and Rita. Among participants, 47% scored at or above the clinical level for depression, with 6% ... have been used to describe the stress of work- ing with trauma ...
MENTAL HEALTH, SUBSTANCE USE, AND ADAPTIVE COPING AMONG SOCIAL WORK STUDENTS IN THE AFTERMATH OF HURRICANES KATRINA AND RITA
Catiierine M. Lemieux
Cassandra E. Simon
Louisiana State University
University of Aiabama
Caroi A. Piummer
Amy L. Ai
Louisiana State University
University of Pittsburgh
Rosiyn Riciiardson Southern University and A&iVI Coliege
The current study examined mental health symptomology, substance use, and adaptive coping among 416 social work students following Hurricanes Katrina and Rita. Among participants, 47% scored at or above the clinical level for depression, with 6% of students showing clinical PTSD-like symptoms, and 16.9% reporting substance use. Two thirds (66.9%) employed 8 of the 10 adapfive coping responses. Negafive cognifive and emofional reacfions to the hurricanes correlated posifively with mental health symptomology and 7 of the 10 adaptive coping responses. In the aftermath of a natural disaster, it is crifical to provide students with education, information, and close supervision to address issues around impairment and vulnerability and to maximize resilience.
IN THE FALL OF 2005, Hurricanes Katrina and Rita brought about an unprecedented catastrophe to the entire Gulf Coast. During the months of August and September, 470 shelters and evacuation centers were established across the United States for survivors. Professional and lay volunteers served the medical and mental health needs of 386,000 evacuees, providing care for depression, anxiety, and posttraumafic stress disorder (PTSD)
(American Red Cross, 2005). In the midst of intensified needs, students at local universities volunteered a broad array of services for evacuees. Plummer et al. (2008) described volunteerism among graduate and undergraduate students, many of whom were relocated evacuees themselves and had experienced numerous losses. Despite great personal distress, students demonstrated high levels of altruistic emotions and behaviors. The current
Journal of Social Work Education, Vol. 46, No. 3 (Fall 2010). ©2010, Council on Social Work Education, Inc. All rights reserved. DOI: 10.5175/JSWE.2010.200900004
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JOURNAL OF SOCIAL WORK EDUCATION
descriptive study examined social work students in the aftermath of Hurricanes Katrina and Rita (H-KR), with specific emphasis on personal traits and characteristics, mental health symptomology, substance use, and adaptive coping.
Creamer & Liddle, 2005), including the experiences and perspectives of students (e.g.. Ai, Evans-Campbell, Santangelo, & Cascio, 2006). Stress and Coping Among Students
The impact of stress on graduate students and on those entering the helping professions has been investigated, with evidence suggesting that disciplines that combine coursework with a clinical internship evoke more stress than do traditional graduate programs. The nursing profession, for example, describes methods to reduce student anxiety and stress levels specifically (Kushnir, Malkinson, & Ribak, 1998). Poison and Nida (1998) found that the clinical training component was an additional source of stress for psychology and counselor education students. Tobin and Carson's (1994) study of undergraduate social work students revealed high levels of psychological distress related to the demands of coursework and field education. Pottage and Huxley's (1996) research comparing graduate-level social work students with practitioners in mental health settings showed that the students experienced greater levels of stress than did the employed professionals. Home's (1997) Researchers also have developed a subresearch with female social work students stantial body of knowledge about the psychofound elevated levels of stress among women logical distress experienced by providers who reporting higher perceived role demands, care for traumatized clients (Bride, 2007; lower income, and low levels of social supFigley, 2002; Stamm, 2002). Different terms port. After developing and testing a successful have been used to describe the stress of working with trauma survivors: compassion fatigue, stress management seminar for undergraduvicarious traumatization, and secondary traumat- ate social work students, Dziegielewski, Turnage, and Roest-Marti (2004) concluded ic stress 0enkins & Baird, 2002). In recent that the paucity of research on stress and years, there has been heightened scholarly burnout prevention among students in the interest in how mental health responders are helping professions is striking in light of the affected by disasters (e.g., Adams, Boscarino, demonstrated need for such interventions. & Figley, 2006; Akin-Littie & Little, 2008; The past two decades have witnessed a proliferation of research on interpersonal violence and other traumatic events and the concomitant development of mental health interventions targeting the posttraumatic health and well-being of survivors (Feldner, Monson, & Friedman, 2007). Recent global events, such as the September 11, 2001 (9/11) terrorist attacks, catastrophic natural disasters, and U.S. involvement in combat overseas, have not only sharpened popular interest in such issues but also have challenged researchers to clarify the relationship between the experience of trauma and the development of PTSD. In addition, researchers currently are employing a dual focus that counterbalances the prevailing emphasis on PTSD pathology with equal attention to resilience and posttraumatic adaptation (Ai & Park, 2005; Pfefferbaum et al., 2008).
MENTAL HEALTH, SUBSTANCE USE, ADAPTIVE COPING
393
Research conducted by Ai and colleagues
The percepfions and training needs of stu-
with 457 social work students following the
dents about the 9/11 disaster also have been a
9/11 terrorist attacks examined interrelation-
topic of research interest. Matthieu and col-
ships among mental health symptoms, life
leagues conducted a needs assessment with 286
experiences, emotional reactions to the disas-
first-year social work students and 206 field
ter, and measures of resiliency. One study
supervisors in New York City. One study exam-
showed that hope, faith, and spirituality con-
ined students' and supervisors' percepfions of
tributed to lower levels of depression and
the school's disaster response one month after
anxiety (Ai, Cascio, Santengelo, & Evans-
the attacks (Matthieu, Lewis, Ivanoff, & Conroy,
Campbell, 2005). Another study found that
2007). Results were mixed: Some students want-
prayer and distress were mediated by faith
ed normal school routines, whue others found
and posifive attitudes (Ai, Tice, Peterson, &
group discussion beneficial, and some field in-
Huang, 2005). Drawing on research invesfi-
structors felt supported whereas others felt un-
gafing the impact of anfi-state terrorism on
derufilized. An addifional longitudinal study
cifizens. Ai and Evans-Campbell (2006) ex-
used students' narrafive responses at 1 month
plored students' sociopolitical reactions to
(n=286) and at 6 months out (n=135) to examine
9/11. Results showed diverse patterns of
postdisaster needs and impact on fieldwork
responses, with the majority of the sample in-
(Matthieu, Conroy, Lewis, Ivanoff, & Black-
dicating that two types of acfions were war-
more, 2007). Results showed that almost half of
ranted in response to the attacks: faith and
students' field agencies were closed, rendering
community-oriented responses, and under-
clients inaccessible. Although students reported
standing and global peace-oriented responses.
mental stress and doubts about their ability to
This latter research is one of only a few stud-
help traumafized clients, most returned to work
ies that have addressed the impact of anti-
the next day. Six months later, the majority of
state terrorism on political reactions. A final
field sites were no longer affected and the need
study showed that PTSD symptoms were
for training in debriefing and trauma work
associated with personal loss and exposure to
decreased (Matthieu, Conroy, et al., 2007).
past trauma (Ai et al., 2006).
Research invesfigafing students' reacfions
Tosone et al.'s (2003) article describes the
to and coping with serious natural disaster is
collective refiections of a class of 19 MSW stu-
sparse. A recent report from the H-KR disaster
dents who were in close proximity to the New
area (Plummer et al., 2008) examined volun-
York City disaster site. Analysis of students'
teer acfivifies and predictors of volunteerism
refiective comments indicated that their inifial
among social work students. Results showed
reacfions were best understood in the context
that 97% of students volunteered, despite ex-
of secondary traumafic stress. Tosone et al.
periencing a wide range of disaster-related
(2003) concluded that students' realizafions
Stressors. The strongest predictors of height-
that their lives would be permanently altered
ened volunteerism included Stressors, in-
by the experience presented a unique oppor-
creased commitment to social work values,
tunity for posttraumafic growth.
and altruism (Plummer et al., 2008).
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JOURNAL OF SOCIAL WORK EDUCATION
Coping and Coping Responses: Theoreticai Moorings
(Calhoun, Cann, Tedeschi, & McMillan, 2000). CSDT posits that examining both adaptive and less adaptive coping responses is essential for
Nilsson (2007) systematically reviewed differ-
understanding the process of adjustment during
ent theories of stress-related coping and con-
the aftermath of a traumatic event.
cluded that environmental, cognitive, and tance when examining coping during times of
Summary and Impiications of Literature Review
trauma. The emphasis on both internal states
Students who also are victims during times of
and the actual event is consistent with the work
catastrophe experience, to varying degrees,
of Lazarus (1991, 2000), who has conducted
the psychosocial Stressors and distress that
ongoing research in the areas of stress, apprais-
affect all residents in the disaster area. Because
al, and coping for more than 40 years. The cen-
of their presumably limited knowledge and
tral theory that guides the current study is con-
skill set, such students compose a unique sub-
experiential factors are of paramount impor-
structivist self-development theory (CSDT),
population of professional caregivers that is
which has been used to explain coping in rela-
particularly vulnerable to additional Stressors.
tion to secondary traumatic stress (McCann,
Thus, how students cope with disasters is an
Sakheim, & Abramson, 1988). Similar to the
important professional development issue
person-centered conceptualization proposed
that has implications for both education and
by Lazarus (2006), CSDT emphasizes cognitive,
practice. Research on social work students'
cultural, social, and environmental factors.
reactions to and coping with terrorism sug-
Additionally, CSDT views coping strategies as
gests that disasters and their aftermath pres-
either adaptive or maladaptive. For example,
ent a major challenge, as well as unique
coping strategies that involve problem solving
opportunities for growth (Ai & Park, 2005).
and acceptance are seen as positive, whereas
The current study examines the prevalence of
those characterized by denial and disengage-
PTSD-like symptoms, depression (Ai et al.,
ment are considered potentially dysfunctional
2006), and substance use, which is included
(McCann & Pearlman, 1990).
because of its demonstrated high comorbidity
Standardized measures of coping such as
with PTSD among clinical
populations
the Ways of Coping (Folkman & Lazarus, 1985)
(Chilcoat & Breslau, 1998) and among com-
and the COPE Inventory (Carver, 1997; Carver,
munity
Scheier, & Weintraub, 1989) typically assess both
(Vlahov, Galea, Ahem, Resnick, & Kilpatrick,
adaptive and maladaptive coping responses.
2004; Wu et al., 2006). Ai and Evans-Campbell
residents
exposed
to
disasters
Better mental health outcomes are associated
(2006) examined religious, but not secular
with adaptive coping responses (e.g., problem
forms of coping with 9/11; therefore, adaptive
solving, support seeking, and use of religion)
coping also is examined. The current study
whereas heightened symptomology is associat-
assesses students' emotional reactions to the
ed with more avoidant strategies (e.g., with-
disaster, students' previous traumatic experi-
drawal, self-blame, and excessive rumination)
ences (Ai et al., 2006), disaster-related stres-
MENTAL HEALTH, SUBSTANCE USE, ADAPTIVE COPING sors, and students' negative reactions (Ai, Cascio, et al., 2005). Because the ensuing ineffectual and problematic community response to Hurricane Katrina was viewed worldwide, the current study sought to assess participants' political reactions to the disaster response efforts (Ai & Evans-Campbell, 2006). Altruistic behaviors and emotions (Plummer et al., 2008), optimism, spirituality (Ai, Tice, et aL, 2005), and field internship status (Baum, 2004; Matthieu, Conroy, et al., 2007) are also described. The current study is framed by the following research questions: 1.
To what extent did students experience hurricane-related Stressors and negative reactions to H-KR? 2. To what extent did students report previous traumatic experiences? 3. What emotional and sociopolitical reactions to H-KR did students experience? 4. What is the level of volunteerism, altruism, optimism, and spiritual support reported by students? 5. What is the level of post-H-KR depression, PTSD-like symptoms, and substance use reported by students? 6. To what extent did students employ adaptive coping responses to H-KR? 7. To what extent do the major variables of interest correlate with mental health, substance use, and adaptive coping? Metiiods Respondents Social work students recruited from four universities in disaster-affected areas composed the combined sample (N=416). The majority of
395
the sample was female (88.9%) and African American (60.8%). The mean age was 29.43 (SD=9.43) years. The combined sample included undergraduate (40.9%) and graduate stiidents (59.1%). Among participants, 11.3% were transferred from institutions in areas directly affected by H-KR. Just under half (47.3%) were enrolled in field education. Procedure The questionnaire survey was administered to participants enrolled in four public imiversities in the Gulf Coast area during the 2005 fall semester, approximately 3 months after H-KR. Posters, e-mails, and direct faculty contact were used to encourage participation. Researchers at each site distributed a package containing an informed consent letter, the consent form, the survey, and a return envelope. The human subjects review boards of participating universities approved the documents. The consent letter emphasized voluntary participation, freedom to withdraw from the study, and confidentiality, which included a description of the additional protections afforded by the federal Certificate of Confidenfiality that was obtained for the study. The four subsets of data were aggregated and analyzed at one site. Measures Demographics and internship status. Age, race,
gender, and enrollment in field education were considered as potentially important variables. Race, gender, and field were dichotomized (African American=O, White=l; Male=O, Female=l; No=0, Yes=l). Spiritual support. Spiritual support was measured with the 12-item Spiritual Support
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JOURNAL OF SOCIAL WORK EDUCATION
Scale (SSS; Ai, Tice, et al., 2005), assessing various spiritual relationships (e.g., I have been inspired by my religious or spiritual faith in the face of distress). Respondents were permitted to replace the term God with the higher power in their spiritual or religious faith or belief (e,g., the divine, a higher power, Buddha), Response options ranged from 1 (strongly agree) to 4 (strongly disagree) concerning each statement during the time following H-KR, Cronbach's alpha for the SSS was ,96, Altruism. Altruism was measured with the 20-item Self-Report Altruism Scale (Rushton, Chrisjohn, & Fekken, 1981), assessing the extent to which respondents had ever engaged in different types of altruistic behaviors or actions (e,g., giving money to charity, donating blood, volunteering). Participants recorded their response to each statement using a four-level scale (O=Never, 4=Very often; a=.97). Optimism. The eight-item Life Orientation Test (LOT; Scheier & Carver, 1985, 1992) was used to measure optimism. Using a five-level scale (0=Strongly disagree, 4=Strongly agree; a=.75), participants stated how they felt about each item during the past month (e.g.. In uncertain times, I usually expect the best; I always look on the bright side of things; Things never work out the way I want them), Peritraumatic emotional responses. Partici-
pants' initial emotional reactions to H-KR were measured with the 12-item Types of Peritraumatic Emotional Responses checklist, originally developed for Ai, Cascio, et al.'s (2005) 9/11 study, with a contextual modification. Using afive-levelscale (l=Not at all, 5=A great deal), respondents indicated the extent
to which they experienced 12 types of emotional reactions (e.g., horror/shock, anger/ hatred, fear/anxiety/worry, sympathy for victims and their families, admiration for the first responders, gratitude for the nationwide support) and an additional "Other" item during the month following H-KR. As factored in Ai, Cascio, et al.'s (2005) study, the first five items were summed up as negafive emotional responses and the remaining seven constituted positive emotional responses. Cronbach's alpha for both subscales was ,82, Total volunteer activities. Volunteer activi-
ties were measured with a 16-item checklist developed by the researchers that contained common tasks and activities accomplished by volunteers prior to, during, and following HKR. Participants checked the items for which they volunteered any amount of time (e.g., donated money or food, worked in a shelter, counseled victims, rescued victims). A total volunteer activities score was computed by summing the number of activities undertaken by each participant. Sociopolitical reactions. Participants' socio-
political reactions to the Hurricane Katrina ineffectual/problematic response effort were measured with the 10-item Sociopolitical Reactions to Attacks of International Terrorism, originally developed by Ai and EvansCampbell (2006) with a contextual modificafion. Using response opfions ranging from 1 (Not at all) to 5 (A great deal), respondents indicated their agreement with statements about factors that contributed to the ineffectual/problemafic response to Hurricane Katrina (e.g,, poor planning prior to the storm, racism, poverty and social inequality, ineffecfive leadership), Cronbach's alpha was .78.
MENTAL HEALTH, SUBSTANCE USE, ADAPTIVE COPING
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Hurricane-related Stressors. Respondents
about family members, worry about school-
indicated the Stressors they experienced in the
work), emofional (e.g., mood swings, tearful-
month following H-KR using an 18-item check-
ness, anger about media misinformation,
list developed by the researchers, which includ-
weary of hearing sad stories), and other types
ed common Stressors experienced in various
(e.g., physical health problems, interpersonal
domains of living. Stressors ranged from the
difficulties)
moderate (e.g., experiencing food and gasoline
checked on the list were summed to create a
of negative reactions. Items
shortages, being an evacuee for less than a
composite score of negative reactions to H-KR.
week, experiencing problems contacting loved
Mental health. Mental health consisted of
ones) to the more severe (e.g., experiencing los-
two indicators, depression and posttraumatic
ing personal property, separation from pets,
stress disorder-like (PTSD-like) symptoms.
being an evacuee for a week or more). Items
Depression was measured with the widely
checked on the list were summed to create a
used 20-item Center for Epidemiological
composite score of hurricane-related stiessors.
Studies-Depression Scale (CES-D; Radloff,
Previous traumatic experiences. This con-
1977). Using response options ranging from 0
struct was measured with a seven-item list
(Rarely or none of the time,
