QUÉBEC’S PSYCHOSOCIAL INTERVENTIONS

Québec’s Psychosocial Interventions in an Emergency Measures Situation

Claude Martel

Emergency Measures Ministerial Coordinator Substitute and Emergency Measures Psychosocial Facet Provincial Adviser

Abstract

Provides a background of emergency events in Quebec from 1984-1992. Describes intervention and coordination in health and social services in Quebec. Outlines Emergency measures psychosocial interventions. Presents an inpact model dealing with physical, psychological, living environment and general environmental factors. Identifies phases (Primary, Secondary, Tertiary) affected by events and outlines CLSC 8 module psychosocial training program.

From 1984 to 1992 the Province of Québec had to respond to a series of major disasters:

1984 Shooting at the Quebec National Assembly in Québec City
1988 Earthquake strikes the cities of Québec, Chicoutimi and Rimouski
1988 Fire in a warehouse storing PCB’s in Saint-Basile-Le-Grand
1989 Spill of toxic liquids following a train derailment in Saint-Léonard d’Aston
1989 Massacre at the Polytechnical Institute in Montréal
1990 Tire fire in Saint-Amable
1990 First nations crisis in Oka and Châteauguay
1991 Tornado in Maskinongé
1991 Forest Fire in the Côte-Nord region
1992 Fire at the Father Dowd seniors’ residence in Montréal

These numerous events were the impetus for a more integrated organization of emergency measures at a provincial level and for the development of a new player in the emergency measures field, Psychosocial Services.

Since the objective of this article is to familiarize readers with Québec’s Psychosocial Services’ interventions in times of disasters, let me begin by providing a summary survey of where Psychosocial Services fit within Québec’s emergency measures response structure. When a disaster occurs in Quebec, Le ministère de la Santé et des Services sociaux (MSSS), by virtue of the Act respecting health and social services, must ensure that the population affected by the disaster are provided with three essential health and social services. These are:

physical health,
public health
psychosocial services.

MSSS is responsible for ensuring that response plans for the delivery of these three health and social services components are in place in all 18 Régie régionale de la santé et des services sociaux (RRSSS) funded by MSSS in the province. In turn, the RRSSS can count on the various Centre local des services communautaires (CLSC) in their regions to deliver the primary essential services when disaster strikes. In particular they delive emergency measures psychosocial services.

When a disaster or traumatic incident occurs, workers responsible for the delivery of the three health and social services components to victims respond as follows. If a situation is unusual but can be handled using a local everyday resources, the response is assumed and coordinated by the local level. Regional authorities, however, are informed. If the interventions required go beyond the scope of the normal activities or resources of a CLSC and other CLSCs in the region are called in to assist, then coordination is assumed at the regional level. The region then advises MSSS at a provincial level. If the event or situation goes beyond the regional capacities for intervention or more than one region is affected by the situation, then coordination is assumed at the provincial level and national and international resources may be alerted.

To ensure that our emergency response is swift, smooth and appropriate, we rely on five basic principles of intervention:

1. Focus on our own mission

2. Be aware or our reciprocal roles

3. Work with our other partners

4. Avoid being a one-man hero
5. Encourage clear and precise communications.

When one considers, as we do in Québec, the role and responsibilities of Psychosocial Services (PS) within an emergency measures framework, one becomes aware of the broad areas covered by these services and of the complex issues that they respond to. Such a complex response, therefore, requires an integrated approach. In the table below, I have indicated the many elements that PS needs to consider when intervening within an emergency measures context. These include: the impacts caused by a disaster, the services required to respond to these impacts and the many partners required to assist in responding to the impacts. Imagine for a moment that the table below represents a disaster zone with four concentric circles. At the centre of the circle we have the impact zone and the physical needs that have to be responded to; next to this we have a psychological zone, then the living environment zone and, finally, the global environment zone.

ZONE
ÉLÉMENTS    PHYSICAL    PSYCHOLOGICAL    LIVING ENVIRONMENT    GLOBAL ENVIRONMENT

IMPACTS Survival
Injuries
Morbidity
Sequels
Maladjustment
Vulnerability
High level of stress
Worries/fears
Uncertainties
Mourning/losses
Work
Danger to the health of the population
Increase in suicides
Transportation difficulties
Disorganization of health services
Drug-addiction problems
Family home
School life
Destabilization of the family
Economic losses
Major expenditures
Media impact
Impact on values
Political impact
Quality of the environment
Uncertainty regarding the future

SERVICES REQUIRED Pre-hospital care
Hospital care
Primary care
Psychosocial services
Self-help and support network
Contact with disaster victims
Taking care of dependant individuals
Support to persons in a stressful situation
Adequate information
Services provided Registration and Information, shelter, food, clothing
Financial assistance
Reconstruction assistance
Reorganization of the living environment
Re-establishment of the social framework of the community
Support to families
Health supervision
Temporary transportation
Information center
Reconstruction assistance program
Planning and application of appropriate prevention and protection measures
Consultation with the population affected
Attitude of openness in order to introduce tangible corrective measures following the incident
Control of environmental quality
Collaboration with the media
Quality information

PARTNERS REQUIRED Ambulance companies
Hospitals
CLSC
Private medical clinics
CLSC
Psychology services
Private resources
Corporations
Self-help organizations


CLSC
Public health regional board
Self-help network
Professionnal associations
Schools
Day care centers
Social clubs and community organizations
Volunteers
Transportation companies
Hotels, inns
Municipalities
Ministry of health and social services
Regional board
Other government departments
Universities
Emergency Preparedness Canada
Police
International experts
Media
Health Canada

When intervening in an emergency measures context, Psychosocial services attempt to facilitate the adaptation process of disaster victims by using:

A psychological-educative approach
Emphasizing in all messages that emotional reactions are normal.

Following a disaster, psychosocial interventions are provided in three phases:

Immediate action: Interventions before, during and immediately after the disaster.

Examples

Interventions at the disaster site;

Contact with the clients (home visit if necessary);

Support to people under stress (stress relief);

Individual support;

Setting up of a telephone hotline;

Participatating in information sessions organized by the municipality;

Promoting activities where people can discuss the event;

Preparation of a brochure on normalizing reactions;

Public notification of the availability of a team from the Local community service centre (CLSC).

Transitional measures: Interventions that take place when people begin to return to their daily lives.

Examples

Support to people under stress;

Information activities, brochures for different age groups;

Conferences, workshops, courses;

Information sessions;

Activities to promote discussion about the event.

Program to assist in a return to normal life: Interventions which must continue beyond the transitional measure stage because of ongoing needs in the communtity.

Examples

Follow-up home visits;

Thematic talks to meet identified needs;

Individual or group consultations;

Self-help groups;

Crisis intervention.

The psychosocial interventions aim to reach three groups of clientele:

Primary Client Group

People who experienced the event directly. They include the survivors and the people who witnessed the disaster or tragedy.

Secondary client group People who lost a loved one in the disaster or tragedy. They include families in mourning and anyone emotionnaly close to an immediate victim and those who are affected by the traumatic event.

Tertiary client group The operational staff, the different coordinators and leaders, the people providing psychosocial support and the public.

Psychosocial Emergency Planning Process

The psychosocial response is based on a psychosocial emergency services planning process which includes the following steps:

1. A description of the event;

2. Identification of the different clientele affected by the event;

3. Assessment of the psychosocial impact on the clientele affected;

4. Assessment of needs;

5. Development of an intervention strategy;

6. An analysis of the CLSC’s ability to meet the needs of the clientele affected by the event;

7. Evaluation of activities and re-assessment of needs.

Before a disaster occurs the majority of people are usually in a state of relative equilibrium. When a stressfull incident occurs, people experience a state of disequilibrium and there is a perceived need to return to an equilibrium. Faced with this dynamic situation, the role of psychosocial workers is to support, and at the same time, accelerate the re-equilibrium process. Thus the worker may have to deal with disaster victims who are in various states of recovery. On the one hand there are those who, because of the presence of compensation factors, situational support and appropriate adaptation mechanisms, have a realistic perception of the incident. This usually leads to resolution as one’s equilibrium is regained without crisis. On the other hand, there are others who, because of the absence of compensation factors, of situational support, and of adaptive mechanisms, may have a distorted perception of the incident. Problems then remain unresolved resulting in disequilibrium and crisis. A crisis intervention referral is needed. (Aguilera and Messick, 1976)

Victims of disasters can experience a variety of losses such loss of loved ones, health, material possessions, animals, work, social environment, dreams. When confronted by such losses, each person has to go through the grieving process and deal with their disaster experience in their own way. Some emotional reactions such as fear, sadness, pain or anxiety are linked to what has happened and these emotions affect the behaviour of individuals. The important message to share with those affected is that these reactions or behaviours are human, natural and normal. It’s the disaster that is abnormal.

Major characteristics of Various Age Groups

A major disaster may affect thousands of people from various age groups. Each age group has predominant characteristics. For example:

Young children fear
Children need to understand the how and the why
Adolescents attitudes oscillate between those of adults and of children

Adults conflict between their responsibilities to others and their own needs

Elderly people ability to determine their own needs and request the

services they require

Objectives of the Psychosocial Intervention

Whatever the age groups, the psychosocial intervention and activites seek to restore and increase feelings of security, trust and competence, also to promote self-esteem, autonomy self-affirmation and assimilation of the event.

Assertive Outreach to Disaster Victims

When reaching out to disaster victims, psychosocial workers are asked to adopt the following basic principles. Workers are asked to be proactive. To go out into the community. To mingle with those affected. Not to wait for victims to call on them or arrive at their offices, but to go where the affected people are : at Reception Centres, emergency lodging facilities, hotels, people’s homes or wherever people are.

Training Program for Psychosocial Workers

In 1992 the Québec Ministry of Health and Social Services developed a three day training program on sociosanitary interventions in an emergency measures situation. Each Regional Board were responsible for organizing training for the CLSC workers in their region. Thanks to these training endeavours, there are now one thousand trained psychosocial workers throughout Québec.

This three day training program contains eight modules.

Module 1 Disasters : A Reality

Training objectives :

To be able to identify a disaster situation.
To be aware of the risks of certain disasters within the region.

Module 2 Emergency Measures : A Special Intervention Context

Training objectives :

Describe the characteristics of a situation in which emergency measures are required.
Itemize the elements which must be considered during an emergency measures intervention. CLSC.

Module 3 The Health And Social Service Network’s Regional Emergency Measures plan

Training objectives :

To develop an overall view of the network’s regional emergency measures plan.
To clarify the importance of each partner in the plan.
To situate psychosocial emergencies in relation to the general plan.
To identify the services provided by the clsc as part of the emergency measures.

Module 4 The Adaptation Process

Training objectives :

To define the concept of dynamic equilibrium.
To explore various significant losses during a disaster.
To explore various factors which influence an individual’s adaptation process.
To identify the compensation factors utilized by disaster victims to recover their dynamic equilibrium.
To clarify the stages in the mourning process.
To establish the relationship between the stages in the mourning process and the behavior of disaster victims.
To be aware of the diagnostic criteria of problems associated with a post-traumatic stress disorder.

Module 5 Immediate Action

Training objectives :

To define the basic principles of the psychosocial intervention approach to be utilized during an emergency measures situation.
To define the stages of the psychosocial intervention to be performed in an emergency measures situation.
To understand the bio-psychosocial reactions experienced by the disaster victims.
To determine the characteristics of each age group.
To demonstrate the importance of being proactive in terms of organization and seeking out the disaster victims.
To explore different ways of organizing the intervention and making contact with the disaster victims.

Module 6 Transitional Action

Training objectives :

To identify and detail the procedure to be followed in planning the psychosocial services to be provided within the scope of emergency measures.
To be able to identify different clientele and their needs.
To know how to prepare intervention strategies adapted to the clientele identified.
To establish correlations between the planning process and the stages of the psychosocial intervention during an emergency measures situation.
To integrate the goals of the interventions and activities.
To develop the following activities in more detail: the educational session, the educational tool, the incident debriefing session.
To learn how to organize incident debriefing sessions.

Module 7 The Return To Normal Life Program

Training objectives :

To recognize the criteria identifying the need for a return to normal life program.
To identify examples of support activities for the return to normal life program.
To show an overall view of various activities, corresponding to the stages of the psychosocial intervention.

Module 8 Stress Management For The Practitioner

Training objectives :

To identify the factors which contribute to increasing stress during a disaster.
To become aware that several factors do not depend on the practitioners.
To recognize signs indicating that a practitioner has reached a point where he is no longer able to manage his stress.
To become aware of the risks of exhaustion during an intervention in a disaster situation.
To clarify the effectiveness of our strategies to deal with stress.
To assess the pertinence of developing new strategies.
To recognize our reactions to stress during a disaster.
To recognize the signs and symptoms of acute stress among practitioners.
To list several ways of managing stress.
To clarify the importance of attending a critical incident debriefing session.

Intervention Material

In 1992 the ministry created a tool kit for psychosocial intervention in emergency measures situations. All of the 160 CLSC have this tool kit which contains documents dealing with three components:

The knowledge component

Emergency Measures Psychosocial Services Planning
The Provision of Services to Disaster Victims
Stress among Emergency Service Staff
General Information about Various Types of Natural and Technological Disasters
How to Help Children after a Disaster
Children and Trauma (video)

The Intervention Tools component

Information pamphlets

Pamphlet for 0-to-6-year-olds
Pamphlet for children 7 to 12 years old
Pamphlet for young people 13 to 17 years old
Pamphlet for adults
Pamphlet for the general population
Pamphlet on evacuation
Pamphlet on family dynamics
Pamphlet on bereavement

Activity aids

"The Night There Were Two Moons", a tale for 3-to-6-year-olds
"Buzz", an activity book for children 6 to 9 year old
"Hargus", a banner for children 10 to 12 years old
"Freaking Out : Who Wouldn’t", animation theatre for teenagers
"Debriefing", debriefing session on the event
"Talking pictures", animation technique using photographs

Recent disasters in Québec

In the past two years Québec psychosocial workers have had to respond to three major disasters that gave them an opportunity to put their knowledge into practice:

1. The Saguenay Floods of July 1996

The flash floods that affected the Saguenay region in 1996 produced the following results:

16 000 people affected
15 shelters
150 psychosocial workers from 6 regional CLSC’s, trained in emergency measures interventions
+17 trained psychosocial workers from the Chaudière-Appalaches and Montérégie régions
workers dispatched by helicopters to isolated sectors

2. The Saint-Joseph-de-la-Rive Bus Crash of Octobre 13, 1997

44 dead and 4 injured
services to families at the St-Bernard-de-Beauce municipal hall

(october 13 ^th and 14 ^th)

sessions with children at the elementary school (october 14 ^th)
meetings with students at the high school (october 14 ^th)
sessions with residents of subsidized housing and Villa St-Bernard (october 14 ^th)
support at the St-Charles cemetary during identification of the bodies

(october 14 ^th)

preparation of a service with the municipality and the local priest (october 15 ^th)
workers remain available to anyone affected by the tragedy
15 psychosocial workers from 6 regional CLSC’s, trained in emergency measures interventions
+1 trained psychosocial worker from the Québec region

3. The Ice Storm in Western Québec in January 1998

1300 000 people affected
450 shelters
~ 500 psychosocial workers from 71 regional CLSC’s, trained in emergency measures interventions
+ many trained psychosocial workers from other regions in Québec

Coordination and Support

In an effort to maintain a dynamic and coordinated approach to the psychosocial response within an emergency measures framework, the Québec Ministry of Health and Social Services has appointed a Emergency measures psychosocial adviser. As adviser of this Service, I meet every 4 months with a provincial psychosocial advisory committee made up of representatives from the regional health boards. In addition to the quartely meetings, there are telephone conference calls as needed. As well, MSSS publishes a psychosocial newletter, the Psyjournal, 8 times yearly. In the spring 1998, the Ministry published additional training materials to complement the basic training. This new training document is entitled : Initiation à la pratique de la verbalisation sur l’événement en situation de sinistre (Initiation to the Practice of Incident Debriefing Sessions in Times of Disaster).

Claude Martel

Emergency measures ministerial coordinator substitute and

Emergency measures psychosocial facet provincial adviser

(418) 646-2142

claude.martel@msss.gouv.qc.ca