The 921 Earthquake: Developing a group intervention program for affected soldiers in the Taiwanese military

The Australasian Journal of Disaster
and Trauma Studies
ISSN:  1174-4707
Volume : 2010-2

The 921 Earthquake:
Developing a group intervention program for
affected soldiers in the Taiwanese military

Cheng-Shen Hu, Department of Psychology and Social Work, National Defense University, Taipei, Taiwan. Email: hjs_74709@yahoo.com.tw
Sheng-Che Kuo, Department of Psychology and Social Work, National Defense University, Taipei, Taiwan.

Cheng-Shen Hu & Sheng-Che Kuo

Department of Psychology and Social Work,
National Defense University,
Taipei,
Taiwan

Abstract

Military troops are often expected to be tough even under critical conditions. Those stereotyped expectations could cause extra stress to people serve in the military. This group intervention program was designed to assist soldiers who participated in rescue work after the main shock of the 921 Earthquake. Many of them experienced symptoms of Acute Stress Disorder. Two program evaluation tools were also developed to assess program effectiveness. This program provides affected soldiers a safe place to express their negative feelings and emotions toward the traumatic event. Group members indicate that normalization serves as a protective factor to them. Knowing their physical, emotional, and behavioral reactions are normal for people under abnormal situations is a great relief for them.

The 921 Earthquake:
Developing a group intervention program for
affected soldiers in the Taiwanese military

Introduction

The 921 Earthquake that occurred on September 21, 1999, appeared to be a great challenge for Taiwan’s disaster relief and rescue capacities. Shortly after the main shock, the Taiwanese government declared a state of emergency. Hundreds of thousands volunteers as well as paid workers from international rescue teams, governmental agencies and non-profit organizations rushed into the earthquake-stricken areas to participate in rescue and relief works. Later, the military took over the rescue and relief works. Since then, major manpower came from military troops. Young soldiers were, voluntarily or involuntarily, assigned to help with digging and transporting deceased victims. To many of them, that was the first time to be so close to death. While some soldiers accomplished the mission physically and emotionally intact, others showed signs of acute stress disorder (ASD), with a possibility of evolving into posttraumatic stress disorder (PTSD).

In order to prevent those young body handlers from becoming potential PTSD victims, the authors started conducting a serial of debriefing sessions three weeks after the catastrophe. Based on the information collected from the debriefing sessions, a group intervention program was developed to help young soldiers cope with symptoms of ASD. A total of 11 rescue soldiers with symptoms of ASD participated in the group intervention. This paper discusses the development, evaluation and modification of the group intervention program.

Literature Review

Studies show that the nature of posttraumatic stress process is dynamic, and it is quite normal for victims trying to integrate their trauma experience into cognitive framework for overcoming the stress disorder, unless the process lasts too long and is emotionally overwhelming (Green, Wilson, & Lindy, 1985; Myers, Zunin, & Zunin, 1990; Zunin & Zunin, 1991). In this study, most rescuers eventually return to pre-disaster function levels, in despite of short-term emotional distress. Only a few of them later suffer from PTSD syndromes. Reports from clinical observation indicate that clients with ASD and/or PTSD syndromes may re-experience the traumatic event; try to avoid thoughts, feelings, or conversations associated with the trauma; experience sleep problems and/or anger outbursts (DSM IV, 1994).

There are two common approaches for treating clients with PTSD: medication and psychotherapy. Antidepressants, such as Banzodiazepine, Alprazolam, Bromazepam and anti-anxiety medication, such as Amitryptyline, Doxepine, and Imipramine are commonly used for medicating clients with PTSD. With regard to psychotherapy, individual psychotherapy and group psychotherapy are two main streams (Foa, Davidson, & Frances, 1999). Embry (1990) claims that individual psychotherapy works well for the Vietnam War veterans who suffer from PTSD. Mateczun (1995) asserts that group psychotherapy has been applied to soldiers on U.S. Navy battleship since the World War II. In this study, the authors intend to develop a culturally sensitive group intervention program for the Taiwanese soldiers.

Development of Group Intervention Program

Thomas (1987) suggests five required steps in terms of designing an intervention program: 1.) analysis: a systematic analysis of current situation; 2.) design: designing intervention program based on the results from the step 1; 3.) implementation: practices of the program in the field; 4.) evaluation: assessment of results from the step 3; and 5.) application and promotion: looking for the possibility of broader application. Based on the principles of Thomas’ five-step model, the authors modified it into a three-stage model and developed this program. The three-stage model consists of 1.) program development, 2.) implementation, 3.) evaluation and modification (Table 1). Detailed descriptions as follow:

Table 1 - The three-stage model

Stage 1: Program Development

Studies show that debriefing programs have been widely used among disaster response teams, such as Red Cross personnel (Armstrong et al., 1998) and combat survivors (Koshes, Young, & Stokes, 1994). In order to prevent rescuers from suffering ASD, debriefing sessions were prepared for soldiers who participated in the rescue and relief works two or three days after their mission. With participants’ permission, group sessions were taped and notes were taken. Based on the information collected from the debriefing sessions, a group intervention program was developed to assist those participants who experienced ASD. The participants’ response to the 921 Earthquake was categorized as follow: physical reactions, emotional distress, behavioral change, cognition alteration and social adaptation. Each category was further differentiated positive from negative responses.

Based on the five categories of the participants’ response to the catastrophe mentioned above, purpose of the group intervention program was set to help the participants to bounce back to a healthy life. Five group sessions: 1.) crisis awareness, 2.) catharsis, 3.) relaxation, 4.) strengthening support systems, and 5.) group feedback, were designed to meet the participants’ needs (see Table 2).

Stage 2: Implementation

Prospective group members were first screened by the local military counseling centers. A total of 11 rescue workers with ASD symptoms were selected to participate in the group intervention program. Nine were soldiers and two were military policemen. All 11 of them were 21 years old at the time of group intervention. In regard to their levels of education, two were junior high graduates, three were senior high graduates, and six were college-equivalent vocational school graduates. Speaking of religious affiliations, group members consisted of six Taoists, two Buddhists, one Christian and two without specific religion. Consent forms were signed to ensure that the participants were aware of their rights and the purpose of the group intervention. The corresponding author and his colleagues served as group facilitators. Five consecutive sessions were conducted on a weekly basis. Contents of the group sessions are described in detail in Table 2.

Table 2 - Framework of the Group Intervention Program

Stage 3: Evaluation and Modification

Evaluability assessment was conducted to ensure that the group intervention program was feasible. Upon completion of each group session, participants were asked to complete a 13-item self-rating scale with a 5-point response format (1 = strongly disagree, 5 = strongly agree), to evaluate participants’ levels of satisfactory. The statistical results are presented in Table 3.

In general, participants report high levels of satisfactory. Comparing to other items, Questions 2, 3, 4, 5, and 9 have relatively high mean scores, which may imply that group sessions help participants to 1.) feel more confident of expressing personal opinions, 2.) are more willing to trust facilitators as well as group members, 3.) be more sensitive to others needs, and 4.) feel more comfortable in expressing negative feelings and emotions. On the other hand, Questions 6, 7, 8, and 11 have relative low mean scores. Possible explanations are 1.) participants are not familiar with the terms “support,” “grief, ” and “emotional distress,” 2.) building a support system takes time, and it can be challenging if trying to establish it within a 5-session period., 3.) coping with grief and emotional distress is not an easy task. It is understandable that participants may need more time to work on those issues. Additionally, factors influencing grief and emotional distress coping styles include spirituality, personal background, levels of education, personality, and so forth. It’s not reasonable to expect a 5-session group intervention program to cover them all.

Table 3 - Means and Standard Deviations of the Evaluability Assessment

Note: () = average of 5 sessions

Program Evaluation

Upon completion of the 4 th session, group members were asked to complete a 12-item self-rating scale with a 5-point response format (1 = strongly disagree, 5 = strongly agree), which intended to evaluate the effectiveness of the program. Scale items, means, and standard deviations are presented in Table 4.

Table 4 - Means and standard deviations of the evaluation form

Questions 10, 11, and 12 have relatively high mean scores, which may imply the respondents feel that they have more control over their life after the group intervention. These questions also tend to have less variation. Ironically, questions 2, 6, and 7 have relatively low mean scores, which suggest that the group intervention has less impact on quality of daily life, such as anger management, sleeping quality, and appetite. Furthermore, questions associated with physical reactions tend to have greater standard deviation, which indicates higher degree of inconsistency among respondents on this matter.

From the feedback sheets, the authors found that the intervention program was well-accepted by group members. They affirmed that it provided a safe environment for them to express negative feelings, shared common concerns as well as coping strategies.

Program Modification

Results of the program evaluation suggest that Sessions I and IV were well-received by participants. Session II fails to achieve its objectives. Thus, the group intervention program was modified accordingly. Program modification focused on four dimensions: 1.) program design, 2.) contents of group sessions, 3.) evaluation tools, and 4.) members of the program team. For the program design, in this study, the effectiveness evaluation was only performed after the group sessions. Its major shortcoming was lack of comparison between pre-intervention and post-intervention. It is suggested that the evaluation could be done before-, during-, and after the program. For contents of group sessions, the contents of Session II needs to concentrate more on ‘holistic,’ which concerned with wholes or with complete systems. In this study, the focus was on emotional ventilation, which failed to reach the session objectives. Regarding evaluation tools, two self-rating scales were utilized in this study for program effectiveness evaluation. Reviewing the results, the authors found that four evaluation tools, one for each session, may be required to improve the evaluation quality, because each session focuses on different approaches, such as crisis awareness, catharsis, physical relaxation, and establishment of social support systems. Yet, designing individualized evaluation form for each session can be challenging and troublesome. Another suggestion is to integrate four evaluation tools into a comprehensive one to evaluate the entire program. In terms of members of the program team, it is suggested that at least two properly trained facilitators, one observer, and one experienced supervisor should be recruited into the team. Due to the resource limitations, the group was facilitated by less skilled counseling officers. It is hoped that more specialists, such as psychiatrists, psychoanalysts, and social workers would be recruited into the team.

Conclusion and Implications

Military troops often appear to the public as heroes and heroines. They are expected to be tough even under extreme conditions. Sometimes, those stereotyped ways of expectation can cause extra stress to people serve in the military. They are human beings. Their response to catastrophe would be similar to people in general. No one can experience traumatic events but not to be affected. Mitchell (2001) claims that about 86% of individuals affected by a disaster would experience physical, behavioral, cognitive, and emotional reactions within 24 hours.

This group intervention program was designed to assist rescue soldiers who experienced symptoms of Acute Stress Disorder and potential PTSD victims. Two program evaluation tools were developed to assess program effectiveness. However, due to the emergency of the event, validity and reliability of the evaluation tools were not properly tested, and thus would be limitations to this study. Even though this intervention program was not fully developed, group members reported that it was helpful, because it provided them a safe place to express negative feelings and emotions toward the traumatic event. Group members indicated that normalization served as a protective factor to them. When they learned that their physical, emotional, and behavioral reactions were normal for people under abnormal situations, they felt so relieved.

Mental health issues are taboo in the Taiwanese culture, especially in the military. It is hoped that the group intervention program may increase crisis awareness in the military community. More affected soldiers may benefit from this program. Additionally, other group intervention programs, such as substance abuse, alcoholism, and bereavement may be developed to assist people who serve in the military.

References

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Mateczun, J. (1995). U.S. Naval Combat Psychiatry. In Jones, F. D., Sparacino, L. S., Rothberg, J. M. & Stokes, J. W. (Eds.), War Psychiatry (pp. 211-242,). Washington, DC: The Surgeon General at TMM Publications.

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