professional functions, and experience little to no conflict in the process. Another group of respondents note experiencing significant powerlessness in suppressing personal needs and emotions, resulting in a lessened ability to respond to professional obligations. The largest group of respondents note an ability to maintain professional roles and responsibilities, but not without traces of ambiguity over conflicts between personal needs and professional responsibilities.
Implications
As noted, the majority of our respondents indicated that in the aftermath of a disaster, when the full depth of its meaning is personally felt, ambiguity sets in over tending to personal trauma, while concomitantly trying to respond to the event as a professional. Seeley (2008) details how practitioners who are involved in “common traumatic stressors” like terrorist attacks, may experience such manifestations as a loss of control over time, a diminished sense of protections and control, heightened vulnerability to client subjectivities, overidentification with clients, taking on patient anguish, withdrawal and estrangement, exhaustion and numbness, and tuning out to client grief. The author suggests that when major disasters affecting the whole of society occur, the usual distinction between practitioner and client is blurred (Seeley, 2008). For some practitioners, the concept of professional duty, beneficence, and other values central to professional ethics are overridden by personal welfare/interests and concerns, that could result in tension and uncertainty.
Much has been written in the literature about the psychological manifestations of working with disaster survivors. Work-related stress disorders are psychological conditions commonly found among disaster responders (Dekel, Hantman, Ginzburg & Solomon, 2007; Figley, 1988; McCann & Pearlman, 1990; Schauben & Frazier, 1995; Shamai & Ron, 2009). In some cases, behaviors, motives, and perceptions of disaster responders are affected by stress-related psychological conditions; in other cases, responders are more resilient (Pat-Horenczyk & Brom, 2007). Research shows that social workers who work with traumatized populations are likely to be affected in some way by secondary traumatic stress (STS; Bride, 2007). STS has been shown to impair the ability of health care workers to render effective services (Collins & Long, 2003; Sabin-Farrell & Turpin, 2003).
Trauma associated with disasters typically causes a disruption in an individual’s self-other schema (Cunningham, 2003). Individuals develop notions about self-other on the basis of an array of psychological needs, including safety, trust, esteem, control, and intimacy. STS and other work-based stress disorders can lead to self-other discrepancies (Cunningham, 2003).
In the dialectical interpenetration of self and other, there is an almost instinctive drive to focus on one’s own needs before turning to the needs of others. As one respondent stated, “When something that affects you personally comes into play in your place of work, that makes it very difficult.” A considerable number of our respondents described this dialectical tension, highlighting the ambiguity that was felt over the self-other conflict.
During disaster response, the general public and the professional community alike expect professionals to suspend personal interests, concerns and insecurities in light of professional responsibilities. Findings of this study suggest that despite disaster plans, protocols, expectations, training, and preplanning, professionals are still subject to varying degrees of emotional and psychological stressors, and other states endemic to the human condition, which can affect ones ability to perform critical functions. To counterbalance this risk our respondents indicated that agencies ought to implement strategies that strengthen the ability of personnel to better navigate through issues inhibiting best professional practices during and after disasters, such as emergency drills that incorporate worst-case scenarios, and include psychological debriefing; employing a buddy system in which coworkers are paired together in case one worker becomes impaired; in-service trainings that review and test disaster protocols; and conducting exercises that are designed to strengthen resilience to primary and secondary trauma. We believe that these recommendations offer pragmatic techniques that can be used to augment present policies and procedures while mitigating the negative effects of disaster exposure, whether primary or secondary. The extent to which these types of measures are effective in light of self-other conflicts and other challenges is an area ripe for further research.
Conclusion
Social workers face a complex, intense, emotional experience that is personally and intellectually challenging when responding to disasters (Landau, 1997; Yanay & Benjamin, 2002). Researchers explain that professionals are affected directly through a primary exposure to the event; they worry about the effects of the event on loved ones and others to whom professionals feels close. Professionals can also experience emotional and cognitive arousal symptoms after hearing the stories of their clients (Saakvitne, 2002; Somer, Buchbinder, Peled-Avram, & Ben-Yizhack, 2004).
The dialectical tension between the personal self and the professional self is difficult to assuage, as both identities are totally involved in the disaster experience. Even distancing oneself from the destruction, thereby providing some respite, is fraught with the reality that the personal element is intricately involved in the professional function.
During the aftermath of a disaster, there is little time for expert elicitation. Dynamic tensions are irreducible and inherent in cognitive, affective and behavioral reactions. A good number of the respondents of this study expressed, that although experiencing a certain degree of personal/professional ambivalence, roles and responsibilities were carried out. Respondents did seem to indicate that in general, personal needs and emotions should not play a role during disaster response; however, a fail-safe model to assure this, does not exist. It does appear reasonable to conclude that professional ambiguity ought to be expected as a natural by-product of disaster relief, and should be accounted for in disaster plans and protocols. Maintaining unrealistic expectations of professional invulnerability is naïve, and fails to recognize the self/other dialectic, a construct endemic to the human condition.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.