On The Line

Emerging Research and Practice in Disaster Mental Health

It has often gone unrecognized that the emotional devastation from a disaster can be at least as great as the physical devastation. Traditional disaster attention has often focused on facilitating a physical recovery without appreciating that full recovery in one realm cannot occur without recovery in the other. This is true not only of victims, but of responders as well.

Most early psychological interventions were directed toward those most severely affected, for example, the post-traumatic responses of soldiers from the battlefield and the reactions of children to severe trauma. There was another group potentially needing attention, however: the victims and responders experiencing “normal reactions to a very abnormal event” that were, nevertheless, highly distressful to them and perhaps temporarily incapacitating. Typically, more than 70% of people affected by a disaster will recover “on their own,” but could or should something be done to help them?

The Practitioner Perspective

About 15 years ago, the American Red Cross saw the distress in many of the thousands of people it deployed each year and sought to develop a program that would be responsive to the needs of its workers. Very quickly, it became clear that the same kinds of support could be made available not just to responders, but to others who were directly impacted by disasters.

The overriding assumption at that time was that these responses were normal and that most people can and will recover without classic psychological or psychiatric sessions. However, particularly for those who seek help, some actions are helpful, such as:

  • Psychological first aid to provide a “friendly ear,” keep people together, and reduce physiological distress;
  • Early, brief, on-site support by skilled, trained people, who often simply walk around and make themselves available;
  • Practical provision of information in contrast to in-depth emotional discussions (although some may seek that opportunity);
  • Responsiveness to everyday needs that can range from concerns about safety and security, to food and shelter, to linkages with family and community;
  • Referral and facilitation of support networks; and
  • Consultation with community groups and others.

Terrorism–A Special Case

While some elements of more typical disaster responses were applicable to the events of September 11, additional dimensions confronted practitioners. Many of the impacts parallel experiences with other terrorist events such as the Oklahoma City bombing, but responses to September 11 seem to be different due to the events that triggered them. For example, a higher percentage of those impacted have demonstrated symptoms of post-traumatic stress disorders. Also, this disaster clearly impacted adults and children well beyond its immediate geographic vicinity, and some of these stress reactions continue to persist. Compounding the mental health challenge, the effects of these attacks have been prolonged by protracted nationwide attention, making “anniversary date” reactions and pervasive worry all the more problematic.

Earlier experiences have demonstrated that there frequently can be delayed reactions to traumatic events, particularly for those intimately involved such as emergency responders. Now, more than a year after the attacks, clinicians, teachers, and other help providers report that, for some, this type of pervasive worry persists.

The Research Perspective

In October 2001, a conference of experts from around the country was convened by the departments of Defense, Justice, Health and Human Services, and Veterans Affairs, and the American Red Cross. The conference yielded a comprehensive report released in September 2002, Mental Health and Mass Violence (see the Observer, Vol. XXVII, No. 2, p 24). Several other forums (for example, one co-sponsored by the Pacific Graduate School for Psychology and the American Red Cross in October 2002) have also attempted to evaluate what we know and what we need to know about this problem.

In general, there is agreement (although not universal) that some assistance can be helpful, especially if it is provided on a voluntary basis by well-trained people who respect the normality of most people’s reactions and who can diagnose when reactions are out of the ordinary. However, there remain some very important questions subject to research. These include:

  • Who are those most likely to experience significant effects, and how do we best screen and triage?
  • What kinds of interventions and assistance work best at what stages following a traumatic event?
  • Are there important things practitioners should not do, and are there times when it is best not to intervene?
  • On what basis should we screen and select those who will be involved in providing assistance?
  • What kinds and levels of training do these practitioners need?
  • While some excellent research on these and other questions has been done, much remains to be answered.

An Ounce of Prevention

There has been a quite appropriate focus on providing mental health assistance after a disaster. Equally important for both practitioners and researchers is the question: What can be done to help people prepare for the unexpected and ameliorate potential after-effects? Major initiatives are underway to provide families with preparedness information and to build disaster preparedness into school curricula. A great deal of debate is occurring about what kind of information and preparation is valuable; whether there is such a thing as too much preparedness; and how communities and neighborhoods should prepare.

When first initiated, mental health-related efforts often met with skepticism in the emergency response community. Sometimes there was a desire to “tough it out” as well as a desire to “keep it in the family.” This close-knit pulling together proves to be a true asset that can facilitate recovery. At the same time, it is very clear that the emotional impact of traumatic events–for both those directly impacted and those seeking to help–can be profound, even if it is temporary. Planning to have disaster mental health experts involved in recovery efforts will, in fact, make a difference.

John Clizbe, American Red Cross (retired), Arlington, Virginia

Mental Health and Mass Violence: Evidence-Based Early Intervention for Victims/Survivors of Mass Violence. A Workshop to Reach Consensus on Best Practices (2002. 123 pp.) is available from the National Institute of Mental Health (NIMH), Office of Communications and Public Liaison, 6001 Executive Boulevard, Room 8184, Bethesda, MD 20892; (301) 443-4513.

To locate your local Red Cross Chapter, visit http://www.redcross.org.

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