Training Manual
for
Mental Health and Human Service Workersin Major Disasters
SECTION 3
Disaster Reactions of Potential Risk Groups
Although there are many feelings and reactions people share in common following a disaster, there are also expressions that are more specifically influenced by the survivor's age, cultural and ethnic background, socioeconomic status, pre-existing physical, and psychosocial vulnerabilities. Disaster mental health workers are better prepared to design effective interventions when they have an understanding of how demographic and health factors interact with disaster stress.
This section describes groups commonly found within communities following a disaster and provides suggestions for disaster mental health interventions. Common issues, concerns, and reactions are also briefly presented in this section.
Common Needs and Reactions
First is a review of some thoughts, feelings, and behaviors common to all who experience a disaster:
Concern for basic survival
Grief over loss of loved ones and loss of valued and meaningful possessions
Fear and anxiety about personal safety and the physical safety of loved ones
Sleep disturbances, often including nightmares and imagery from the disaster
Concerns about relocation and related isolation or crowded living conditions
Need to talk about events and feelings associated with the disaster, often repeatedly
Need to feel one is a part of the community and its disaster recovery efforts
Potential Risk Groups
Each disaster-affected community has its own demographic composition, prior history with disasters or other traumatic events, and cultural representation. When disaster program planners review the groups impacted by a disaster in their community, consideration should be given to the following, as well as additional groups unique to the locale:
Age groups
Cultural and ethnic groups
Socioeconomic groups
People with serious and persistent mental illness
Human service and disaster relief workers
The majority of survivors are resilient and with time can integrate their disaster experiences and losses and move on. However, survivors who have significant concurrent psychosocial, health, or financial problems are at greater risk for depression, anxiety, post-traumatic stress symptoms or an exacerbation of their pre-existing condition. When survivors have personally sustained severe disaster losses (e.g., death of a loved one, devastation of home and community), their reactions are more intensely expressed and over a longer period of time (Solomon & Green, 1992). This section includes a brief overview for each group. The disaster reactions described normally resolve over time with sufficient support and physical recovery. References for more detailed information are provided.
Age Groups
Each stage of life is accompanied by special challenges in coping with the aftermath of a disaster and age-related vulnerabilities to disaster stress. For children, their age and development determine their capacity cognitively to understand what is occurring around them and to regulate their emotional reactions. Children are more vulnerable to difficulty when they have experienced other life stresses in the year preceding the disaster, such as a divorce, a move, or the death of a family member or pet (Vogel & Vernberg, 1993). For adults, stress associated with family and home disruption, financial setbacks, and work overload predominate. For older adults, concerns regarding health, financial stability, and living independently become primary.
The age groups considered in this section are:
Preschool (ages 1-5)
Childhood (ages 6-11)
Pre-adolescence and Adolescence (ages 12-18)
Adults
Older Adults
Reactions and problems vary depending upon the phase of the post-disaster period. Some of the problems discussed appear immediately; many appear months later.
Preschool (ages 1-5)
Small children view their world from the perspectives of predictability, stability, and the availability of dependable caretakers. Disruption in any of these domains causes distress. Preschool age children often feel powerlessness and fear in the face of a disaster, especially if they are separated from parents. Because of their age and small size, they are unable to protect themselves or others. As a result, they may feel considerable anxiety and insecurity.
In the preschool years, children generally lack the verbal and conceptual skills necessary to understand and cope effectively with sudden unexpected stress. They typically look to parents and older siblings as behavior models, as well as for comfort and stability. Research has shown that children's reactions are more related to how their family or caregiver is coping than the actual objective characteristics of the disaster itself (Green et al., 1991).
Children who have lost one or both parents are especially in need. Loss of a relative, a playmate, or a pet is also a disturbing event for children. They will need opportunities to express their grief. One of the major fears of childhood is abandonment, so children need frequent reassurance they will be cared for.
Preschoolers express their upset through regressive behaviors such as thumb sucking, bed-wetting, clinging to their parents, a return of fear of the dark, or not wanting to sleep alone. They often have sleep problems and frightening dreams. These problems are best understood as normal expressions of anxiety about the disruption of their familiar routines and previously secure worlds.
In the natural course of events, small children will try to resolve traumatic experiences by reliving them in their play activities. They may reenact the earthquake, flood, or tornado repeatedly. Children should be encouraged to verbalize their questions, feelings, and misunderstandings about the disaster so that adults can listen and explain. Relief of disaster fears and anxiety is attained through reestablishing the child's sense of security. Frequent verbal reassurance, physical comforting, more frequent attention, comforting bedtime rituals, and mealtime routines are helpful. As much as possible, young children should stay with people with whom they feel most familiar.
Childhood (ages 6 - 11)
School age children are developing the cognitive capacity to understand the dangers to family and environment inherent in disasters. They are more able to understand the disaster event and the mitigating role of disaster preparedness. This awareness can also contribute to preoccupation with weather and disasters, and fears about family members being killed or injured. School age children have a great need to understand what has happened and the concrete steps that they can take for protection and preparedness in the future.
Children often have special bonds with playmates or pets. When the disaster causes loss of significant others due to death or relocation, the child may grieve deeply. They experience the full range of human emotions, but may not have the words or means to express their internal experience. Adults can assist children to express these powerful emotions through talking, play, art, and age-appropriate recovery or preparedness activities.
School age children also manifest their anxiety through regressive behavior. Returning to behavior appropriate for a younger age is trying for parents, but serves an initially functional purpose for the child. These behaviors include: irritability, whining, clinging, fighting with friends and siblings, competing with younger siblings for parents' attention, or refusing to go to school. Bedtime and sleep problems are common due to nightmares and fearfulness about sleeping alone or in the dark.
Sometimes children's behavior can be "super good" at home, because they are afraid of further burdening their parents or causing more family disruption. They may show disaster stress at school through concentration problems, a decline in academic performance, aggression toward classmates, or withdrawal from social interactions. Some children may have somatic reactions and seek attention from the school nurse for stomach aches, headaches, nausea, or other complaints.
Pre-adolescence and Adolescence (ages 12 - 18)
This age group has a great need to appear competent to the world around them, especially to their family and friends. They struggle with the conflicts inherent in moving toward independence from parents on the one hand and the desire to maintain the dependence of childhood on the other. Approval and acceptance from friends are of paramount importance. Adolescents need to feel that their anxieties and fears are both appropriate and shared by their peers.
Disaster stress may be internalized and expressed through psychosomatic symptoms such as, gastrointestinal distress, headaches, skin problems, or vague aches and pains. Sleep problems such as insomnia, night terrors, or sleeping excessively may signal internal upset. Adolescents may turn to alcohol or drugs to cope with their anxiety and loss.
Social or school problems may also occur. Acting out or rebellious behavior may involve fighting with others, stealing, or power struggles with parents. Other adolescents may express their distress through withdrawal from friends and family and avoidance of previously enjoyed activities. School performance may decline. When the disaster causes major destruction of home and community, an older adolescent may postpone the developmental step of moving away from home.
Adults
Adults are focused on family, home, jobs, and financial security. Many are involved with caring for elderly parents as well. Pre-disaster life often involves maintaining a precarious balance between competing demands. Following a disaster, this balance is lost with the introduction of the enormous time, financial, physical, and emotional demands of recovery. Children in the family are in special need of attention and familiar routines, yet parents do not have enough hours in the day to accomplish all that is before them.
Over time, this stress overload can be manifested through physical symptoms of headaches, increased blood pressure, ulcers, gastrointestinal problems, and sleep disorders. Somatic reactions are especially present in those who are less able to experience and express their emotions directly. Cultural, gender-based, or psychological factors may interfere with emotional expression and seeking social support.
Emotional reactions often oscillate between numbness and intense expression. Anxiety and depression are common, as adults grapple with both anxiety about future threats and grief about the loss of home, lifestyle, or community. Anger and frustration about relief efforts abound, sometimes reflecting a displacement of the "less rational" anger that the disaster happened to them and was out of their control.
Older Adults
In the normal course of life, older adults typically have coped with losses prior to the disaster. They may have successfully adjusted to losses of employment, family, home, loved ones, or physical capabilities. For some, coping with these prior losses has strengthened resilience. For others, the prior losses may have worn down the individual's reserves and the disaster is an overwhelming blow (Norris et al., 1994). As a result of the disaster, irreplaceable possessions such as photographs or mementos passed on through generations may be destroyed. Pets or gardens developed over years may be lost. Mental health workers must recognize the special meaning of these losses, if they are to assist with grieving.
Older adults living on limited incomes tend to reside in dwellings that are susceptible to disaster hazards due to the location and age of the buildings. Because of financial limitations and age, they may not be able to afford the repairs to their homes. Leaving familiar surroundings is especially difficult for those who experience deficits in hearing, vision, or memory, because they rely on known environmental cues to continue living independently.
Many older adults fear that if their diminished physical or cognitive abilities are revealed, they risk loss of independence or being institutionalized. As a result, they may under report the full extent of their problems and needs. They may continue living in damaged or unsanitary conditions, because they do not have the physical strength, stamina, or cognitive organizational ability to undertake disaster clean up. Disaster mental health workers must carefully assess the range and full extent of problems in living faced by the older survivor. Often, concrete practical assistance for recovery, stabilization, and engagement with appropriate resources allows the older adult to continue living independently.
A larger proportion of older persons, as compared with younger age groups, have chronic illnesses that may worsen with the stress of a disaster, particularly when recovery extends over months. They are more likely to be taking medications that need to be replaced quickly following a disaster. While older adults may be in more need of multiple services for recovery, they are often especially reluctant to accept help and what they perceive as "handouts." Disaster mental health programs can more quickly gain acceptance when they work closely with known, trusted organizations and employ older adults as outreach workers.
Disaster Reactions and Intervention Suggestions
Age Groups
Behavioral Symptoms
Physical Symptoms
Emotional Symptoms
Intervention Options
PRESCHOOL
(1 - 5)
Resumption of bed-wetting, thumb sucking
Clinging to parents
Fears of the dark
Avoidance of sleeping alone
Increased crying
Loss of appetite
Stomach aches
Nausea
Sleep problems, nightmares
Speech difficulties
Tics
Anxiety
Fear
Irritability
Angry outbursts
Sadness
Withdrawal
Give verbal assurance and physical comfort
Provide comforting bedtime routines
Avoid unnecessary separations
Permit child to sleep in parents' room temporarily
Encourage expression regarding losses (i.e., deaths, pets, toys)
Monitor media exposure to disaster trauma
Encourage expression through play activities
CHILDHOOD
(6 - 11)
Decline in school performance
Aggressive behavior at home or school
Hyperactive or silly behavior
Whining, clinging, acting like a younger child
Increased competition with younger siblings for parents' attention
Change in appetite
Headaches
Stomach aches
Sleep disturbances, nightmares
School avoidance
Withdrawal from friends, familiar activities
Angry outbursts
Obsessive preoccupation with disaster, safety
Give additional attention and consideration
Relax expectations of performance at home and at school temporarily
Set gentle but firm limits for acting out behavior
Provide structured but undemanding home chores and rehabilitation activities
Encourage verbal and play expression of thoughts and feelings
Listen to the child's repeated retelling of disaster event
Involve the child in preparation of family emergency kit, home drills
Rehearse safety measures for future disasters
Develop school disaster program for peer support, expressive activities, education on disasters, preparedness planning, identifying at-risk children
Disaster Reactions and Intervention Suggestions (Continued)
Age Groups
Behavioral Symptoms
Physical Symptoms
Emotional Symptoms
Emotional Symptoms
PRE-ADOLESCENCE AND ADOLESCENCE
(12 - 18)
Decline in academic performance
Rebellion at home or school
Decline in previous responsible behavior
Agitation or decrease in energy level, apathy
Delinquent behavior
Social withdrawal
Appetite changes
Headaches
Gastrointestinal problems
Skin eruptions
Complaints of vague aches and pains
Sleep disorders
Loss of interest in peer social activities, hobbies, recreation
Sadness or depression
Resistance to authority
Feelings of inadequacy and helplessness
Give additional attention and consideration
Relax expectations of performance at home and school temporarily
Encourage discussion of disaster experiences with peers, significant adults
Avoid insistence on discussion of feelings with parents
Encourage physical activities
Rehearse family safety measures for future disasters
Encourage resumption of social activities, athletics, clubs, etc.
Encourage participation in community rehabilitation and reclamation work
Develop school programs for peer support and debriefing, preparedness planning, volunteer community recovery, identifying at-risk teens
ADULTS
Sleep problems
Avoidance of reminders
Excessive activity level
Crying easily
Increased conflicts with family
Hypervigilance
Isolation, withdrawal
Fatigue, exhaustion
Gastrointestinal distress
Appetite change
Somatic complaints
Worsening of chronic conditions
Depression, sadness
Irritability, anger
Anxiety, fear
Despair, hopelessness
Guilt, self doubt
Mood swings
Provide supportive listening and opportunity to talk in detail about disaster experiences
Assist with prioritizing and problem-solving
Offer assistance for family members to facilitate communication and effective functioning
Assess and refer when indicated
Provide information on disaster stress and coping, children's reactions and families
Provide information on referral resources
Disaster Reactions and Intervention Suggestions (Continued)
Age Groups
Behavioral Symptoms
Physical Symptoms
Emotional Symptoms
Intervention Options
OLDER ADULTS
Withdrawal and isolation
Reluctance to leave home
Mobility limitations
Relocation adjustment problems
Worsening of chronic illnesses
Sleep disorders
Memory problems
Somatic symptoms
More susceptible to hypo- and hyperthermia
Physical and sensory limitations (sight, hearing) interfere with recovery
Depression
Despair about losses
Apathy
Confusion, disorientation
Suspicion
Agitation, anger
Fears of institutionalization
Anxiety with unfamiliar surroundings
Embarrassment about receiving "hand outs"
Provide strong and persistent verbal reassurance
Provide orienting information
Use multiple assessment methods as problems may be under reported (e.g., repeat observations, geriatric screening questions, discussion with family)
Provide assistance with recovery of possessions
Assist in obtaining medical and financial assistance
Assist in reestablishing familial and social contacts
Give special attention to suitable residential relocation
Encourage discussion of disaster losses and expression of emotions
Provide and facilitate referrals for disaster assistance
Engage providers of transportation, chore services, meals programs, home health, and home visits as needed
Cultural and Ethnic Groups
Disaster mental health programs must respond specifically and sensitively to the various cultural groups affected by a disaster. In many disasters, ethnic and racial minority groups may be especially hard hit because of socioeconomic conditions that force the community to live in housing that is particularly vulnerable. Language barriers, suspicion of governmental programs due to prior experiences, rejection of outside interference or assistance, and differing cultural values often contribute to disaster outreach programs' difficulty in establishing access and acceptance. Communities that take pride in their self-reliance are reluctant to seek or accept help, especially from mental health workers.
Cultural sensitivity is conveyed when disaster information and application procedures are translated into primary spoken languages and available in non-written forms. Intense emotions are typically experienced and expressed in a person's language of origin, so outreach teams that include bilingual, bicultural staff, and translators are able to interact more effectively with disaster survivors. Whenever possible, it is preferable to work with trained translators rather than family members, especially children, because of privacy concerns regarding mental health issues and the importance of preserving family roles.
Cultural groups have considerable variation regarding views on loss, death, home, spiritual practices, use of particular words, grieving, celebrating, mental health, and helping. The role of the family, who is included in the family, and who makes decisions also varies. Elders and extended family play a significant role in some cultures, whereas isolated nuclear families are the decision-makers in others.
It is essential that disaster mental health workers learn about the cultural norms, traditions, local history, and community politics from leaders and social service workers indigenous to the groups they are serving. Program outreach workers and mental health staff are most effective when they are bilingual and bicultural. During the program development phase, establishing working relationships with trusted organizations, service providers, and community leaders is helpful. Being respectful, nonjudgmental, well informed, and following through on stated plans dependably are especially important for outreach workers.
Socioeconomic Groups
Many affluent, middle to upper middle class people live with a sense of security and see themselves as invulnerable to the devastation and tragedy associated with disasters. Because of their financial resources and life situations, they may have been protected from crises in the past, and have purchased insurance for "protection" in the future. They are more accustomed to planning and controlling life events, rather than unexpected overwhelming events controlling them. Shock, disbelief, self blame, and anger predominate in the hours and days following a major disaster, as the reality of losses, danger, and the work that lies ahead begins to sink in.
Higher income families may never have received assistance from social service agencies before. Accepting clothing, food, money, or shelter can be difficult and sobering. While they may need emergency assistance initially, they often do have social, financial, family, or other resources that engage quickly and buffer the disaster's impact.
Affluent families typically rely on known professionals for their support-their family physician, minister, or psychotherapist. Disaster mental health programs focus on educating local health care professionals and religious leaders about disaster stress, because these providers are most likely to encounter upper class survivors in need. Psychosocial Issues for Children and Families in Disaster: A Guide for the Primary Care Physician (CMHS, 1995) is an informative resource for training. Recovery programs can also coordinate disaster mental health counseling and support groups through these known and trusted entities.
In contrast, low-income survivors have fewer resources and greater pre-existing vulnerability when disaster strikes. While they may have developed more crisis survival skills than the more protected upper class individuals, they often lack the availability of support and housing from family and friends and do not have insurance coverage or monetary savings. Without these, the recovery process is even more arduous and prolonged, and sometimes impossible. Federal and State disaster assistance programs are designed to meet serious and urgent needs. The intent of these programs is not to replace all losses. Uninsured, poor families may have unmet needs and should be referred to non-profit disaster relief organizations and unmet needs committees. If they are renters, they may be faced with unaffordable increases in rent after landlords have invested money to repair their properties. They may be dislocated to temporary disaster housing that is undesirable and removed from their social supports. Relocation may make transportation and getting to appointments more difficult.
Faced with these multiple challenges and assistance that falls short of solving the problems before them, low-income disaster survivors can feel overwhelmed. For those with limited reading and writing abilities, obtaining accurate information and completing forms is difficult. Disaster mental health workers are most effective when they provide concrete problem-solving assistance that facilitates addressing priority needs. Workers must be knowledgeable about the full range of community resources available to people of limited economic means and actively engage this resource network with those in need.
People With Serious and Persistent Mental Illness
Clinical field experience has shown that disaster survivors with mental illness function fairly well following a disaster, if essential services have not been interrupted. People with mental illness have the same capacity to "rise to the occasion" and perform heroically as the general population during the immediate aftermath of the disaster. Many demonstrate an increased ability to handle this stress without an exacerbation of their mental illness, especially when they are able to maintain their medication regimens.
However, some survivors with mental illness have achieved only a tenuous balance before the disaster. The added stress of the disaster disrupts this balance; for some, additional mental health support services, medications, or hospitalization may be necessary to regain stability. For individuals diagnosed with Post Traumatic Stress Disorder (PTSD), disaster stimuli (e.g., helicopters, sirens) may trigger an exacerbation due to associations with prior traumatic events.
Many people with mental illness are vulnerable to sudden changes in their environment and routines. Orienting to new organizations and systems for disaster relief assistance can be difficult. Program planners need to be aware of how disaster services are being perceived and build bridges that facilitate access and referrals where necessary. Disaster mental health services designed for the general population are equally beneficial for those with mental illness; disaster stress affects all groups. In addition, when case managers and community mental health counselors have a solid understanding of disaster mental health issues, they are able to better provide services to this population following a disaster. Responding to the Needs of People with Serious and Persistent Mental Illness in Times of Major Disaster provides a comprehensive discussion of planning, preparedness, and options for service delivery with this population (CMHS, 1996).
Human Service and Disaster Relief Workers
Workers in all phases of disaster relief, whether in law enforcement, local government, emergency response, or victim support, experience considerable demands to meet the needs of the survivors and the community. Typically, disaster workers are altruistic, compassionate, and dedicated people who occasionally have difficulty knowing when it is time to take a break from the operation. For many, the disaster response takes precedence over all other responsibilities and activities. The brochure, Prevention and Control of Stress Among Emergency Workers-A Pamphlet for Workers, is an excellent resource for both disaster relief workers and mental health providers (NIMH, 1987). This brochure highlights the importance of having a personal emergency preparedness plan, so that workers are assured that their families are safe while they devote themselves to disaster relief for the community.
Relief workers may witness human tragedy and serious physical injuries, depending on the nature of the disaster and their role. This contributes to the psychological impact of their work. In disasters in which there is a high level of exposure to human suffering, injuries, and fatalities, providing psychological support and interventions for workers is especially necessary. In addition, relief workers and first responders should be considered a target group for ongoing services during the course of the disaster mental health recovery program.
As some order returns to the community, many workers, particularly volunteers, return to their regular jobs. However, they may attempt to continue with their disaster work. Over time, the result of this overwork can be the "burn-out" syndrome. This state of exhaustion, irritability, and fatigue creeps up unrecognized and can markedly decrease the individual's effectiveness and capability. These workers may be avoiding problems at home by working constantly. Disaster mental health workers should be on the lookout for workers whose coping resources have eroded due to their personal vulnerabilities and seemingly unrelenting workload. The next section in this manual, "Stress Prevention and Management," offers suggestions for identifying, educating, and intervening with those who may be having stress reactions and difficulty coping.
References and Recommended Reading
Bolin, R. & Bolton, P. Race, Religion and Ethnicity in Disaster Recovery. Colorado: University of Colorado Institute of Behavioral Science, 1986.
Center for Mental Health Services. Manual for Child Health Workers in Major Disasters. Washington, D.C.: U.S. Department of Health and Human Services; Publication No. (ADM) 86-1070. (Rev. ed. in press.)
Center for Mental Health Services. Responding to the Needs of People with Serious and Persistent Mental Illness in Times of Major Disaster. Washington, D.C.: U.S. Department of Health and Human Services; Publication No. (SMA) 96-3077, 1996.
Center for Mental Health Services. Psychosocial Issues for Children and Families in Disasters: A Guide for the Primary Care Physician. Washington, D.C.: US Department of Health and Human Services; Publication No. (SMA) 95-3022, 1995.
Gerrity, E. T. & Steinglass, P. Relocation stress following natural disasters. In: Ursano, R. J., McCaughey, B. G., & Fullerton, C. S. (Eds.). Individual and Community Responses to Trauma and Disaster: The Structure of Human Chaos. Great Britain: Cambridge University Press, 1994.
Gist, R. & Lubin, B. (Eds.). Psychological Aspects of Disaster. New York: John Wiley & Sons, 1989.
Green, B. L., Korol, M., Grace, M. C., Vary, M. G., Leonard, A. C., Gleser, G. C. & Smitson-Cohen, S. Children and disaster: Age, gender, and parental effects on PTSD symptoms. Journal of the American Academy of Child and Adolescent Psychiatry, 30, 945-951, 1991.
Green, B. L. & Solomon, S. D. The mental health impact of natural and technological disasters. In Freedy, J. R. & Hobfoll (Eds.). Traumatic Stress: From Theory to Practice. New York: Plenum, 1995.
LaGreca, A. M., Vernberg, E. M., Silverman, W. K., Vogel, A. L. & Prinstein, M. J. Helping Children Prepare for and Cope with Natural Disasters: A Manual for Professionals Working with Elementary School Children. BellSouth Corporation, 1995. (To obtain copies: Contact Dr. La Greca, Department of Psychology, University of Miami, P.O. Box 248185, Coral Gables, FL 33124.)
Mitchell, J. & Bray, G. Emergency Services Stress: Guidelines for Preserving the Health and Careers of Emergency Services Personnel. New Jersey: Prentice-Hall, 1990.
National Institute of Mental Health. Prevention and Control of Stress Among Emergency Workers: A Pamphlet for Workers. Washington, D.C.: U. S. Department of Health and Human Services; Publication No. (ADM) 90-1497, 1987.
Norris, F. H., Phifer, J. F. & Kaniasty, K. Individual and community reactions to the Kentucky floods: Findings from a longitudinal study of older adults. In: Ursano, R. J., McCaughey, B. G., & Fullerton, C. S. (Eds.). Individual and Community Responses to Trauma and Disaster: The Structure of Human Chaos. Great Britain: Cambridge University Press, 1994.
Saylor, C. F. (Ed.). Children and Disasters. New York: Plenum Press, 1993.
Solomon, S. D. & Green, B. L. Mental health effects of natural and human-made disasters. PTSD Research Quarterly, 3 (1), 1-8, 1992.
Sue, D. W. & Sue, D. Counseling the Culturally Different: Theory and Practice. New York: Wiley, 1990.
Ursano, R. J., McCaughey, B. G., & Fullerton, C. S. (Eds.). Individual and Community Responses to Trauma and Disaster: The Structure of Human Chaos. Great Britain: Cambridge University Press, 1994.
U. S. Department of Health and Human Services. Action Plan of the Administration on Aging to Strengthen the Disaster Response Capacity to Serve Older People. Rockville, MD, 1994. Vogel, J. M. & Vernberg, E. M. Children's psychological responses to disasters. Journal of Clinical Child Psychology, 22(4), 464-484, 1993.
