Week 9

Article

The Aftermath of Humanitarian Crises: A Model for Addressing Social Work Interventions With Individuals, Groups, and Communities

Eileen A. Dombo1 and Frederick L. Ahearn2

Abstract

This article reviews the aftermath of displacement caused by natural calamities such

as hurricanes, earthquakes, and man-made disasters such as war, ecological degrad-

ations, and political, religious, and ethnic persecution. These are traumatic events for

individual, families, and communities that require social work interventions.

Specifically, the authors will (a) explore the effects of displacement on individuals,

families, and communities; (b) propose an explanatory model of the effects of

trauma, loss, stress, and separation on behavioral outcomes as mediated by social

supports and coping styles; and (c) suggest humanitarian intervention strategies

conceptualized by the multilevel public health prevention model, with emphasis on

interventions at the individual, group, and community levels.

Keywords

disasters, humanitarian interventions, loss, separation, coping, trauma, social work

interventions, psychosocial wellness

Illness, Crisis & Loss

2017, Vol. 25(2) 107–126

! The Author(s) 2015

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DOI: 10.1177/1054137315606830

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1National Catholic School of Social Service, The Catholic University of America, Washington, DC, USA 2Center for International Social Development, National Catholic School of Social Service, The Catholic

University of America, Washington, DC, USA

Corresponding Author:

Eileen A. Dombo, National Catholic School of Social Service, The Catholic University of America,

Washington, DC 20064, USA.

Email: [email protected]

There has been growing attention to the emotional and psychological plight (behavioral outcomes) of survivors of natural and human-induced disasters. Human displacement is the result of these forces, often beyond the control of individuals, families, and communities, requiring social work interventions within humanitarian settings. One might ask, “What happens to an ordinary individual, group, family, or community who has go through an extraordinary experience?”

This article attempts to answer this query by (a) reviewing the emotional and behavioral effects of displacement on individuals, families, and communities; (b) presenting an explanatory model of the interactive effects of trauma, stress, loss, and separation, as these are mediated by social and emotional supports and one’s coping style; and (c) proposing an array of social work intervention stra- tegies with individuals, groups, and communities viewed through the lens of the public health model of primary, secondary, and tertiary levels of intervention.

Effects of Displacement on Individuals, Families, and Communities

As of 2013, there are an estimated 42.9 million refugees, stateless, and internally displaced persons in the world, the largest number in the past 15 years. The bulk of refugees are found in Africa and the Middle East, while the stateless, mostly Palestinians, are located in the Middle East, and one finds the majority of internally displaced persons in the Americas, especially Columbia and South America (UNHCR Statistics, 2013). Social work practice with these populations has been greatly influenced by the various psychosocial theories popularized in recent years by mental health professionals. These theories are theories of trauma, loss, separation, stress, coping, and social supports. Three of these, loss, separation, and stress, often result from the traumatic experiences that cause displacement and are interactive, often leading to negative psychosocial consequences. We refer to these as the interactive variables. The theories of social support and coping are mediating factors that often soften the effects of the negative outcomes.

Interactive Variables

In this section, we will explore the role of trauma in the experience of displace- ment and discuss the interactive factors of loss, separation, and stress.

Trauma. Contemporary trauma theory asserts that a traumatic experience is defined as a situation that overwhelms the normal ability to cope. Traumatic stressors cause neurological as well as biological reactions, causing the indivi- dual to shut down or numb out due to an inability to process and integrate the experiences. These experiences are understood to be normal, expected reactions

108 Illness, Crisis & Loss 25(2)

to unexpected events. Trauma theory shifts the focus from individual pathology to include a systemic, societal issue that requires intervention. Through this lens, it is not just the individual’s mental health needs that must be addressed (Weaver & Burns, 2001). Social workers also attend to the traumatized community, restoring social systems and community structures that have been destroyed, so that basic needs can be met. The traumatic reactions of individuals are under- stood to be symptoms of distress that occur following overwhelming and terrify- ing experiences. It is not the individual who is sick, so much as it is the environment in which the displaced person exists.

An additional understanding of trauma is that individuals can adapt by tap- ping into their own strengths and capacity to heal. This concept of posttraumatic growth is a critical part of understanding resilience as reflected by the internal resources displaced persons may bring to bear on their own adaptation. The role of culture, traditional medicine, spiritual and religious practices, and other inter- nal resources will be crucial in helping survivors acknowledge that they hold the ability to heal themselves and that they may not require intensive psychosocial interventions.

Social work practice with survivors of war, disasters, and other forms of displacement frequently refers to traumatization and posttraumatic stress dis- order. Given the stresses of displacement and acculturation, social work inves- tigators found that a long-term vulnerability to trauma results from experiences of separation (Cohen, 2008), flight and uprooting (Khawaja, White, Schweitzer, & Greenslade, 2008), persecution, oppression, and torture (Weaver & Burns, 2001), natural disasters (Mathbor, 2007), and other stressful life events (Davies, 2008). Trauma is both a cause of problems in social functioning of those displaced as well as an effect of the displacing experience. Due to the subjective nature of trauma, the experience of displacement that involves loss, stress, and separation may or may not have a lasting traumatic impact. In sum, we find that trauma has been associated with displacement, flight, persecution, oppression, torture, and war and related to ones culture and religion. In turn, studies reveal that the manifestations of trauma are seen in emotional, physical, and biological reactions and behaviors as well as the traumatic effects of com- munity and organizational damage and destruction. In exploring the effects of displacement, we explore the interactive concepts of loss, separation, and stress.

Loss. Fried (1963) studied former residents who grieved for their lost homes which were destroyed to make way for a new highway and upscale apartments. More recently, Landau and Saul (2004) and Keller (2011) reported similar find- ings, stressing the importance of resiliency when community members have experienced loss, as they rely on natural supports and relationships. Another key variable is the importance of helping networks that mitigate the loss from neighborhood dislocation. Zinner and Williams (1999) documented this by refer- ring to group survivorship when a community weeps.

Dombo and Ahearn 109

Studies in the area of disaster intervention highlight the interrelationship of loss and grief (Iravani & Ghojavand, 2005). Loss of family members, relatives, and property are associated with increased anxiety, stress, and depression (Suar, Mandal, & Khuntia, 2002) and substance use problems (Cepeda, Valdez, Kaplan, & Hill, 2010). Significant losses may occur before, during, and after the disaster (Dow, 2011). These include change of personal status and plans for the future and loss of family members, loved ones, one’s culture and language, and freedom. War survivors of Sierra Leone (Kline & Mone, 2003), Cambodia (Rousseau & Drapeau, 2003), and Bosnia (Miller, Worthington, Muzurovic, Tipping, & Goldman, 2002), all suffered loss of parents, home, and the effects of migration and displacement. Keller (2011) reported similar findings, stressing the importance of resiliency when community members have experienced loss, as they rely on natural supports and relationships.

This is because the loss is not just in the physical environment but is also connected to a loss of internal world; a loss of meaning and purpose and identity (Alcock, 2003). Therefore, as these populations experience loss in flight, in seek- ing asylum, or in resettlement after a disaster, they will react by experiencing the various stages of bereavement, which often create serious adjustment problems for an individual and the community as a whole.

Separation. The impact of displacement on families must be understood within the context of separation and forced restructuring of the realms of family life, such as internal relationships, external community connections, roles and obligations, and communication patterns. If and when the family is reunited and made whole again, a process of finding a new normal creates a new stressor in itself (Doostgharin, 2009). One recalls the work of Freud and Bellingham (1943) which revealed that English children, removed from cities during the German blitz of World War II for the safety of the countryside, fared worse than those children who stayed in the war-affected area with their parents. There are consequences of separation and loss. It has been shown, for example, that separation and displacement are major life events that impact one’s well-being that often lead to anger and cultural bereavement (Cohen, 2008). In other studies, it was found that Middle Eastern refugee children exhibited anxiety, sleep disturbance, and depressed mood resulting from separation from parents (Montgomery, 2011). Finally, we know that the “Lost Boys of Sudan,” separated from their parents, coped using both emotional- and problem-focused strategies with strong support from their peers and elders (Luster, Qin, Bates, Johnson, & Rana, 2009). Similarly, lost boys resettled in Belgium had a greater risk of trauma compared with other refugee adolescents who resettled with their parents (Dertuyn, Mels, & Broekaert, 2009).

It is evident that separation is a form of displacement, often cited as a major event that has a serious impact on structures of community affecting the well- being of individuals. These experiences may result in trauma, guilt, anger, coping deficits, and other emotional manifestations.

110 Illness, Crisis & Loss 25(2)

Stress. In the 1970s, we witnessed considerable theoretical work dealing with the topic of stress. Stress, conceptualized as a multifaceted element in mental health, creates a burden for the individual that may be expressed by physical or psy- chological symptoms. On one hand, stress may be caused by outside agents (events or life situations) or as an internal process where stress is produced by the actions or thinking of an individual. Stress may manifest itself as (a) a stimulus or an event or class of events; (b) a response that is accompanied by bodily changes, physical and emotional such as sweating, anxiety, or fear; or (c) a blending of the two through interaction. Stresses may be endemic or chronic and cumulative. The processes of displacement and resettlement are frequently viewed as stressors, while the reactions of individuals to these events are seen as stresses. For example, researchers have found that Vietnamese adults and youth who have suffered from premigration and acculturation stresses were also prone to depression, nightmares, and physical illness (Weaver & Burns, 2001). For displaced persons, these stressors result from change, acculturation, bereave- ment, family and intergenerational conflict, occupational and economic uncer- tainty, discrimination, poor physical health, and cultural adjustment (Orley, 1994).

In the disaster literature, there are similar report of the association of stress and a variety of psychological symptoms. The degree of exposure to the stresses of Hurricane Katrina by women led to increased psychological distress (Lowe & Rhodes, 2013) and partner abuse (Schumacher et al., 2010). Partner abuse was also found to increase after the Sichuan earthquake (Chan & Zhang, 2011). In doing clinical assessment, authors have recommended attention to stress, apprai- sal, and coping theories in forming an intervention plan (Matthieu & Ivanoff, 2006).

The literature on stress reveals that displacement causes endemic and cumu- lative stressors that are frequently associated with a variety of physical and emotional symptoms, such as sleeping disorders, nightmares, depression, inabil- ity to relate to others, and physical illness.

Mediating Factors

Social Supports. An additional body of literature has developed regarding social supports that serve as mediating factors that facilitate adjustment or readjust- ment. Individual characteristics, such as intelligence, personality, age and experi- ence, resilience and fortitude, and belief system, serve as guides to navigating daily life. External supports that are most significant for individuals include the family, relatives, friends, neighbors, the school, church, or civic or mutual aid associations (Renner, Laireiter, & Maier, 2012). The availability of and acces- sibility to community resources, services, and networks are also important sources of support in confronting and coping with stressful life events. Lack of social support and social interactions has been linked with poor educational

Dombo and Ahearn 111

and employment outcomes, and anxiety and depression for displaced persons (Finn, 2012; Renner, et al., 2012).

Social supports strengthen one’s capacity to deal with displacement and the concomitant problems in daily living, including psychological and emotional behaviors. These supports may be the family, a significant relative or friend, and the external programs and services.

Coping. Paralleling the theoretical work of the stress theorists is the early work of Pearlin and Schooler (1978), who posited that coping behaviors protect people from further psychological harm. They presented three fundamental ways by which persons cope with the trauma of loss and stress: (a) control, (b) tolerance, and (c) minimization. Noting the importance of appropriate developmental tasks, Davies (2008) found that inadequate coping skills were one factor that hindered educational and psychological developmental in adolescence among Sierra Leonean refugees in New York City public schools. Furthermore, the significance of coping strategies among Sudanese refugees was highlighted by Khawaja et al. (2008), who found that individuals used religiosity, cognitive strategies, and hope for the future as well as social supports to aid in coping.

More recently, religion and spirituality have been understood to be the key factors in coping. Religious faith is often an underlying mechanism for adjust- ment to adversity, and spiritually based group support is effective in teaching adaptive coping skills and has also been established as a coping mechanism among African torture survivors (Leaman & Gee, 2012) and with Hindu Bhutanese who have been resettled to the United States (Benson, Sun, Hodge, & Androff, 2012).

Often overlooked in assessing coping is the role that resilience plays in mitigating long-term psychosocial problems. Resilience is not a zero-sum phenomenon, where it is either present or absent. Resilience is transactional and contextual; elements of resilience can be found in individuals, families, and communities who have experienced the most profoundly traumatizing events. The inability to distinguish between normal reactions to displacement and true psychological trauma has caused a Western belief that all displaced persons are vulnerable, powerless, and in need of being rescued (Pupavac, 2008). Therefore, when assessing and understanding the level of coping, it is essential to look for expressions of resilience (Khawaja et al., 2008). By highlighting and validating the internal resilience in the individual, family, or community, the social worker is starting where the client is and working from a strengths perspective.

It is our conclusion that a defining characteristic of those in need of huma- nitarian aid is the experience of displacement caused by man-made and natural disasters. In turn, as we have seen, displacement is characterized by community disorganization and destruction that can lead to psychosocial outcomes

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associated with trauma, stress, loss, and separation for some members of the community. How displacement is experienced depends on many things, such as the nature and degree of the disastrous event; what was going on in a person’s life before, during, and after the disaster; and the availability of social supports and one’s coping style that may lead to resolution and adjustment. Here, we extend this review of findings in the literature to an explanatory model of psy- chosocial outcomes.

Explanatory Model of Psychosocial Outcomes

The explanatory model presented in Figure 1 illustrates the causative nature of traumatic incidents on the displacement. The experiences of loss, separation, and stress are mediated by the presence or absence and strength or weakness of social and community supports and coping abilities. These variables will have a sig- nificant impact on psychosocial outcomes that may require social work inter- ventions not only at the individual but also the community levels in the aftermath of a humanitarian crisis. Social workers can utilize this model to deepen their understanding of the effects of displacement. Expressions of beha- vioral and psychological problems can be understood as an inability to cope with the traumatic experience of displacement, such as the stress of adaptation to the loss of home, loss of life, and separation from family and community. Additionally, it will help to inform problem formulation and the selection of appropriate interventions within humanitarian settings that can be chosen from the prevention model described in the next section.

Traumatic Event

Displacement Psychosocial

Outcomes

Community Social Supports and Individual Coping

Loss Stress

Separation

Figure 1. Explanatory model of psychosocial outcomes from displacement.

Dombo and Ahearn 113

Social Work Intervention Strategies Conceptualized by the Multilevel Public Health Prevention Model

We have demonstrated that social work practitioners and researchers are very much attuned to the concepts of trauma, stress, crisis, loss, coping, and social supports systems as concepts to guide them in the understanding the experiences of displacement, the nature and extent of the problems, and ways in which to intervene to give assistance to survivors. Social workers often used crisis inter- vention techniques and rapid and short-term strategies designed to return the person to his or her previous functioning. Some employed play therapy with children, psychotherapy with individuals, family treatment, social group work, informal support from peers and elders, and the removal barriers to accessing services in the environment (Finn, 2012). Practitioners have expanded their psychosocial interventions to include connecting the individual and family with social, economic, and educational resources they need to reestablish them- selves, as well as rebuilding community supports and structures while promoting individual and community empowerment.

However, given the nature of the extensive needs of displaced individuals, some researchers have suggested that social workers form interdisciplinary part- nerships with teachers, church representatives, job counselors, employers, and court personnel in solving the many day-to-day problems (Xu, Bekteshi, & Tran, 2010). Historically, the conception of social work with these groups came to include considerable community work as well as clinical services. Montero and Dieppa (1987) advised that social work practitioners assist displaced persons with their daily coping skills and also work with indigenous, mutual assistance agencies to connect with language, employment, and cultural resources, approaches not dissimilar from those that began in the settlement houses in the 19th century. Adding to an emphasis on family treatment, case management, and empowerment, social workers may also consider (a) work with ethnic orga- nizations and (b) a focus on policies impacting displaced persons.

Toward a Model of Social Work Interventions in the Aftermath of Humanitarian Crises: Transferable Insights From the Past

It is apparent from this review of social work practice with displaced persons that treatment interventions must combine both clinical and community strate- gies. Given the stresses and losses associated with displacement, individuals and families may experience social, psychological, and economic problems while communities are involved in the rebuilding of social structures and supports. Both the individual and the community are targets for social work intervention, but the intervention must not come from a Westernized view of displaced per- sons as helpless and powerless (Pupavac, 2008). To integrate these approaches,

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we propose the utilization of the schema of public health prevention levels view- ing social work practice methods, clinical and community, as means to (a) pre- vent problems from occurring, (b) intervene rapidly to restore balance and homeostasis, and (c) promote long-term assistance and rehabilitation. These roles can be infused into an existing or newly created program. In many ways, the public health model supports social work’s person-in-environment perspec- tive in that it recognizes targeting for intervention individual, families, and communities. Marsella (2011) clearly argues for health promotion and commu- nity action when working in developing countries. This approach:

consists of social educational, and political actions that: enhance public awareness

of health; foster healthy life styles, and community action in support of health: and

empower people to exercise their rights and responsibilities in shaping environ-

ments, systems, and policies that are conducive to health and wellbeing Marcella.

(Marsella, 2011, p. 7)

As this model is presented in Table 1, we illustrate the levels of prevention in an actual case example as personally experienced by one of this article’s authors.

Case Example: Cuban Refugees in America

In 1980, Fidel Castro publically announced that any Cuban who wished to leave

the island could do so. When the exodus became enormous and embarrassing for

the regime, Castro emptied prisons and mental institutions and rounded up people

considered to be undesirables such as homosexuals, street kids, and Seventh day

Adventist to send as well. One hundred and twenty-five thousand (125,000) refu-

gees landed in Florida and were hastily screened by the U.S. Army. Of these, 19,000

were sent on to a Pennsylvania National Guard camp, Fort Indiantown Gap,

where a mental health program was set up alongside the general health system

(Mariel Boatlift, 2015).

Primary Prevention: This massive migration of Cubans to the United States was

sudden and caught Americans by surprise. However, many departments of the U.S.

government had prepared for mass emergencies due to nature disasters and forced

migrations. Plans had been made in the case of an emergency. Practice simulations

involved many governmental and nongovernmental organizations preparing for

such a calamity as each of the organizational entities coordinated their roles with

other responders. This is just what happened when the thousands of Cubans landed

on the shores of Florida. The military were on hand to provide security, personnel

for the State Department registered the newcomers, medical staff of the Public

Health Service conducted cursory medical examinations, and the Red Cross was

on hand in an attempt to contact relatives to vouch for and sponsor individuals and

Dombo and Ahearn 115

Table 1. Model for Social Work Practice With Displaced Persons.

Intervention phases Social work interventions

Primary phase Purpose: to prevent

psychosocial problems arising from displacement.

1. Advocacy of humane immigration policies as well as policies that prevent, avoid, or mitigate the effects of displacement.

2. Education of and information for individuals and groups at the appropriate levels to facil- itate cultural understanding and acceptance.

3. Integration of social and economic policies and programs that strengthen displaced indivi- duals, their families, and communities.

4. Training of mental health professionals to understand and identify trauma sequelae in displaced persons.

Secondary phase Purpose: to intervene

rapidly when psychosocial problems occur.

1. Advocacy to change and rectify policies that contribute to the negative effects of displacement.

2. Planning of social and economic programs that strengthen the existing social fabric of com- munities, their structures, and institutions.

3. Repairing social networks, strengthening families, and enhancing of resources and support.

4. Assessment for initial indicators of trauma such as shock, numbness, and dissociation. Refer for crisis intervention if needed to strengthen adaptive coping.

Tertiary phase Purpose: to provide

long-term interventions when psychosocial problems become chronic.

1. Advocacy of policies that seek peace, reconci- liation, human rights, and social justice.

2. Planning of social and economic programs that rebuild communities and revitalize structures, culture, and values.

3. Rehabilitation of communities that have suf- fered from the chronic problems from displacement.

4. Long-term psychological treatment to address the traumatic impact of loss, stress, and separation.

116 Illness, Crisis & Loss 25(2)

families out of the camp. Those not sponsored were then sent to other camps in

Arkansas, Wisconsin, and Fort Indiantown Gap, Pennsylvania.

The first step in the creation of the mental health program in the camp was the

recruitment of qualified staff. Through the Public Health Service and the National

Institute of Mental Health, a call was put out for mental health volunteers, drawing

scores of social workers, psychologists, and psychiatrists who donated weeks of

their time for the effort. Overtime, it became evident that there were also mental

health professionals among the refugee population who were then recruited,

oriented, and teamed with an American mental health professional. The Cuban

and American teams focused on primary prevention activities each morning, train-

ing, and orienting the camp and barrack leaders to this mental health resource for

refugees under their command or in their area. This was done to facilitate case

finding and case follow-up.

An organizational chart for mental health services in an inpatient and outpatient

system was designed; cooperative agreements set with other actors in the camp; and

a plan for the training and supervision of staff established. Space was located,

required permissions sought and granted. The program was ready for take off.

Secondary Prevention: An outpatient clinic for individual and group treatment was

opened daily in the afternoon. Attached to the clinic was a pharmacy that dis-

pensed medications. In addition to the professional mental health staff, two groups

in the refugee population were also brought into the system to assist the mental

health clinic. One was the serendipitous discovery that next door to the clinic was a

facility for body builders. A number of these men were recruited and trained as

guards at the front door to maintain order and at the dispensing window to prevent

robbery of medication from patients. The other group to be involved as collabora-

tors was the curanderos, or local medicine men or women. They agreed to refer

clients in need to the mental health clinic and in turn the clinic staff, where appro-

priate, could call upon a curandero for assistance.

Tertiary Interventions: As soon as the camp opened, there was a need for an

inpatient system, as hundreds of former mental patients, most without their med-

ications, were in crisis, acting out, and becoming dangerous to themselves and

others. This required the immediate establishment of an inpatient psychiatric facil-

ity to support these individuals. Some obviously required continuing care, while

others were immediately stabilized with medication and returned to the general

camp population.

Three months later, the camp closed as all but 3,000 refugees were sponsored out of

the camp by relatives or friends. The remainder of the refugees were sent to Federal

psychiatric or prison facilities in the United States.

Dombo and Ahearn 117

How, then, might we apply the lessons of this case to situations that social planners and practitioners may meet today? Viewing Table 1, one can begin to see the many social work roles during the various levels of prevention (interven- tions). In this case, drawn from the Mariel boatlift, micro (individual and group) and macro (camp as community) social work strategies were employed. These strategies are considered later.

Primary Phase

Key in the primary phase of the model for social work practice with those displaced is advocacy, education, policies, and training. Aware of national and local laws regarding immigration, refugee status, disaster relief, and huma- nitarian aid, social workers will join with other groups in calling for sane, just, and humane regulations for the admittance of those who face persecution and oppression elsewhere or have been separated from family members who already reside in the country. Educational programs and forums that promote dialogue and cultural exchanges are strategies that social workers may employ to foster understanding and goodwill among displaced persons and their temporary or permanent homes and communities.

The planning of programs similar to the social settlements of the past will provide the newly resettled with the resources they need to be independent. Language courses, job training, day care, youth activities, citizenship classes, and legal advice are the type of resources that prevent problems from occurring later. The literature points out the importance of indigenous social, civic, and religious programs, services, and rituals that make up the social fabric of an immigrant community and support the adaptation and integration of indivi- duals and families. These programs should be created in conjunction with the leaders of the community and follow the 10 principles for creating trauma- informed services (Elliot, Bjelajac, Fallot, Markoff, & Reed, 2001) as part of this prevention phase, so that all providers and service delivery systems are not re-traumatizing. This groundwork is laid out in the primary phase in anticipa- tion of the needs that will arise in the secondary and tertiary phases, where rapid intervention and long-term treatment will be provided. Through intentional advanced planning and training, the goal of trauma-informed services is to prevent problems that can arise when the delivery method of psychosocial ser- vices is re-traumatizing. These principles state that trauma-informed services and programs:

. Recognize the impact of trauma on development and coping;

. Place the recovery from trauma as the primary goal;

. Use an empowerment model;

. Maximize client’s control over the recovery process;

. Utilize relational collaboration in trauma recovery;

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. Address need for safety, acceptance, and respect;

. Have a strength-based focus on adaptation and resilience;

. Minimize the potential of the delivery of services to be re-traumatizing;

. Strive for cultural competence; and,

. Involve those receiving services in program design and evaluation.

In this primary prevention phase, social workers and other mental health professionals must receive training in the traumatic effects of displacement, with particular attention to cultural and linguistic factors in the situation. Through education and awareness about the needs of displaced individuals and families, social workers gain the knowledge and skills to play a crucial role in the prevention of social problems that may arise through the trauma of geopolitical dislocation. Through all phases, teaming is the guiding principle, as social workers are not do for, but doing through collaboration with the community.

Secondary Phase

As problems occur, it is imperative that social workers intervene quickly to reverse trends and restore individuals and communities to their former state of functioning. Oftentimes, there is economic hardship, intergenerational con- flict as children acculturate rapidly to the new culture, family separation, isola- tion, lack of social supports, and even family and community breakdown. Therefore, the required social work roles of advocacy, planning, assessment, and intervention are necessary not only at the individual and group levels but also directed toward the rehabilitation of organizations and the community.

In this secondary prevention phase, the role of the social worker at the macro level is to work with community leaders to identify gaps in policies and services that prevent rapid intervention. This advocacy will allow for the evaluation of strengths and posttraumatic growth that already exist, and help displaced people build on this by accessing resources and supports to repair their social networks and find family and community members from whom they have been separated. Oftentimes, communities will also need assistance in revitalizing sociocultural institutions, mediating intergroup conflicts, and bringing economic resources into the community to repair social networks, offer job opportunities, and pro- vide social services. The social worker can act as a cultural bridge between the community and the new environment.

On a microlevel, the social worker is assessing for the early warning signs of trauma by screening for shock, numbness, and dissociation that often occur when an individual’s normal methods of coping do not work in the current situation. Appropriate social work interventions may include trauma-focused counseling with individuals, family treatment, the formation of support groups, and linking people with resources to foster independence. In these

Dombo and Ahearn 119

instances, the social worker’s role in providing culturally sensitive interventions (McKinney, 2007) is crucial in stemming the tide of chronic, complex trauma developing.

Other examples of social work roles in this phase are as follows:

. Building existing structures of support;

. Planning programs that increase a sense of agency and capacity;

. Empowering individuals and communities to play a role in recovery;

. Organizing local communities around issues of concern;

. Planning and implementing gender responsive interventions;

. Addressing the issue of sustainable livelihood options; and,

. Using media and the Internet for advocacy.

In each of these strategies, the social worker emphasizes relationships, colla- boration, and multilevel integrations of their programs using local knowledge in the mobilization of resources.

Connecting policy and microlevels of practice, social workers will attend to the provision of and proposals for trauma-informed programs and services to displaced persons. Recent efforts in some countries to deny social, health, and educational assistance to both legal and illegal immigrants demonstrate the importance of social work intervention in the policy arena. Some immigrants depend on welfare assistance, health services, or public schools for their children. This has been a right for legal immigrants, a right that social workers should actively support through collective lobbying and professional pressure.

Tertiary Phase

The crucial roles for social workers at this tertiary prevention phase consist of advocacy, planning, rehabilitation, and long-term treatment. For all social workers, it is a professional responsibility to take note of the global migration of peoples and become an active part of the call for peace, human rights, and social justice. The role of the social worker is found in organizing for grassroots involvement in local, state, and federal policies to change in this regard. Social workers are a voice for policies and programs that rebuild and revitalize these communities and their social fabric. These approaches are necessary if programs are nonexistent or policies do not support the provision of basic services to refugees, immigrants, and disaster survivors, and their communities. Since dis- placed persons have low political capital, community leaders easily overlook the needs of these communities. By returning to the roots of the profession in supporting immigrants, social workers address the issues of those suffering the effects of displacement.

There will be some individuals who are severely traumatized by the long-term pressures of displacement, when resilience and posttraumatic growth are

120 Illness, Crisis & Loss 25(2)

insufficient to counteract the pain and suffering they have endured. These indi- viduals will require long-term psychological support. They may face depression, anxiety, sleeplessness, and other endemic physical and emotional problems because of the stresses of the past and the difficulties of adapting to the new reality. However, clinical social work methods can be difficult to provide and often vary because of language and cultural barriers and the stigma of seeking help. However, the social worker may carry out a number of interventions that can be adapted in ways that honor the culture of the displaced person and the trauma they have experienced (Schottelkorb, Doumas, & Garcia, 2012; Weine et al., 2004).

Others experience misfortunes due to illness, poverty, and isolation that create dependency on systems for support. A critical social work role here is to assist the individuals in obtaining sufficient health, welfare, and social resources to manage their conditions and enhance independence. Links with community resources are often blurred due to a lack of knowledge, inaccessi- bility, inappropriateness of the service, or discrimination. Removal of these barriers becomes an objective in working with the community to link with needed resources.

Discussion

The Cuban Refugee example illustrates the emotional and behavioral outcomes that can result from the traumatic experience of displacement and the various levels of interventions that required mental health intervention. This example has relevance for social workers today in responding to the humanitarian needs of displaced persons and communities. It is our contention that, through imple- mentation of the multilevel Public Health Prevention Model, social workers can team with community leaders to engage in important primary prevention tasks, such as advocating for policies to facilitate movement to permanent housing. This intervention would mitigate the effects of loss and separation. The host communities would benefit from education on the culture of their new neigh- bors. To facilitate a smooth transition of displaced persons to their new homes, specific policies and social supports are necessary. Mental health professionals and paraprofessionals would receive trauma training and be able to identify the psychosocial needs of those most impacted by the trauma of displacement. Trauma-informed services would be created to lay the groundwork for the secondary and tertiary phases.

On the level of secondary interventions, much effort would need to go into advocating for policy changes to address any negative impacts on the displaced. Creating community centers, planning employment programs, and social sup- ports would be added to these interventions to begin to create stability. Helping displaced persons find those from whom they have been separated would begin the work necessary to repair social networks. When mental health professionals

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assessed initial indicators of trauma (dissociation, shock, and numbness), they could refer individuals to the services set up in th primary phase at the mental health clinic.

Finally, in the tertiary phase, social workers would join in solidarity with those working in camps or in local communities to advocate for social justice and peace. Planning for the long-term needs of the community and rehabilitating the economic and social structures and would take a prominent focus. Finally, the example of the inpatient psychiatric facility set up in the camp would ben- eficial in other settings to address the long-term psychological treatment needs in this phase of the model.

Conclusion

The authors of this article caution the reader not to fall into the trap of advocat- ing the use of Western concepts, especially those that are clinical or psycholo- gical in nature, to attempt to understand the reactions and behaviors of non-Western populations. While this issue is not the purpose of this article, the authors believe that Western measures may be used with non-Western groups if the measures are standardized and validated for that particular group, and the results are supported by a variety of ethnographic strategies such as narratives of lived experiences, focus groups, and group discussions. This is very much the position of Marsella (2011) who has stated that for “valid clinical and psychological assessment to occur, it is essential that there be linguistic, conceptual, scale, and normative equivalence for the clients being tested or assessed” (p. 7). In other words, we are cautioned about the risks of using assessment measures that are standardized on Western populations with non-Western individuals and communities and have means available to adapt measures to different cultures.

This article reviewed the serious nature of displacement and its effects on individuals, families, and their communities. Social work practitioners have historically assisted these groups; however, their contributions have not been highly visible. We have explored the pernicious effects of displacement on indi- viduals and communities and proposed a causative model of psychosocial out- comes seen in those persons and villages who have had traumatic experiences of loss, separation, and stress. Depending on the mediating variables of social supports and coping, some will require social work intervention. Addressing these emotional and behavioral challenges through the use of a multilevel public health prevention model, social workers will provide much needed social and emotional support to survivors of humanitarian crises.

We argued that social work services to these populations should be combined with community-focused approaches and therefore have proposed a model of social work practice that builds on a public health approach and conceptualizes social work interventions during specific phases of prevention (primary,

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secondary, and tertiary interventions) in a trauma-informed, humanitarian manner. These roles require social work practitioners to be versed in clinical and group strategies, such as crisis intervention and family treatment, as well community roles such as advocacy, lobbying, planning programs and services, and organizing groups for needs assessment as well as for action.

Thus, we envision a commitment of social work professionals to intervene effec- tively in assistingdisplaced individuals and familieswith their traumatic experiences, aswell as emphasizing building and restoring their communities and camps through community action that focuses on building capacities for long-term recovery. The subjective experience of trauma can be explored and understood when viewed through trauma-informed lenses. Through each phase of intervention, resilience and posttraumatic growth are explored to determine if intervention is needed; it should not be assumed that all would be in need of services.

This model builds on the body of literature on displaced persons and trauma- informed services and offers coordinated and consistent humanitarian interven- tions. It has implications and great value for social work practice in these areas as it provides a framework for creating or adapting services that are culturally relevant. The causative model of psychosocial outcomes should be tested through research to explore the interactions of these variables. Finally, we recommend that social workers providing humanitarian relief receive ongoing training in providing trauma-informed service under appropriate cultural con- texts in providing care to individuals, groups, and communities.

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.

References

Alcock, M. (2003). Refugee trauma—The assault on meaning. Psychodynamic Practice, 9(3), 291–306.

Benson, G., Sun, F., Hodge, D., & Androff, D. (2012). Religious coping and accultur- ation stress among Hindu Bhutanese: A case study of newly-resettled refugees in the

United States. International Journal of Social Work, 55(4), 538–553. Cepeda, A., Valdez, A., Kaplan, C., & Hill, L. E. (2010). Patterns of substance use among

hurricane Katrina evacuees in Houston, Texas. Disasters, 34(2), 426–446.

Chan, K. L., & Zhang, Y. (2011). Female victimization and intimate partner violence after the May 12, 2008 earthquake. Violence and Victims, 26(3), 364–376.

Cohen, J. (2008). Helping adolescents affected by war, trauma, and displacement. Journal

of the American Academy of Child & Adolescent Psychiatry, 47(9), 981–982.

Dombo and Ahearn 123

Davies, A. Z. (2008). Characteristics of adolescent Sierra Leonean refugees in public schools in New York City. Education and Urban Society, 40(3), 361–376.

Dertuyn, I., Mels, C., & Broekaert, E. (2009). Mental health problems in separated refugee adolescents. Journal of Adolescent Health, 44(3), 291–297.

Doostgharin, T. (2009). Children affected by earthquakes and their immediate emotional

needs. International Social Work, 52(1), 96–106. Dow, H. D. (2011). An overview of stressor faced by immigrants and refugees: A guide

for mental health practitioners. Home Health Care Management and Geriatric Practice, 23(3), 210–217.

Elliot, D. E., Bjelajac, P., Fallot, R. D., Markoff, L. S., & Reed, B. G. (2001). Trauma- informed or trauma-denied: Principles and implementation of trauma-informed ser- vices for women. Journal of Community Psychology, 33(4), 461–477.

Finn, H. B. (2012). Overcoming barriers: Adult refugee trauma survivors in a learning community. TESOL Quarterly, 44(3), 586–596.

Freud, A., & Bellingham, D. T. (1943). War and children. New York, NY: Ernst Willard.

Fried, M. (1963). Grieving for a lost home. In L. Dahl (Ed.), The urban condition (pp. 151–171). New York, NY: Basic Books.

Iravani, M. R., & Ghojavand, K. (2005). Social work skills in working with survivors of

earthquake: A social work intervention—Iran. Social Work & Society, 3(2), 265–272. Keller, J. (2011). Experiences of public housing residents following relocation:

Explorations of ambiguous loss, resiliency, and cross-generational perspectives. Journal of Poverty, 15(2), 141–163.

Khawaja, N. G., White, K. M., Schweitzer, R., & Greenslade, J. (2008). Difficulties and coping strategies of Sudanese refugees: A qualitative approach. Transcultural Psychiatry, 45(3), 489–512.

Kline, P. M., & Mone, E. (2003). Three strategies employed by adolescent citizens of Sierra Leone. Child and Adolescent Social Work Journal, 20(5), 321–222.

Landau, J., & Saul, J. (2004). Family and community resilience in response to major

disaster. In F. Walsh & M. McGoldrick (Eds.), Living beyond loss: Death in the family (pp. 151–171). New York, NY: Norton.

Leaman, S., & Gee, C. (2012). Religious coping and risk factors for psychological distress among African torture survivors. Psychological Trauma: Theory, Research, Practice,

and Policy, 45(5), 457–465. Lowe, S.,&Rhodes, J. (2013). Trajectories of psychological distress among low-income, female

survivors of Hurricane Katrina. American Journal of Orthopsychiatry, 83(2/3), 398–412.

Luster, T., Qin, D., Bates, L., Johnson, D., & Rana, M. (2009). The lost boys of Sudan: Coping with ambiguous loss and separation from parents. American Journal of Orthopsychiatry, 79(2), 203–211.

Mariel Boatlift. (2015). Retrieved from http://www.globalsecurity.org/military/ops/ mariel-boatlift.htm\

Marsella, A. J. (2011). Twelve critical issues for mental health professionals working with

ethno-culturally diverse populations. Psychology International, 22(3), 7. Retrieved from http://www.apa.org/international/pi/2011/10/index.aspx)

Mathbor, G. M. (2007). Enhancement of community preparedness for natural disasters: The role of social work in building social capital for sustainable disaster relief and

management. International Social Work, 50(3), 357–369.

124 Illness, Crisis & Loss 25(2)

Matthieu, M., & Ivanoff, A. (2006). Using stress, appraisal, and coping in clinical prac- tice: Assessments of coping strategies after disasters. Brief Treatment and Crisis

Intervention, 6(4), 337–348. McKinney, K. (2007). Culture, power, and practice in a psychosocial program for sur-

vivors of torture and refugee trauma. Transcultural Psychiatry, 44(3), 482–503.

Miller, K. E., Worthington, G. J., Muzurovic, J., Tipping, S., & Goldman, A. (2002). Bosnian refugees and the stressors of exile: A narrative study. Applied Journal of Orthopsychiatry, 72(3), 341–354.

Montero, D., & Dieppa, I. (1987). Resettling vietnamese refugees: The service agency’s

role. Social Work, 27(1), 74–81. Montgomery, E. (2011). Trauma, exile and mental health in young refugees. Acta

Psychiatrica Scandinavica, 124(440), 1–46.

Orley, J. (1994). Psychological disorders among refugees: Some clinical and epidemio- logical considerations. In A. Marsella, T. Bornemann, S. Ekblad & J. Orley (Eds.), Amidst peril and pain: The mental health and wellbeing of the world’s refugees

(pp. 193–206). Washington, DC: American Psychological Association. Pearlin, L. I., & Schooler, C. (1978). The structure of coping. Journal of Health and Social

Behavior, 19(1), 2–21.

Pupavac, V. (2008). Refugee advocacy, traumatic representations and political disen- chantment. Government and Opposition, 43(2), 270–292.

Renner, W., Laireiter, A.-R., & Maier, M. (2012). Social support as a moderator of acculturated stress among refugees and asylum seekers. Social Behavior and

Personality, 40(1), 129–146. Rousseau, C., & Drapeau, A. (2003). Are refugee children a risk group? A longitudinal

study of Cambodian adolescents. Journal of Refugee Studies, 16(1), 67–81.

Schottelkorb, A. A., Doumas, D. M., & Garcia, R. (2012). Treatment for childhood refugee trauma: A randomized, controlled trial. International Journal of Play Therapy, 21(2), 57–73.

Schumacher, J., Coffee, S., Norris, F., Tracy, M., Clements, K., & Galea, S. (2010). Intimate partner violence and hurricane Katrina: Predictors and associated mental health outcomes. Violence and Victim’s, 25(5), 588–603.

Suar, D., Mandal, M. K., & Khuntia, R. (2002). Supercyclone in Orissa: An assessment

of psychological status of survivors. Journal of Traumatic Stress, 15(4), 313–319. UNHCR Statistics. (2013). 25 years of global displacement. Retrieved from http://

www.unhcr.org/54cf99109.html

Weaver, H. N., & Burns, B. (2001). ‘I shout with fear at night.’ Understanding the trau- matic experiences of refugees and asylum seekers. Journal of Social Work, 1(2), 147–164.

Weine, S., Muzurovic, N., Kulauzovic, Y., Besic, S., Lezic, A., Mujagic, A., . . .Pavkovic, I. (2004). Family consequences of refugee trauma. Family Process, 43(2), 147–160.

Xu, Q., Bekteshi, V., & Tran, T. (2010). Family, school, country of birth and adoles- cent’s psychological well-being. Journal of Immigrant and Refugee Studies, 8(1), 91–110.

Zinner, E. S., & Williams, M. B. (1999). When a community weeps: Case studies in group

survivorship. New York, NY: Brunner/Mazel.

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Author Biographies

Dr. Eileen A. Dombo, PhD, LICSW, is an assistant professor at the Catholic University of America’s National Catholic School of Social Service as well as serving as an assistant dean and BSW Program Chairperson. She has 20 years’ experience in trauma treatment and services to sexual abuse survivors as a direct service practitioner, supervisor, and clinical director. In addition, she has worked with many organizations to address issues of vicarious trauma and burn-out in social workers. Dr. Dombo’s research interests are in testing clinical models of practice; exploring effective therapeutic intervention techniques for social workers in trauma treatment; and exploring the links between trauma work and vicarious trauma. She is licensed as an independent clinical social worker in Washington, DC.

Dr. Frederick L. Ahearn is an ordinary professor at the Catholic University of America’s National Catholic School of Social Service. He has an international reputation in the area of psychosocial issues of forced migrants, particularly refugees and persons displaced by disasters. He has served on international missions in the aftermath of disasters and consulted with state and local mental health agencies in designing a mental health response in the case of disaster. Fluent in Spanish, Dr. Ahearn taught in Chile, Nicaragua, and Peru. Currently he is editor of the Journal of Religion and Spirituality in Social Work: SOCIAL THOUGHT, and an editorial board member for the Journal of Refugee Studies and the Journal of Immigration & Refugee Studies. Dr. Ahearn was granted the Global Commission Award by the Council on Social Work Education and a Lifetime Achievement Award from the National Association of Social Workers.

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