Evan Parks
A professional colleague in the United States mailed me a seminar notebook on Critical Incident Stress Management (CISM) in 2003 (Mitchell and Everly, 2001). I previously had discussed with him my work of intervention in crisis events across Eastern Europe and Eurasia when he suggested I look at the CISM material. In this brief case study, I recount the process of moving from a western, American mindset to a growing understanding and appreciation of the life, history, and culture of East Europeans. A critical element of effectiveness in mental health work is credibility. Arriving in Hungary in 2001, I was met with deep suspicion by neighbors and acquaintances. Obviously I lacked important elements of credibility that were going to be necessary for me to work in a cross-cultural context. I would need to overcome the perception and historical fact that psychologists were a part of the former oppressive regime, used to break political prisoners and extract false confessions from innocent victims.
The Cultural Context
Since 2001, I have been living and working in Hungary providing mental health services to religious and humanitarian organizations, as well as national churches in Eastern Europe and throughout Eurasia. Helping people traumatized by war and political unrest has been a regular and ongoing aspect of my work. But psychological injury caused by war is just one of many sources of trauma in this region.
Tragedy often finds a way into people’s lives through the impact of suicide. Lithuania, Slovenia, Hungary, Latvia, Belarus, Ukraine, Croatia, Russia, Moldova, and Poland are European countries that lead the world in suicide (World Health Organization, 2014). In Eastern Europe, alcohol use often starts early in the teen years and leads to an increased risk of violence, illness, and suicide (Felson et al., 2011; Alström and Östweberg, 2005; Landberg, 2008). According to the World Health Organization (Lynch, 2014), the countries with the highest annual consumption of alcohol among those 15 years old and older consume more than twice the world average of 6.2 liters of pure alcohol. Of the top ten alcoholconsuming countries, eight are former Soviet Union republics and former Soviet-bloc East European states: Belarus (17.5 liters); Moldova (16.8 liters); Lithuania (15.4 liters); Russia (15.1 liters); Romania (14.4 liters); Ukraine (13.9 liters); Andorra (13.8 liters); Hungary (13.3 liters); Slovakia (13 liters); Portugal (12.9 liters).
It has been my experience in meeting people from throughout this region that almost every family, village, and city has its own story of struggle, hardship, and tragedy. As I began to know East Europeans on a personal level, they willingly shared their family stories of trauma. Individuals suffered for multiple reasons besides the obvious harm caused by war and political unrest. Some encountered abusive teachers, religious persecution by school administrators, police harassment, deportation, sexual abuse, and loss of jobs and property. Others experienced daily verbal abuse, discrimination, and hatred by people from different ethnic groups.
The breakdown of society and the loss of stability in communities are intimately related to the political structure or the lack thereof. Political unrest has led to a great deal of instability, fear, and hatred in the region. The values, traditions, and relationships that held families and communities together for generations have been torn apart. Jochen Neumann (1991) writes about Eastern Europe: “Values that were binding and predictable in the past are gone without the establishment of new equivalents. Fear of poverty and unemployment weigh heavily on many people. The ‘biologically’ strong often dominate the weak, and unscrupulous profiteers abuse this time of transition for their own benefit” (p. 1387).
While Neumann’s observation was about a particularly unstable time period in Eastern Europe after the fall of the Berlin Wall in 1989, little has changed since that time in terms of a collective sense of hope or optimism for the future. There is greater political stability in some regions, but ongoing corruption, high taxes, and poor government services eat away at public confidence. Among our friends we repeatedly hear stories of being taken advantage of in the workplace, such as working 60 to 80 hours a week only to be paid for less than half the time worked, or not paid at all. People are afraid to speak up for fear of losing what little they have. One individual I spoke with believes that instability and fear in the workplace lead to self-protection and the desire to undermine others. She explained the mindset this way, “It is not important whether or not I get ahead. What is important is that you don’t get ahead.”The economic situation varies greatly across Eastern Europe. What we see in Hungary is an exodus of friends and neighbors, people wanting to find work, hope, and a future somewhere else. Across Eastern Europe, people of all ages are leaving every day, looking for a better life in Western Europe, Canada, and the United States.
A Hungarian Case Study
Having described a few aspects of the culture, atmosphere, and ongoing struggles of the people in this part of Europe, I will briefly outline one model of working with critical incidents that I have recently found effective. I received a call from a Hungarian minister asking me to come to his church to meet with the leadership team. A church staff member had just killed himself. As I sat down with the leadership, it was clear that they were struggling to understand what had happened and how to respond. There was no prepared protocol to follow, but I was not expecting that there would have been such a plan. Immediately it was clear that there were a number of decisions that needed to be made, but the leaders were in crisis themselves. Without a protocol to follow, the situation was even more stressful.
One key element of any crisis management response is having a comprehensive crisis response plan in place before a crisis occurs. This plan takes time and energy to develop, and people in busy organizations often do not see this as a high priority. Not having a plan in place creates an additional stress as a crisis event begins to unfold.
The crisis plan should include specific information about who will communicate with the public, and who will communicate with the church membership. The plan needs to address how legal or police matters will be handled and by whom, the description of a team that is trained and in place to work with grieving family and church members, and the designation of who will coordinate community resources such as medical, mental health, pastoral care, and humanitarian aid. The makeup of the death notification team should also be in place.
Since my work began in 2001 in Europe, I have yet to respond to a crisis situation at a church, school, NGO, or Christian mission organization where there was a specific protocol already in place to handle the crisis. This means as I enter a crisis there are some basic structural and organizational steps that I outline for the leadership. This simple framework is always well received by the local leadership, except in situations where there is no clear leader or leadership structure. In these situations, I attempt to recruit a co-leader from the organization to work with me to implement a crisis response plan.
Without a plan and structure in place for how communication takes place, to whom information is communicated, and what part of the leadership structure has final authority in decision-making, the ensuing chaos eventually creates significant stress for everyone involved. The fallout from lack of planning results, in turn, in burnout, depression, and anxiety for those who are trying to manage the crisis. Laying the Foundation As I began to live and work in Eastern Europe, I saw value in providing basic education about mental health to churches, mission organizations, schools, and hospitals. There was very little available knowledge of how mental health problems developed. I presented lectures, seminars, and papers on depression, anxiety, shame, sexual abuse, trauma, family life, parenting, marriage, crisis counseling, addictions, and forgiveness.
The CISM Model
As I approached the situation in the church where a staff member committed suicide, I followed the basic structure of crisis management outlined in the Critical Incident Stress Management Model. This model provides a clear outline of what needs to be done in a crisis, when different interventions need to be employed, and how to assist various groups and individuals. There are four specific goals in Critical Incident Stress Management work. These include: 1) stabilization to reduce the distress and keep the situation from getting worse; 2) reduction of the acute signs and symptoms of distress, dysfunction, or impairment; 3) restoration of adaptive independent functioning; and 4) facilitation of access to a higher level of care (Everly and Mitchell, 2003).
Implementation
As I worked with the church minister and his staff, several elements of the CISM Model were implemented. I first began to work with the staff, briefly educating them on their reaction to the crisis. I also provided them with information on suicide and gave a summary of how family and friends may respond to the crisis. We then worked together on planning the large group, small group, and individual meetings that would take place in the days that were to follow. A brief training was provided to help small group leaders facilitate discussions. We assigned responsibilities to each team member for communicating information, relating with the deceased’s family, coordinating activities, and interacting with the police. With these steps in place, we then implemented the plan over the following two weeks. Both community and church members participated in group meetings. Discussion groups were held after the main group meetings and individual people, couples, and families were assisted as needed. Referrals were made for people who needed ongoing mental health care.
The CISM Model provides a standard for what should be included in the response to a crisis and a structure that helps individuals and organizations respond effectively. For this model to be implemented in Eastern Europe, training in the local language needs to be provided to emergency service workers, mental health professionals, and community leaders. Teams also need to be formed that will be ready to respond to crisis events. Based on the counseling and crisis intervention training that I have provided over the past 13 years, I have already witnessed the development of national initiatives to deliver mental services and crisis intervention in a variety of settings. It is my hope that as I come in contact with emergency services (police, ambulance, and fire department), and provide training to ministers, doctors, school administrators, and mental health professionals, I will be able to encourage national leaders to implement CISM in their country, community, workplace, and church.F
Sources:
Alström, S. and E. Österberg. “International Perspectives on Adolescent and Young Adult Drinking.” Alcohol Research and Health 28 (No.4, 2005): 258-68.
Everly, G. and J. Mitchell. “ The Evolving Nature of Disaster Mental Health Services.” International Journal of Emergency Mental Health 5 (No. 3, 2003): 109-15.
Felson, R., J. Savolainen, T. Bjarnason, A. Anderson, and I.T. Zohra. “The Cultural Context of Adolescent Drinking and Violence in 30 European Countries.” Criminology 49 (No.3, 2011): 699-728.
Landberg, J. “Alcohol and Suicide in Eastern Europe.” Drug Alcohol Review 27 (No. 4, 2008): 361-73.
Lynch, D. “WHO Global Alcohol Report: What Kills 3.3 Million of Us Per Year and Which Country Drinks the Most.” International Business Times (2014); http://www.ibtimes.com/who-globalalcohol-report-what-kills-33-million-us-year-whichcountry-drinks-most-1583391.
Mitchell, J. and G. Everly. The Basic Critical Incident Stress Management Course: Basic Group Crisis Intervention, 3rd ed. Ellicott City, MD: International Critical Incident Stress Foundation, 2001.
Neumann, J. “Psychiatry in Eastern Europe Today: Mental Health Status, Policies, and Practices.” American Journal of Psychiatry 148 (1991): 1386- 89.
World Health Organization. “Preventing Suicide: A Global Imperative.” (2014); http://www.who. int/mental_health/suicide-prevention/world_ report_2014/en/.
Edited excerpts reprinted with permission from Evan Parks, “Building a Foundation for Crisis Intervention in Eastern Europe,” International Journal of Emergency Mental Health and Human Resilience (No. 1, 2015): 352-55.
Evan Parks is a clinical psychologist and adjunct professor, Liberty University, Budapest, Hungary.