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Training Manual
for Mental Health and Human Service Workers
in Major Disasters
SECTION 2
Responses to Disaster
A survivor's reactions to and recovery from a disaster are influenced
by a number of factors, some inherent and some malleable. These factors are depicted in the diagram below, and, as shown, contribute to recovery outcomes. The disaster event itself has characteristics, such as speed of onset or geographic scope, which generates somewhat predictable survivor responses. Each survivor has a combination of personal assets and vulnerabilities that either mitigate or exacerbate disaster stress. The disaster-affected community may or may not have pre-existing structures for social support and resources for recovery. Disaster relief efforts that effectively engage with survivors and the overall community promote recovery.
This section describes critical variables associated with each factor. The term "psychosocial" is often used to capture the breadth of effects of disaster on survivors. As shown in the diagram below, disasters unavoidably impact survivors both psychologically and socially. Disaster mental health program planners, administrators, and providers can more easily assess their own communities and design effective interventions when they have an appreciation for this "macro" view of interacting factors.
Characteristics of Disasters
Disasters are not uniform events. Each disaster, be it a flood, earthquake, hurricane, or human-caused disaster, has intrinsic unique elements. These elements have psychological implications for survivors and communities. The disaster characteristics discussed in this section are: natural vs. human causation, degree of personal impact, size and scope, visible impact/low point, and the probability of recurrence. Each of these, individually or collectively, has the potential for shaping and influencing the nature, intensity, and duration of post-disaster stress.
Natural vs. Human Causation
While there are divergent findings regarding whether natural or human-caused disasters produce greater overall psychological effects, there are clearly psychological reactions unique to each (Weisaeth,1994; Rubonis & Bickman,1991). In human-caused disasters such as bombings and other acts of terrorism, technological accidents, or airline crashes, survivors grapple with deliberate human violence and human error as causal agents. The perception that the event was preventable, the sense of betrayal by a fellow human(s), the externally focused blame and anger, and the years of prolonged litigation are associated with an extended and often volatile recovery period.
In true natural disasters, the causal agent is seen as beyond human control and without evil intent. For some, accepting mass destruction as "an act of God" is easier, whereas for others it can be more difficult. The world can temporarily seem to become unsafe with its potential for random, uncontrollable and devastating events (Yates, 1998).
In reality, there is a continuum between natural and human factors. Many disasters occur or are worsened through an interaction of natural and human elements (Green & Solomon, 1995). For example, damage from the natural event of flooding may be increased due to human factors such as inadequate planning, governmental policies, or faulty warning systems. An aircraft accident may result from an interaction of poor weather conditions and pilot error. Survivors experience reactions consistent with each dimension as they struggle with causal attributions.
Degree of Personal Impact
Researchers have consistently shown that the more personal exposure a survivor has to the disaster's impact, the greater his or her post-disaster reactions (Solomon & Green, 1992). Death of a family member, loss of one's home, and destruction of one's community exemplify high impact factors. In each of these, the intertwining of grief and trauma processes compound the effects and extend the duration of the recovery period for many survivors (Kohn & Levav, 1990). High exposure survivors experience more anxiety, depression, sadness, post-trauma symptoms, somatic symptoms, and, in some studies, alcohol abuse.
Size and Scope of the Disaster
As with the degree of personal impact, a dose-response relationship between community devastation and psychological impact exists. When entire communities are destroyed, everything familiar is gone. Survivors become disoriented at the most basic levels. Researchers have found higher levels of anxiety, depression, post-traumatic stress, somatic symptoms, and generalized distress associated with widespread community destruction (Solomon & Green, 1992).
When some fabric of community life is left intact (e.g., schools, churches, commercial areas), there is a foundation from which recovery can occur. Social support occurs more readily when community gathering places remain. Survivors are then more able to continue some of their familiar routines. Family roles of provider, homemaker, or student are more able to be fulfilled when structures and institutions remain.
Visible Impact/Low Point
Most disasters have a clearly defined end point that signals the beginning of the recovery period. After a tornado, hurricane, or wildfire has passed through an area, the community sees the total extent of resulting physical destruction and begins the recovery and rebuilding process. The disaster threat is over and healing can begin.
However, in contrast technological events like nuclear accidents or toxic spills are "silent" disasters and do not show visual damage or have an observable "low point." The health consequences of increased risk for cancer and birth defects continue for decades (Green & Solomon, 1995; Berren et al., 1989). This prolonged impact period with no clear end impedes the recovery process. Survivors suffer the effects of chronic stress and anxiety due to the extended period of anticipation, fear, and threat (Davidson & Baum, 1994).
The end point of the disaster can be ambiguous in some natural disasters as well. Although an earthquake has its major impact, the aftershocks keep survivors worrying that "the big one is yet to come." Slow moving, repeat flooding, and related landslides may continue for months through a period of heavy rains. While there is visual physical damage to be reckoned with, it may be weeks or months before survivors feel that the disaster is truly over.
Probability of Recurrence
When the disaster has a seasonal pattern, such as hurricanes or tornadoes, survivors are concerned they will be hit again before the season ends. During the low-risk portion of the year, communities rebuild. Vegetation grows back and visual reminders of the disaster diminish. At the one-year anniversary, the reminder that the area is potentially at-risk again causes disaster stress and hypervigilance to resurface.
The immediate probability of recurrence is perceived as high following earthquakes and floods. The aftershocks following an earthquake or the increased risk of flooding due to ground saturation and damaged flood control structures following major floods keep many survivors anxious and preoccupied. In flood plain areas prone to repeat flooding, survivors can be kept in limbo regarding governmental buyouts, re-zoning, or the rebuilding of their homes as local, State, and Federal agencies address jurisdictional and legislative issues. This can be especially threatening and anger inducing when the next year's flood season approaches and decisions and/or repairs have not yet been made.
These five characteristics of disasters-natural vs. human causation, degree of personal impact, size and scope, visible impact/low point, and the probability of recurrence-contribute to dynamics that have potential psychosocial implications. These characteristics further define the disaster event portrayed in the diagram at the beginning of this section. Now, the discussion will shift to the survivor's characteristics that can mitigate or elevate disaster stress outcomes.
Survivor/"Person" Characteristics
A major disaster indiscriminately affects all who are in its path. Some disasters, such as a tsunami or landslide, may happen disproportionately to destroy wealthy people's shoreline or cliff-top view properties; whereas, another disaster, such as an earthquake or hurricane, may destroy poor people's structurally unsound housing. The disaster may affect thousands to millions of people in a densely populated urban area, or affect comparatively small numbers of people in a sparsely populated rural area.
Each survivor experiences the disaster through his or her own lens. The meaning the survivor assigns to the disaster, the survivor's inherent personality and defensive style, and the survivor's world view and spiritual beliefs contribute to how that person perceives, copes with, and recovers from the disaster. Experiences with losses or disasters may enhance coping or may compromise coping due to unresolved issues associated with those past events.
Having sufficient financial resources and being able to benefit from a social support network buffer the potentially devastating effects of a disaster and greatly assist the recovery process. An additional resilience factor includes the ability to tolerate and cope with disruption and loss. In contrast, vulnerability factors include preexisting health or emotional problems and additional concurrent stressful life events (McFarlane, 1996). In addition, cultural experience and ethnic background may facilitate or interfere with a survivor's ability to engage with disaster relief efforts.
Research findings are inconsistent with regard to the impact of gender and age on psychological outcomes. There is some indication that those in the forty to sixty age range may be more at risk because of the competing demands of child rearing, jobs, and caring for elderly parents (Green & Solomon, 1995). While single survivors may be more vulnerable than those who are married, increased marital conflict has been demonstrated following disasters. Refer to Section 3 for more information on the disaster reactions of potential risk groups.
Disaster Relief Efforts
When disaster relief efforts "fit" the community being served, survivors' access to assistance is enhanced. Information is available in native languages through print media, radio, and television. Relief workers are respectful of differences and work with trusted community leaders. Barriers are identified and addressed as every effort is made to connect survivors with resources for recovery.
While the above description is a goal, relief efforts may fall short. Disaster mental health workers may identify survivor groups who are not receiving services or recognize incompatibilities between the relief operation and the disaster-affected community. When individual survivors are unable to access services because of their limitations, disaster mental health workers may assist the survivor with overcoming personal or institutional barriers.
The relationships depicted in the Phases of Disaster diagram (page 5) shift over time. The experiences and needs of survivors and the community are different in the first week following the disaster compared with those at three months. Disaster relief efforts, including mental health programs, must maintain awareness of and accommodate to the time-based phases of disaster response (Tassey et al., 1997).
Phases of Disaster
Both community and individual responses to a major disaster tend to progress according to phases. An interaction of psychological processes with external events shapes these phases. Examples of significant time-related external events are the closure of the emergency response phase, the damage assessment of one's personal residence, or receiving financial determinations. The following represents a compilation of phase lists developed by different disaster experts. These particular phases have been selected and described because of their relevance to disaster mental health planners and workers in providing ongoing disaster recovery assistance.
Warning or Threat Phase
Disasters vary in the amount of warning communities receive before they occur. For example, earthquakes typically hit with no warning, whereas, hurricanes and floods typically arrive within hours to days of warning. When there is no warning, survivors may feel more vulnerable, unsafe, and fearful of future unpredicted tragedies. The perception that they had no control over protecting themselves or their loved ones can be deeply distressing.
When people do not heed warnings and suffer losses as a result, they may experience guilt and self blame. While they may have specific plans for how they might protect themselves in the future, they can be left with a sense of guilt or responsibility for what has occurred.
Impact Phase
The impact period of a disaster can vary from the slow, low-threat buildup associated with some types of floods to the violent, dangerous, and destructive outcomes associated with tornadoes and explosions. The greater the scope, community destruction, and personal losses associated with the disaster, the greater the psychosocial effects.
Depending on the characteristics of the incident, people's reactions range from constricted, stunned, shock-like responses to the less common overt expressions of panic or hysteria. Most typically, people respond initially with confusion and disbelief and focus on the survival and physical well-being of themselves and their loved ones. When families are in different geographic locations during the impact of a disaster (e.g., children at school, adults at work), survivors will experience considerable anxiety until they are reunited.
Rescue or Heroic Phase
In the immediate aftermath, survival, rescuing others, and promoting safety are priorities. Evacuation to shelters, motels, or other homes may be necessary. For some, post-impact disorientation gives way to adrenaline induced rescue behavior to save lives and protect property. While activity level may be high, actual productivity is often low. The capacity to assess risk may be impaired and injuries can result. Altruism is prominent among both survivors and emergency responders.
The conditions associated with evacuation and relocation have psychological significance. When there are physical hazards or family separations during the evacuation process, survivors often experience post-trauma reactions. When the family unit is not together due to shelter requirements or other factors, an anxious focus on the welfare of those not present may detract from the attention necessary for immediate problem-solving.
Remedy or Honeymoon Phase
During the week to months following a disaster, formal governmental and volunteer assistance may be readily available. Community bonding occurs as a result of sharing the catastrophic experience and the giving and receiving of community support. Survivors may experience a short-lived sense of optimism that the help they will receive will make them whole again. When disaster mental health workers are visible and perceived as helpful during this phase, they are more readily accepted and have a foundation from which to provide assistance in the difficult phases ahead.
Inventory Phase
Over time, survivors begin to recognize the limits of available disaster assistance. They become physically exhausted due to enormous multiple demands, financial pressures, and the stress of relocation or living in a damaged home. The unrealistic optimism initially experienced can give way to discouragement and fatigue.
Disillusionment Phase
As disaster assistance agencies and volunteer groups begin to pull out, survivors may feel abandoned and resentful. The reality of losses and the limits and terms of the available assistance becomes apparent. Survivors calculate the gap between the assistance they have received and what they will require to regain their former living conditions and lifestyle.
Stressors abound-family discord, financial losses, bureaucratic hassles, time constraints, home reconstruction, relocation, and lack of recreation or leisure time. Health problems and exacerbations of pre-existing conditions emerge due to ongoing, unrelenting stress and fatigue.
The larger community less impacted by the disaster has often returned to business as usual, which is typically discouraging and alienating for survivors. Ill will and resentment may surface in neighborhoods as survivors receive unequal monetary amounts for what they perceive to be equal or similar damage. Divisiveness and hostility among neighbors undermine community cohesion and support.
Reconstruction or Recovery Phase
The reconstruction of physical property and recovery of emotional well-being may continue for years following the disaster. Survivors have realized that they will need to solve the problems of rebuilding their own homes, businesses, and lives largely by themselves and have gradually assumed the responsibility for doing so.
With the construction of new residences, buildings, and roads comes another level of recognition of losses. Survivors are faced with the need to readjust to and integrate new surroundings as they continue to grieve losses. Emotional resources within the family may be exhausted and social support from friends and family may be worn thin.
When people come to see meaning, personal growth, and opportunity from their disaster experience despite their losses and pain, they are well on the road to recovery. While disasters may bring profound life-changing losses, they also bring the opportunity to recognize personal strengths and to reexamine life priorities.
Individuals and communities progress through these phases at different rates depending on the type of disaster and the degree and nature of disaster exposure. This progression may not be linear or sequential, as each person and community brings unique elements to the recovery process. Individual variables such as psychological resilience, social support, and financial resources influence a survivor's capacity to move through the phases. While there is always a risk of aligning expectations too rigidly with a developmental sequence, having an appreciation of the unfolding of psychosocial reactions to disaster is valuable.
Key Concepts of Disaster Mental Health
The following guiding principles form the basis for disaster mental health intervention programs. Not only do these principles describe some departures and deviations from traditional mental health work; they also orient administrators and service providers to priority issues. The truth and wisdom reflected in these principles have been shown over and over again, from disaster to disaster.
No one who sees a disaster is untouched by it.
There are two types of disaster trauma-individual and community.
Most people pull together and function during and after a disaster, but their effectiveness is diminished.
Disaster stress and grief reactions are normal responses to an abnormal situation.
Many emotional reactions of disaster survivors stem from problems of living brought about by the disaster.
Disaster relief assistance may be confusing to disaster survivors. They may experience frustration, anger, and feelings of helplessness related to Federal, State, and non-profit agencies' disaster assistance programs.
Most people do not see themselves as needing mental health services following a disaster and will not seek such services.
Survivors may reject disaster assistance of all types.
Disaster mental health assistance is often more practical than psychological in nature.
Disaster mental health services must be uniquely tailored to the communities they serve.
Mental health workers need to set aside traditional methods, avoid the use of mental health labels, and use an active outreach approach to intervene successfully in disaster.
Survivors respond to active, genuine interest, and concern.
Interventions must be appropriate to the phase of disaster.
Social support systems are crucial to recovery.
(CMHS, 1994; See Chapter 1, page 1, for more information.)
Community Outreach
Outreach approaches that offer practical assistance with problem-solving and accessing resources are key to a successful program. Returning to the diagram at the beginning of this Section, "disaster relief efforts," as shown, include disaster mental health services. It is essential that those services have the flexibility to engage with diverse individual survivors and the varied elements within the community. Programs should establish a vital presence early in recovery, developing creative strategies to meet survivors where they are and bring them forward in their recovery process.
Most people who are coping with the aftermath of a disaster do not see themselves as needing mental health services and are unlikely to request them. People reacting to disasters tend to have little patience with implications that they are in need of psychological treatment. This is why terms like "psychotherapy" or "psychological counseling" are often rejected and terms like "assistance with resources" and "talking about disaster stress" are more acceptable.
Survivors who will be using program services are, for the most part, normal, well-functioning people who are under temporary emotional stress.
Disaster mental health workers must go to the survivors and not wait and expect that the survivors will come to them (Cohen, 1990). This means being visible in the disaster-affected neighborhoods, often going door-to-door to check-in with residents to see if they want assistance. Establishing relationships with community gatekeepers like corner store owners, or local cafe staff is important for referrals of survivors in need. Attending community gatherings at churches, schools, or community centers is useful for connecting with local residents and providing disaster mental health information. Besides these outreach approaches, educational materials that describe and emphasize the normalcy of reactions are of great benefit for disaster survivors. Educational outreach through the media-television, newspaper, radio, and community newsletters-reaches survivors whom other means might not contact. Disaster Response and Recovery: A Handbook for Mental Health Professionals provides extremely useful and detailed information about community outreach in a range of settings (CMHS, 1994).
Disaster mental health workers are most likely to find people struggling with the disruption and loss caused by the disaster. Disaster-related psychological symptoms warranting diagnosis are rare (Ursano, et al., 1995). People vary in the ability to recognize their own needs and in comfort level with asking for help. They may, for example, feel that it is personally degrading to request clothing or to seek an emergency loan. This reluctance can usually be overcome by personal contact with a caring person, who has the correct information and encourages the seeking of assistance.
Above all, disaster mental health programs must actively fit the disaster-affected community. Salient dimensions for consideration include: ethnic and cultural groups represented, languages spoken, rural or urban locales, values about giving and receiving help, and who and what the affected groups are most likely to trust. Access and acceptance is gained more quickly when disaster mental health programs coordinate and collaborate with local trusted organizations.
References and Recommended Reading
Austin, L, S. Responding to Disaster: A Guide for Mental Health Professionals. Washington, DC: American Psychiatric Press, 1992.
Berren, M. R., Santiago, J. R., Beigel, A., & Timmons, S. A. A classification scheme for disasters. In: Gist, R. & Lubin, B. (Eds.) Psychological Aspects of Disaster. New York: John Wiley & Sons, 1989.
Center for Mental Health Services. Disaster Response and Recovery: A Handbook for Mental Health Professionals. Washington, D.C.: U.S. Department of Health and Human Services; Publication No. (SMA) 94-3010, 1994.
Cohen, R. E. Post-disaster mobilization and crisis counseling: Guidelines and techniques for developing crisis-oriented services for disaster victims. In: Roberts, A. R. (Ed.). Crisis Intervention Handbook: Assessment, Treatment and Research. California: Wadsworth, 1990.
Davidson, L. M. & Baum, A. Psychophysiological Aspects of Chronic Stress Following Trauma. 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.
Fullerton, C. S. & Ursano, R. J. Posttraumatic Stress Disorder: Acute and Long-Term Responses to Trauma and Disaster. Washington, D.C.: American Psychiatric Press, 1997.
Gist, R. & Lubin, B. (Eds.). Psychological Aspects of Disaster. New York: John Wiley & Sons, 1989.
Green, B. L. & Solomon, S. D. The Mental Health Impact of Natural and Technological Disasters. In Freedy, J. R. & Hobfoll, S. E. (Eds.) Traumatic Stress: From Theory to Practice. New York: Plenum, 1995.
Hobfoll, S. E. & deVries, M. W. Extreme Stress and Communities: Impact and Intervention. Dordrecht, The Netherlands: Kluwer, 1995.
Kohn, R. & Levav, I. Bereavement in disaster: An overview of the research. International Journal of Mental Health. 19(2), 61-76, 1990.
McFarlane, A. C. Resilience, vulnerability, and the course of posttraumatic reactions. In: van der Kolk, B. A., McFarlane, A. C., & Weisaeth, L. (Eds.) Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body and Society. New York: Guilford Press, 1996.
Miller, E. (Ed.). Special issue: Theoretical and empirical issues in disaster research. Journal of Personal and Interpersonal Loss, 3(1), 1998.
Rubonis, A. V. & Bickman, L. Psychological impairment in the wake of disaster: The disaster-psychopathology relationship. Psychological Bulletin, 109, 384-399, 1991.
Solomon, S. D. & Green, B. L. Mental health effects of natural and human-made disasters. PTSD Research Quarterly, 3(1) 1-8, 1992.
Tassey, J. R., Carll, E. K. Jacobs, G. A., Lottinville, E., Sitterle, K., & Vaugn, T. J. American Psychological Association Task Force on the Mental Health Response to the Oklahoma City Bombing, 1997.
Ursano, R. J., Fullerton, C. S., & Norwood, A. E. Psychiatric dimensions of disaster: Patient care, community consultation, and preventive medicine. Harvard Review of Psychiatry, 3, 196-209, 1995.
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.
van der Kolk, B. A., McFarlane, A. C., & Weisaeth, L. (Eds.). Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body and Society. New York: Guilford Press, 1996.
Weisaeth, L. Psychological and psychiatric aspects of technological 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.
Yates, S. Attributions about the causes and consequences of cataclysmic events. Journal of Personal and Interpersonal Loss, 3(1) 7-24, 1998.
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