Composed of clinical psychologists, psychiatrists, occupational medicine physicians, disaster relief specialists, and community
members affected by hazardous waste sites.
To develop public health strategies to prevent and control long-term stress-related health problems in communities near hazardous waste sites. Panel
members were not asked to evaluate prevention and intervention strategies
associated with specific sites. They were asked to use their complementary
backgrounds and areas of expertise to provide an overview of 1) what is known
and not known about the effectiveness of previous prevention and therapeutic
strategies in these communities, 2) the most effective methods for preventing and
mitigating stress-related health problems in communities near hazardous waste
sites, and 3) methods for increasing public and professional capacity to respond
to psychological issues related to hazardous waste sites.
How has the extent of the psychosocial effects and possible public health impacts in these communities been assessed to date?
Background
Most of the recent psychological research on the effects of technologic disasters has
been designed according to the principles of psychiatric epidemiology with the use
of case-control populations and known standardized instruments. According to these studies, psychological disorders
found in populations possibly exposed to hazardous substances are similar to those found in communities that have
experienced natural disasters: heightened incidence of anxiety, clinical depression,
and post-traumatic stress disorder (PTSD).
Panel Presentation
Dr. John Eyles began the discussion on this question. The following is a summary of
the discussion and is divided into three parts:
How we currently assess impacts and effects: Currently, there are three
to four scientific ways of assessing psychosocial impacts and effects. These include a small
number of epidemiologic studies, clinical studies, case studies of communities, and
the use of key informants' studies. Epidemiologic studies are usually based on cross-sectional or
case-control designs. The evidence from these few epidemiologic studies does not seem to be particularly
strong. Clinical studies are symptom-based and rely to a great extent on case studies by physicians or
self reports of symptoms. Studies based on physician judgments are few in number and have very small
sample sizes. Therefore, they lack the power to provide the usual quality of evidence
that scientists want. Many more of the studies of psychological effects rely on
self reports, and there are differences of opinion on what is scientific evidence.
Some in the scientific community regard self-reports as quite meaningless and open
to reporting and observer biases. Others regard self-reports as key information
sources. Self reports are the first means to identify the psychosocial impacts of any
event. Key informants can be used to help chart out the effects on communities.
This might be useful in the early stages as a rapid assessment technique.
How we might assess impacts and effects: A determinants of health approach could be used
to assess impacts and effects. This approach looks at how certain demographics and socioeconomics contribute to
health, well-being, or illness. This important information can add to the assessment process. Another
approach that could be used involves the values and interests of stakeholders or other involved parties. This
means understanding their values and what they feel threatens their interests. This
may involve property values, children, and/or the future in general. Essentially,
that is what has come from the in-depth studies of Edelstein and others. For this type of
study, a partnership with the community is critical. Strategies that could be used
include those mentioned above, as well as data pooling to look for common themes,
reviewing and learning from occupational health studies of stress, and creating and
instituting rapid assessment tools to assess the problem swiftly.
The context of assessment: Responses to contaminating events are
socially and culturally mediated in complex ways. To some degree, they are unique to the
particular study setting and cannot be divorced from context. Each community's circumstances are unique.
Data Gaps and Recommendations
The extent to which psychosocial public health impacts have been assessed to
date is relatively limited. There are opportunities for more studies to define the
problem. There are various techniques and processes that warrant further use.
A comprehensive community needs assessment is a critical first step in
shaping the design of interventions and adapting implementation plans to unique community
characteristics.
What previous prevention and therapeutic strategies have been used in these communities? What were the results of
these interventions and what issues did they raise?
Background
Prior research on stress prevention and therapeutic strategies following trauma has
focused primarily on natural disasters. Scientists and clinicians recognized that some
people who have been exposed to various natural disasters, such as earthquakes, hurricanes, and floods, could develop psychological sequelae such as major depression, chronic anxiety, and
PTSD. As the number of studies devoted to the psychological effects of disasters increased, findings indicated that disasters did not
always result in widespread, severe psychological disturbance. These studies found
that only a relatively small number of disaster victims suffer serious, long-term
psychological damage. A somewhat larger portion of the affected community may
be expected to manifest at least transient symptoms of various forms of emotional disturbance (31). Current thought among disaster relief workers is that these
symptoms of emotional disturbance are normal reactions to an extraordinary and
abnormal situation and should be expected.
The treatment model used for victims of natural disasters involves aggressive outreach and crisis counseling that
combines psychological support, education, and practical disaster relief (e.g., helping meet needs for food and
shelter). People who appear more severely affected by the disaster are referred to the local mental health
system for continued care. The use of crisis intervention techniques in the aftermath
of a disaster is recommended for several reasons. 1) As previous studies suggest,
disaster victims typically do not sustain serious, long-term mental health impairment.
Much of the initial mental health response involves normalizing feelings. Victims need
to be assured that the emotions they are experiencing are normal. 2) Disaster victims are often
reluctant to seek out mental health services or facilities on their own. Because of this, outreach to the
community is essential. 3) Outreach and crisis intervention emphasizes the use of paraprofessionals and
volunteers. Individuals who are perceived by the affected community as "being one of us" can play a vital
role in intervention activities.
In addition, 14 key concepts of disaster mental health have come out
of the outreach/crisis intervention model (32). These key concepts could serve as a
valuable framework and guide for planning and implementing successful mental health services at
hazardous waste sites. These concepts are as follows:
No one who sees a disaster goes untouched by it.
There are two types of disaster trauma: individual trauma and
collective trauma.
Most people pull together and function during and after a disaster, but their
effectiveness is diminished.
Disaster stress and grief reactions are normal and appropriate responses to
an abnormal situation.
Many emotional reactions of disaster survivors stem from problems of everyday
living brought about by the disaster.
Disaster relief procedures have been called "The Second Disaster."
Most people do not see themselves as needing mental health services
following a disaster and will not seek out such services.
Survivors may reject disaster assistance of all types.
Disaster mental health assistance is
often more practical than psychological in nature.
Disaster mental health services must be
uniquely tailored to the communities they serve.
Mental health staff need to set aside traditional methods, avoid the use of
mental health labels, and use an active outreach approach to intervene successfully.
Survivors respond to active interest and concern.
Interventions must be appropriate to the phase of disaster.
Stable support systems are crucial to recovery.
Panel Presentation
Mrs. Cynthia Babich reported her observations of the things that have been
conducted at the Superfund site in her community. There are now some counselors
in the community who are
talking to some of the people, but
there is a stigma associated with doing
so. Some residents, particularly the
men, see asking for help as a
weakness. Mrs. Babich believes what
is needed is someone who is going to
listen to the community members and
document what they are saying.
Dr. Brian Flynn followed up by talking about nine strategies that have been
consistently used in disaster mental
health programs. These experience-based, not research-based, strategies are as
follows:
Early intervention: Intervention should begin as soon as possible. It is
a myth that psychological problems occur only later in a situation. We know a great deal about
what can be done early in situations to help mitigate
stress. Providers who assist early are much more accepted than those who are late-comers. This can be a
problem because the majority of Superfund sites have been around for many years,
but the sooner psychological aid is provided, the less total stress individuals will
experience. Additionally, residents at hazardous waste sites may believe that their
circumstance is something that cannot be understood by someone who has not
shared the experience. Early intervention allows providers to see, hear, and feel
experiences very similar to those of the residents. It can also help establish the
community members' trust in the provider.
Validation: The effects of stress are real, and any prevention or intervention
strategy should include validation of the stress-related problems.
Normalization of reactions: Many people find themselves demonstrating
signs or symptoms of stress. Counseling interventions, such as those
based on psychoeducational or psychosocial models, are more appropriate as opposed to the
more traditional mental health interventions. This counseling should help individuals
understand that their responses are normal, typical, and expected in an abnormal
situation.
Telling of the
story: The intervention
strategy should promote the "telling of
the story." This seems to be a common thread across various kinds of trauma.
There are three benefits to telling one's story: 1) it is a way to gain control of
an experience that is outside of the individual's past experience; 2) it can
have a cathartic effect; 3) it provides an opportunity for bearing witness to
what happened and for documenting and putting on the record what the experience has been. Whether
you're dealing with disasters, refugee situations, torture situations, or other
situations, it seems to be important for people to tell their story.
Outreach
orientation: People do not usually seek assistance for a variety of reasons, including stigma and not
identifying themselves as appropriate recipients of psychological services.
Providers of intervention strategies need to be aggressive in their outreach
to people in the community. Services will have to be provided in nontraditional, community-based
settings where people live, work, and socialize.
Blending response
teams: Licensed mental health professionals and trained community leaders should work
together. Some services could be provided by trained nonprofessionals who are part of the community. This
community involvement helps to build trust and may be more appropriate where ethnic and
cultural differences exist between citizens and outside intervention teams.
Designing and encouraging
actions:
Actions that involve the community
and increase community control have a
high probability of some success.
Training: A need for training in crisis intervention and traumatology exists;
therefore, training should be provided to survivors on how to prevent, identify, and
reduce their stress. Training should also be provided to the members of helping
professions (e.g., clergy, school counselors) and mental health professionals or any
others in
the community that people may turn to
for assistance.
Consulting with community
leaders: It is important to establish ongoing communication with community
leaders and to keep them involved throughout the process.
The rest of the panel discussion
focused on which of the nine techniques outlined by Dr. Flynn would be most amenable or
transferable to a Superfund setting and which might be problematic. Panel
participants stated that in contrast to disaster situations, in which communities affected usually pull
together, community division often exists at Superfund sites. Communities
tend to coalesce around problems, so having a community take an action that
is noncontroversial is tougher in this context. Consultation with community
leaders may not be as easy at a hazardous waste site as it is in a natural
disaster. The types and number of support systems may be lacking.
Validation may be difficult as well. Natural disasters are more salient.
People can see the problems and aftereffects. This is not always true of Superfund sites where
the contamination is often invisible. Some may deny there is a problem. Others
may state that they know or feel there is a problem but not be taken seriously. At times,
environmental agencies are a part of the problem because they state there is an
environmental problem but do not show compassion for the affected community or
provide a rapid response to the problem. Government agency staff do care, but
often are experiencing their own set of frustrations and worries.
Data Gaps and Recommendations
If early interventions are provided,
many of the remaining eight actions would not be needed.
Some type of measurement and program evaluation should be built into
any intervention strategy to determine its success.
Another action to take is to "help the helpers." Sometimes those most
impacted are the helpers-researchers, government field workers, therapists, or the first
responders. As a result of overwork, they may experience burnout. Helpers should
be trained to recognize early signs of burnout, and support should be provided.
What methods are most effective in preventing the acute stress of learning of the existence of a hazardous waste site
from becoming chronic in adults? In children?
Background
The basic principle in working with children or adults who have experienced any
type of disaster is to remember that they are essentially normal people who have
experienced great stress (33). Many people can effectively use their existing coping
skills to deal with the consequences of a traumatic event if they are made aware of
the normal and predictable responses to expect as recovery progresses. Thus, education about
stress reactions and ways to handle them should be provided. This normalizing or validating of feelings and
help in recognizing some very common signs of a stress reaction can help to mitigate the effects of acute and
chronic stress in both adults and children.
For adults living near a hazardous waste site, the uncertainty about health
consequences inherent in exposures to hazardous substances will most likely be their greatest source of stress. For
example, in some cases people (e.g., community residents, epidemiologists, and health assessors) aren't sure who
has been exposed to a hazardous substance or how much they have been exposed to.
In most cases, the exact degree of individual exposure, in terms of duration and level, cannot be
determined. This creates uncertainty and heightened feelings of powerlessness and
lack of control, both of which are associated with higher levels of stress (34).
Access to information and educational activities about the consequences of toxic
exposure is necessary to prevent or mitigate chronic stress in these adults; therefore,
primary care physicians and mental health and other health care providers should be
informed about the contamination, its potential health consequences, and field assessment
difficulties that may contribute to their patients' feelings of uncertainty (e.g.,
fluctuating contamination levels). Provider support and understanding of the contamination and psychological
stressors associated with living near a hazardous waste site are vital to helping individuals living near the site
cope with the situation.
Panel Presentation
Dr. Charles Figley discussed the possibility of using PTSD research; traumatology
research such as that done with prisoners-of-war (POW) and missing-in-action (MIA) families,
agent-orange families, hostage families, and terminally ill patients; and crisis
intervention strategies as models for preventing acute or chronic stress in individuals living near a hazardous
waste facility.
Dr. Figley also made the following recommendations for preventing stress in adults
and children living near a hazardous waste site:
Establish trust: The situation invites a general loss of trust in others and in
government specifically. Efforts will have to be made to establish trust and credibility. If you don't have trust, no
one is going to listen to you, not to mention hear you or follow your interventions.
Bear witness: Individuals should be encouraged to bear witness. They
should be given the opportunity to articulate what took place and what happened to them,
why it happened, and their beliefs and fears about the situation. One very effective
strategy that has been used in traumatology research is to videotape these conversations so that when a person is
talking into the videotape, they are talking to everybody. This method can provide an oral history, not only for the
person giving the account, but in many cases, for those people who don't want to bear witness.
For those community members who don't want to share their pain and emotion, they
can watch the videotapes and their heads will nod quite a bit, and they will feel
understood. They will say "that person on that video is like me."
Identify standards of measurement: Substantial research exists with respect
to understanding the immediate and long-term psychosocial consequences of highly
stressful events. What we now need is a model to understand the trauma induction
and trauma reduction processes. On the basis of an established model, ways to prevent
suffering and other consequences can be identified-ways to stop and prevent peoples' suffering from reactions to a
traumatic event as thoroughly and quickly as possible.
Identify needs: Do not assume knowledge of what a community wants. Ask the
community members to identify their needs and goals. Listen during the process of
bearing witness and identify what the individuals think their needs are.
Implement interventions: Implement
the most appropriate types of interventions (e.g., stress reduction and management, psychosocial education,
post-traumatic stress symptom elimination) one at a time or together.
Utilize existing infrastructure:
Utilize the media, business groups, religious organizations, school systems, and other social institutions as a means
to providing psychosocial education to both adults and children.
These principles are the same for children and adults. What is critically
important, however, is that children even more than adults live in an external world, defined by
the outside environment. Any time intervention is necessary, even in terms of assessment, the work must involve the
significant people in the children's lives.
Data Gaps and Recommendations
A number of public health agencies in the United States are finding their
resources increasingly cut back. Their efforts to try to get out into the community
and to deal with the behavioral and social issues around a site are often limited by a
lack of adequate resources. However, a number of individuals in the faith groups or
church communities share our values about health. By enlisting these individuals, we
may find very natural allies and trusted sources in a community. These groups may
be able to reach the people we cannot.
In preventing stress, anger must also be considered. Anger often exists at
these waste sites and needs to be validated. It's part of the method of coping for some.
When people are angry, they need to know that they have every reason to be angry. In both
natural and technologic disasters, there are so many system frustrations and problems that are real that, as they
build up, people naturally react with anger. That's when intervention is needed to help them find and solve
problems that are within their control to change and cope with those that are not.
What are the best methods to prevent demoralization fromm occurring in these communities?
Background
Demoralization, according to the Comprehensive Textbook of Psychiatry, is a
"state of mind of hopelessness and helplessness" (35). Demoralization is a common
distress response when people find themselves in a serious predicament and can see
no way out. Demoralization stems from a perceived lack of control. Control is defined as the belief that one
can influence an event; whereas, lack of control is defined as the belief that nothing one does or can do will change
what will occur (19). Some studies of technologic disasters have reported increased rates of
demoralization in affected communities (8, 19). For example, Dohrenwend and colleagues
(36) found evidence of heightened demoralization during the months following the Three Mile Island
incident.
Panel Presentation
Dr. Jeff Kindler and Dr. Charles Figley led the discussion on the issue of demoralization.
Dr. Kindler suggested that environmental agencies concentrate on enhancing
two-way communication between agency representatives and community residents. In other words,
communication plans should be designed to increase the mutual understanding of issues, data, and
possible solutions to the problems that are contributing to community demoralization. These agencies should
continually strive to improve their partnerships with communities and the sharing of decision-making
power with residents.
Models for improving partnerships can be found in the adult education, group
dynamics, and interaction analysis research literature.
When communicating scientific information in communities, residents need to be
assisted in processing this information through an encouraging, indirect style. This
will help residents talk about and discuss their concerns about the meaning of the
information provided. Talking with the community and inviting residents into the
process helps reduce their anxiety, anger, and suspicion and is a good beginning to
building trust. In return, communities give back ideas that agency representatives
can use to develop better scientific models to help us all.
Dr. Figley stated that there is significant overlap between
demoralization and learned helplessness. There are a number of ways to prevent learned helplessness.
Part of demoralization and learned helplessness is the extensive isolation and not
knowing that other people are having the same experience. Communities should be given as
much accurate information as possible so they can devise solutions or options to
improve their situation. A helpful intervention may be to help them connect with
other communities that have experienced similar circumstances.
Data Gaps and Recommendations
A primary way to prevent or lessen demoralization is to help citizens gain a
sense of control over their situation. Government, state, and local agencies should seek
meaningful input and participation of community members. Of particular importance
is residents' involvement in the decision-making and problem-solving processes concerning the cleanup of their
community. In most instances, the cleaning or
remediation of the waste site is lengthy, and causes residents chronic stress and
feelings of helplessness. Cleanup of the site should be quickened, when possible,
and the community should be involved throughout the process.
Demoralization often occurs when people feel isolated and alone. Often
conflicts occur between those neighbors living within the impacted area and those living
outside the impacted area. Many of those living within the impacted area may disagree
on exposure and health effects. Better communication between neighbors could prevent this.
How can seriously affected individuals be identified and appropriately referred in these
communities?
Background
An effective method for identifying seriously affected individuals is an active
outreach approach like that used in crisis management programs after
natural disasters. The first step is to perform a thorough needs assessment
with the community to determine which individuals and groups are most severely impacted
and which persons are experiencing the most difficulty. The second step is to contact those
who can be assumed to be in the most need of psychological help. Such persons include those who have lost
one or more family members, those whose homes have been destroyed, those being relocated from their homes,
those who are seriously ill, and those who have been or are currently under psychiatric care (37).
In toxic contamination, there may be an absence of concrete (i.e., identifiable)
death and destruction. High-risk groups should include those who are likely to have been
exposed to chemical hazards or who have experienced property devaluation. Underserved segments of the
population, such as the poor and racial and ethnic minorities, should be given priority as well. The third step should
be to attempt to reach those who are geographically isolated or without transportation.
Educational efforts should be designed to reach as many people as possible
and should express simple themes relating to Superfund sites and communities, such as
stress reactions and management. Educational materials should also include information about
available sources of mental health services and provide specific directions on how to locate help. Because people
often identify "mental health" with "mental illness," measures should be taken to avoid these labels. Emphasis
should be placed on the common practice of people experiencing stress to use such services.
Not all community members will experience the same types of needs at the same
time; therefore, the needs assessment should be ongoing and should include periodic
reassessment of both mental health needs and services.
Panel Presentation
Dr. Brian Flynn led the discussion on this issue.
Dr Flynn:
In some cases, these individuals will
"self identify," i.e., they will seek treatment on their own. Others may be identified by their support systems
(e.g., family, friends), while others may be identified by their family doctors,
counselors, or other health providers.
Once these individuals are identified,
how they are referred for further treatment varies. Referral depends on their eligibility for treatment and
whether they have the financial resources (e.g., private monies or health insurance) to cover treatment
costs. They may be limited in their choice of providers for treatment, and their
geographical location may hinder access to treatment.
To whom they get referred may vary
as well. Before referral, trained professionals with expertise in crisis counseling or traumatology should be
identified. Often the local mental health system is the least prepared to handle
these problems. Its services and resources are generally restricted to those with serious mental illness
and/or drug addictions. In addition, they often lack staff with expertise or training in
crisis counseling or disaster relief work.
The expertise of volunteer providers
should also be qualified. Sometimes those who go out of their way to volunteer their help are the least
prepared and qualified. Additionally, mental health providers should coordinate their efforts and establish a
close link with the primary care physicians in the area. There may be a need to
provide training to the mental health and primary care providers. This training should
be designed to help providers develop a sensitivity to the issues of contaminant
invisibility and health uncertainty.
Data Gaps and Recommendations
Because individuals stress response can vary, those living near hazardous
waste sites will differ in the degree of stress they exhibit. Some may experience little or no
stress, others a moderate amount of stress, and some will exhibit high levels of
stress. Individuals who exhibit high levels of stress might include those who are
unable to deal with the situation because of inadequate coping skills, an inadequate
support system, a lack of trained providers to accurately diagnose and treat their
problems, or a preexisting mental or physical illness. Those experiencing high stress
levels may require more long- term, structured treatment, so identification of these
individuals is important.
Public health agencies should be in a
position to deal with stress or mental health problems emerging at waste sites. Unfortunately, they are not in that
position at present. This is one of the problems facing public health officers right now: the
whole business of redefining the role of public health.
What is the best method for increasing public and professional capacity to respond effectively to psychological
issues related to hazardous waste sites?
Background
One of the most effective ways to build capacity within a community is through
education. Neither public nor professional community members can effectively respond to psychological
issues unless they understand what those issues are. An awareness and understanding of disaster-related
psychosocial effects, in particular those associated with living near a hazardous
waste site, are vital to increasing a community's ability to respond. An effective way to provide this education
is by establishing a community-level outreach program.
Panel Presentation
The discussion centered around five key factors for increasing public and
professional capacity:
Community-based education: Community-based education programs
would help to heighten awareness of community members, public health professionals, and
providers and to teach them how to identify psychological sequelae.
Evaluation: An evaluation of any existing programs in the community should be
conducted to determine their appropriateness and usefulness in addressing psychological issues.
Empowerment: Ask community members what their needs and concerns are. Give
them the information and training they need to help them understand and cope with
the problem. Agencies should form partnerships that enable discussions and decisions about their community.
Collaboration: Trained mental health and health care providers should
collaborate and communicate with each other on the issues.
Data Gaps and Recommendations
Increase public and professional capacity for responding, including
making the issue of psychological responses at hazardous waste sites less marginalized. Rather
than "preaching to the choir," attempts should be made to bring this social issue to
the attention of the American public.
More must be done to enable communities to respond to the problem. Ask communities what
assistance, resources, and education efforts they want, and then make sure you can come through for them. Give
them technical assistance and education. Teach them how to access environmental
resources from the
Internet, libraries, and other information sources.