Disasters begin and end as local events. While there may be a large influx of outside expertise and resources in the days following the disaster, local mental health practitioners must be prepared to go it alone in the initial response. Inevitably, there comes a day when the media moves on to the next tragedy and state and federal resources stop flowing in, once again leaving the local community to care for its own.
Psychiatrists can play many important roles in helping their communities prepare for and respond to disasters. Disaster psychiatry entails a reorientation from general clinical practice and draws on particular areas of medical school and residency training.1"3 Perhaps the most important shift is the emphasis on the normality of responses, the focus of this article, rather than on psychopathology. In addition, the disaster psychiatrist thinks in terms of populations of high-risk groups rather than planning individual treatment.
Brushing up on epidemiology and public health from undergraduate medical education is helpful in providing a framework for understanding disaster psychiatry. Consultation skills that enable the psychiatrist to work closely with primary care colleagues can facilitate the recognition of underlying psychological distress in patients presenting solely with somatic complaints. Child and adolescent psychiatrists' consultation skills and abilities to work within school systems may provide entree to helping children and families. Finally, with our current appreciation of the threats posed by bioterrorism and emerging infectious diseases, psychiatrists' medical backgrounds become particularly helpful in the recognition of organic mental disorders, familiarity with hospital environments, and experience in working with medically ill patients and their families.
The 9/1 1 terrorist attacks in the United States have resulted in a surge of interest in the field of disaster psychiatry. Training and education are now available in multiple venues in addition to the longstanding opportunities provided at the Annual Meeting of the American Psychiatric Association (APA). The APA's Committee on Psychiatric Dimensions of Disasters offers a Web site4 that allows district branch disaster representatives to share ideas and ask questions in addition to providing a number of excellent references and links to other internet resources.
Although this issue and the September issue of Psychiatric Annals are excellent introductions to the specialty of disaster psychiatry, clinicians are encouraged to attend psychiatric and other medical and nonmedical lectures and workshops in person. This allows for networking in addition to enhancement of the fund of knowledge.
PHASES OF DISASTER
Familiarity with the phases of disaster (Figure, see page 599) helps psychiatrists frame their expectations of what they likely will encounter during time in their communities.5 The predisaster phase is used to develop, test, and refine comprehensive "all hazard" disaster plans for response and subsequent reconstruction efforts. It is important for psychiatrists to be involved at this stage, forging the necessary relationships and learning about both theirs and others' roles and responsibilities if they expect to play a formal role in the immediate aftermath of the disaster.
Indeed, if a psychiatrist does not have a formal role identified in advance of a disaster, it is best to stay away from the disaster scene and to make availability known to a district branch. "Spontaneous volunteers," as highly trained as they may be, are a major logistical problem, diverting resources from their primary response mission, adding to confusion at the scene, and potentially endangering the safety of first responders. Psychiatrists will be critically needed in the weeks, months, and years following a disaster to treat people whose distress responses have not abated but rather have become disorders.
For some disasters, such as hurricanes, there is a period of warning during which one can prepare for the disaster. In other instances, notably terrorism, there is no warning and there may even be a time lag between the terrorists* actions and recognition that a disaster has occurred - for example, the incubation period for microbes in a bioterrorism attack.
Phases of Disaster5
During the initial phase of a disaster, prosocial behaviors are the norm rather than the often-depicted disaster myths of panic and looting. Heroic acts will be reported, and the community generally will pull together, leading to the "honeymoon" period. This is marked by the influx of resources, recognition, and validation of suffering and heroism, and a general feeling of good will for having survived and helped others.
As the external supports gradually withdraw, however, the realities of loss and mourning hit. the hassles of dealing with insurance companies and government agencies begin, and the hardships associated with damage to infrastructure, such as transportation, become part of daily life. The disillusionment phase takes place. This is often heralded by the beginning of investigations into what mistakes might have been made and, in general, the emergence of a great deal of anger, usually targeted at public officials.
The reconstruction phase begins when the community's spirits have begun to work through the worst of the grief and anger and a sense of "getting on with it" begins to settle in. In this final phase, it is important to keep in mind the importance of reminders of the community trauma - both the predictable times of distress, such as anniversaries or dedications of memorials, and the unpredictable times, such as trauma befalling another community, rekindling unbidden thoughts and images.
UNDERSTANDING PSYCHOLOGICAL AND BEHAVIORAL RESPONSES
In the immediate aftermath of extraordinary events, both individuals and communities invariably respond in adaptive and maladaptive ways that need to be understood before the event in order to mount effective responses.1,2,6,7 While providing psychological assistance to victims of disasters is not new, there is a continuing need for better understanding of the psychological sequelae, risk and protective factors, efficacy of various interventions, and new models for conceptualizing and organizing response.8
The psychological responses of most people exposed to a catastrophic event, are fear, anger, and distress, reactions that do not significantly affect behavior nor rise to me level of a disorder. A smaller group will be affected to the extent that they significantly change their behaviors (such as not flying, reducing travel, and so on). An even smaller group will develop a psychiatric disorder.
One of the cornerstone principles of understanding the effects of emergencies and disasters (of any type) is the assumption that virtually everyone who experiences such an event is affected by it. Nature, magnitude, and duration are quite variable, but some type of psychological effect is to be expected. Most reactions represent ordinary responses to an extraordinary situation. That said, "normal" does not mean trivial. Ideally, interventions reduce the number of people who subsequently develop psychiatric disorders over the long term and diminish the severity of those disorders.
However, even if those goals are not achieved, other important aims can be realized. Analogous to an orthopedic surgeon prescribing an analgesic to promote range of motion, not to heal a fracture, early mental health interventions aim to diminish suffering, preserve function, and promote resilience and recovery, not necessarily to prevent disease. Psychosocial responses are among the most widespread, long-term, and costly of all health consequences.
While physical, emotional, cognitive. and behavioral signs of stress are commonly dealt with, spiritual signs of stress are addressed less often. Because of the centrality of religious beliefs in most cultures, understanding how the religious beliefs of people are challenged is important. Seeking help, finding social support, and understanding adversity often take place in the context of religious belief and in the religious community. Mental health experts who do not understand this dynamic and, irrespective of their personal beliefs, do not involve the faith community in designing and delivering interventions are not making good use of one of the most significant natural healing systems.
Common acute psychological, behavioral, cognitive, and physical responses encountered after a disaster, as well as longer-term behavioral health consequences, are listed in the Table (see page 60I).6
Frequently, mental or behavioral health priorities are viewed exclusively in the affective domain (ie, how people feel about what they have experienced). Although important, this is not the only, or usually primary, focus of behavioral healtJi interests. For example, in events involving potential large-scale health consequences, the overriding goal of behavioral health providers and leaders should be to influence individual and collective behavior in a positive manner. Should people seek care immediately? Should they not seek healthcare? Should people evacuate? Should they shelter in place? Each of these issues is about preserving and protecting the public's health, and each is potentially a life and death behavioral choice. Compliance or lack of compliance will enhance or impede the effectiveness of the overall disaster response. Compliance is greatly influenced by psychosocial factors.
POPULATIONS AFFECTED BY DISASTER
It often is helpful to think of those affected in various categories of the severity of trauma. Primary victims and survivors are typically defined as those who experienced direct personal effects such as injury, death of a loved one, loss of property, and so on. Secondary victims are those who may not have been directly exposed to the threat or lost a loved one but for whom there is. nonetheless, significant reaction. Examples of secondary victims include community members who witnessed the event or whose lives are disrupted because of the adverse effects on community structures or institutions.
Tertiary victims are those who were affected indirectly and may not even reside in the community. These people may have witnessed the event on television or experienced economic consequences due to an indirect effect (eg, hospitality industry employees in New York City and Washington. DC. following the 9/1 I attacks).
Each of these groups often has unique stressors and may require services and interventions tailored to their particular roles, experiences, and occupational cultures.
Not all extreme events are the same. Differing events have elements that tend to reduce or exacerbate psychosocial sequelae. Disaster events are typically categorized in two primary ways: natural and human-caused.
Natural disasters are often acknowledged as part of living, are associated with less assignment of blame than other types of events, and are experienced by more people and communities. Examples include hurricanes, floods, and tornadoes.
Human-caused events may be unintentional or intentional. With unintentional events, blame is typical and an important psychological component that may impede resolution of distress if people do not move past it. Examples of unintentional human-caused disasters include industrial accidents, air or ground transportation events based on equipment failure, and dam collapses.
By contrast, intentional events produce rage, helplessness, and a sense of vulnerability. Psychological sequelae are more serious, more complex, more long-term. and. when the total cost of treatment and lost productivity are considered, more expensive.
The psychological effects of intentional violence directed at civilians, especially children, are captured in this description of a visit to the site of the Alfred P. Murrah Federal Building bombing in Oklahoma City, OK, written by the first author of this article:
"When ... 1 was asked to relate the worst single event of my stay, this is the story I told. Although I had viewed it several times from a distance, after leaving the temporary morgue, I first stood in front what remained of the Murrah Federal Building. My first impression was amazement that something capable of fitting in a small truck could do so much damage. A complex mixture of powerful emotions then overwhelmed me, some of which look me quite by surprise. First, I was struck by my intense identification, as a Federal employee, with the victims. I have spent much of my career viewing myself as different from most of my Federal colleagues and being a Federal employee has been only a minor part of my ego identity. My response shocked me. I saw desks, chairs, and filing cabinets that were just like the ones in my office! Even the building had a similar design to the one in which I work.
A very primitive intense rage enveloped me and I began to cry. I have seen damage before in other disasters, and in many ways worse than this. But I could not get over the fact that someone had done this! Someone had intentionally created this carnage! Rage is an emotion that frightens me and, in that moment, it consumed me. ...
Common Responses and Long-term Effects of Disasters
In the days that have passed, I have thought much about the strength and complexity of my feelings as I stood before the building. Many of those thoughts have been about the nature of grief. It occurs to me that grief is neither a gift nor a curse although it may, at times, seem like both. Perhaps, instead, it is the dividend of our investment in or commitment to an individual or a group (parents. Federal workers, children). Without investment there is no loss. Without loss there is no grief. We earn our grief with our investment in others. It is therefore a precious dividend not to be avoided or shunned but embraced.'"'
One subset of intentional disasters that creates especially strong psychological, behavioral, and sociocultural responses is terrorism that employs chemical, biological, radiological, or nuclear agents, often referred to collectively as "weapons of mass destruction.''10*12 Although the use of anthrax in the US in 2001 and the 1995 sarin attack in Tokyo, Japan, did not cause mass death or destruction, they were very effective weapons of mass disruption. In these types of events, fear-driven behaviors may overwhelm medical care, influence evacuation behaviors, produce fear of exposure or contagion, create anxiety over what to expect or do, prompt hording of medication, and fuel intense worries about the status and well-being of loved ones.
NATURE OF PSYCHOLOGICAL RESPONSES
Norris and colleagues1314 reviewed the empirical research literature on 160 samples of disaster victims that were published between 1981 and 2001 and analyzed the findings, which incorporated more than 60,000 people. While in some areas the literature was conflicting, many predictors of distress (and in some studies, disorders) shared high commonality across a wide range of disasters. Some of the findings include:
* Women were more likely to be distressed than men (eg, women experienced twice the rate of posttraumatic stress disorder [PTSD | as men).
* Middle-aged adults reported more distress than did older and younger adults.
* Ethnic minorities generally experienced more distress than majority victims (often confounded by greater exposure).
* Children of distressed parents were more distressed than those of non-distressed parents.
* Mothers with young children were at high risk of distress.
* The greater the number of significant life events or chronic stress, the greater the probability of being distressed.
* Those with predisaster psychological symptoms or problems were more likely to be more highly distressed (especially true in low-magnitude disasters, not as helpful in extremely traumatic situations).
* Those who had higher neuroticism and worry and anxiety traits were more vulnerable to distress.
* Those with a greater loss of resources were more distressed than those with lower losses.
Most of these studies focused on psychopathology. However, some studies examined factors related to resilience (see also the article by Dr. Reissman et al., page 626). In one prospective study, three types of coping - active outreach, informed pragmatism, and reconciliation - were associated with a lower risk for psychiatric disorders.15 Feelings of self-efficacy, mastery, and higher self-esteem predicted less distress.16'21
Social and community factors were also important. Those who experienced higher "social embeddedness" and who received (or perceived) higher levels of social support were less distressed.1314,22 Other community factors that have not been well studied but are believed to play a major role include the severity of damage to the community's fabric and leadership, often due to relocation and job loss.
For most people, acute response to disaster resolves as time passes. However, for some, responses will persist and cause suffering and disability. When thinking of psychiatric disorders resulting from trauma, acute stress disorder and PTSD quickly come to mind.
It is important to remember, however, that other disorders may result, and that PTSD usually is a comorbid condition. Other diagnoses associated with disasters include major depression, increased substance use or abuse, panic disorder, phobic disorders, somatization disorders, and traumatic bereavement.20
Large numbers of people exposed to disaster will experience some level of disaster-related stress. These normal reactions should be recognized, normalized, and identified as such for those experiencing these stress signs. For disaster survivors, the first priorities are the restitution of safety, food, shelter, sanitation, attention to medical needs, resolution of physiological arousal, and contact with loved ones.
While not researched sufficiently, there is consensus23 that early intervention in the form of psychological first aid may be beneficial. While many models of psychological first aid are emerging, most involve components of proximity (intervening in reasonable physical closeness), immediacy (intervening as quickly as possible), and expectance (expect return to normal functioning).
In terms of psychosocial interventions, years of experience in a wide variety of extraordinary events have demonstrated a number of common factors that characterize what happens to people and how they respond to interventions and services.24 Few who experience a disaster are unaffected by it, and most psychological responses can. and should, be viewed as normal responses to an abnormal event. There are always both individual and collective responses to disaster. Individuals live in the context of their communities and often within families, and communities are composed of individuals. It is important to monitor, assess, and positively influence community response and recovery on individuals and visa versa.
For a variety of reasons, especially stigma, few people will seek services or treatment. Assertive outreach is necessary to reach large numbers of victims and survivors. Psychoeducational approaches are a key mode of reaching significant numbers of victims and survivors. Information, education, and a comforting therapeutic presence are universal interventions. These can be provided with reasonable expectation that they have positive effects, as well as a reasonable expectation that they will do no harm.
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Common Responses and Long-term Effects of Disasters