This is a review of relief activities following the 1995 Great Hanshin-Awaji Earthquake and subsequent practice/research on post-traumatic stress management. During the first three months after the quake, the author organized a relief volunteer center and managed its crisis response activities. As a post-crisis professional response, a series of workshops was organized on disaster stress management. Out of these workshops, a stress-coping model and several stress management techniques were shared among helping professionals in Kobe. Utilizing the framework and newly acquired methods, community based projects were launched to offer debriefing services to mothers of preschoolers in disaster hit areas in Kobe. Debriefing experiences revealed that preschoolers were well protected by their mothers both physically and mentally, however, a greater number of mothers were still suffering from post-traumatic stress 10 months after the earthquake. The Kobe Mother-Child Stress-Coping Research substantiated the earlier practice findings. Lessons learned from this research for future disaster stress management include the importance of treating families as a whole rather than focusing only on children, the role of the family's ability to change its power structure as a coping resource, and the need to encourage mothers to use their internal resources to alleviate their own stress rather than directing all of their resources to benefit their children.

Crisis Response

The Kwansei Gakuin University (KGU) Relief Volunteer Center organized student volunteer relief activity efforts during the three months following the Great Hanshin-Awaji earthquake in 1995. The Center was started by a group of university professors and it managed student relief volunteer workers from January 21 to April 6, 1995. An accumulative total of 7,277 volunteers engaged in relief work and at the peak of the Center's activity, helped to maintain fourteen temporary shelters in the area surrounding the university. In retrospect, there were three phases in our relief activities: emergency, development, and ending phases, each of which lasted approximately one month. The following sections describe each phase from a volunteer management viewpoint with a focus on the person-environment fit of the earthquake survivors.

The emergency phase: Instrumental and interpersonal emergency work

The initial emergency phase was characterized by a high mobilization of student relief volunteers. The wide media coverage of the earthquake disaster prompted an empathy-forming triangulation between the earthquake victims and the rest of the nation. The Hyogo Prefectural government estimates that about 1.3 million volunteers came from all over the country to a concentrated area between Nishinomiya, Kobe and Awaji Island. The main recruitment media for the KGU Relief Volunteer Center were newspaper public announcement messages to KGU students regarding the cancellation of remaining classes and the intention to conduct end-of-term examinations as originally scheduled. At the end of these public announcements, the Center managed to negotiate with the university crisis response committee the inclusion of volunteer recruitment messages. As soon as the messages appeared on major newspapers on January 24, the number of relief volunteers skyrocketed.

The earthquake caused an unprecedented imbalance in person-environment fit. External resources were needed to assure the basic safety of the survivors. Student volunteers engaged in moving, sorting, and storing relief food and materials, as well as preparing hot soup for the victims. They even helped to build temporary toilets. Night shift volunteers patrolled from midnight to morning so that the evacuees could feel safe and protected while they slept. Providing rice balls, hot soup and blankets as well as guaranteeing safety at midnight was the best external coping resources that the earthquake survivors could utilize for their sense of adaptedness at that moment of turmoil.

Interpersonal support for the earthquake survivors came after the Center established the logistics of manpower and relief food/materials to shelters. In order to encourage the relationship formation between the relief volunteers and the evacuees, the Center established a system that would encourage student volunteers to return to the same shelter where s/he was assigned on previous occasions. Showing up to the same shelter twice or three times allowed the volunteers to be socially acquainted with evacuees. The Center especially encouraged the students to spend time and to be acquainted with children, elderly, and handicapped at the shelter. They were considered to be more vulnerable to stress than others. In short, participating in more instrumental emergency work at the beginning of the emergency phase facilitated rapport-building which later became the basis for social support to those vulnerable populations at the shelter.

A week after we started the Center, the first overnight children's camp tour bus left for KGU Sengari camp, where the children from evacuation shelters spent a night in camp cabins. Instead of playing Gameboy or reading comic books as they did at the shelters, the children participated in various indoor and outdoor camp activities and enjoyed a hot bath. It was almost the first time for them to play freely. The camp helped children to alleviate stress caused by the disaster, sudden changes of their life and forced co-habitation with other disaster victims. For the elderly at the shelter, day trips to Sengari camp were organized. The main attraction for them was to have a hot bath at the camp. A professional comedian volunteered to join one tour, so the tour passengers laughed during the trip and enjoyed a stage show after the bath. It was the first time since the onset of the earthquake for those who joined the tours to take a bath and become relaxed both physically and mentally. Both the children's camp and the elderly bus tour were intended as ways to provide a safer environment and to help them regain a sense of control over their own lives.

The development phase: focus shifting from emergency intervention to personal empowerment

The Center redefined the purpose of its relief activity from emergency relief work to empowerment of individual citizens at the beginning of the second month. Too much relief volunteer involvement seemed to prevent the shelter residents from forming their own governance over their lives. The Center sent faxed messages to 14 shelters announcing that the Center would shift its focus from providing basic relief supplies and services to encouraging self-reliance, helping the survivors to go beyond a victim role, and empowering the citizens to determine their own course of action by themselves.

The Center put more emphasis on working with vulnerable populations at shelters, namely the children and elderly. However, we noticed that people at shelters in general showed high resistance to so-called "psychological care (kokoro-no-kea)" staff and volunteer workers. Asking for psychological help was considered to be a self-admitted sign of weakness and vulnerability. To overcome this barrier, about 70 social work and educational psychology major students as well as a casework professor were recruited and the casework professor gave a half day of training on basic attending and listening skills. The students were then divided into subgroups and each subgroup was in charge of one of the 14 shelters. In order to initiate social conversations, the student volunteers, all of whom were female, brought apples to the shelters. They asked the elderly if they would like to have an apple peeled. The girls sat next to the elderly person and started chatting while they peeled apples. Thus were they called "apple girls". The apple girls kept a daily log of the elderly at their shelter. The casework professor supervised the apple girls" friendly visits by providing written feedback through the daily log book for each shelter.

A group of theology professors visited shelters by bicycle with a drip coffee maker and real china coffee cups. They opened the coffee shop called "Shalom" and sat down with and listened to housewives, unemployed, and elderly survivors while offering free cups of coffee. The theology professors responded that their customers" worries about stress response symptoms such as high arousal, irritation, sleeplessness and fatigue were quite normal responses to abnormal situations. Even psycho-physiological symptoms were explained as "the body's wise reaction" to cope with an imbalance between person and environment. They attempted to normalize people's reactions to the disaster and helped them to arrive at a more positive reappraisal of their person-situation configuration.

What the Center emphasized during the development phase for the vulnerable populations was not "psychological care" but rather focusing on the positive and healthy functioning of each survivor. Even symptoms were reframed as a way to cope with stress and maintain some level of person-environment balance. In order to cope better with stress, exploration and acknowledgment of available resources were encouraged. The utilization of internal and external resources empowered the victims to take a more active role in deciding courses of action in their lives.

Ending phase: preparing for re-entry

The ending phase was characterized by further decline in the number of relief volunteers, fatigue and internal conflict. The difference in views of what the Center could offer to the earthquake survivors produced conflicts among the Center staff members. The internal conflict developed to a level of factional power struggles and one group of student volunteers demanded that the Center expand its services to such areas as Higashinada and Nagata ward of Kobe, where the earthquake damage was more severe and the emergency phase type of manpower, relief supplies and food mobilization were still in great need. This particular group dared to transport relief materials in the middle of the night despite the advice of the Center managers not to do so because of manpower shortages and the foreseeable burn-out of the few remaining dedicated volunteers.

In retrospect, the cause of the conflict was the Center's failure to project when and under what circumstances it would finish its operation. The Center managers defined its role as a crisis response group at its inception in January. However, the time-limited nature of crisis response work was not fully recognized until the ending phase. Because of this, a decline of manpower was felt, somehow, to be a failure in the Center's mandate and thus, factional activities began in order to restore the Center's momentum.

The Center manager/professors asserted the importance of entire staff meetings and encouraged open communication at the meetings. These formal meetings institutionalized the democracy of the Center operation and various opinions were shared concerning the Center's course of action. The formal staff meetings revealed clear differences in opinion but at the same time made it unnecessary to covertly protest the Center's decision-making process by ignoring the chain of command, sabotaging other group projects, or other passive-aggressive reactions. The formal staff meetings provided a forum for irrational and emotional outbursts and enabled the meeting participants to reflect on the need to draw the Center's activities to a close and re-enter their own post-quake realities.

POST-CRISIS RESPONSE

The Kwansei Gakuin University Relief Volunteer Center closed its activities as of April 15, 1995. The Center has been granted a new mandate since then and its name has become the Kwansei Gakuin Human Service Center. The Center's new mandate includes 1) management of student volunteer activities, 2) education and promotion of volunteerism on campus, and 3) research on a) disaster relief for the earthquake victims and, b) on volunteerism. In June 1995, with help from the American Jewish World Service, the Center organized a workshop on post-traumatic stress management. 24 helping professionals including medical doctors, public health nurses, social workers, clinical psychologists, and volunteer managers participated in this 7 day overnight workshop. Dr. Robert J. Lifton of New York City University outlined the psychology of disaster victims citing his works about atomic bomb survivors in Hiroshima and holocaust survivors (Lifton, 1967; Lifton & Mitchell, 1995). Dr. Reuven Gal of Carmel Institute in Israel presented an integrated framework based on Lazarus's stress and coping model (Lazarus & Folkman, 1982) and on an Israel-based coping style model (Lahad & Cohen, 1989). Dr. and Mrs. Gal introduced several stress management techniques such as the Critical Incident Stress Debriefing, Relaxation, Scribble Therapy, Movement Therapy, and Biblio Therapy (Gal, 1995). The Center further helped to organize three more workshops sponsored by the Japanese Organization for Crisis Response (JOCR) from March 1996 to March 1997.

Utilizing knowledge, skills and the personal network gained from the first workshop, the author participated in community-based debriefing group work projects organized by the Kobe City Child Guidance Clinic from November 1995 to March 1996. The project aimed at mothers of preschool age children. A team consisting of a social worker, a clinical psychologist and a psychiatrist instigated an out-reach program to local preschools. The program started with a public lecture on stress and coping, followed by the participation of the audience in the "six piece story" technique. The six pieces of the story consist of 1) a main character, 2) a mission, 3) a thing or person that will assist in the accomplishing of the mission, 4) an obstacle, 5) a means to overcome the obstacle, and 6) an ending. This is a projective technique to identify individual coping styles based on Lahad and Cohen's BASIC-Ph (Belief, Affect, Social, Imagination, Cognition, and Physical) model. Lehad and Cohen (1989) suggest that the most favored coping resources were projected to each individual's story writing. The story writing exercise and scoring of coping styles helped to reveal the strength and positive resources that each preschool mother mobilized in order to alleviate the impact of disaster-related stressors. Debriefing group work followed the six piece story exercise. During the debriefing session, information concerning the coping styles was explained as evidence of each participant's strength and healthy functioning. Thus, this debriefing group work not only ventilated the participants' affect and provided psychoeducation regarding stress responses, but also facilitated the positive reappraisal of the situation and the self.

The Kobe Mother-Child Stress-Coping Research (Noguchi, Tsubokura, Taniguchi, & Tatsuki, 1997;  Tsubokura, Noguchi, Taniguchi, & Tatsuki, 1997) was conducted during the same period as the debriefing group work project. This study examined the impact of the Great Hanshin Earthquake on preschool children and their mothers, and the way the families coped with traumatic stress. 445 mothers of preschool children residing in the area heavily hit by the earthquake responded to the questionnaire. The instruments include the DSM-IV based the Children's Stress Symptom Scale, a Japanese translation of the Impact of Event Scale (Horowitz, Wilner, & Alvarez, 1979), the Family Adaptability and Cohesion Evaluation Scale at Kwansei Gakuin version 3 (Tatsuki, 1993), and the Post-Earthquake Daily Hardship Scale. Three times as many PTSD symptom scale outliers (i.e., extremely high scores suggesting immediate clinical intervention) were found among mothers (8.2 %) as compared with children (2.5%).

Structural equation modeling techniques identified that 1) hardships caused by the earthquake damage were responsible for an increase in mothers' psychological stress, which in turn caused a higher stress reaction among their children; 2) mothers reacted to the hardships by empowering internal and external resources of their own but those empowered resources were used solely to alleviate their children's stress level; 3) the family adaptability balance alleviated the children's stress.

*) Acknowledgment

The Kobe Mother-Child Stress-Coping Research, which was supported by a grant from the Asahi Glass Foundation for the year of 1996 to the author, was conducted with adminstrative assistance from the Kobe Child Guidance Clinic. Their help  was most appreciated. Mr. Keiji Noguchi, a graduate student at the time of the research, was involved with the questionnaire design, administration, data entry, and data analyses towards the completion of his masters thesis under the supervision of the current author.

References

Gal, R. (1995). Trip Report: Training Workshop for Japanese Mental-Health Professionals in Kobe, Japan - June, 1995. Carmel Institute for Social Studies, Zikhron Yaakov, Israel.

Horowitz, M., Wilner, N., & Alvarez, W.(1979). Impact of Event Scale: A Measure of Subjective Stress. Psychosomatic Medicine, 41(3), 209-218.

Lahad, M., & Cohen, A.(1989). BASIC-Ph: The Study of Coping Resources. In M. Lehad (Ed.) Community Stress Prevention, Vol. 2. Kiryat Shmona, Israel: Center For Emergency.

Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. NY: Springer

Lifton, R. J. (1967). Death in life: Survivors of Hiroshima. NY: Random House.

Lifton, R. J., & Mitchell, G. (1995). Hiroshima in America: Fifty years of denial. NY: G. P. Putnam's Sons.

Noguchi, K., Tsubokura, Y., Taniguchi, H., & Tatsuki, S. (1997). A Family centered eco-system model of traumatic stress and coping I: Structural equation modeling on stress and coping, Kwansei Gakuin University Department of Sociology Studies, 76, 101-115

Tatsuki, S. (1993). The construct validity of the Circumplex Model of marital and family systems(VII): Confirmatory factor analytic inter- and intra-cultural cross validation, Kwansei Gakuin Sociology Department Studies, 66, 143-165.

Tsubokura, Y., Noguchi, K., Taniguchi, H., & Tatsuki, S. (1997). A Family centered eco-system model of traumatic stress and copingII: Qualitative analysis of free-romatted responses, Kwansei Gakuin University Department of Sociology Studies, 76, 117-131