|Year : 2010 | Volume
| Issue : 3 | Page : 267-274
Group counseling: A silver lining in the psychological management of disaster trauma
Nidhi Maheshwari, Ravinder Yadav, Nirender Pal Singh
Strategic Behaviour Division, Defence Institute of Psychological Research, Drdo, Lucknow Road, Timarpur, Delhi - 110 054, India
|Date of Submission||13-Jul-2010|
|Date of Decision||17-Jul-2010|
|Date of Acceptance||19-Jul-2010|
|Date of Web Publication||16-Aug-2010|
Nirender Pal Singh
Strategic Behaviour Division, Defence Institute of Psychological Research, Drdo, Lucknow Road, Timarpur, Delhi - 110 054
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Management of disaster effects, physical or psychological, has been the subject of considerable research. Though physical rehabilitation of the victims of any disaster, whether natural or man-made, receives immediate attention, the management of psychological trauma often remains a challenge for the disaster management machinery, in general, and mental health professionals, in particular. The magnitude of population affected, on the one hand, and lack of sufficient mental health professionals, on the other hand, often hinders the psychological rehabilitation of a cross section of the affected population. We attempt to present an overview of the literature to bring home the understanding of correlates of psychological effects in the mass disaster affected population in this article. It dwells on the efficacy of group counseling as the most appropriate paradigm of primary prevention to check the onset of severe psychological disorders. The article also presents an overview of two case studies: tsunami disaster (Nagapatanam, Tamil Nadu, India) and victims of bomb blast (Dhimajee, Assam, India) to highlight the silver lining in the psychological management of disaster traumas. It is proposed that group counseling can prove to be a most important mental rehabilitation program to further strengthen the efficacy of individual therapeutic interventions.
Keywords: Group counseling; psychological rehabilitation; therapeutic intervention; disaster trauma
|How to cite this article:|
Maheshwari N, Yadav R, Singh NP. Group counseling: A silver lining in the psychological management of disaster trauma. J Pharm Bioall Sci 2010;2:267-74
|How to cite this URL:|
Maheshwari N, Yadav R, Singh NP. Group counseling: A silver lining in the psychological management of disaster trauma. J Pharm Bioall Sci [serial online] 2010 [cited 2019 Dec 10];2:267-74. Available from: http://www.jpbsonline.org/text.asp?2010/2/3/267/68509
Throughout evolution, humans have been exposed to various terrible events or disasters that have ravaged their physical and mental health. Some people have adapted to such terrible life events with flexibility and creativity, while others have fixated to trauma and gone onto lead traumatized lives. Despite the human capacity to survive and adapt, traumatic experience can allow people's psychological, biological and sociological equilibrium to such a degree that the memory of one particular event comes to taint all other experiences, spoiling appreciation of the present.  This tyranny of the past interferes with the ability to pay attention to both new and familiar situations.
In recent times, the impact of both natural as well as man-made disasters has taken a heavy toll on the human lives and psyche of the victims, despite various scientific and economic advancements in hand. Chernobyl nuclear disaster, earthquake in China, WTC attacks, or Katrina storms have proved that the management of the effects of these disasters goes beyond the economic strength and scientific advancements. These are just the facilitators to minimize the impact of such disasters.
In India, some of the natural as well as man-made disasters in recent times like Orissa super cyclone (1999), tsunami (2005), bomb blasts in North-East (2004), 26/11 terrorist attacks (2008), earthquakes (2008), Uphaar cinema tragedy (1997), Shramjeevi express (2005) and Gyaneshwari express (2010) blast have awakened the management authorities to resolve to draw comprehensive road maps for the management of such disaster effects with a strong command and control system. The establishment of National Disaster Management Authority (NDMA) is an outcome of such an awakening. Other steps like introduction of disaster management courses at various academic levels are another proactive mode of preventing the effects of such disasters.
Management of the psychological effects of various disasters has been quite challenging for the command and control professionals due to the magnitude of population affected and its wide effects. Psychologically though, individual level therapies, interventions and counseling have proved quite useful and effective, but dealing with mass effected strata of the society demands intervention for group rehabilitation programs before the administration of individual or small group therapies.
In this context, we attempt to dwell in this article on the hypothesis that the effectiveness of individual and small group psychological therapeutic interventions shall depend on the rehabilitation created through a mass group counseling strategy. It presents a qualitative overview of two case studies: 1. tsunami affected population (natural disaster) and 2. bomb blast victims (man-made disaster) to emphasize the efficacy of above drawn hypothesis. The article starts with an empirical review of the dynamics and development of psychological effects of a disaster along with the correlates which moderate such effect. Such an understanding is important to the fact that pre-therapeutic group counseling needs to be guided by the correlates of trauma effects in order to target various sections of the population. In the end, the model adopted in the two case studies is described in the form of various stages followed during the schedule of group counseling.
| Psychological Impact of Disasters|| |
Most psychologists identify stress as a leading cause of psychopathology following a disaster but theories as to how stress affects its victims are varied. Some focus on the physiological overload of stress,  some on the unpredictability and uncontrollability of stress  and some on the conditioning that takes place between a frightening stressor and other aspects of life, with a resulting avoidance of stimuli that are reminders.  Losses in a disaster, of other people, of material goods, of one's own health and security are also critical. 
Some theorists focus on the shift in cognitions that take place after a disaster. Janoff-Bulman and Frieze  speculated that cognitions shift after a disaster. The individual asks "Why me?" and the answer involves a change in one's sense of invulnerability, in the world's predictability, and in one's own worth. Victims who made what have been labeled depressogenic attributions, seeing negative outcomes as related to internal, stable and global causes,  were more likely to develop depressive symptoms.
Victimization, primarily child physical and sexual abuse, has been shown to lead to other diagnoses beyond the ones investigated in disasters. These include schizophrenia and other psychoses, dissociative disorders  and borderline personality disorder.  None of these diagnoses has been investigated to see if higher rates result after disaster, although dissociative symptoms have been reported during and after some disasters, , and can be part of the avoidance criterion of Post- Traumatic Stress Disorder (PTSD).
Norris et al.  reported that PTSD was found in 68% of the disaster victims, which constituted the research sample. The second most common psychiatric problem was depression, found in 36% of the sample. Anxiety in various forms was shown in 32% of the sample, and health concerns were also often present (23% of the sample). Moreover, alcoholism and levels of drug abuse have been found to rise after disasters. Livanou et al. looked at PTSD and depression as outcomes of the Turkish 1999 earthquake, and found that there were different predictors for each. A review of various studies available shows the following pertinent psychological effects of disaster  :
- Impairment of basic trust
- Lack of sense of responsibility
- Negative effects on identity
- Excessive interpersonal sensitivity
- Intrusive re-experiencing
- Autonomic hyperarousal
- Numbing of responsiveness
- Intense emotional reactions
- Learning difficulties
- Memory disturbances and dissociation
- Aggression against self and others
- Psychosomatic reactions
| Correlates of Psychological Impact of Disaster|| |
The more stressful the disaster experience, the more negative are the consequences, but it is not always possible to identify which of the many factors within a disaster make it more stressful. Psychological impact of disaster has been proposed to be a function of intensity and duration of disaster along with the vulnerability of the victims and resources available to mitigate these effects. A layout of these correlates along with the socio-administrative response is presented in [Figure 1]. The figure describes the magnitude of disaster effects as a function of correlates prevailing at three axes. Axis I describes the impact of disaster as a function of a, b, c and d. Axis II describes the impact as a function of A, B and C. Axis III shows the nature of these socio-administrative response levels which ranges from 1 to 6.
Impact of disaster = f (Intensity Χ Duration Χ Vulnerability Χ Resources)
A brief description of the empirical status of each correlate is provided below.
Intensity and duration
The magnitude of the disaster along with its duration defines the impact on the victims of a terrible incident. Theorists have identified the following as important characteristics of disaster: mass violence,  the experience of terror and horror, duration of the disaster  and the amount of unpredictability and lack of control. 
Various researches have identified a number of characteristics of victims that make them more vulnerable to disaster effects. [16,17] Vulnerability factors include, but are not limited to, socioeconomic status (SES), available resources, previous level of psychopathology, age, social/family factors, gender and ethnicity. The factors have been elaborated subsequently.
a) Socioeconomic status: Norris et al.  found that 13 of 14 samples which investigated SES and disaster outcome found lower SES to be associated with increased post-disaster distress. Poverty leads to lower access to post-disaster resources for minorities. In India, majority of the population is often concentrated in the lower income strata and are more likely to live in less safe homes and at risk areas increasing their trauma exposure. Also related to low SES is a higher pre-disaster exposure to community violence. Similarly, immigrant members of minority groups or individuals who live in developing nations may live or have lived in cultures where they are likely to have experienced trauma. This could include the community or personal violence that is common in countries characterized by political or social unrest.
b) Pre-existing psychopathology: According to Norris et al.,  individuals who suffer from a psychological disorder are more susceptible to further distress in the aftermath of a disaster. Pre-disaster anxiety disorders, depression, and suicidal ideation  were found to increase the likelihood of post-disaster psychopathology.
c) Age: Norris et al.  noted that middle-aged adults appear to be the group most affected by disasters. This age group carries more burdens and stresses, such as caring and providing support for a family, which may be amplified in the aftermath of a disaster.
d) First responders and disaster workers: They are at special risk for PTSD and other negative emotional consequences of disaster. , This vulnerability has usually been perceived to be related to the experience of the work rather than to any inherent vulnerability factors, as often people choosing these professions have high levels of emotional hardiness. Disaster workers' experience of the disaster is often more long term than that of other victims, as for instance, the long term digging out after September 9/11 attack. In addition, the experience of helplessness and lack of control for successes is often distressing.
e) Gender: Norris et al.  stated that in 94% of 49 studies which investigated the issue, female survivors of disaster were more seriously affected than were males. There are several possible explanations for this difference. As mentioned in the previous paragraph, low SES is a risk factor for post-disaster psychopathology, and women more often live in poverty than men. 
The gender differences may also be explained by differences that are often observed between the genders in the way psychological distress is expressed. In general, women are more likely than men to acknowledge psychological symptoms and to report them.  After a disaster, males may suppress feelings of psychological distress because of the expectation that men must be strong and capable.  Moreover, men are more likely to express psychological distress through substance abuse and other acting out behaviors rather than reporting neurotic-type symptoms like depression and anxiety. 
f) Resource system: Resource system encompasses the governmental and non-governmental agencies, community health workers, counselors, etc., who shape the impact of disaster to a large extent. Resources include material resources (for instance, helping victims locate temporary housing after a flood, or locate missing family members) and social resources (for instance, providing emotional support to an individual who lost a family member in the flood), and locating other individuals who can provide support. Thus, lack of perceived  or received social support may lead to greater post-disaster distress.
Social resources may be especially critical for female victims. Women's PTSD symptoms have been shown to increase as their available social supports decrease, a finding that was not true for men.  In a study with vicarious victims of the September 11 attacks, more than twice as many women than men reported engaging in collective helping behavior.  When women offer support to other people, not only can they be further exposed to the trauma through contact with others but also they may be burdened by the stress of providing support in times of need. A particularly devastating situation may be the one in which a woman provides support services to others in the aftermath of a disaster, but does not receive an equal amount of social support back.
g) Ethnicity: Gap in PTSD symptoms in men and women is higher in societies that are more traditional.  In third world countries like India, the gender roles are strictly compartmentalized, which leads to atypical behavior of males and females under duress vis-a-vis the more egalitarian societies. Post-disaster effects in developing countries tend to be greater than in the USA,  and within the USA, adult members of ethnic minority groups are more negatively affected by disasters. 
Looking at the various factors associated with the impact of disaster, it becomes imperative to devise plausible ways of ameliorating this impending threat. The following section dwells on group counseling as a most plausible theory for an effective management of psychological effects.
| Group Counseling: Concept and Efficacy|| |
Observation of the victims of various disasters reveals that victims often look forward to a social support mechanism at all levels like infrastructural, medical or psychological. In psychological paradigm, there is often a desire for communication to facilitate affiliation and identification, which defines the basic need for social support. Counseling is a process whereby the relationship and communication provided allows development of understanding of one's self, explore possibilities, and initiate changes which are reinforced by one's identification and affiliation with a group. It is the artful application of scientifically derived psychological knowledge and techniques for the purpose of changing human behavior. Many models of crisis counseling have been proposed and discussed.  Most tend to be solution focused, with an emphasis on the victims' strengths and finding appropriate solutions to the problems they face. In general, active problem solving strategies are more effective than passive ones. 
Two ways that dominate the professional art of counseling are individual and group counseling, which have their own strengths and weaknesses. However, because of the certain limitations of individual counseling, group counseling takes an upper edge in the face of a disaster. The following section describes the disadvantages of the individual counseling and advantages of group counseling.
Disadvantages of individual counseling
The most fundamental disadvantage of an individual therapy is its ineffectiveness in administration on mass population for rehabilitation.
The client may not be able to generate ideas from other members' pattern of thoughts and behaviors just like in a group setting, especially if others have similar issues and experiences which could help him make better choices and decision making.
Advantages of group counseling
Group counseling is better than individual counseling when it comes to developing new behaviors that clearly communicate their needs and help in attaining fulfillment in the reality. Group therapy considers the key elements of what the group are looking for and what will make their life better, what the group will do to bring about what they want and how they are able to make alternative options and come up with a common plan.
Group counseling also provides members with the opportunities to learn with and from other people and to be able to understand own patterns of thoughts and behaviors, as well as those of others. Other people may see attitudes and behavior patterns that are limiting and difficult to see in self.
Group counseling gives an opportunity to receive genuine support, honest feedback, and useful alternatives from peers. It also enables members to experiment and work toward improved attitudes and ways of coping with stress. A group may also help individuals with relationship concerns and general difficulties in dealing with other people.
Techniques used in group counseling
Various techniques have been evolved regarding the administration of group counseling according to the demands, nature and severity of target population. However, some of the most suitable techniques fitting to mass population are described by Jacob et al. which are given below:
a) Fishbowl: The fishbowl technique can be used with a variety of groups, especially with larger groups. The modus operandi includes dividing the group into two parts. The first half includes the members who form an inner circle and discuss the effects of a particular prevailing disaster. The second group members form an outer circle, and they listen to the details expressed by inner circle.
After a given time period, the members switch places with the new inner group sharing its reactions to the previous discussion. The new inner group may provide constructive criticism or build on the ideas already generated.
b) Small group interactions: Small group interaction can almost always be useful. Here the members of the group have the opportunity to discuss the disaster and its effects in greater detail and more people get to talk because the group is smaller. Members in small groups may work on the same task or on different phases of the task. The results of the small group discussions are then shared in the larger group.
c) Guided fantasy: In this intervention, the guided picture, think about, or get a feeling for the outcome of various solutions is generated by the group. Here members may fantasize the outcome and then construct what must happen for that outcome to be realized, thus generating various solutions which are shared by the group.
Stages of group counseling
According to Corey,  irrespective of the technique being followed, the group counseling needs to follow a pattern at various stages of transition. These stages are described as follows, which have also been explained in the two case studies presented in the subsequent sections.
- Developing a written proposal for the formation of a group
- Letting prospective clients know about the group
- Conducting pre-group individual interviews
- Screening and selecting prospective group participants
- Composing the group
- Organizing the practical details necessary to launch the group
- Preparing psychologically for the leadership tasks
- Preparing the members for a successful group experience
- Developing ground rules and setting norms
- Teaching the basics of group process
- Creating a trusting and safe climate
- Modeling the facilitative dimensions of therapeutic behavior
- Being psychologically and emotionally present
- Being open with yourself and with others in the group
- Sharing your expectations and hopes for the group
- Showing members they have a responsibility for the direction and outcomes of the group
- Helping members develop concrete and meaningful goals
- Clarifying general group goals
- Dealing with the members' fears and concerns
- Dealing openly with the participants' questions
- Making sure all the members participate in the group's interaction, so that nobody feels excluded
- Working toward decreasing leader dependency on the part of the members
- Teaching group members the importance of recognizing and expressing their anxieties
- Helping participants recognize the ways in which they react defensively and creating a climate in which they can deal with their resistance openly
- Noticing signs of resistance and communicating to the participants that some of these resistances are both natural and healthy
- Teaching the members the value of recognizing and dealing openly with the conflicts that occur in the group
- Pointing out behavior that is a manifestation of the struggle for control and teaching the members how to accept their share of responsibility for the direction of the group
- Providing a model for the members by dealing directly and honestly with any challenges to the leader as a person or as a professional
- Assisting the group members in dealing with any matters that will influence their ability to become autonomous and independent group members
- Emphasizing the fact that the participants' behavior will change only if they are willing to take action
- Modeling appropriate behavior, especially in terms of confronting with care and honesty, disclosing ongoing reactions to the group, and demonstrating respect toward others
- Supporting the members' willingness to take risks as they attempt to break new ground in the group and practice new behavior both in the group and in their everyday lives
- Interpreting the meaning of patterns of behavior constructively and at the appropriate time, so that members will want to engage in deeper self-exploration and consider alternative behaviors
- Assisting members to ventilate pent-up feelings when this emotional release is appropriate
- Assisting members to make sense of what they are experiencing in the group and to take steps toward cognitive restructuring
- Teaching participants how to confront others with respect
- Encouraging members to keep in mind what they want from the group and to ask for what they want
- Helping members to consider options and alternatives for dealing with difficult situations
- Focusing on the importance of translating insight into action
- Promoting continued group cohesion
- Providing systematic reinforcement of desired group behaviors that foster cohesion and productive work
Consolidation and termination stage
- Reinforcing the changes that members have made and ensuring that any unresolved issues between members or between members and leader are attended to before the group terminates
- Assisting the members in determining how they can apply what they have learned in the group to their lives outside the group
- Encouraging members to develop specific plans - perhaps in the form of contracts and homework assignments - that will help them make the desired changes
- Allowing enough time for any member to bring up unfinished business related either to the group itself or to out-of-group problems
- Assisting participants to develop a conceptual framework that will help them understand, integrate, consolidate, and remember what they have learnt in their group
- Giving members feedback that will help them apply what they have learnt and structuring the group so that all the members can give and receive feedback
- Encouraging the participants to fully express their feelings about termination and assisting them to work through sadness or anxiety related to separation
- Stressing the importance of maintaining confidentiality even after the group ends, by not discussing identities or specific situations connected with the group
- Providing a framework that will enable group members to evaluate the impact of the group on themselves as well as on the group as a whole
- Offering private consultations should any member need to discuss issues arising out of the group, and/or making suggestions concerning further counseling
- Arranging for a follow-up session with the entire group to discuss the group experience in retrospect
- Assisting members in developing contracts to carry out action-oriented programs that will help them apply their insights to their ongoing behavior and enable them to practice newly acquired interpersonal skills
- Finding out about specific referral resources for members who need or want further consultation
- Encouraging members to find some avenues of continued personal growth, so that the ending of the group can be truly a new beginning in the search for self-fulfillment
- Being available to participants on an individual basis, should they need or request help in sorting out the group experience; providing support and guidance in the event of a crisis situation originating in group participation
- Considering the possibility of a private post-group session with each of the members to discuss the outcomes of the group for them
- Developing some type of organized plan for evaluating the results of the group
| Case Studies|| |
Case study 1: Tsunami disaster (Nagapatanam, Tamil Nadu, India)
Tsunami which hit the coastal areas of Tamil Nadu (South India) on 26 th Dec' 2004 caused an extensive damage to human life and properties in the district of Nagapatanam. The trauma created by this incident had been of great magnitude and various governmental and non-governmental agencies came forward to help the victims by providing shelter, food and other materials, so as to speed up the rehabilitation work. However, providing material relief was not enough as the trauma had deep adverse psychological impact on the victims, which needed long-term psychological intervention. Mental Health Experts (MHEs) insisted for a structured comprehensive counseling for the victims in general and school children/college students, in particular, to check the onset of various mental health problems and PTSD disorders in the long run. A team of professional psychologists from DIPR, including one of the authors as head of the team, was deputed to conduct group counseling as a mode of primary prevention.
The psychological wound that had been caused by Tsunami was much deep among school-going children, especially because many of them lost their parents and siblings at a very early age. Moreover, a sizable percentage of them lost their houses. This had affected their life, in general, and studies, in particular. Thus, the aim was to bring them back to normalcy using both group and individual counseling techniques, and with the available time, it was decided that school and college teachers who interact with these students would be an ideal medium through whom counseling could be imparted to the students. However, direct counseling to students also was undertaken wherever it was felt by the school/college authorities that the trauma faced by the students was too acute.
The team of counselors visited one women's college and seven schools. A total of 247 teachers were given 1 day training in handling Tsunami generated emotional problems in children. The teachers were asked to spend at least 1 hour every day with the children so as to give them enough social and emotional support. In addition, 1070 children were subjected to group counseling module. The groups were divided according to their age, gender and professional status. The module administered to the victims as well as the trainees is described in [Figure 2].
Case study 2: Victims of bomb blast at district Dhimajee, Assam, India
The joy of 54 th Independence Day proved horrendous for the people of District Dhimajee, Assam, due to the senseless killings of 12 children and 3 women in a terrorist bomb blast during the Independence Day celebrations in the Dhimajee college grounds. The killings spread a wave of shock and fear in the minds of school-going children with age ranging from 7 to 17 years. Subsequently, children stopped going to schools and their parents became the victims of horrifying rumors spreading in the town. Security forces became the target of public frustration.
The most common symptoms prevalent among the citizens, as expressed by the trainee group, were: shock, fear of going outside, or sending their children to schools, sleeplessness, recurrent intrusions of bomb blasts, flashback of the trauma events and an uncertainty about the safety in future. The hysteric reactions were manifested in the form of loud voice with a fast tone, excitation, trembling and shaking, sweating, shortness of breath, feeling of choking, discomfort, unsteadiness, fear of losing control and fear of dying. The depressive mood in others subjects was manifested in the form of: low tone voice, hopelessness, meaninglessness, depersonalization, headache, flashbacks of trauma, sleeplessness, choking, dryness of mouth, stiffness, steadiness of body, continuous grief, etc. Most of the participants started identifying with one form of reaction or the other and most of the symptoms emerged common across the group.
Group counseling was arranged for the four groups keeping in view their age, gender and profession. Group 1 consisted of 43 teaching staff of Dhimajee School and District College. Group 2 consisted of 64 school children of an age range of 7-17 years and Group 3 consisted of 73 parents of the victims and other citizens. Group 4 consisted of 40 women adults. Group counseling module, as described in [Figure 2], was effective in moulding the traumatized victims to a well-shaped rejuvenated group.
[Figure 2] describes the schedule and impact of group counseling on the victims of trauma in both the case studies of natural as well as man-made disasters. The traumatized victims suffering from chaos and panic were subjected to various sessions of counseling which were as follows.
Session 1 (ice-breaking): Dealt with an ice-breaking phase which was focused to have emotional ventilation followed by verbalization of trauma, identification of self with the suffering hero, play way communication and externalization of grief and trauma. The aim was to let the victims surface their reservoirs of pent-up emotions so as to save them from fixating onto various unconscious states of psychopathology.
Session 2 (cognitive restructuring): Dealt with cognitive restructuring which focused on perception modulation, acceptance of reality, rejuvenation of resources and hope, triggering in-built defense mechanisms and developing unconditional positive regard for self. The aim was to rehabilitate the victims by changing their attitude in order to help them embrace their realistic identities. It was also aimed to rejuvenate their psychological strengths for the generation of hopefulness and meaningfulness in life.
Session 3 (relaxation): Focused on the relaxation techniques in order to build the psycho-physiological adaptability of the subjected victims. This was achieved through administration of exercises like deep breathing, progressive muscular relaxation, meditation and autogenic training.
It may be mentioned here that these group counseling sessions helped to identify the severe cases that were later given individual therapy. Overall, the module proved to be quite effective in rehabilitating the participants and bringing them back to main stream of social identity and building the social capital of the nation. It was observed that if such a process of psychological rehabilitation remains ignored, then victims are prone to become a social liability and spread chaos and panic followed by various disorders. Conclusively, the group counseling proved to be a silver lining in the psychological management of disaster trauma, on the one hand, and enhancing the robust social growth of the nation, on the other hand.
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[Figure 1], [Figure 2]