Psychological Interventions in Times of Crisis (Book Review)

Author:  Barbanel, Laura
Publisher: Springer Publishing
Reviewed By: Harriette Kaley, Vol. XXVII, No. 3, pp. 71-73

Trauma Horror and Disaster: What Psychologists Do to Help

The year 2006 was the 100th anniversary of the birth of Hannah Arendt, one of the major philosophers of our times, and numerous conferences were held to celebrate the work of a woman whose political engagement was demonstrated throughout her life. A theme in one conference I attended was her insistence that, in order to understand evil—the sort of evil embodied by the Holocaust, or totalitarianism in its many 20th century forms—one must truly understand the position of the Other—in her time, the Eichmanns, the Arabs, in our time the Hutus and the terrorists. Taking such a perspectivist view is not the same as obliterating the sense that evil has been done, but it helps to grasp why it has been done.

In Psychological Interventions in Times of Crisis, edited by two well-known psychologists, Laura Barbanel (one of our current APA Council Representatives and a former APA Board of Directors’ member), and Robert J. Sternberg (a former President of the APA,) a somewhat unexpected theme along similar lines emerges. Especially in a chapter about the aftermath of the genocide in Rwanda, there is a sense that healing, reconciliation, and progress forward require that the victim and the perpetrators hear each other out. That is surely not the sole or even the major way in which to move forward, but it is not the least. That is one of the many unexpected illuminations in this ground breaking, educational, and heart-breaking book.

The title alone, coupled with the cover photo of civilians ministering to other civilians lying on a dirt embankment, tells us that we are in uncharted territory. This is not a book about the interventions we as psychologists and therapists know so well, where we minister to individuals or even small groups, in times of personal crises; it is about responding to the effects of natural disasters and man-made sociocultural catastrophes like war, nuclear plant explosions and terrorism. The book’s strength is in collecting several accounts of actual crisis intervention work: responses to 9/11 here at home; living in the midst of civil warfare in West Africa while trying to support cross-cultural workers there; efforts to promote healing in Rwanda after genocide; working with traumatized Israeli children; studies of the effects of the Chernobyl nuclear disaster; and efforts to help Bosnian mothers support their children. If the book has limitations, they are the inevitable result of its being an early player in the job of trying to feel our way into working out helpful responses to unthinkable events.

These chapters vary significantly in style and as a result, the effect is uneven. Among the most compelling, naturally, are first person accounts of work done among the traumatized, often while the traumatic conditions continue: Karen E. Carr’s heart-stopping account of her work in West Africa under conditions of siege; and Esther Cohen’s description of her play therapy sessions with young children “identified as having been directly exposed to terrorism” (p. 156). This, incidentally, is the only report on the use of fairly standard psychological interventions. There are drier accounts, such as the detailed summary of the facts of the Chernobyl disaster and all the research on its aftereffects, the only crisis for which there was little or no intervention of the sort recommended elsewhere in the book (a matter of governmental reluctance to acknowledge the events and the government’s total unpreparedness in dealing with them), but even these convey massive amounts of information about the effects of disasters on people, places, and communities. In fact, merely reading some of these chapters exposes the reader to one of the dangers the authors often warn about: the risk of vicarious traumatization of the rescuers. This book is necessary reading, but it is not for the faint of heart.

The book is divided into three sections, with a foreword by Karen Saakvitine, whose work is often cited in the chapters that follow, and an introduction by the editors. Part I deals with theoretical issues, with an overview by Judith Alpert, (founder and current president of the Division of Trauma Psychology), and her colleague P. T. Mukherjee. There is a helpful discussion of the difference between bereavement, depression, and PTSD as well as a useful presentation of the concept of psychological first aid, an essential form of immediate psychological support that even nonprofessionals can be readily trained to give. As early as this opening section of the book, one discerns a repeated theme: interventions must be community–based and culturally sensitive in order to be effective in a devastated community.

The core of the volume, of course, is the set of eight chapters each of which tells the story of a different traumatic event. Except for the chapter on Chernobyl, where interventions and rescues were sadly lacking, each one describes the more or less successful efforts to mitigate the effects of unspeakable trauma. Themes turn up recurrently: local community members must be recruited as care givers; caregiving proceeds best in teams and in coordination with various local institutions that provide for needs other than mental health needs, such as medical care, food, and shelter; the local culture, traditions, and myths must be understood and folded into the intervention process; basic survival must be assured, which is often a very challenging thing to arrange; helping sufferers know that their reactions are normal responses to terrible situations is helpful to them, as are almost any forms of accurate information; and the process of providing help may itself retraumatize victims, as when telling their stories risks re-opening wounds and renewing enmities (for example, imagine a Tutsi in Rwanda telling his or her story to the communal “courts” in the presence of Hutus, or a Hutu reciting his or her story to that same court without expressing remorse); and it always risks traumatizing the helpers, either directly, through exposing them to danger, as in West Africa, or indirectly, when reading a mother’s description of believing her surviving son to be dead because her daughter’s brains covered his face (p. 174).

The final part of the book is just one chapter long. In it, co-editor Robert Sternberg summarizes twelve lessons learned. He notes the difficulty of helping those most in need of help precisely because they are the most difficult to reach; the importance of identifying those who can be of service (complex support networks need to be activated); the risks of caregivers themselves being traumatized; the problems of diagnosis (in emergency conditions, how do you differentiate acute grief from chronic depression?); the absolute primacy of cultural comprehension and the use of local culturally—credible structures, systems, and people; the need to function even when information is lacking or erroneous; the profound and hitherto unknown ethical dilemmas that arise (should, for example, the perpetrators of genocide be kept separate from the families of victims from their own villages?); and the willingness to accept imperfect results. It is impressive that a book whose chapters mostly describe action with very little outcome research nevertheless yields so many solid guidelines for future crisis interventions of the sorts that, sadly, will come.

This book is assuredly the first of many soon to come that deal with its topic, and its considerable strengths issue from that position. For example, it posits on the basis of experiences in the field what is not necessarily intuitively obvious: the same approaches that are helpful in dealing with natural disasters like floods are also helpful in such man-made of catastrophes as Chernobyl, war and genocide. As for shortcomings, it is hard to fault the book for its main one, which is a certain absence of useful detail, since the urgent conditions it describes often preclude such detail.

Fortunately, some chapters do in fact tell us all that we could want to know about what happened (and sometimes more than we wish we had to hear), who did what, and what psychologists and other caregivers said and did—to each other and to those they were helping. The chapter on the Firehouse Project is a good example of this. The several authors, all of them psychoanalysts and Division 39 members, report specific exchanges they had, sometimes in a single episode, sometimes over extended periods, with firemen in companies that had lost members on 9/11. But then there are also chapters about “workshops” or “seminars,” mostly intended to train the local caregivers who then fan out into stricken communities, but sufficient details are lacking about just what happened in those workshops and seminars. What went on that was so effective? For example, a four-and-a-half day workshop that “provides training in key knowledge, attitudes and skills . . . for developing and maintaining healthy relationships . . . listening, building trust, living in community . . . .” (p. 90) and so on, sounds like something we should all be told more about, and in some detail. There is also a great deal of description about the effectiveness of the interventions, but very little data. Even though one can sympathize with the paucity of information about how programs were evaluated, the fact that there are occasional reports of respect-worthy research, complete with control groups (for example, regarding the effectiveness of community work in Rwanda when groups were run by seminar-trained facilitators as compared to untrained facilitators) suggests that in the future more outcome research could be done, and that it would serve to sharpen our understanding of how to help.

The oft–repeated discussions of unprecedented ethical concerns raises, in my mind, another issue never addressed directly in the book. While it is clear that the goal of all the interventions is to relieve suffering, and in that sense the goal is entirely apolitical, often unexpressed political issues are nibbling at the edges. For example, when we are talking about large scale efforts in devastated places, what groups and individuals finance these operations? Sometimes they are openly religious, as with various missionary projects, and at other times they seem international, as when the United Nations becomes involved. But who or what is the Rwandan National Unity and Reconciliation Commission (p. 213)?

When the failures of the Russian government in response to Chernobyl are cited, are there no political implications? Without minimizing the urgent need to help first and engage in political analysis afterwards if at all, it is worth noting that questions like this may arise and ought to be addressed if only later on, once the crisis is over.

What would Hannah Arendt have made of this painful, important book? She would, I think, have approved. She would have seen that the concern of the book is to promote healing, especially for the victims, though also for their adversaries. Arendt would have recognized and applauded one of the underlying recommendations for achieving this: know the Other. To know those who perpetrate evil is not to forgive (though that might happen), but to understand evil. While Arendt would have unflinchingly gone on to explore the political chasms between victims and others, she would probably have acknowledged this book and its understandings as a major step in the direction of healing.

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