Crisis Counseling Programs for the Rural Community

Disaster Crisis Counseling Services for Rural Areas

Definition of Rural Areas

"Rural" for the purpose of this publication uses the U.S. Census Bureau definition of areas with less than 2,500 people. Wilderness or frontier territories, farming or ranching areas, small towns, and peripheral areas to suburban communities may all be considered rural. Often these areas have a sparse population with large areas of unpopulated geography. Rural States generally have one or two decidedly urban environments with attached suburbs, although most of the State is less densely populated. The rural economy is likely to be based on agriculture, mining, or oil and gas fields.

The economic farm crisis of the late 1970s and early 1980s graphically demonstrated the interconnection between the farm community and the small towns and cities that comprise rural areas. When the farm community suffers, agriculture-related businesses suffer as well. The impact continues to grocery stores, clothing stores, restaurants, churches, and flows through the entire community. The following excerpt from Taking Rural Into Account: Report on the National Public Forum (CMHS, 1993) provides an excellent summary regarding challenges of health care in general and mental health care in particular in the rural areas of our nation:

Rural areas have a limited and fragile economic base. The out-migration of rural people, industry, and resources further erodes the rural economic base. Many rural Americans are at or below the national poverty level. This immense poverty results in physical and psychological harm.

Rural Americans experience incidence and prevalence rates of mental illness, substance abuse, emotional disturbance, and developmental disability equal to or greater than their urban counterparts. Yet only 25 percent of the rural poor qualify for Medicaid compared to 43 percent of the poor in inner cities (Special Committee on Aging, United States Senate, 1988).

The rural population has a disproportionate number of poor, elderly, children and adolescents, minorities, and migrant workers, who are at high risk for mental disorders. Despite this reality, the public mental health system is often the only mental health provider in a rural area. Sixty-one percent of rural Americans live in designated psychiatric-shortage areas (U.S. Congress, 1988). As a result, rural individuals often have to travel long distances to obtain services or depend on providers who travel periodically to rural areas. This means that rural individuals frequently do not get the help they need or they wait until they are in a crisis situation.

In rural areas, the primary economic base is usually dependent upon natural resources. The immediate losses from any disaster are compounded in rural areas as the resources for continued existence are destroyed. Along with the resources, rural residents often lose hope for the future. The lands, lakes, fisheries, and enterprises that encompass the rural culture are more than a job. They form the economic base, value systems, and the way of life in rural America. Many people quit farming as a result of the Midwest floods of '93, leaving their way of life. The impact of the disaster for many culminated in the fall, months after the initial flooding. It was the harvest that determined the ability to persist or give up. In this disaster, much of the emotion was suppressed until the final accounting took place.

A socioeconomic factor in extreme rural areas is the lack of sufficient population base to generate economic or political attention. A sparse population's disaster-related problems may not demonstrate impressive statistical numbers unless a large geographic area is affected.

Finally, the impact of a disaster in an area where agriculture accounts for a major portion of the local economy may not be evident until months after the event. The impact on planting and harvest seasons, erosion of the topsoil, contaminants, and fluctuations in market prices combine to form an economic crisis. The economic impact on agribusiness is impossible to measure in the first several weeks or months after the declaration. Farmers may not apply for assistance or underestimate their need if they do apply. Stress is generated by:

• Uncertainty (level of crop damage, price fluctuations, etc.)
  
  
• Time limits on applying for assistance
  
  
• The culture, competition, and beliefs on self-reliance as a measure of worth
  
  
• Distrust of outsiders and government intervention
  
  
• A maze of programs, red tape, and paperwork in the disaster recovery process
  
  

The Crisis Counseling Program can play a very important role in helping rural families to assess the issues involved and make good decisions regarding their immediate and long-term needs.

Characteristics of Rural Areas and People

An eroding population base in most areas comprises the rural economic outlook. Young adults completing college often do not return to their rural home communities. Social and health service agencies face an increase in demand and a decrease in funding from local and/or State resources.

CHARACTERISTICS OF RURAL AREAS

• High poverty levels
• Increasing percentage of older adults
• High unemployment
• High levels of social and health related problems
• Pockets of minorities within a largely homogeneous population
• Heavy dependence on agricultural, oil, mining, or tourism related businesses
• Large numbers of people involved with and reliant upon organized religion

Under normal circumstances, a scarcity of people, resources, mobility, and support services has characterized rural areas. There is no doubt that rural programs must contend with a more isolated population. However, it can no longer be assumed geographic isolation means social isolation as well. A farmhouse, a barn, a grain bin, and a satellite dish characterize some rural farms. Farmers are increasingly "on-line" through computers, connected with universities and other information services. People who live in the country today have daily access to the same information, education, and entertainment options as their urban counterparts.

Rural Culture and Ethnicity

Cultural and ethnic groups may or may not be identified in great numbers as living in disaster-affected areas. In response to the Midwest floods, some programs offered services to pockets of groups that required special consideration. A targeted response to African American, Asian, Hispanic, Native American, and other cultural and ethnic groups was necessary in order for the programs to truly reach all groups affected by the disaster. In addition to the above-mentioned groups, other rural crisis counseling projects have served migrant farm workers and homeless individuals.

Training on cultural sensitivity was provided and materials were made available in several languages and workers representative of each local community were hired. In most cases, hiring people from within each cultural or ethnic group produced the most successful results. Public information provided in the language preferred and understood by each group increases the likelihood that all people, no matter what their nationality or race, will get the message.

In rural areas, ethnic groups may be difficult to find and reach, and gaining their trust may be a challenge. Key community contacts and matching outreach workers to the communities they are to serve can create opportunities for service. Sensitivity to language, traditions, cultural values, and ethics is vital.

As noted previously, the crisis counseling project must reach out to agencies and organizations already known to ethnic and cultural groups. Training staff, providing literature, and interagency collaboration are expected in a crisis counseling project. Consideration should be given to subcontracting service delivery to minority groups or minority-serving agencies. This is often more cost effective than learning new skills or politicking to overcome barriers.

Even if a rural area appears to be homogeneous, ethnic differences can exist. Differences exist in educational background, religious beliefs, country versus town dwellers, farmers versus ranchers, people who live by the river versus those who do not. Some small communities are as divided along socioeconomic lines of income, education, and religion as are the most diverse inner-city neighborhoods.

The rural culture varies from urban areas in the seasonal effect of the work, accessibility, and free time available. Besides the normal phases people experience after a disaster, there are other timing considerations. In a farming area, times of seeding, ground preparation, and harvest typically offer reduced accessibility of outreach workers to the impacted population. Consideration should also be given to the differing roles and corresponding stressors that apply to men, women, and children in the area. Switching the focus of service delivery to coincide with stress levels and availability may help the program's efficacy overall.

Cultural Values in Rural Populations

Individualism

A sense of independence and self-determination appears to be more of a hallmark of the residents in rural areas than in urban or suburban locations. Many rural residents tend to view themselves and their communities as possessing a higher quality of life and a more realistic, down-to-earth lifestyle than their urban counterparts. Family, close friendships, and a highly developed sense of community, combine to create a sense of self-sufficiency that persists even in the most difficult of circumstances. Frequently, in times of disaster, these values are demonstrated as family, friends, and community members provide mutual support, shelter, and care to one another.

Rural people may not actively seek help. Residents of rural areas are often not aware of available services or how to access them. They may think the process is too cumbersome or intrusive. It is also common for a farmer or small business owner not to apply for assistance due to their pride, an underestimation of loss, or a belief that others are more in need of help. If the decision is made to apply for assistance, the process may be particularly difficult for someone unaccustomed to admitting need and seeking assistance. Asking for help is very difficult when the cultural expectation is competence and self-reliance.

Mental Health Stigma

Receiving any form of mental health services may be seen as a negative reflection on a person's character or family life. This pervasive attitude is even more prevalent in rural communities. Disaster survivors may have a negative impression of mental health services and thus would be offended if made to believe they needed such support. Programming and project identity should avoid the use of mental health jargon and frame services in terms of disaster survivors deserving counseling services. Having fewer mental health resources in a community and a self-reliant cultural bias, people in rural communities may lack an understanding of the need and use of mental health services. They may benefit from educational presentations about stress management, disaster stress, and coping mechanisms and techniques (NIMH, 1983).

Spiritual Traditions

Some anthropologists and sociologists suggest that all human beings hold some form of spiritual belief. All cultures use spiritual stories, rhetoric, and ritual to find definition for themselves and the world around them. In rural areas, people have a decidedly spiritual quality to the attitudes about natural resources, using land, raising crops or livestock, and living in a community. Rituals surrounding planting and harvest, birth and death, physical and spiritual transformation, patriotism, and loyalty are embedded in the rural culture.

In rural America, traditional, organized religion is often a powerful exponent of the more basic spiritual values mentioned above. The religious traditions of individuals, families, and communities have become the primary expression of their sense of right and wrong, moral and immoral, good and bad. These traditions provide the structure and language by which they evaluate the world and make decisions.

Spiritual traditions provide the context through which people understand their origin, why they are here, and where they are going. Knowing a person's spiritual context is very important in disaster mental health. Such a personal belief system can aid greatly in the disaster recovery process. In rural communities, churches provide a valuable resource for finding and serving literally hundreds of people. Collectively, the community churches represent a cross-section of the local social structure with respect to income, education, vocations, and community involvement.

Special Populations in the Rural Community

Children

Children are resilient and vulnerable at the same time. They are typically very healthy physically and even when injured recover quickly. They are often in the care of loving, supportive care givers. Many social and educational resources exist to provide a positive and productive atmosphere of growth and development for children.

Several factors make outreach efforts to children a high priority:

• Children experience the same cognitive, physical, emotional, and spiritual reactions as adults. However, they lack experience in dealing with stress, vocabulary to express themselves, and conceptual ability to form a well-rounded perspective.
  
  
• Children have limited perspective on life-events and are more dependent on others than adults.
  
  
• Children may have experienced the injury or death of a family member or friend in the disaster.
  
  
• There may have been significant damage or total loss of home or possessions.
  
  
• Children and their family may have moved due to the disaster.
  
  
• Parents may be unusually preoccupied with their own disaster response.
  
  

Children may lack verbal skills for expressing their concerns and thoughts. They have not developed the cognitive skills needed to interpret their experience. Children communicate through play, imaginative story, and art. Few adults take the time or have the insight to grasp the significance of such communication. Children are physically smaller than adults. This may not seem significant, but it does contribute to the ease with which they are often "lost in the shuffle" or "overlooked" by the adults around them. They may have to escalate attention-getting behaviors in the chaos of disaster recovery. Children will express their hurt to adults who are hurting as well. Parental adjustment directly impacts the emotional recovery of children (CMHS, 1996).

The nature of rural family farm businesses is another factor to consider when targeting children for crisis counseling services. Children whose parents' family business is farming, often are required by necessity to assume certain farm chores as a part of their typical family/household chores. After the disaster happens, there is often an expectation that they will be required to assist their parents with farm-related disaster clean-up chores. Sometimes this may mean long absences from school or community activities.

Families, schools, churches, and other groups responsible for providing care and service to children may be the most likely sources of access to rural children affected by disaster. These resources are often difficult to collaborate with and may require some diplomacy or an "in" with the establishment. Balancing the need to provide services for children with the need to be respectful of the parents, teachers, and other caregivers is a challenge for almost every crisis counseling project.

A package of services designed to address and serve the needs of schools should be developed. Various schools in disaster affected areas have different levels of need for services and at times different perceptions of need. Because of this, marketing crisis counseling services to schools cannot be a "one size fits all" approach. Tailoring a package of services on an individual basis with each school is one way to enhance the potential for gaining access. School administrators and key staff need to understand that the Crisis Counseling Program exists to help them deal with these potentially disruptive and troubling issues in their school.

Whole school assemblies, small groups, one-on-one counseling, peer counseling, consultation, and training are effective approaches for reaching teachers and other staff. School-based activities that may be useful include: disaster-related coloring books, poster contests, poem writing, song writing, essay writing, art therapy, puppet programs, skits, and service projects.

If the disaster has impacted the local school(s), rural students may have to travel a great distance to a neighboring school or attend a makeshift school in a facility that is overcrowded. Some administrators are concerned that providing any program dealing with the disaster will only create more disturbance in the school. Experience has shown the opposite is more often the case. The anxiety and related energy levels of children in disaster affected areas often result in various levels of chaos if not given a productive outlet. Interactive programs, such as those mentioned above, provide a positive alternative to loss of interest in school work and acting out while promoting discussion and expression of feelings.

Older Adults

It is important to note that older adults are concentrated in the central parts of metropolitan areas, but also heavily populate the small, rural towns across the country. Compared to their urban counterparts, rural older adults are in poorer health, have lower incomes, and are more restricted and isolated by inadequate transportation.

Becoming old means facing a time of transition and changing roles and is a stage of life that increases the likelihood of psychological problems such as low self-esteem and depression. Older adults have the highest suicide rate of any age group in American society. They also tend to be socially isolated. In rural areas, geographic isolation may compound social isolation. Adequate social support mitigates these problems.

This life phase also includes role shifts of retirement, widowhood, and death. Often, children move far away. Health problems develop that can lead to loss of mobility and independence. The older adult encounters many losses during this stage of life.

A disaster only magnifies these issues, particularly if older adults have experienced loss of their home and material possessions including treasured mementos of a life time that cannot be replaced. Older rural adults who have lost not only their homes, but farming businesses as well are particularly at high risk. The additional stressor associated with loss of income/livelihood is a special factor to consider when providing services to the "aging farmer." Many older adults will be reluctant to move from their home even if remaining is hazardous. Many rural older adults have resided in the same home for most or all of their lives. Their home and land may have been passed down through their family and serve as a strong symbol of their identity. Not only may they have to leave their home, but the lack of available housing in their rural community may force them to move to an unfamiliar area. Older adults often require assistance in relocating to new housing. Special counseling and follow-up services should be provided to all older adults moving to post-disaster housing.

Older rural adults prefer not to have to ask for help or even acknowledge their need for any disaster services, because they view such services as charity. Develop an educational program that markets these programs in a way that the local elderly will know how to access services and feel comfortable about doing so. The role of the informal, social support system of the older adult cannot be underestimated, particularly after a disaster. Special efforts will be needed to contact hard-to-reach older adults. In determining long-term needs, flexibility should be stressed.

Outreach to the Older Adult

Linkages should be immediately established with the Area Agency on Aging and the Meals on Wheels program. Networking should also be done with the local churches. Outreach is conducted door-to-door, at senior citizen centers, senior citizen apartments/residential facilities, board and care homes, and trailer and mobile home parks.

Services provided will include the following:

• Home-based counseling
  
• Services to families and caregivers of older adults
  
• Older adult support groups
  
• Video presentations
  

Services should be provided at locations convenient for older adults, families, and caregivers. Home-based counseling is in high demand in rural areas for this reason. Older adult support groups have been successful for many communities and provide an opportunity for older disaster survivors to come together and share their fears and worries about the disaster. Video presentations, particularly Voices of Wisdom (available through CMHS), provide a great opportunity for the seniors to come together and discuss their experiences. Psychosocial Issues for Older Adults in Disasters (CMHS, 1999) is also an excellent resource.

The following examples demonstrate other ways to find seniors, family members, or neighbors who may know of rural older adults in need:

Often certain community religious groups will emerge as local recovery leaders. In one Midwestern town, the local Methodist minister was also a fire fighter and trained in crisis intervention. He and his wife were both hired as crisis counselors and proved invaluable to the community's recovery and the success of the local crisis counseling project.

To reach all community members, some programs developed flyers explaining common disaster reactions with a phone number for more information, and had them placed in grocery bags at the check-out stand, posted on community bulletin boards, and distributed at banks.

Always remember the power of the pulpit. Provide religious leaders with background information for Sunday sermons. Offer religious organizations inserts for church programs and bulletins, flyers for bulletin boards, and coloring pages for Sunday school.

People with Serious and Persistent Mental Illness or Developmental Disabilities

An individual who is physically or emotionally challenged may have developed a philosophy that confronts adversity directly. People who are emotionally challenged, depending on their functional level, are often quite capable and able to manage stress. Having the experience of adjusting and adapting to the unique circumstances and needs caused by their particular situation, they can often adapt these coping skills and strategies to respond to the challenges of disaster recovery.

At times, the coping ability of a person who is emotionally challenged is dependent on the support structure surrounding them. The risk to the individual is greater when the support structure is also stressed and temporarily or permanently removed. Many such people are also assisted with medications. Following a rural disaster, maintaining or refilling prescriptions can be a significant problem if there is only one local pharmacy and it was damaged or destroyed by the disaster.

People with physical challenges often need to adapt to the environment around them. When that environment undergoes significant change, the person who is physically challenged is greatly affected. Accessibility, safety, and autonomy are all diminished, making the person more dependent on the care and assistance of others in responding to the changes brought by the disaster. Limited options for transportation in the rural community, as well as disruptions in transportation services, can add to the physically challenged person's dependence.

Economically Disadvantaged

Rural poverty levels are often higher than in urban areas. Many rural individuals and families have fewer resources and may not own a home, carry insurance, or have any savings for responding to emergencies. When living from paycheck-to-paycheck, the loss of employment due to disaster places them at particular risk.

Economically disadvantaged people are often difficult to locate. A lack of stable employment, living arrangements, and social relationships can make these people a moving target when it comes to outreach. The pre-existing level of need, the present difficulties, and the lack of potential for a very positive outcome all create an almost overwhelming set of needs.

Migrant Farm Workers

They are often the "hidden" backbone of the farming community's labor pool. They often may be monolingual, difficult to reach, and suspicious of government assistance and intervention. They often reside in "temporary" housing, have limited access to news, radio, or telephones.

Phases/Stages of Rural Crisis Counseling

Despite the differences between types of major disasters and geographic areas the aftermath follows predictable phases. The disaster's impact on the physical, emotional, and spiritual health of the people living in the affected area will be experienced as a progression through the following phases: warning or threat, impact, rescue or heroic, remedy or honeymoon, inventory, disillusionment, and recovery (NIMH, 1983).

PHASES OF DISASTER

• Warning or Threat Phase
  
• Impact Phase
  
• Rescue or Heroic Phase
  
• Remedy or Honeymoon Phase
  
• Inventory Phase
  
• Disillusionment Phase
  
• Recovery Phase

Phases often overlap; rather than being a discreet process, each phase blends with the others and will vary in response to the aspect of the disaster with which one is dealing at that moment. For example, a feeling of great pride and accomplishment (honeymoon phase) regarding the rescue of a family from flood waters may suddenly turn to anger or self doubt (disillusionment phase) when one is reminded of another instance that ended in death.

Additionally, much of the distress of dealing with a disaster depends upon one's interpretation of the event. The meaning one assigns to a certain aspect of the disaster will either help or hinder the recovery process. Each individual will respond and react from their own unique point of view. That is, though the phases outlined here offer a predictable sequence of the human experience to disaster, each individual will experience the distress differently. Predisposing factors, ambient stressors, physical health, community reactions, and actual and perceived levels of support will influence the distress one experiences during and following the impact of the disaster.

In the early phases of a disaster, the scope and intensity of their loss simply overwhelm most people. Commonly in rural areas, the primary economic base is dependent upon natural resources. The immediate losses from any disaster are compounded in rural areas as the resources for continued existence are destroyed. The lands, lakes, fisheries, and enterprises that encompass the rural culture are more than a job. They form the economic base, value systems, and way of life for rural America. Along with resources, rural residents often lose hope for the future. The recovery process must focus on the meaning of the disaster in a way that transforms the interpretation of being a helpless victim to one of being a successful survivor. Given the confusing maelstrom of need and emotion involved throughout the phases of disaster, the most important facets of the psychological healing process are validation and perspective. Disaster survivors/victims must hear that the reactions they are experiencing are normal and expected. They must also have access to discussions revolving around a realistic appraisal of the challenges presented and their options and response to those challenges. The crisis counseling project may be the first source of perspective afforded a disaster survivor/victim.

Physical, social, emotional, and spiritual recovery take place simultaneously but at different rates. An individual may be well into recovery physically, but still be distressed socially or emotionally. Given these realities, it is best to view disaster crisis counseling as assisting persons with a process of coping rather than seeing them through to some predetermined outcome.

The process will continue long after the crisis counseling project is terminated. Crisis counseling services must be delivered in a way that provides connections to ongoing community services, such as social services, mental health providers, jobs and training programs, educational opportunities, financial services, and other services. In this way, the crisis counseling project equips disaster survivors with the capability of continuing their recovery as the phases progress (CMHS, 1994).

The key word in disaster circumstances is CHANGE. The massive changes in personal and community life cause physical, emotional, and social problems. Because these changes are dynamic and on-going, any program striving to be responsive to them must also be dynamic.

With a sixty-day IS grant and a nine-month RS grant (barring extensions) the Crisis Counseling Program is designed to last just short of a calendar year. Distinct stages of crisis counseling services can be tracked along with the phases of the disaster. The impact of these stages and their corresponding disaster phases on rural populations are described below.

CONFUSION AND DISORGANIZATION
Corresponds with IMPACT PHASE and RESCUE OR HEROIC PHASE

How, when, and where to proceed in responding to the disaster are questions that can only be answered for each disaster individually. While effective statewide planning can reduce and shorten this stage, during the early response some confusion and disorganization are inevitable. Experience is useful, but may not be readily adaptable to the current disaster. What if the State disaster coordinator is not available? Is there anyone else who knows what to do? Is anyone else within the State aware that funding for disaster crisis counseling is a possibility? Do local community mental health providers have their own plan for dealing with a disaster in their area? Do they know about the Stafford Act? Proper planning and experienced staff will minimize and shorten the period of confusion. Areas within the State where there is a higher level of disaster response organization and more frequent disasters may initiate response with less confusion.

Rural areas often find it more difficult to plan and mobilize for disaster preparedness and training for response. Confusion and disorientation can be minimized through statewide disaster planning and identification of a cadre of disaster response experts, nationally and statewide, who are willing to assist the State when requested.

Even if preplanning has not occurred, the early stages of the crisis counseling project can be less chaotic if program staff have solid direction. In rural areas, there are a number of organizations that are already stakeholders in the well being of the population in disaster. These groups will often begin providing services of various types immediately. Crisis counseling staff at this stage need to be identifying and connecting with existing organizations. Contacting churches, unions, university extension services, fire or police auxiliaries, agricultural networks, civic groups like the Lions, Rotary, Optimists, Masons, and literally every group or concern in the area can help in developing the needs assessment and a strategy for service delivery. Insurance agents and adjusters may also be good contacts. Even if a person's property is insured, they may still benefit from crisis counseling services in dealing with psychological recovery.

EMERGENCE OF ORGANIZATION AND IDENTITY
Corresponds with RESCUE OR HEROIC PHASE and REMEDY OR HONEYMOON PHASE

During the emergence of the organization and identity stage, a structure for mental health disaster response is developed. Local providers are identified, the needs assessment is initiated and tabulated, and there may be a Federal declaration triggering a formal Crisis Counseling Program. The Federal declaration is important because it provides, through the Crisis Counseling Program, a clear set of guidelines and goals for the mental health response. A Presidential Declaration also connects the State more solidly with Federal resources.

Emphasis shifts from playing catch up to establishing lines of authority and communication. At this stage, work will be focused on generating contacts with providers, formulating various memoranda of understanding, establishing reporting requirements and forms, developing an agenda for initial training efforts, and scheduling meetings to coordinate and monitor the program. By this time, the program is generally distinguishing itself in the community at large. The program should be identified with a name that is separate and distinct from the traditional mental health program which unifies and identifies the workers and staff associated with the project. Examples of project names used in the past - Project Rebound, Project COPE, Project Fireweed, Project Rainbow, Neighbor to Neighbor, and Project Heartland - reinforce the positive aspects associated with the recovery.

Establishing a location is especially important in rural areas. There are two primary considerations. One, is the average resident of this area going to feel comfortable coming into this facility? Two, is it easily accessible? In rural areas there are often matters of rivalry between towns or townships, or other regional lines of demarcation that will prevent some people from traveling to a certain location. For instance, it may seem like a good idea to locate offices at the county seat or a larger city within the area affected. However, there may be a significant number of people in the outlying areas that will identify that town as foreign or hostile. Checking with various agencies may illuminate these separations and thus prevent a misstep in providing access to services. Establishing more than one office in any given area may be beneficial. Another consideration would be to co-locate with existing agencies if there is ample space. Placing service staff along with the university extension or the Agricultural Soil Conservation Service (ASCS) office may help reduce stigmas and barriers of pride.

GAINING MOMENTUM
Corresponds with REMEDY OR HONEYMOON PHASE

Workers begin to become established and identified as the core of the program. Frequent staff training, accompanied by efforts at integrating activities with other community responders, usually causes a period of enthusiastic, high-output effort in outreach and crisis counseling. This stage is also characterized by increased networking with community groups and local, State, and Federal organizations still active in the community. Participation in inter-agency groups and unmet needs committees is especially useful in a rural community where resources are limited. It brings the program staff into contact with those who constitute the infrastructure of the disaster response and recovery effort. Unmet needs committees during the Midwest Flood of '93 ensured that survivors received the aid for which they qualified. Local representatives of agencies, such as Salvation Army, American Red Cross, crisis counseling project, Family Services, Area Office on Aging, and religious groups coordinated available resources for maximum impact and to prevent duplication of services (Project Rainbow Final Report, Missouri, 1994).

ESTABLISHMENT OF ROUTINE
Corresponds with INVENTORY and DISILLUSIONMENT PHASES

There comes a point during the regular services project when workers have been on-the-job long enough to have established some routine. Ironically, this feeling of routine often comes at the point when serious planning must be underway for program closure. Many outreach workers find this frustrating. At this point, a diminished level of enthusiasm in the program commonly emerges. Staff, especially those who have been with the program from its inception, are beginning to show effects of burn out. People in the community may question why these services are needed so long after the disaster. In some people's minds, when the disaster is no longer the media's lead story, the disaster must be over. A large number of people being served at this time may be in the disillusionment phase of their own recovery process. Others may not.

For some, the recovery phase may mean a new way of life. Rural living is sometimes fragile and usually heavily reliant on natural resources. Farming is always a gamble. If this disaster destroyed the opportunity for profit, it may mean that increasing debt to recover is out of the question. Many farms and agricultural businesses simply could not recover after the Midwest floods. In rural areas, each dollar is recycled through the community seven to eight times. The economic losses resulting from millions of dollars in lost crops changes the face of rural America tremendously. Rural crisis counseling projects should consider establishing linkages and referral mechanisms to identify resources for retraining those forced out of work.

In a rural disaster, the sudden dependence upon outside resources, especially government services, may threaten the pride of many who espouse self-reliance. Those who accept assistance may feel as though they have lost face. Others may judge them harshly for "being on the dole." From the onset of crisis counseling services, that pride should be taken into account. Confidentiality and discretion must be built in so that those who would benefit from the services are approached in a palatable way. Plans need to be made for non-traditional service delivery by avoiding mental health jargon, being where people are, using community people as gatekeepers, and providing practical help.

During the disillusionment phase, people affected by the disaster are apt to feel estranged from others and may distance themselves from other community members and even their own family. Together, the normal reactions to a disaster and isolation from others can result in serious depression. Hopelessness and even thoughts of suicide may be common during this time. The red tape of bureaucracy may seem like an insurmountable barrier. The crisis counselors can be a source of encouragement and hands-on assistance in pursuing needed help. If not already in place, this may be a good time to develop support groups.

PROGRAM TERMINATION
Corresponds with DISILLUSIONMENT PHASE and RECONSTRUCTION OR RECOVERY PHASE

This stage of the program may be the most difficult. Preparing survivors and staff for closure usually comes at what seems to be the wrong time. Many people are still emotionally vulnerable due to the slowness of the recovery process. Delayed stress reactions are beginning to emerge. The anniversary date looms with the potential for anniversary stress reactions. Staff will naturally begin to think about and possibly take action on new employment opportunities. Team cohesiveness and structure are disrupted. One outreach worker in Illinois described the impact of this stage as a gradual "unraveling" of the program (Project Recovery Final Report, Illinois, 1994). Staff will refer disaster survivors with ongoing needs to other resources in the community. Returning to their normal life in the small rural community that now identifies them as a source of support and help may be difficult for staff.

POST-PROGRAM
Corresponds with DISILLUSIONMENT PHASE and RECONSTRUCTION OR RECOVERY PHASE

Local providers, besides supplying data, narrative, and fiscal information to the State, have completed their program activities. The final month of the program is often set aside for report writing, fiscal accounting, and other close-out activities. There may be a major readjustment of individuals and the community if appropriate linkages have not solidified and the reality of program termination is a fact.

Challenges Encountered by Rural Crisis Counseling Programs

Crisis counseling staff responding to a rural disaster face unique challenges related to the values and characteristics of rural areas and people discussed in Chapter Two. Planning and persistence may help to overcome some of the challenges associated with rural areas. Recommendations are provided on how to reach farm families, people who are emotionally isolated and independent, and how to overcome constraints of geographic isolation and access hard to reach groups.

Emotional Isolation and Independence of the Rural Population

Initial contact may reveal a person or family caught in an angry reaction to a multitude of aggravations. Doors may be slammed and workers may bear the brunt of yelling and abusive language. While forcing the issue is never appropriate, a contact later in the program may reveal a completely different temperament. A person who was completely closed at a prior point, may in a few short days or weeks, be open to contact and appreciative of services. Phases of recovery shift and change. As trust begins to develop, people gradually become receptive to the efforts of outreach workers. Over the long haul, outreach workers gain respect for their willingness and tenacity from the people they have attempted to serve.

Reaching Farm Families

The Crisis Counseling Programs that were successful with rural outreach to farm families were those that had the assistance of organizations experienced in dealing with farm families and farm issues. One such group, the Farm Resource Center in Illinois, has been operational since the early 1980s providing families with crisis counseling, financial planning assistance, and referrals to other programs. The experience of the Farm Resource Center's workers served as a model to crisis counselors on how outreach is conducted in the farm community.

Other Midwest States used similar organizations with connections to the farm community to open the door to outreach efforts. Many contacts and services were facilitated by these working relationships. This is further reinforcement of the principle that no matter what type of group a program is attempting to reach, finding outreach workers representative of that group is the best way to gain access.

Geographic Isolation

Geography's role in rural crisis counseling is significant. It often takes days to accomplish the same number of outreach contacts one can make in an afternoon in an urban area. Traveling from place to place can be difficult given the disaster's impact on roads and bridges. A rural outreach worker needs information from State and county highway departments and law enforcement officials to stay current on conditions. Detailed topographical maps may be available from the FEMA Disaster Field Office or State Emergency Management Office.

An outreach worker's inability to reach some impacted people often means that the survivors themselves cannot get out except with four-wheel drive vehicles. Such isolation creates difficulty getting into town, getting children to school, and perhaps most important, obtaining food and medical care. In many rural areas, emergency medical services are not immediately available.

Basic access issues can be a consideration, such as getting to the grocery store, gasoline station, bank, and other businesses following a disaster. During the height of the '93 Midwest floods, thirty-minute commutes to work and school became two hours and longer due to washed out roads and bridges (Project Recovery Final Report, Illinois, 1994). Because of the distances involved and lack of easy access, rural residents may forgo attending meetings or accessing services at some "in-town" location. Consequently, support groups, educational events, and other group services may not be the best option in some areas. Most counseling will take place at the disaster survivor's home rather than at an office.

Many addresses are only listed by a rural route number or a post office box number. Locating the home of such a person means developing a good set of directions. Information from local officials about access problems, as well as information about the physical characteristics of the location, such as color of the house, type of siding, and model of parked automobiles, may be the only way to find the correct dwelling. In addition, the presence of outbuildings and large landmarks, such as grain silos or dairy storage tanks, can be valuable identifiers in locating the right farm or homestead.

Many people served by rural programs are at or below the poverty level. Finding people who do not have a telephone is common. Contact with such people to see if they are home before making the trip may be difficult if there is not a neighbor or family member close by to relay information. While mail contact is possible, it takes more time and is not responsive to short-term emergency needs. Also, literacy levels should be considered in the development of any mailing, flyers, and outreach educational materials.

Accessing Hard-to-Reach Groups

Some organizations, such as health care, child welfare, and schools function in a somewhat self-contained environment. Though such an organizational structure does not render interagency communication impossible, it does make access a challenge. The following strategies may assist rural crisis counseling projects in providing a wide array of services to these hard-to-access groups:

Do Your Homework

Before making the first contact, find out as much as possible about the organization and the best person to contact. With this information, developing a presentation or package of services that will be received positively may be feasible.

Develop a Personal Contact

Trust and confidence, especially in programs that are new and time-limited such as disaster crisis counseling must be built person-to-person. People in rural areas refer to other people more often than to programs. The person who is a primary contact may not be the person who has authority to invite crisis counseling services into the organization. Having someone who can exert influence from within can result in the decision maker contacting the outreach worker to request services.

Knowing people's names also provides a point of contact in case there are difficulties or miscommunications. Being able to pick up the phone and call a person you know by name, have met face to face, and have established a working relationship with is a tremendous asset to an outreach worker.

Hire Outreach Workers or Volunteers Who Have Worked in the Organization or Field that is Difficult to Penetrate

Certain groups or organizations will be key to the success of the outreach effort. In the rural area, schools, agricultural and religious groups and organizations are especially helpful. Hiring staff who know those groups, and better yet are known by them, can help get quick and effective outreach efforts into those groups.

Hiring a retired school administrator, teacher, or counselor to do outreach can provide a natural relationship to access schools. Some agricultural groups may be difficult to access unless the crisis counseling project has farmers or university extension personnel either doing outreach or assisting outreach workers in meeting farm families in need. In Ventura County, California, the Northridge earthquake survivors included non-English speaking families and migrant workers with minimal education. Language, low-literacy, isolation, and the fear and anxiety of deportation presented challenging barriers for the outreach workers to overcome. The crisis counseling project assigned bilingual, bicultural staff, and provided door-to-door outreach to identify the specific needs of the survivor. Linking disaster survivors to counseling services with trusted church and community-based organizations was also a successful service delivery method. The church is an effective catalyst in the provision of services to these special populations. Churches have historically been a place where migrant workers and monolingual families feel comfortable in seeking services (Northridge Earthquake Final Report, Ventura County, California, 1995).

Use Easy-to-Reach Groups to Reach Hard-to-Reach Groups

Sometimes crisis counselors will not make the first contact. An organization already working cooperatively with the crisis counseling project can provide great assistance in influencing other groups. By conveying a sense of the nature, importance, and credibility of the crisis counseling effort, these partners can help unlock new opportunities for outreach.

Do What You Can, When You Can

If a full range of outreach services are not what an organization or group desires, provide what they are willing to accept. Perhaps all that can be done is distribute materials or give an educational presentation. Just as people progress through phases of recovery, so do organizations. Maintaining contact at any level may result in more significant services later as the organization's needs become more apparent or change with time.

Chapter 3 | Table of Contents