In the days and weeks following the 9/11 attacks in New York, Raymond F. Hanbury, PhD, was struck more by the silences than the noise — the hush that fell over people when a victim's body was recovered from Ground Zero or the silence on ferry rides from New Jersey that carried people to the site so they could commemorate lost loved ones.
"You could feel the tremendous sadness everyone had," says Hanbury, who is chief psychologist at the Jersey Shore University Medical Center in Neptune, New Jersey, and has served after many disasters since Hurricane Andrew in 1991.
In the weeks that followed, he witnessed people's grief, shock, confusion and anger. He also saw resilience.
"Most people have a fairly good coping process," he says, though reactions vary widely. "The idea is to support them in that process."
Hanbury is unusual in the amount of training he's received to help people in the wake of such crises. He is mental health and public information officer for New Jersey's team within the National Disaster Medical System, he coordinates the New Jersey Psychological Association's Disaster Response Network, he's a Red Cross disaster mental health advisor for the state, and he is a team leader with the state's disaster response crisis counselor program.
Still, he and others say, all psychologists can learn how to be effective and have a role in the face of emergencies and disasters.
Whether you respond to the event by volunteering your time and skills, or simply learn ways to protect your important paperwork, computers and computer files (see page 66), what's key is understanding the basics of preparedness, people's varied responses to disasters, and the interventions and strategies that work.
Mental health workers first began responding to disasters in large numbers in the 1990s. At the time, they assumed that people would be traumatized by the event and need mental health intervention. To this end, they applied various structured group interventions where responders, survivors and family members of loved ones could share the cognitive and emotional aspects of the incident.
Since then, psychologists have learned that many survivors demonstrate resilience in the face of disasters. As a result, today's response teams — which include members of the APA Disaster Response Network who work in conjunction with groups like the American Red Cross and the National Disaster Medical System — use interventions that include explaining and normalizing people's psychological reactions to an event, meeting basic needs like food, clothing and shelter, connecting survivors with support systems, and referring those in need to more targeted psychological support.
Research also suggests that most people want to work out their post-crisis life on their own, adds Patricia Watson, PhD, who is senior educational specialist for the National Center for PTSD at the University of California, Los Angeles, and an assistant professor at Dartmouth Medical School.
"The general strategy for most disaster survivors is to provide resources that can help them adjust to their post-disaster life, and if necessary, to help them accept it and encourage them to continue to proceed step by step, day by day," says Watson, who with other psychologists summarized the state of post-disaster intervention research in the September 2011 American Psychologist. "If they're stressed out, it doesn't mean they're weak or that their responses are ‘pathological,'" she adds. "Disaster survivors have been through a lot, so stress reactions are to be expected."
Behavioral health triage
Today, the protocol used by most disaster organizations is based on empirically tested behavioral health strategies. Among the most common initial interventions is psychological first aid. Its goals are to promote safety, stabilize survivors in basic ways and connect survivors with additional resources, especially people who exhibit distress or problems functioning immediately after a disaster.
"Psychological first aid helps people start to pull together again, and helps to mitigate their immediate emotional, behavioral and physical signs of distress," Hanbury says.
For people still traumatized several weeks after an event, more intervention may be needed. This often comes in the form of crisis counseling, a type of intervention provided by lay and mental health professionals that is funded by the Federal Emergency Management Agency and sometimes administered by the Substance Abuse and Mental Health Services Administration after presidentially declared disasters.
Crisis counseling, which lasts from one session to as many as are needed, is "much more directive and pragmatic than normal counseling," says disaster researcher Lisa Brown, PhD, of the University of South Florida. If you're helping someone who has lost a loved one process their reactions, for instance, you will also address their practical concerns, such as finding them reliable transportation or helping them fill out FEMA paperwork.
"Most people recover within eight to 12 months after a disaster, but my argument is, ‘Why would you want to struggle alone when there are resources and people willing to help you make that a shorter process?'" says Brown.
Psychologists engaged in disaster response often take the American Red Cross's Disaster Mental Health Fundamentals course, says Margie Bird, director of the Disaster Response Network for APA. The course and its accompanying handbook describe likely client needs, appropriate interventions and responder self-care. APA member psychologists write portions of the frequently updated course and incorporate the latest psychological research related to disasters, she says.
Another example of specialized, evidence-based crisis counseling is Skills for Psychological Recovery, an intervention developed at the request of the Substance Abuse and Mental Health Services Administration by Watson, early intervention researchers and colleagues at the National Center for PTSD and the National Child Traumatic Stress Network. Tailored to individual needs and flexible in content and number of sessions, it is based on five elements of recovery first delineated by Stevan E. Hobfoll, PhD, Watson and colleagues in a 2007 article in Psychiatry: promoting a sense of safety, calm, self- and community efficacy, connectedness and hope.
Interventions to foster these outcomes include helping survivors and family members to problem solve, to build positive activities back into their lives, and to manage stress through simple interventions such as breathing or writing in a journal. Other strategies include reframing thinking about the stressful aspects of life and building a healthy social support network.
"That could be an aunt you haven't talked to for years but who was always nice and supportive, or another disaster survivor who is struggling as much as you are — who understands how hard things are," Watson says.
One middle-aged survivor entered counseling after Hurricane Gustav with problems related to diabetes, the recent loss of her two sisters, a car she couldn't afford to repair and an expired driver's license. Her counselors helped her connect with doctors, seek new social support and renew her license online, among other interventions, Watson says.
If a person is still struggling several months later, the model calls for more intensive, specialized therapy. Some interventions are more effective than others. Randomized controlled trials find, for example, that tailored cognitive-behavioral interventions help to reduce PTSD, depression and anxiety among disaster survivors and first responders. Uncontrolled studies show similar results for terrorism-related PTSD, according to the American Psychologist article.
Who's more vulnerable
In the wake of a disaster, it is also helpful to know who statistically is most prone to psychological distress. Research shows that people closer to the ground zero — be they bystanders, first responders or members of the media — are often at greater risk for stress reactions than those who were farther away.
Other at-risk groups include children and teens, women, people who are socially isolated, those with financial hardships and those whose language and cultural differences hinder clear communication during and about an event. People who are chronically ill, cognitively impaired or have histories of extreme trauma, substance abuse or severe mental illness also are more vulnerable than others.
Research also suggests that terrorist attacks — because they are human-made, unpredictable and deliberately aimed at hurting people — may cause more, different or longer-term reactions than natural disasters, suggests a 2013 article in the Annual Review of Public Health and a 2002 literature review in Psychiatry.
Media exposure has a big effect, too, finds disaster researcher Roxane Cohen Silver, PhD. In an article in the Jan. 7 Proceedings of the National Academy of Sciences, she and University of California, Irvine, colleagues E. Alison Holman, PhD, and Dana Rose Garfin, PhD, found that people exposed for six or more hours a day to traditional and social media content related to the Boston Marathon bombings reported higher levels of acute stress than those directly exposed to the event.
"We speculate that when you see repeatedly the event, online or on TV, you are effectively reliving it over and over again," Silver says.
Reactions also vary widely depending on such demographic factors as age, gender, mental health status and socioeconomic status, and people can react to events on behavioral, cognitive, emotional, physical and spiritual levels, says Hanbury. On the behavioral level, for instance, people may renew an addictive behavior or isolate themselves. Children may become more clingy, impulsive and fearful. Spiritually, a crisis may cause people to question or strengthen their faith — one of the reasons the Red Cross is looking to integrate chaplains more fully into disaster efforts, Hanburysays.
"Chaplains can give survivors and their families a way to identify with their culture, religious faith and resources," he says. "The spiritual component can actually be a coping mechanism."
Tori DeAngelis is a journalist in Syracuse, New York.
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