An older woman moves erratically around the remains of her demolished home after it was leveled by a tornado. The disaster that killed 30 people also destroyed almost everything this woman owned. When she is allowed to return to the scene of devastation, she finds a memento of her mother among the ruins. As she searches without success for a tangible remembrance of her deceased son, anxiety and sadness take over, and she begins to sob.

Some viewing television coverage of this women's tragedy might think her behaviors are abnormal. After all, the woman is a survivor; her life was spared. She should be glad she's alive, some might reason. However, emergency professionals and disaster teams recognize the victim's responses as typical of the varied responses observed immediately after a disaster.

This article focuses on disaster psychology, a multidisciplinary body of knowledge that is an offshoot of traumatology. However, this now-psychiatric subspecialty has a stronger community-based model of assessment and intervention, in contrast to the previously prevalent clinical model, which focused on individual responses.1 This article examines aspects of both models.

Types of Disasters

Prior to 9/11, if you asked healthcare professionals to define disaster psychology, they likely would have been unable to provide a cogent answer. In fact, until America's greatest national terrorist tragedy occurred and affected the psyches of all - victims, survivors, caregivers and fellow citizens - there was considerable ambiguity about what disaster psychology encompassed.

Perhaps the primary reason for this is that the definition of disaster is variable, even among experts. A frequently used definition for disaster is an event that overwhelms local resources and threatens the function and safety of the community.2 Disasters are classified as natural, man-made or a combination of the two.

Natural disasters include hurricanes, earthquakes, tornadoes and floods. Man-made disasters include plane crashes, explosions, fires and terrorist attacks. Very often, there are combinations of natural and man-made disasters, such as home construction in areas where mudslides are known to occur.

While more attention has been paid to disaster psychology since 9/11, emergency medical personnel were already quite skilled in assessing and managing the psychological needs of disaster victims, survivors and caregivers. Case studies and research gleaned from previous disaster debriefings were invaluable in increasing the knowledge about how individuals cope with natural and man-made disasters.

Psychological Casualties of War

Another source of information about how to identify and address the mental health needs of trauma victims came from the military. Both military and civilian mental health professionals have studied the psychological casualties of war, revealing how individuals react and adapt to severe and prolonged stress.

Well-documented reports are available on soldiers affected with shell shock in World War I and diagnosed with combat neuroses in World War II. Vietnam-era veterans affected with posttraumatic stress disorder (PTSD) were probably the largest group of individuals ever studied for this condition. This data helped facilitate diagnosis and treatment in those affected with PTSD from other causes. During the Gulf War, the threat and fear of bioterrorism became new issues for those in the military, and a new area for mental health clinicians to study and learn how to manage.

Effects of Denial

Pre-9/11, government agencies attempted to implement well-coordinated disaster plans quickly and efficiently. However, these plans didn't include how to project the needs of an entire region or country following terrorist attacks. For example, during citywide disaster drills, the most severe scenario ever tested was commonly the crash of two jumbo jets at a metropolitan airport.

Despite the fact that natural and man-made disasters occur each year, most believe disasters happen to other people, not them - until they become the victims. Denial serves as a powerful coping skill to protect them from dealing with these dire realities.

A belief system that disasters only happen to other people is healthy to a certain extent. It allows individuals to be free of paralyzing fear and anxiety that at any moment, a tragedy beyond of their control can happen to them. Mental health clinicians have coined the term "catastrophizing" for chronic worriers obsessed with thoughts that a disaster could befall them at any time.

Varied Reactions

Many individuals live in regions prone to natural disasters. They have firsthand experience with these catastrophes. The thought processes and emotional and behavioral responses of these victims are varied. For some those who experience their first disaster, they make plans to flee the scene as soon as they can safely leave, then never return. For others, particularly those who don't have the resources to relocate, they stay but suffer chronic anxiety, fearful that a similar disaster could occur any day.

However, many of these veteran disaster victims wouldn't think of relocating. Denial, rationalization and secondary gains allow them to continue to live in these disaster zones relatively stress-free. For example, in California late summer and fall can herald the combination of natural and man-made disasters - forest fires ignited accidentally or intentionally followed by floods caused by the heavy, seasonal rains.

Residents who remain in these disaster-prone areas don't believe that the same area couldn't possibly be hit again; they rationalize, saying the benefits of living in such a beautiful place outweighs the risks. Also, a victim camaraderie develops among the survivors. They develop a strong bond with their neighbors built on shared pride in their survival skills and ability to rebuild their community. This bond becomes a secondary gain for the victims/survivors.

Emotional Scars

In the television age, viewers can view the carnage and destruction of disasters minutes after they happen. However, if it isn't happening locally and viewers aren't personally involved, the event can be forgotten in days or weeks.

It is always interesting to compare the physical and psychological recovery process of those who were affected by the event. Television news programs often follow-up a community's post-disaster reconstruction efforts some years later. As the camera spans the community, it's hard to believe that a razed town or city could have been rebuilt so quickly. However, when victims are interviewed, it is usually evident that for many the emotional scars remain.

After the 1995 bombing of the Murrah Federal Building in Oklahoma City that claimed the lives of 168 individuals and resulted in 600 casualties, Americans had to face the reality that terrorist attacks could occur in this country. As mental health clinicians from all parts of the nation rushed to Oklahoma to provide psychological first aid and to assess those affected for normal and abnormal emotional responses, the rest of the country - the victims from afar - looked on in horror. Most of these individuals never received any counseling or had the opportunity to vent their feelings about what they saw.

Although it appeared that a sense of normalcy had returned for most Americans after the bombing, many began to verbalize their fears and exhibit symptoms of anxiety. This tension increased as more incidents of random violence such as the Columbine school shootings occurred.

Lost Feelings of Control

What fears enter people's minds in the wake of terrorist attacks? One of the greatest fears is loss of control, according to John Tassey, PhD, a psychologist at the VA Hospital in Oklahoma City.3

"When people learn of a plane crash, some decide that they are never going to fly again. When they hear about a shooting incident, they decide that they are never going to visit certain sections of town. By making these decisions, people feel like they can control what is happening," said Dr. Tassey, chair of the American Psy.chology Association (APA) task force on the mental health response to the Oklahoma City bombing.

"In the instance of Oklahoma City, people felt a real loss of control," he continued. "Here was a town that never makes the international news. Here were innocent children in a daycare center. But then we hear about their death - and it's not from a natural disaster. The bombing shattered the illusions of society. People asked the question, 'Where do you go to be safe?'"

After 9/11, Americans could no longer remain in denial. Unlike previous traumatic events, this one wouldn't go away. The horrific images of that day are permanently etched in the collective memory. Because the threat of a repeat attack is always there, this anxiety never completely subsides.

Terrorist attacks involve many people. Among those most impacted are survivors of past traumatic events, those who witness or were actual victims, and those whose friends, family and acquaintances were victims. Individuals constantly exposed to media coverage of the trauma may also be severely affected. First responders, rescue workers and those who are part of recovery efforts also are impacted by disasters. The impact varies with each individual, but it can be a lingering effect.

Phases of Response

Familiarity with the chronology of a disaster is helpful to emergency personnel in being able to predict with some certainty the psychological reactions they will encounter in victims, sur.vivors and caregivers. These responses, according to each disaster phase, include:4
  • Warning - Not every disaster has a warn.ing phase. If there is one, most people living in the area will experience anxiety. For some, it means listening for the latest news reports but being paralyzed against making preparations; others are energized and immediately swing into action to secure their homes and proceed to a shelter. However, at this stage, most people do not heed warnings. They may become angry and refuse to evacuate the area when told to do so by authorities.
  • Alarm - Many disasters have no alarm phase or, perhaps, the alarm is not heeded. There is ample documentation that prior to school shootings, perpetrators provide many clues about their intent to harm others. These threats are rarely reported. In the alarm phase, one might expect panic to be widespread. However panic only happens in about 10 percent of all disasters and this is when there are limited escape routes or no protection from the disaster.
  • Impact - When the disaster hits, the prevalent response of those living in the area is to do what is necessary to protect themselves and their family from danger. As the stress response is triggered, the autonomic nervous system triggers the release of additional glucose to the brain. This assists the individual to think more clearly about whether to fight or flee. Later, shock sets in. Some individuals are stunned and dazed. They may wander aimlessly and injure themselves if there are no emergency personnel in the area.
  • Inventory - This phase immediately follows the event. It is when survivors assess damage and try to locate other survivors. They also try to assess the level of danger. At this point, outside help has not yet arrived. Research indicates that roughly half the people in the disaster area move quickly into this adaptive mode. They help others experiencing difficulty adjusting to the situation.
  • Rescue - At this point, emergency personnel arrive at the scene. The survivors take direction from the rescuers. They are elated and almost euphoric that they are alive. In fact, if they are helping with the rescue effort, they don't want to rest when told to do so. They want to keep on working even though they may be overworked and tired.
  • Recovery - The positive feelings experienced previously begin to turn to anger and irritability. They maintain a common bond with their fellow survivors, but their anger is directed toward rescuers and agencies they believe are not working fast enough to get them what they need. This usually begins 48-72 hours after the crisis. The feelings of anger and guilt may be caused by survivor guilt, as survivors can't reconcile why their life was spared and others were not.
  • Reconstruction - At this point, the immediate danger has subsided and the rescue effort has been completed. Most victims have adapted to the change and returned to a functional level. They may not feel or act like they did before the event, but most have the emotional resources to return to work and daily activities. However, it is important for teachers, counselors and healthcare professionals to watch for abnormal behaviors. Some individuals may think they have processed the event and moved on, only to become depressed or angry long after the disaster. These individuals should be educated that acceptance will be an ongoing process.
Duties of Professionals
The primary responsibility of those charged with emergency planning and management is to always expect the unexpected. They cannot be lulled into thinking disasters don't happen. For example, JCAHO requires healthcare facilities to have plans for internal disasters (hospital fires, violent acts) and external disasters (local floods, hurricanes, bioterorism events, etc.). These plans are to be updated and tested at regular intervals.

It is important that each healthcare provider receives training in disaster preparedness and response. One does not know where they will be should a disaster occur, so having training prior to the event is imperative. Disaster and mental mealth training is provided free of charge by local Red Cross chapters.

Emergency care professionals are adept at assessing abnormal behavioral responses in disaster victims. However, it is always important to keep in mind that disasters affect people in different ways. Some respond immediately, while others' symptoms may be delayed for months or years. Some are affected by the event for a long time and others recover quickly. Reactions can change over time, as is not unusual for some victims to initially feel increased energy but later become depressed.

Although there are common initial responses in disasters followed by post-disaster behavioral responses5 the victim/survivor should be assessed as an individual. In other words, even though mental health workers can recognize symptom constellations after a traumatic event, validation by the victim is essential. It is imperative that caregivers are knowledgeable about these prevalent behavior patterns in order to assess and intervene as quickly as possible.

Psychiatric Diagnoses

While most disaster survivors experience only mild, normal stress reactions, as many as one out of three experience severe stress that can result in PTSD, acute stress disorder (ASD), anxiety disorders or depression.2

To prevent or plan treatment for victims at high risk of developing these disorders, mental health professionals must monitor those at risk, including:
  • children who were victims or experienced the trauma;
  • people, including rescue personnel, exposed to other trauma;
  • those with chronic medical problems and psychological disorders;
  • people with recent major life stressors or emotional strain; and
  • those experiencing poverty, homelessness, unemployment or discrimination.4
PTSD may be the most common psychiatric diagnosis associated with trauma response. It is characterized by exposure to a serious event in which there is threat to life or physical in.jury (the victim's or others), accompanied by intense feelings such as terror, helplessness or fear. In addition to these criteria, the individual must have experienced intrusive thoughts of the event, avoidance of related reminders and physiological arousal. Symptoms must be present for more than a month.6

ASD is similar to PTSD in that the symptoms are the same, except that dissociative symptoms also are present.2 Dissociative symptoms include feeling unreal or outside of oneself, and having little memory of distinct periods of time. ASD occurs within 4 weeks after the traumic event, persisting for a minimum of 2 days and a maximum of 4 weeks.6

PTSD Treatment

The National Center for PTSD encourages treatment immediately after the diagnosis is made. This includes working with the client to:
  • educate him about the disorder and explain that it is a medically recognized anxiety disorder;
  • expose him to the event through imagery; and
  • help him examine and resolve strong feelings such as anger, shame or guilt.7
A proactive approach to preventing PTSD is crisis intervention. Crisis intervention programs offer victims and healthcare professionals a form of psychological first aid. Widely used to help emergency personnel perform effectively during a disaster and later to debrief the event is critical incident stress management.7

Effects on Children, Adolescents

Child and adolescent development can be significantly altered as a consequence of exposure to disasters.6 Like adults, there is a wide range of symptoms and behaviors noted in children who have been exposed to severe trauma. PTSD, depression and separation anxiety are commonly diagnosed in children. The reactions of parents, teachers and significant others affect children's responses to trauma.

A child's reactions to severe trauma can be correlated to developmental stages. For example, preschool children through second graders commonly experience fear, confusion, helpless.ness, regressive behaviors, sleep disturbances and separation anxiety. These children may have trouble talking about what's bothering them. Third through six graders experience sleep disturbances, difficulty concentrating and concerns about their safety and the safety of others.

Adolescent Responses

The emotional responses of adolescents post-disaster mirror those of adults. However, differences include profound changes in their attitudes toward life and their future. These attitudes often trigger risk-taking behaviors. While many of these responses are normal, if prolonged they can have secondary effects. For example sleep disturbances and increased sick days may result in poor school performance, causing failing grades and lowered self-esteem.

Helping children after a major traumatic event requires a team approach between parents, the schools and community agencies. Guidelines to assess children's responses and appropriate interventions include the following:8
  • Utilize the classroom for assessment and intervention; drawing and storytelling techniques can help children discuss their fears.
  • Parents should listen to and tolerate a child's retelling of the trauma but put limits on scary or hurtful talk.
  • Expect an initial decline in school performance.
  • Maintain communication with others in children's lives - teacher, coach, etc.; monitor how they are coping with demands of home, school and community activities.
  • Maintain a routine of daily activities.
Lessons from Oklahoma City

Since the Oklahoma City bombing was the first major terrorist attack in this country, it became a model for mental health responses to future disasters of such magnitude. In fact, many of the mental health professionals who led the mental health teams in Oklahoma were dispatched immediately to New York and Washington after 9/11 and assisted in recovery efforts.

Immediately following the Oklahoma blast, mental health clinicians provided services at the bombing site, local hospitals and the local Red Cross. More than 70 local psychologists responded the first day after being notified by the state's disaster response network.

A church where death notification took place became known as the Compassion Center.9 Much of the work performed by the mental health workers in Oklahoma occurred at the Compassion Center, where families and friends went to seek information about their missing loved ones. The center became a highly complex, multidisciplinary, multiagency operation under the direction of the medical examiner.

However, since it was the hub of mental health operations, the center was flooded with calls from individuals wanting to help. Many just arrived at the scene, creating a major logistical problem. Mental health professionals had to be screened and credentialed. Unauthorized persons had to be prevented from entering the build.ing and creating more chaos. A database to track the mental health workers and set work schedules had to be established.

Almost 400 mental health professionals were involved during the 18 days the Compassion Center was in operation. These services were organized into four primary functions: support services, family services, death notification and staff mental health services for all volunteers.

Project Heartland

Although mental health services have been provided for victims of any presidentially declared disaster since the 1970s, this aid has been criticized as being too narrow and short-term, according to the American Psychology Association (APA) Task Force on Mental Health Response to the Oklahoma City Bombing.9 To improve mental health care services following a disaster, APA became the first national mental health organization to sign a statement of understanding with the American Red Cross in 1991. The network of psychologists agreed to provide pro bono mental health services to disaster victims and relief workers.9

Despite this reported lack of long-term care for disasters victims, in May 1995 the Oklahoma Department of Mental Health and Substance Abuse Services received an immediate service grant from the Federal Emergency Management Agency (FEMA) to provide mental health services to individuals living in proximity to the federal building. Project Heartland became the first FEMA-funded community health program to intervene with terrorist survivors in the United States.

In its first year of operation, Project Heartland's client base increased each month following the bombing. It rose sharply in the months leading up to the bombing's first anniversary and then dramatically fell off. Services - all provided free of charge - included crisis counseling, outreach and public information, support groups, training and consultation.

APA Conclusions

The APA task force report addressing the mental health services delivered in Oklahoma set forth a detailed list of recommendations for future consideration. The four primary areas identified for immediate study were immediate response, long-term services, research and the need for all agencies to recognize that mass-casualty incidents such as the Oklahoma City bombing are not typical of other disasters and require far more services.

Since 9/11, there has been a growing body of published information dealing with the emotional reactions of victims and survivors, as well as other citizens who immediately became victims from afar as they viewed the tragedies unfolding in New York, Washington, DC, and Somerset County, PA. Some of these reports have been scientifically based, while many are anecdotal in nature or use suspect methodologies.

Silver and colleagues have acknowledged that the Oklahoma City disaster showed that emotional, cognitive and behavioral responses to terrorist attacks vary considerably.10 However, they noted that information related to the range and rates of distress following terrorist attacks was limited. They also stated there was a myth held by the public and even professionals that the degree of response in trauma is directly proportional to the degree of loss experienced.

Responses Not Limited

The researchers set out to examine the degree to which demographic factors, mental and physical health, lifetime exposure to stressful events, 9/11 experiences and coping strategies used after the attack predicted psychological outcomes. A random sample of 2,729 adults living in the New York City area and 1,069 randomly selected adults outside the area completed Web-based surveys 9-23 days after the attack, and at subsequent intervals of 2 and 6 months. The mental and physical health histories of the subjects before the attack also were collected.

The study concluded that psychological effects of a major national trauma are not limited to those who experience it directly. The researchers also found the degree of response cannot be predicted by objective measures of loss experienced. Additionally, the coping strategies used initially may be associated with mental health symptoms over time.10

Conclusion

Disasters do happen - and not just to others. After 9/11, most Americans don't challenge that premise anymore. In fact, if anything, they fear a similar attack could and will happen again. To be effective in any type of rescue effort, nurses and other healthcare professionals must having a working knowledge of disaster psychology.

References
  1. University of South Dakota. (2001). International disaster psychology course description. [link]
  2. Norwood, A.E., Ursano, R.J., & Fullerton, C.S. (2000). Disaster psychiatry: principles and practice. Psychiatric Quarterly, 71(3), 207-226.
  3. Tassey, J. (1996). Psychology in daily life: Coping with the aftermath of a disaster. [link]
  4. Mental Health Center of North Iowa. Background phases of disaster. Mason City, IA: Author. [link]
  5. American Red Cross. (1997). Emotional health issues for victims. Arlington, VA: Author. [link]
  6. Norris, F.H., et al. (2002). The range, magnitude, and duration of effects of natural and human-caused disasters: A review of the empirical literature. White River Junction, VT: National Center for PTSD. [link]
  7. Bensing, K., et al. Healing the wounded: Both patients and caregivers begin the healing process. ADVANCE for Nurses Serving the Greater Philadelphia/Tri-State Metro Area, 3(19), 20, 32.
  8. Gurwitch, R.H., et al. (2003). Reactions and guidelines for children following trauma/disaster. Washington, DC: American Psychological Association. [link]
  9. Final report: American Psychological Association Task Force on the Mental Health Response to the Oklahoma City Bombing. (1997, July). [link]
  10. Silver, R., et.al. (2002). Nationwide longitiudinal study of psychological responses to September 11. Journal of the American Medical Association, 288(10), 1235-1244.