For further examples and details relating to each theme please see Additional file 2. For a summary of theme and sub-theme please see Fig. 1.
Hierarchical organization
Forms of organization
Mental health workers suggested that MHCI should be integrated with overall rescue and emergency medicine response systems instead of conducting their work independently. Additionally, MHCI teams should stay up-to-date with information from the primary rescue response teams, so that they can perform effective and scientific MHCI fieldwork.
“The problem was that our mental health intervention work did not follow up with the overall rescue work. We were not under the same working arrangement, lacking clear information”.
Many participants mentioned that the local mental health interview team should lead the intervention as the primary force, with support from the external team.
“It would be too late if the external intervention team takes a long time to come here”.
Management system
Overall, respondents regarded major improvement had been observed in post disaster MHCI. One improvement has been the shift from an approach of “individual combat” to the promotion of MHCI team cooperation. Effective team cooperation depends upon a unified and powerful management organization, an effective team provides stability for MHCI workers, and this stability consequently provides benefits for the victims being supported.
“In my view, the MHCI work for the Wenchuan Earthquake was a complete mess. Everyone was doing their individual job without a holistic work plan or scheme, and no unified management.”
“I think the psychological intervention after an accident is different from my normal routine job. Once arriving at the site, I was suddenly dumb, knowing nothing about what I should do. My immediate reaction was to find the organization and accept my task through organization. I felt much more at ease when the rescue command center assigned me to work with the mental health intervention team organized by local medical institution. I could finally carry out my work without worries. Therefore, an organization is of vital importance; it settled me down at the beginning.”
Team construction
Team leaders
The effectiveness of the MHCI depends largely on the abilities of the team leader. This is embodied in the quality of their management, organizational skills, and professionally. Additionally, good MHCI leaders were associated with particular personality traits, especially modesty and trustworthiness.
“No one knows how this team would work if there was not an excellent leader whom everyone respected. It is possible that everyone would ignore each other and everything would end with a mess.”
“This leader deserves its name. He is indeed our role model. Not only for being amazing at work, he also shows perfect personality, with a great approach for dealing with people. Everything goes on well as long as he is present, and we understand and support each other during group discussions. In fact, to some extent, whether our work can meet the expectations depends on the leader’s encouragement and model effect.”
Team experts
As reported by the respondents, external team experts mostly came from the national crisis intervention team who have abundant experience. These experts provided guidance and assistance to the local MHCI team. Respondents commented that the establishment and operation of expert groups had and could facilitate the overall MHCI work. Many MHCI workers agreed that this primarily depends on creating a group with a sensible composition of experts and the personal qualities of the experts.
“What left me with a strong impression is the way that the mental health intervention expert group worked out. In that mental health intervention mission, the psychologists appointed by National Health and Family Planning Commission suggested that local hospitals and university volunteer organization mental health intervention team select several cooperative and professional experts to form an expert group. In that mission, this group played a fundamental role. It gathered the problems we met in work, then offered advice to these problems one by one, and finally adopted the consensus decisions. This also reflected the centralized democratic manner of working.”
“After the accident, we soon established a psychological intervention team. Although we did not have much experience, external rescue experts have offered much support and encouragement, helping us to make work plans and other mental health intervention materials, and taught us how to do the intervention from the beginning. This laid a solid foundation for later psychological rehabilitation. Therefore, our work became increasingly familiar and proficient.”
Team members
MHCI workers discussed the abilities and competencies required for their role. Physical, mental and mutual trust among team members were reported to be key determinants. Some MHCI workers mentioned that collaborating with team members from different disciplines caused tension and affected their enthusiasm for collaboration. Some workers noted their personal limitations and the need to improve their coping mechanisms for crisis intervention fieldwork.
“We felt that it was very hard to cooperate with psychiatrists. They seemed to look down upon us and I think they only know how to prescribe medications.”
“I could still remember that when I first joined this work in Jingzhou, it felt uneasy and worrying. I had no previous experience. MHCI fieldwork is completely different from my everyday work. I would have liked to have a deeper background and more abilities in psychology.”
“Our local Mental health workers lack adequate abilities to cope with crisis intervention for the clients. They urgently need further training from an experienced expert.”
Intervention pathway
Based on the descriptions of MHCI workers, this paper presents a six stages MHCI intervention pathway from work plan through to handover.
Work plan
MHCI workers mentioned the importance of formulating a work plan and corresponding documentation. When faced with a new working environment, only having access to vague information about the role increases anxiety. Therefore, formulating a clear work plan with guidance and requirements – including working principles and clear job duties of each MHCI member – provides reassurance and stability. However, many local governments do not yet have emergency work plans for post-disaster MHCI.
“Being the leader of the intervention team, I felt under more pressure. My responsibility was to establish a bridge between the crisis intervention decision-makers and the MHCI worker. I needed to make a plan for myself, as well as for other team members, so that everyone could work under regulation without any omission, and we could save time avoiding repetitive notifications. This also made the working procedure more standard.”
“We need to follow relative requirements and principles in every day psychological counselling and psychotherapies. However, MHCI for public accidents, apparently, calls for special requirements, and we need to be clear about this. Because I understand that the success of MHCI does not only rely on psychological factors, additional factors such as social, humanistic, and even medical factors, also play a role. Therefore, the formulation of relative documents must be comprehensive. Any missing parts might cause the intervention to become chaos.”
Resource preparation
Resource preparation consists of providing the necessary materials to support two key aspects: MHCI workers’ day-to-day living arrangements, and working equipment. MHCI workers referred to experiences of chaos caused by insufficient resource preparation and therefore stressed the importance of this important aspect of work.
“Our hospital always puts MHCI at priority level, being prepared for material supply in peacetime, and doing regular checks and updates. Because of this, once an accident occurs, we are soon able to grab the materials and arrive at the site. Actually, the key to this work lies in daily preparation. Without careful daily treatment, it is impossible to be responsive to emergencies. This substantiates the professionality of the MHCI team of our hospital.”
“As the sky turned dark, we still were unable to offer any help and everyone became hungry. We then had to settle down at a temporary resettlement point, and received some food together with other victims. Even now I feel embarrassed about it.”
Circular investigation
Circular investigation refers to circulation of the disaster site and nearby locals for information-gathering and provision of initial practical support. MHCI workers universally recognize this aspect of interventions from their past practical experiences, and comment that continued circular investigation throughout the intervention can bring a sense of stability to disaster victims.
“The circular intervention in my definition is visiting the victims with a helpful attitude as a professional, detecting and solving the problems.”
“Once when I knocked on the door of this family and introduced ourselves to them, they treated us with bad attitudes, saying ‘get out, get out, we don’t need your help.’ We felt very uncomfortable, but our leader told us that this was the point of our work. While observing the way people communicate with us, we could learn that how this accident influenced this family. Therefore, we must show our tolerance and understanding.”
Designated intervention
Designated intervention refers to the work of MHCI workers in establishing a steady relationship with clients and offering long-term professional mental health treatment. MHCI workers mentioned two forms of designated intervention. The first is the mental health services provided by psychiatric professionals at mental health institutions, the second is the mental health services provided by psychological professionals at a client’s home.
“Circular investigation and designated intervention together contribute to a satisfactory mental health intervention. We arrive at a location, and visit the families one by one. Whenever we spot any emotionally unsteady clients, we find out more about him through observation or chatting with his family, and report to the leader.”
“In one investigation task, we found someone with abnormal behaviors at the resettlement point, with salient depressed mood and glazed eyes. We then entered his house and found a rope. We immediately got in contact with his family and learned that he once suffered from bipolar disorder. According to the psychiatric assessment then conducted, there was major depression going on, and we thought he was of high suicidal risk. After patient communication with his family, he was referred to a local mental health center and taken care of.”
Intervention supervision and training
To ensure the quality of MHCI, effective training and supervision of MHCI workers is required as the rescue/relief operation evolves. Specifically, a regular meeting system, a training scheme, and a supervision schedule are necessary as precautions for preventing, identifying and solving problems as early as possible in the fieldwork.
“Actually, initially, I didn’t care much for regular meetings. After a whole day’s work, all I wanted to do is to have a rest. Also I thought there is nothing wrong with my duties, so no need to report again. It’s a waste of time. However, the meetings were required by the expert group, so I had to attend. After attending, I realized that it is worth doing. First, I found out that there were some minor deficiencies I can improve, thanks to observations from other colleagues. Second, everyone possesses some values which I could learn from, and it was an enjoyable experience to share my opinions with the team. In sum, the meeting process is a place to share knowledge and offer mutual encouragement.”
“I received short training in mental health crisis intervention at the beginning of work. This indeed was helpful, as it clarified many of my questions and relieved my anxiety. After all, MHCI differs in many ways from my daily job. In the meantime, I wish the training could involve more case analysis and role playing. Maybe this would help me to better understand the principles. In addition, I think training should be divided into stages. At the initial stage, just telling us what is correct and what is wrong. Later we can include deeper discussion and training according to the developmental pattern of crisis client’s mental state. At the final stage the training could tell us about sadness and trauma treatment.”
Handover
Handover is the process during which one staff explains his or her duties and other work-related situations to another staff before his or her responsibility terminates (e.g., after a two-weeks’ working contract), so as to assure uninterrupted crisis intervention services. MHCI workers showed concerns specifically about the last stage of MHCI; due to various factors, this is frequently handled poorly. They suggested that it is necessary to develop a plan for tracking follow-up of victims and disaster mental health rehabilitation in China.
“As the overall rescue work has come to an end, however, there is no subsequent psychological rehabilitation scheme for these clients. Although we try to do something; there seems to be no alternative ways.”
“I think the follow-up work of MHCI is as important as the emergent stage. Yet due to many internal and external factors, this duty has not received enough attention, therefore its implementation is not ideal. In fact, the follow-up of MHCI involves various types of work, for example the trauma therapy for crisis clients, scientific research on group disaster community rehabilitation, and policy research on future MHCI management, etc.”
Intervention strategy and technique
Assessment, screening and referral
Assessment, screening, and referral are the core procedures mental health workers need to follow. They first conduct a thorough assessment on client’s psychological state (assessment), sort them into groups according to their symptoms (screening), and come up with different intervention strategies (referral). MHCI workers mentioned issues regarding the screening and assessment of clients. Many lacked a clear and correct understanding of these tasks.
“We met with serious trouble once during the MHCI work after the shipwreck. One lady’s husband had died in this accident. Upon hearing this news, the lady presented with serious psychotic responses, claiming that her husband was waving his hand towards her on a small island far away, and she could hear his shouting at her. This was typical illusion and delusion. After careful consideration, we made the decision to refer this lady to a mental health institute for further psychiatric diagnosis and treatment.”
“I used to treat assessment and screening as the same procedure, but now I believe that these two should be separated.”
Some MHCI workers stated that questionnaire assessment and interventional research should be based on clients’ interest and permission, and that a process of research ethics must be created and followed.
“Although taking questionnaires showed their prudence in work, a lack of humanistic care should still be considered unethical.”
“We could never force them to participate in the research, which should be based on crisis clients’ permission.”
Worker-client relationship establishment
MHCI workers discussed their strategies for establishing and maintaining cooperative relationships with crisis clients, noting that the goals required for different stages of the disaster response vary.
“I think in MHCI, the most significant part is how to establish a good relationship with the clients at the beginning.”
“When first approaching the clients, the first priority is to win their trust.”
“To tell the truth, most clients I engage with gradually recover to a rational and peaceful state. As our mutual understanding moves forward, they change from being initial passive and helpless to initiating communication with us, and starting to plan for the future. Now, being MHCI workers, not only should we continue our support, but also show full respect to these clients. We need to think twice about our positions and realize that we are just a supportive role, so that we can further improve crisis client’s initiative.”
Solving practical problems
MHCI workers frequently talked about their experiences with solving practical problems for crisis clients. They agreed that problem solving should follow the principles and professional standard of clinical psychology practices, using strategies and techniques based in psychological understanding.
“Social work is my major. I remember that I was very confused during my first experience of MHCI. I admired my psychiatrist and psychologist colleagues, who could make use of their expertise, while my responsibilities seemed not important at all. The leader of our team seemed to realize my depression, saying ‘Every single MHCI worker plays his or her role. As for a worker with a social work background, you should substantially fulfill your duties, which are helping victims to solve their practical problems. This requires professional knowledge, and is never easy-peasy.”
“As a psychiatrist, we share some advantage in practical MHCI work. Because, you know, the most important responsibility for clinical work is to guarantee patient’s life safety. Therefore, in MHCI, we are always cautious about this, observing closely the mental conditions of the patients to see if they are related to their injuries. Once potential risk has been spotted, we will handle it immediately. I think this is an important part of crisis intervention.”
Psychotropic medication intervention
Most of the interviewed MHCI psychiatrists mentioned psychotropic medication intervention, including discussion of the ideal availability and usage of psychotropic medication, types of medication, and importance of prescription notes.
“Although the majority hold that crisis client’s mood swings do not require medication, I think this does not apply to all situations. For example, three days after the accident, some people still cannot have a good night sleep, even though they have been settled at a safe place. Therefore, medication treatment is necessary, but must be assessed by a psychiatrist.”
“The medication treatment in MHCI clearly differs from psychiatric clinical treatment. Although the dose of the medication in the overall working period is not large, if there is a mistake with the medication, serious consequences might occur. Therefore, I suppose that we must take care of every single detail of medication treatment. For example, specifically recording the medication and personnel, make sure everything is safe.”
Psychological intervention
During intervention, crisis intervention workers need to pay attention to clients’ emotions, cognition, and behaviours, and offer appropriate treatments accordingly. Major intervention techniques include Mood Stabilizing, Cognitive Integration, and Behavioral Leading. Mood Stabilizing requires workers to acutely identify and understand clients’ emotions, provide sympathetic responses, and lead them to a calm and rational state at the right moments. Cognitive Integration is a technique in which crisis intervention workers help the clients to understand the abnormal symptoms they are experiencing and the whole picture of the event. This includes pointing out how their negative thoughts affect their behaviors and distort their cognition; strengthening their positive and optimistic thoughts, etc. Behavioral Leading is a more active and suggestive technique, in which workers perform activities such as muscle relaxation, positive implantation, trauma isolation, and crisis desensitization. However, these methods require professional training in psychological treatment.
“A stable emotional state is the most important thing for crisis clients after public accident. However, this goal is not easy to achieve at the beginning, and neither is it a practical goal. The victims I witnessed were usually either crying, or terrified, or completely silent, or showing impulsive behaviors. We must stay calm in these messy situations. Not try to persuade them to do anything, instead we should accompany them, staying by their sides. Using their body reaction to understand their feelings, and using practical actions to protect, support them. Because when people are involved in the emotional waves caused by natural disasters, our work at a cognitive level, e.g. persuasion, explanation, will be futile. It is malposed communication.”
“I notice that crisis clients are often not able to talk about the complete picture of their accident experiences. They tend to exaggerate the horrible scenes they witnessed and their helplessness under that condition. In fact, many positive elements in the accident are missing. These positive elements include not only crisis client’s calmness and persistence during crisis, but also the support and help they received from others. Therefore, during intervention, what I need to do is to restore this content at a cognitive level, diluting their negative thoughts.”
“Relaxation techniques are frequently adopted in MHCI. Because MHCI workers will often need to deal with crisis clients who present with tense emotions or sleeping disorders after accidents. However, many workers are rather rigid and stiff when performing this technique, ignoring the principles and procedures. This has resulted in poor efficiency of the technique and even some side problems. Therefore, the implementation must be based on crisis client’s absolute trust in MHCI workers, and the worker should be wary about the opportunity for implementation, following the principles and correct procedures.”
Public health information
Text-based public health information
MHCI workers said that they commonly prepared mental health material for public dissemination before departure, as well as disseminating mental health brochures to the disaster victims during circular investigation and putting up posters in salient places.
“Four cornerstones of health education are healthy diet, regular exercise, limiting cigarettes and alcohol, and mental harmony. These tips should be remembered, because after the crisis, many victims lose their regular life and eating habit. The loss of finance or of family members drives them into deep agony and uneasy. Some might drown their worries in drink, and be in a mentally uncontrolled and unbalanced state. Therefore, every one of our MHCI team should hold a general idea about health, offering health education properly, since this is the premise to help crisis clients to recover to a normal state soon.”
Media interactions
MHCI workers frequently commented on media response to disasters; some argued that some media practices may impede the implementation of MHCI and be harmful to victims’ mental health.
“I have an aversion to the media. This indeed interferes with our work and efficiency.”
“Sometimes the journalists follow us everywhere we go to. Although I completely understand this is their job, they really know nothing about the specialty of our MHCI work. The priority of our work is not to interrupt the crisis clients, yet these journalists do not follow this approach, always directly asking them about sensitive issues. Some residents are not willing to answer [media requests], and [media] still keep on asking. In fact this is of harm to the victims.”
Hotline counseling
Another method for disseminating mental health knowledge to the public is hosting a psychological hotline. MHCI workers believed that a hotline could not solve complex problems, but could offer scientific explanation and guidance on some psychological phenomena and that hotline counselling is a valuable way to improve MHCI services and information access.
“Hotlines are good. They not only help to handle crisis situations, but also strengthen later periods of psychological rehabilitation work. However, this job requires people, material, and money. If these cannot be guaranteed, this job is hard to continue for long. Therefore, this cannot be decided by MHCI workers.”
