Journal of Interprofessional Care

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Experiences in disaster-related mental health

relief work: An exploratory model for the
interprofessional training of psychological relief
workers

ZhengJia Ren, HongTao Wang & Wei Zhang

To cite this article: ZhengJia Ren, HongTao Wang & Wei Zhang (2016): Experiences in
disaster-related mental health relief work: An exploratory model for the interprofessional
training of psychological relief workers, Journal of Interprofessional Care, DOI:
10.1080/13561820.2016.1233097

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Published online: 18 Nov 2016.

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JOURNAL OF INTERPROFESSIONAL CARE
http://dx.doi.org/10.1080/13561820.2016.1233097

ORIGINAL ARTICLE

Experiences in disaster-related mental health relief work: An exploratory model for

the interprofessional training of psychological relief workers
ZhengJia Rena, HongTao Wangb, and Wei Zhanga
a
Mental Health Center, West China School of Medicine/West China Hospital, Sichuan University, Chengdu, China; bDepartment of Burns and
Cutaneous Surgery, Burn Centre of PLA, Xijing Hospital, Fourth Military Medical University, Xi’an, China

ABSTRACT ARTICLE HISTORY

The purpose of this study was to begin to generate an exploratory model of the disaster-related mental Received 10 November 2015
health education process associated with the training experiences of psychological relief workers active Revised 20 June 2016
during the Sichuan earthquake in China. The data consisted of semi-structured interviews with 20 Accepted 2 September 2016
psychological relief workers from four different professions (social workers, psychiatric nurses, psychia- KEYWORDS
trists, and counsellors) regarding their experiences in training and ideas for improvement. The model Disaster management;
explains the need to use a people-centred community interprofessional education approach, which interprofessional education;
focuses on role-modelling of the trainer, caring for relief workers, paying attention to the needs of the psychological services;
trainee, and building systematic interprofessional education strategies. The proposed model identifies qualitative research
areas for the comprehensive training of relief workers and aims to address the importance of people-
centred mental health service provisions, ensure intentional and strategic training of relief workers using
interprofessional concepts and strategies, and use culturally attuned and community-informed strate-
gies in mental health training practices.

Introduction different from many Eastern traditional cultures, such as

those in rural China, which relate more to interpersonal
On 12 May 2008, an earthquake with a magnitude of 8.0
interdependence (Markus & Kitayama, 1991) and have their
struck Wenchuan in Sichuan province, China, leaving 87,476
own common language, customs, belief systems, and cultural
dead and 374,643 injured (McClean, 2010). The large-scale
resilience, including resources for coping with disasters, loss,
devastation of the affected populations resulted in an urgent
illness, and grief, which are undervalued and unappreciated
need for mental health services (Chan, 2008). Currently, in
(Chiang, Lu, & Wear, 2005). Western popular individualized
Sichuan province there are only 1.24–1.54 psychiatrists per
psychotherapy was even stigmatized and treated as alien in
100,000 people and 1.91–2.65 licensed psychiatric nurses per
the communities affected by the disaster (Keats & Wang,
100,000 population (Liu et al., 2013; Mathers, Fat, & Boerma,
2013; Ren, 2009). Moreover, most of the training was found
2008). Additionally, the services provided by psychologists,
to focus on the spread of knowledge, attitudes, and helping
psychological counsellors, and social workers are new to
behaviours; this approach was focused on the short-term and
China; these services were mostly unavailable before the
lacked follow-up, supervision, and sensitivity to relief workers
earthquake. A number of studies have recommended that
and their own chronic fatigue and emotional disturbances
interprofessional collaboration is at the core of ‘best practices’
(Ng et al., 2009; Yan, Turale, Stone, & Petrini, 2015). Until
for patient care and can significantly improve patient out-
now, the training needs and training experiences of long-term
comes (Pechacek et al., 2015; Tierney & Vallis, 1999).
psychological relief workers who provide disaster-related
However, most professionals are poorly trained to and ill
mental health services have been largely unknown. This qua-
prepared for collaboration in China, as most of their training
litative research study was designed to explore relief workers’
is primarily hospital-based, institutionalization-oriented, bio-
training experiences in depth, as these experiences are infor-
medical, and single-profession focused; comprehensive and
mative for developing comprehensive, collaborative, and cul-
collaborative mental health training has long been neglected
turally sensitive disaster-related mental health training
in the psychiatric and psychological training curriculum in
programmes.
this country (Gao et al., 2010).
Additionally, a large proportion of the disaster-related
psychological intervention techniques and practices used in Methods
Sichuan were created and previously used in Western cultures
We utilized a qualitative research design with tenets from
that gravitate towards individualism. This is fundamentally
grounded theory for this study; the grounded theory approach

CONTACT Wei Zhang or HongTao Wang weizhang27@163.com; wanght@fmmu.edu.cn Mental Health Center, West China School of Medicine and West
China Hospital, Sichuan University, #28 Dian Xin Nan Jie, Chengdu, Sichuan 610041, China; Department of Burns and Cutaneous Surgery, Burn Centre of PLA, Xijing
Hospital, Fourth Military Medical University, No. 169, Changle West Road, Xi’an, Shanxi 710032, China.
Colour versions of one or more figures in the article can be found online at http://www.tandfonline.com/ijic.
© 2016 Taylor & Francis
2 Z. REN ET AL.
is an inductive method of qualitative research that involves
analysis of social interactions or experiences, and the research
aim is to develop a theory from the ground up (Corbin &
Strauss, 1990). Grounded theory uses a recursive process of
data collection, data coding, comparative analysis, and theo-
retical sampling of phrases until theoretical saturation has
been reached (Corbin & Strauss, 1990; Thai, Chong, &
Agrawal, 2012).
Participants and sampling
Twenty participants who had been working in disaster set-
tings and had been trained in disaster-related mental health
services by various organizations (e.g., universities, hospitals,
non-governmental organizations, and psychological consulta-
tion programmes) were recruited. We purposely recruited
psychiatrists, psychiatric nurses, psychological counsellors,
and social workers who had been routinely trained for service.
First, we used a selective sampling strategy aimed at phenom-
enological variation; we then proceeded to use theoretical
sampling. The average period of time the participants spent
working in the earthquake psychological relief zone was
47.7 months (24–75 months), and the average number of
hours worked per week was 31.95 (6–60 hours).
Data collection
The authors conducted semi-structured interviews in Chinese.
Each was digitally recorded and ranged from 60 to 90 minutes
in length. The questions that were initially part of the inter-
view included the following: how well did your training for
work in the disaster areas prepare you for providing disaster-
related mental health services; what parts of the training were
helpful; which parts did you not find especially relevant; and
what advice can you provide to guide future mental health
disaster trainers? All interviews were transcribed verbatim.
Field notes were written at the completion of each interview
for future data analysis. Data collection continued until theo-
retical saturation was achieved.
Data analysis
The first two authors performed line-by-line coding and
used both inductive and deductive processes that involved
going back and forth between the data and emerging
codes, categories, and themes to generate a thematic cod-
ing framework. First, categories were abstracted through
constant comparisons among cases, instances, and codes.
Then, axial coding was explored by putting the data back
together in a new way and constantly comparing cases,
instances, and codes to identify relationships between the
different categories of conceptual properties and dimen-
sions; the categories were studied in terms of their con-
texts, consequences, causes, conditions, covariance, and
contingents (Backman & Kyngas, 1999). Lastly, selective
coding was initiated to integrate the different categories
into a core variable to build a model. The three coding
processes mentioned above were recursive and complete
only when we reached theoretical saturation (Thai et al.,
2012).
Quotations, field notes, and memos regarding each topic
were integrated and evaluated to illustrate processes and pat-
terns identified within the categories and to formulate emer-
gent theoretical constructs. Memos written at the beginning of
the research, which were used to maintain a record of emer-
ging ideas related to data collection, sampling, and analysis,
were eventually used as the analytical building blocks from
which the new model was developed. The rigor of the study
was maintained via member checks, peer checks, and expert
checks.
Ethical considerations
Ethics Committee of West China Hospital, Sichuan
University, and verbal and written consent was obtained
from all study participants.
Results
This section initially presents details of the following themes
generated from the analysis: ‘role-modelling of the trainer’,
‘needs based training’, ‘caring for relief workers’, and ‘building
systematic interprofessional education strategies’. The section
then presents the model developed from these analysed data.
Role-modelling of the trainer
The data indicated that role-modelling was a favoured style
used extensively by participants. It has been widely acknowl-
edged by relief workers that it is important to obtain informa-
tion from the trainers; however, the trainees’ morals, attitudes,
and behaviours were more strongly influenced by the tea-
cher’s behaviour and attitude than by what he or she said.
As indicated in the following quote:
It is the trainers’ attitudes that matter more, especially attitudes
towards disaster survivors and their trainees . . . What they can
really influence is a person’s attitude. They [the attitudes] are
more important than the teacher’s professional knowledge or
practical experiences . . . that part deeply influenced my disaster
relief work. (P15, psychiatric nurse)
As relationships grow between relief workers and trainers,
it was found that the behaviour of influential role models
shaped the behaviour of trainees through their interactions
during the training process:
At the beginning of the disaster, many trainers came to provide
training for us, but several years later, just a few trainers still stand
beside me . . . Without their professional and emotional support, I
couldn’t have kept going for so many years. This is what I learned
from my trainer, so I accompanied many survivors and their
suffering. . . (P18, psychiatrist)
Indeed, most relief workers stated that professional ten-
dencies and attitudes are the most valued thing and that they
can be learned through simply imitating their teachers.

Caring for relief workers
Working with traumatic emotions is part of the job of mental
health disaster services and can result in deep personal trans-
formation as reported by many relief workers. Interviewed
mental health disaster relief workers commonly reported
burnout, compassion fatigue, and secondary trauma:
During that period, I was struggling, upset, depressed, and angry.
I was stuck in a bad mood. . . In addition to professional training,
we also need care on the personal level. (P4, counsellor)
During that period, I knew several of my colleagues who took
SSRIs (selective serotonin reuptake inhibitors) to handle their
stress. You know it is too much; most of the job is to care for
disaster survivors, but the relief workers also need care, and the
training needs to take that part into consideration. (P18,
psychiatrist)
Taking care of mental health disaster relief workers is
extremely important. Without properly prepared and sup-
ported disaster relief workers, it was noted the disaster-related
mental health services will suffer:
Many relief workers quit disaster relief work because they neither
received enough supervision nor emotional support. (P12, social
worker)
Another participant stated the importance of caring for
relief workers:
When you did not have good psychological well-being while
doing this job, it was painful not only for yourself but also for
the survivors. . . There needs to be more training to care for
disaster mental health relievers’ mental health and wellness.
(P17, counsellor)
Many of the participants complained of burnout and other
psychosocial disturbances related to their relief work. Most of
the time, the participants could only try their best to comfort
themselves as well as the survivors. Their experiences expose a
common theme: training systems have not been developed to
adequately address relief workers’ wellness, and they lack
sensitivity to their psychological needs.
Needs-based training
The data suggested that needs-based training should be
designed to address the local and ongoing elements of disaster
relief work. Disaster-related mental health training pro-
grammes need to identify the specific needs of relief workers
in their clinical encounters and then design a course or
programme that addresses these specific needs:
My suggestion for future training of disaster relief workers is to
listen to the needs of front line workers. . . They encounter many
problems in their clinical encounters; knowing their difficulties
can help them to help survivors more effectively. (P9, social
worker)
More importantly, the data indicated that needs-based
training is grounded in local and professional knowledge
and should reflect the needs of survivors. After all, training
for future relief workers must also strongly relate to the needs
of the victims:
JOURNAL OF INTERPROFESSIONAL CARE 3
The training is supposed to train disaster relief workers to accom-
pany and support disaster survivors; this is what disaster survivors
need, right? Future disaster-related mental health training is not
training for a clinical or family psychologist. That is not the aim of
disaster-related mental health training. The training is to cultivate
a person who has a practical capability to help disaster survivors.
(P16, counsellor)
Building systematic strategies of interprofessional
education
The data suggested that interprofessional education needs to
involve knowing the roles and responsibilities of fellow relief
workers and enhance team efficiency across different profes-
sions to work well in complex situations. Disaster situations
are highly complex and the relief workers active in them
frequently requested training to better understand other pro-
fessional duties, responsibilities, and limitations and ethical
standards. Systematic interprofessional education can aid in
the response to local complex issues because such a collabora-
tive approach can facilitate a comprehensive understanding of
the local reality, whether that means bridging the gap between
theory and practice or reconciling local needs and interna-
tional guidelines. Interprofessional education strategies are
integrative, which underpins the process of developing colla-
borative competency and cultural sensitivity in community-
based disaster settings. These strategies include four interac-
tive and progressive processes: ‘regulation of training’,
‘enrichment of interprofessional cooperation’, ‘continuous
supervision’, and ‘empowerment of culturally informed
practices’.
Regulation of training
This element was used to maintain and monitor the quality of
training programme contents, standards, ethics, and code of
conduct at all levels. Relief workers were confronted with
many unregulated, one-time trainings. The workers recog-
nized that those short trainings did not sufficiently prepare
them to react to the challenges of emergency situations, but
instead caused more challenges and chaos:
It seems to me that they [the training programs] are just bom-
barding us. It looks like they are fighting for academic authority
. . . They fly in from different countries and feel like they need to
do something big here (5/12 Wenchuan Earthquake). It leads to
secondary trauma. It’s inhumane. . . We need to standardize the
training here. More chaos is not needed here. (P3, counsellor)
Many mental health disaster relief workers reported that
most of their training was conducted during short-term
courses and often lacked any follow-up, making it hard to
put what they learned into practice in their clinical
encounters:
We need comprehensive training. . . One of the big problems in
training is inconsistency. Every time you would have different
trainers, so you were confused about which one . . . to follow.
Different trainers tell you different approaches, and sometimes
those approaches even conflict with each other. (P6, counsellor)
Some relief workers claimed that some of their trainings
contradicted each other. They went on to say that some did
not work, and some even caused negative effects:
4 Z. REN ET AL.
Some trainers came to do two days of training, and then they’d
run away. You did not really get it, and you did not know how to
practice it. . . You saw many relief workers who worked in the
same way. They came to do several days worth of service, and
then they ran away. I believe this phenomenon was related to their
own training, which was inconsistent and fragmented. Their
training did not work, even worse, it may have caused negative
effects. . . (P7, counsellor)
Many relief workers mentioned the need to develop train-
ing regulations, with standards and regulations for both indi-
viduals and organizations to provide qualified training to
relief workers and avoid unnecessary, redundant, unscientific,
and harmful training.
Enriching interprofessional cooperation competencies
As previously stated, China has limited experience in provid-
ing disaster-related mental health services, and hence the
crisis of 5/12 overwhelmed the mental health services system.
Most mental health professionals were hospital-based and not
community-based. They were often single profession workers
who knew little about other relevant professions. Coming
together in the disaster zones prompted professionals to rea-
lize the importance of interprofessional cooperation. Indeed,
training can help many professionals transition from acute to
community-based care. One relief worker provided the fol-
lowing comment:
You cannot do the job by yourself or just with your team; instead,
we have to cooperate with different organizations because the
survivors have many needs. We have cooperated with hospitals,
communities, and the government. (P19, counsellor)
Many relief workers reported difficulties related to working
in a disaster setting. Especially in the rural disaster setting, an
ill-prepared mental health system makes it difficult for differ-
ent types of professionals to collaborate. Lack of collaboration
is inefficient, leads to overlapping roles, and contributes to
redundancy, which confuses situations and has a negative
impact on survivors:
In the beginning, many different teams came to provide services
to the disaster survivors. Sometimes, different relief workers
would give multiple interventions to the same survivor. In the
beginning, there was a lack of communication and cooperation
between different teams . . . The situation was a mess. (P2,
psychiatrist)
The capacity for interprofessional cooperation is essential
and requires training relief workers to cooperate with each
other and better understand which task each person can be
responsible for, to whom survivors with differing needs can be
referred, and when and where to cooperate with each other:
If I found a disaster survivor in need of psychiatric services, I first
obtained his consent and then contacted the psychiatrist; then, I
worked together with the psychiatrist, and I followed up with the
client to instruct him on how to take his medication. (P13,
psychiatric nurse)
I had worked in the hospital before. It was simple work. I just
prescribed drugs to my clients, I did not have any experience with
psych rehabilitation services and community services. Some train-
ing is really good . . . You can hear different opinions from the
training. (P2, psychiatrist)
The majority of relief workers stated a strong desire for
interprofessional training, which helped them work together,
learn about each other, and capitalize on individual profes-
sions’ strengths; learning about each other’s roles improves
mental healthcare.
Continuous supervision
Relief workers almost unanimously agreed that supervision is
a key part of the mental health disaster field. Most post-
disaster mental health training is inconsistent, impractical,
and unusable. Continuous supervision provides a chance for
trainers to facilitate learning and supervise trainees so that
they can be more efficient in their clinical settings and
become better acquainted with local situations. Supervisors
can also support trainees in their struggles and help build
deeper relationships:
You need to digest many things there. One is the negative feelings
sent from your patients. In the meantime, I myself suffer from
confusion about how to handle and balance the complicated
relationship between counsellor and patient. It involves frustra-
tion and disappointment as well as joy when a patient shows
improvement. After I talked with my supervisor, I felt like there
was nothing special between us from our talk, but I did feel more
relaxed afterwards. . . (P11, counsellor)
Many participants cited the importance of continuous
supervision of their clinical work:
In the past, I knew the theories behind the methods, but I was
confused in my clinical practice. [The trainer] taught me hands-
on how to practice, which I felt was quite helpful. (P13, psychia-
tric nurse)
When I report to my supervisor, I can not only learn about
practical techniques, but, most importantly, my supervisor can
tell me how I can improve. (P6, counsellor)
Supervision is of central importance, but most participants
reported a lack of supervisors, which made their work harder:
One of the common problems we encountered was a lack of
supervision. . . It’s undeniable that there were almost no super-
visors equipped with enough theory and practical experience.
(P12, social worker)
The aim of supervision is not only to support and help
relief workers to develop the necessary skills to become a
competent practitioner when doing fieldwork but also to
provide companionship and emotional support for them.
Empowering culturally informed practices
Relief workers revealed that most of the training they experi-
enced did not fit their setting. They felt confused about what
to do and how to provide mental health disaster-related
services; therefore, most of the time, the workers experienced
strong feelings of powerlessness. After they creatively worked
with disaster survivors, the relief workers suggested the
importance of culturally informed services:
Once, when we had a free clinic, we had a sign outside the clinic
that said Mental Health Service. No one came to us. Then, I
changed the sign to say Insomnia Clinic because I discovered
that many people had problems sleeping after the earthquake.
Then, people came to us one after another. (P18 psychiatrist)

Figure 1. People-centred community interprofessional training model.
The disaster setting is very different from the setting of our
regular mental health services. Many mental health profes-
sionals had to respond to survivors in culturally sensitive ways:
I am a psychologist, but in the disaster setting, I felt like a social
worker. I had to step into survivors’ families to provide services to
them or else they would never come to find help from you. Before
the disaster, they knew nothing about mental health and mental
health services. (P16, counsellor)
To provide culturally sensitive services, many disaster relief
workers found local resources to work with disaster survivors:
Neither of us had any experience with disaster-related mental
health services. . . We had to rely on our basic knowledge and
resources available in the affected areas. I was hesitant about this
before, but then I discovered that the locals could do embroidery,
so we developed an embroidery group. We performed psycholo-
gical therapy while embroidering. Now I really feel proud of my
idea. (P1, counsellor)
Developing empowering strategies through the training pro-
cess may be a means of helping relief workers recognize power-
lessness in difficult situations and take appropriate action.
Model development
As noted above, the above categories were used to develop an
exploratory model called the ‘people-centred community
interprofessional training model’ (see Figure 1).
This model identifies areas for the training of relief work-
ers and aims to address the importance of people-centred
mental health service provisions. It was also designed to
ensure intentional and strategic training of relief workers
using interprofessional concepts and strategies, using cultu-
rally attuned and community-informed strategies in mental
health training practices.
Discussion
Community-based disaster-related mental health services in
most developing countries do not have adequate resources to
JOURNAL OF INTERPROFESSIONAL CARE 5
respond to the care of earthquake survivors with noticeable
post-traumatic mental health disorders (Chan, 2008; Jia, Ying,
Zhou, Wu, & Lin, 2015). This limitation is primarily due to
the inadequacy of early training, which hinders the provision
of efficient and qualified mental healthcare.
Caring for caregivers, knowing the needs of the trainees and
survivors, and being aware of the importance of trainer role-
modelling are fundamental to ensuring further systematic stra-
tegies of interprofessional education. Inquiring as to their needs,
rather than relying on assumptions, helps identify the true needs
of trainees and local survivors, and this can help meet survivor,
trainee, family, and community healthcare needs optimally and
cost-effectively. The training institutions also have a responsi-
bility not only to be responsive to frontline workers’ training
needs but also to ensure that they can function in their clinical
work (Chastonay et al., 2015) Meanwhile, relief workers fre-
quently suffer from burnout and many other negative feelings,
which all usually lead to lower competence, more clinical errors,
and less motivation and a tendency to quit relief work
(Halbesleben & Rathert, 2008; Wilters, 1998). Thus, stress man-
agement, problem-solving methods, cognitive restructuring,
effective preventive measures, and various continuing psycho-
social coping strategies for reducing burnout are needed
(Fothergill, Edwards, & Burnard, 2004; Rudman & Gustavsson,
2012; Skodova & Lajciakova, 2013). Moreover, other scholars
suggest that providing practitioners with a better understanding
of their boundaries and limitations in their caregiving role helps
them to be mindful of their own psychological well-being and
find meaning in their work, which is necessary to avoid feeling
threatened and exhausted (Moody et al., 2013; Nancarrow, 2004;
Shanafelt, 2009). Indeed, training in self-preparedness may con-
tribute to better outcomes on a personal and organizational level
(Palm, Polusny, & Follette, 2004). Obviously, without proper
care for relief workers, we can have no disaster-related mental
health services, because without proper care for the workers,
there will be no one to provide frontline services.
Relief workers cannot simply rely on their skills and
instead must nurture trusting therapeutic relationships and
have a humanistic attitude. These necessary relationships and
6 Z. REN ET AL.
attitudes can be acquired from their trainers (Levine, 2015;
Wright, Wong, & Newill, 1997). The spirit of professionalism
and interprofessional teamwork is best learned specifically
through observation of role models (Byszewski, Hendelman,
McGuinty, & Moineau, 2011; Selle, Salamon, Boarman, &
Sauer, 2008). Relief workers identified the need for strong
positive role models in their learning environment, especially
in carrying out post-disaster services. The foundations of
disaster-related mental health education need to teach relief
workers to treat traumatized people as whole persons, worthy
of respect. That humanistic spirit and attitude is best con-
veyed by a role model, a teacher who the students perceive as
caring and who understands and gives weight to the needs
and voices of relief workers. This attitude is foundational in
any humanitarian service and deserves focus during the edu-
cational process (Marcus, 1999; Umbach & Wawrzynski,
2005).
As presented in Figure 1, this study identified four progres-
sive and interactive core elements. The first two elements are
consistent with the core competencies of the American
Association of Colleges of Nursing’s training strategies for inter-
professional collaborative practices, which emphasize the regu-
lation of ethical conduct and enriching interprofessional
cooperation competencies (Schmitt, Blue, Aschenbrener, &
Viggiano, 2011).
The first step is to build and effectively regulate training
content, which includes the quality of teachers, ethical guide-
lines, cultural-awareness, and empirical evidence standards
(Browne et al., 1995). Without well-planned trainings, we
can only bring about disorder and negative effects, which
may even harm survivors. The second step is to enrich inter-
professional cooperation and collaboration. These are impor-
tant due to the huge demand and short supply of
interprofessional collaborative practices in China. As a result,
interprofessional education has lagged dramatically behind its
practice, generating an urgent ‘gap’ in the response of mental
health teams to earthquakes. Many scholars have stated that
enriching interprofessional cooperation competencies has a
dynamic relationship with practice needs and practice
improvements and additionally increases trainee’s satisfaction
with learning and the overall training experience (Curran,
Sharpe, Flynn, & Button, 2010; Lumague et al., 2006). These
improvements lead to better teamwork, relationships with
patients, clinical skills, and professional identity as well as
fewer emotional disturbances and medical errors (Gould,
Lee, Berkowitz, & Bronstein, 2015; Korner et al., 2016;
Roberts & Kumar, 2015). To maintain the efficiency and
expertise of interprofessional cooperation competencies, con-
tinuous training and supervision is a key element of systema-
tic interprofessional education, which helps ensure that
knowledge becomes practice through long-term training and
clinical supervision. This approach can help students better
obtain professional skills, offer more effective services, and
reduce clinical mistakes (Begat, Ellefsen, & Severinsson, 2005;
Watkins Jr, 2011).
The final and most important step is to empower students
to take proper actions based on their local situations rather
than apply knowledge mechanically. Providing this service is
very complicated; China has a parable from 2,000 years ago
that states ‘Sweet orange seeds of one orchard grow bitter in
another’. This parable implies that a mechanical application of
foreign methodology cannot solve problems locally and may
even sometimes cause negative effects. Empowering culturally
informed practices involves treating human beings with an
integrity and promoting the use of social cultural resources of
the people we serve (Shearer, 2009). Specifically, empower-
ment requires the relief workers to recognize that any disaster
mental health service will focus not only on the use of the
disaster survivor’s personal resources such as self-capacity, but
also on their social cultural resources such as community
support individuals, networks, agencies, and cultural
resources. From this perspective, empowerment is a dynamic
process focused on purposefully participating in a process of
changing, improving, or integrating oneself and one’s envir-
onment (Shearer, 2009), which can ensure the cultural con-
tinuity and harmonize the mental, spiritual, emotional, and
physical well-being of the cultural unit and its environment
(Armstrong, 1987; Gauthier & Matteson, 1995; McConaghy,
2000).
There is limited evidence regarding the optimal way for trai-
ners to provide training to trainees in mental health disaster
situations. Nevertheless, our model can help researchers form an
explicit hypothesis regarding how training can support learning
that can be empirically investigated. Ultimately, we hope our
exploratory research can help advance the goal of more humane,
integrated, and comprehensive mental health services in the
future.
In relation to study limitations, our research does not aim to
build a comprehensive theory to explain global views on disaster
mental health education for relief workers in a variety of contexts.
In contrast, the information generated from this study provides
an exploratory model (see Figure 1), which evolved in a particular
rural remote situational context. As with all qualitative studies,
the transferability of the findings is limited by the small sample
size and the uniqueness of the natural disaster setting being
studied; therefore, caution must be taken in generalizing this
model to other disaster-related mental health service settings.
Concluding comments
The findings of this study indicate that more attention should be
paid to culturally appropriate or worker-informed trainings
because the setting for mental health professionals involved in
disaster relief work in rural China is complex and difficult.
Indeed, consistent with our model, to build deeper connections
and understanding, future trainers must fully respect the world
of the trainees while being committed to the needs of workers.
Additionally, role-modelling is a primary method through
which experienced trainers can teach relief workers humanistic
aspects of disaster relief work. Moreover, issues surrounding the
regulation of training, clinical supervision, empowerment, inten-
tional and strategic training of mental health relief workers
using interprofessional concepts and strategies, and the roles
and responsibilities of different professions must be addressed
in future studies.

Acknowledgements
We want to take this opportunity to thank our friends Professor Alvin
Dueck and Professor Chow Lam. They nurture our understanding of
human suffering and culture psychology.
Declaration of interest
The authors report no conflicts of interest. The authors alone are
responsible for the content and writing of this article.
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