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Disaster Psychology
by Susan Hamilton, Ph.D.
Learning Objectives
- Learn the different definitions and classifications of a disaster.
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Learn the challenges to providing psychological assistance to disaster survivors.
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Learn the history of the American Red Cross Disaster Mental Health program and the reasons for its inception.
Fortunately, for much of the population
their closest experience of a disaster is through the media or from
movies. These snap shot views are dramatic, frequently unrealistic,
and present an incomplete view of the complexity of disaster response.
They rarely focus on longer-term psychological, sociological, and financial
effects. Psychologists have long been part of the cadre of mental health
professionals who work with the American Red Cross to provide pro bono
counseling services to disaster survivors. For psychologists interested
in becoming actively involved in disaster preparedness and response,
reviewing current trauma and resilience research and studies on evidence
based early interventions will provide a background to appreciate the
needs of disaster survivors and responders and how compassion fatigue
or secondary traumatization can affect mental health professionals providing
service to them.
A disaster environment is often described
as organized chaos. Clinicians arriving at the scene of a disaster should
have specialized training in disaster mental health, understand the
role of mental health professionals, the chain of command, and the operational
changes that take place daily (American Psychological Association [APA],
1997). Following the 1995 bombing of the Alfred P. Murrah Federal Building
in Oklahoma City and the events of September 11, 2001, large numbers
of spontaneous volunteers arrived wanting to help the survivors. A 2002
Oklahoma City report, critical of spontaneous volunteers, maintained
that they have little effect (or even a negative effect) unless directed
to the place where they are needed and with the necessary tools (Memorial
Institute for the Prevention of Terrorism [MIPT], 2002). It is essential
for mental health volunteers to understand the relationships among federal,
state, county, and local agencies, non-government agencies, and the
safety and security issues present in disaster settings. They should
know how to recognize and build upon the resilience of individuals,
refer the more severely affected for treatment and most importantly,
understand their own capacity to work with crisis, trauma, and a frequently
changing situation. If “growth is an active process of constructing
and organizing meaning” (Higgins, 1993), then disasters are an opportunity
for growth.
Disaster Response in the United States
The United States has a long history
of disaster response. The Congressional Fire Act of 1803 is usually
considered the first national disaster legislation. By authorizing federal
assistance to the town of Portsmouth, NH when a massive fire had exhausted
community and state resources, the act changed how the country responded
to disasters. Over the next 150 years, Congress passed more than 125
individual pieces of aid legislation before passing the 1950 Disaster
Relief Act. The large number of disasters requiring federal assistance
during the 1960s and 1970s drew national attention to the issue and
related concerns and resulted in two new acts, the 1968 National Flood
Insurance Act, which gave new flood protection to homeowners, and the
1974 Disaster Relief Act that established the process of Presidential
Disaster Declarations.
In 1979, many of the numerous emergency
agencies that had developed merged to form the Federal Emergency Management
Agency (FEMA). In 1988, the Stafford Disaster Relief and Emergency Assistance
Act created the system whereby a Presidential Disaster Declaration triggers
financial and physical assistance through FEMA. Available following
a Presidential Disaster Declaration, the FEMA Crisis Counseling Program
was created to provide short term services aimed at relieving grief,
stress, or mental problems caused or aggravated by disasters. The funding
was channeled to state and local mental health agencies. In 2003, FEMA
became part of the Department of Homeland Security and was tasked with
responding to, planning for, recovering from and mitigating against
disaster. Disasters of all types, together with the terrorist threat
of chemical, biological, radiological, nuclear, and explosive (CBRNE)
weapons, have driven legislative change and prompted the government
to develop disaster response agencies, as well as stimulated researchers
to further examine the psychological sequelae of disaster. The National
Response Plan (NRP) has replaced the Federal Response Plan and other
plans, and established multi-agency coordinating structures at the field,
regional, and headquarters level. The NRP defines under what circumstances
incidents of national significance occur.
Definitions
Disasters are defined and classified
in several ways and viewed from different perspectives. The United Nations
definition derives from a societal perspective: “A serious disruption
of the functioning of society, causing widespread human, material or
environmental losses, which exceed the ability of affected society to
cope using only its own resources.” The Federal Emergency Management
Agency defines a major disaster as “any natural catastrophe, or regardless
of cause, any fire, flood, or explosion that causes damage of sufficient
severity and magnitude to warrant assistance supplementing state, local,
and disaster relief organization efforts to alleviate damage, loss,
hardship, or suffering” (FEMA, 1995). At a state level, the New York
State Office of Mental Health Crisis Counseling Guide differentiates
between disasters causing unique problems for private/public organizations
as well as local, state, and federal governments, and routine emergencies
and critical incidents whose response demands can be met with local
resources and do not exceed the normal capacities of any one organization
and/or government, e.g., car crashes, suicides, fires, and shootings.
Reflecting its unique role in disaster response, the American Red Cross
defines disasters by type, level of financial impact, and scope of response
required. Common to all disasters is how they provoke fear and anxiety
and detrimentally affect the physiological and emotional stability of
individuals and the psychological well being of communities.
Classification
Generally, disasters are classified as
natural, human-made (deliberate, through error or negligence), and technological.
Natural disasters alert us to the inevitable collision between humans
and geological and atmospheric forces, whereas those precipitated by
humans remind us of the precarious balance between technology, ecology,
and species. Included in the category of natural disasters are hurricanes,
earthquakes, tornadoes, floods, wild fires, avalanches, tsunamis, sand
storms, waterspouts, and droughts. Each decade they kill one million
people around the world and leave millions more homeless. In 1992, earthquake
losses in California cost $158 million. The FEMA relief costs of the
1994 Northridge earthquake were $5.558 million. Flooding in the United
States in Fiscal Year 1996 cost $6.1 billion (United Nation’s International
Decade for Natural Disaster Reduction, 1997).
Disasters vary in size and duration.
Some occur spontaneously while others are predictable. Using radar and
satellites, meteorologists can reliably plot the path of a hurricane,
a predictable weather event, giving people sufficient time to purchase
emergency supplies, board up homes and/or leave the vulnerable area.
In early August 2004, Charlie, the third tropical storm of the Atlantic
Hurricane Season, appeared as a tropical wave. It developed into a tropical
depression, strengthened to a tropical storm, and reached hurricane
strength on August 11. The following night, it passed over mainland
Cuba but on August 13, Charlie unexpectedly turned northeast and in
three hours increased from a Category 2 storm (110 mph) to a Category
4 (145 mph). Hurricane Charlie took nine hours to cross a wide swath
of central Florida before returning to the Atlantic the next day.
Earthquakes, tornadoes, and tsunamis
give little or no warning. Before the 1994 California Northridge earthquake
happened no one knew that the Northridge fault existed; structures previously
considered secure were unable to withstand the 6.8 quake. Five years
earlier, a 7.1 quake, generated by the San Andreas Fault and lasting
fifteen seconds, caused sections of the San Francisco Oakland Bay Bridge
and Nimitz Freeway to collapse, killing 62 people. On December 26, 2004,
without a global earthquake warning system in place, there was no way
to warn people of an anticipated tsunami following the earthquake off
the coast of Sumatra. The massive tsunami flattened a 3,000-mile area
from Indonesia to Somalia, killing over 160 thousand people and des-troying
the homes and livelihoods of people in several countries. The rebuilding
of the communities is expected to last for several years. The psychological
repercussions are inestimable.
Human negligence and/or poor judgment
also cause disasters. In 1966, following the collapse of slag heaps
at Aberfan, South Wales that killed 144 people, the official Aberfan
1967 Report described the cause as “bungling ineptitude...failure to
heed clear warnings” (Davies, 1967). Similarly, gross human error contributed
to the collapse of dams securing mine waste at Buffalo Creek in West
Virginia in 1972. A 20-30 foot wave of 132 million gallons of black
wastewater tore through the towns. One hundred and twenty-five people
died, 1000 were injured and 4000 were left homeless. Locked doors prevented
people from escaping the 1911 Triangle Factory Fire that killed 145
New York workers and at the 1942 Boston Coconut Grove nightclub fire,
which began from a single lit match held by a man trying to install
a new light bulb and ultimately killed 492 people. More recently, in
February 2003, a pyrotechnic display at the Rhode Island Station Nightclub
triggered an inferno that killed 100 people and left 150 burn survivors
(McGongle, 2003). Spectacular fires receive frontpage headlines. Single-family
house fires that occur daily throughout the United States are less publicized
although they account for approximately 93% of Red Cross disaster response.
Technological disasters involving chemical
spills and radiation leaks contaminate ground soil and waterways, irrevocably
alter the ecological balance and can make geographic areas uninhabitable
for human settlement. Examining the psychological aspects of technological
accidents is especially relevant at the present time when terrorist
radiological and chemical threat exists. The worst nuclear accident
in U.S. history was a core meltdown at the Three Mile Island nuclear
power plant in Pennsylvania, in 1979. Ptacek (2001) suggested that a
conflict of sleep patterns and work schedules may have contributed to
the accident. Initial estimates of potential health risks to the local
population were low. According to the Kemeny Commission, established
by President Carter, the only health threat was mental distress. Epidemiologist,
Stephen Wing, disputed the finding (Wing, 1997). Mangano (2004) commented
on the limited number of radiation monitors near the plant, almost none
beyond the immediate area, and that there were no in-body radiation
levels recorded of people living near or far from the plant, thus making
longitudinal studies of future health impossible. Studies assessing
the psychological aftermath showed acute, medium, and long term effects
similar to those from studies of the psychological effects of radiation
catastrophes at Hiroshima and Nagasaki, which found that generalized
and health-focused anxiety, somatization, and depressive symptoms remained
elevated 10 to 20 years later. Seven years after the Three Mile Island
accident, at the Chernobyl nuclear power plant in northeastern Ukraine,
a nuclear reactor overheated causing a core meltdown with catastrophic
consequences. One hundred and twenty thousand people were evacuated
permanently (Bard, 1997). Eleven years after the accident, the psychological
consequences of the evacuated were examined. Although protective factors
were evident in the lives of the children, the mothers’ perspective
of their children’s well being reflected their own traumatic experience
(Bromet, et al. 2000).
Transportation accidents include those
involving aviation, rail, bus, cruise ships, and also road incidents
involving the release of chemicals. Human error or negligence, technical
malfunction, and the weather can contribute to them. They occur with
less frequency than other disasters but transportation accidents often
involve mass casualties and can be dangerous beyond the immediate area.
Not only are human lives lost and people injured and traumatized, the
environment, wildlife, the economy, and society as a whole are affected.
On September 9, 1996 an executive memorandum designated the National
Transportation Safety Board (NTSB) as the coordinator of federal services
to families of victims of major transportation disasters. The following
month Congress passed the Aviation Disaster Family Assistance Act of
1996. The Federal Family Assistance Plan for Aviation Disasters is built
around a core set of Victim Support Tasks (VST). Family Care and Mental
Health is part of VST. NTSB gave the Red Cross responsibility for the
VST actions, which include coordinating and managing volunteer counseling
and support services, child care services, coordinating with the airline
for the delivery of mental health support to family members, to include
those who do not travel to the incident site, and arranging for a suitable
interfaith memorial service.
Disaster Phases
In disasters where a warning phase occurs
people can anticipate and prepare for its arrival. During and immediately
after the impact, in what is called a heroic phase, emergency responders
are highly active assisting people and resources begin arriving. This
ushers in a honeymoon phase; people are appreciative of the help given
to them, and hopeful that life will return to what it was before the
disaster. When expectations are not entirely met and the reality of
what has taken place becomes apparent, a period of disillusionment occurs
with disappointment, resentment, anger, and frustration surfacing. As
people assimilate what happened and accommodate to the changes, a reconstruction
phase begins. People work through their grief and anger, gradually accepting
that they will have to solve the problems caused by the disaster and
they start the process of rebuilding their lives, a
process that may continue for many years.
The American Red Cross
Since its founding in 1881, the American
Red Cross has responded to disasters. The Red Cross is a nonprofit,
humanitarian organization granted a Congressional Charter in 1905 to
carry on a system of national and international relief in time of peace
and apply the same in mitigating the suffering caused by pestilence,
famine, fire, floods, and other great national calamities. As part of
the International Red Cross and Red Crescent Movement, the American
Red Cross adheres to the movement’s fundamental principles of humanity,
impartiality, neutrality, independence, voluntary service, unity, and
universality. Its mission is to ensure nationwide disaster planning,
preparedness, community disaster education, mitigation, and response.
The Red Cross is community based. Its chapters throughout the United
States and its territories participate in readiness, preparedness, and
response activities. Many have disaster mental health teams. The Red
Cross Disaster program focuses on meeting immediate disaster caused
needs, such as shelter, food, health, and mental health services. Personnel
conduct interviews with affected people in a variety of disaster settings
to determine the extent of family and individual loss, and how the disaster
has affected the family or individual. The Disaster Services program
also feeds emergency workers, handles family disaster inquiries, provides
blood and blood products to disaster victims, and helps those affected
to access other resources. Although they are among the earliest responders
to disasters, Red Cross personnel are not considered first responders.
The American Red Cross has a designated role in the NRP.
American Red Cross Disaster Mental
Health
A major catalyst for the creation of
the Red Cross Disaster Mental Health program was the increased stress
levels experienced by disaster workers and victims in Hurricane Hugo
and the Loma Prieta earthquake of 1989. Development began in early 1990
with the first major deployment of mental health professionals in August
1992. The Red Cross Disaster Mental Health (DMH) program provides for
and responds to the psychosocial needs of clients across the continuum
of disaster, preparedness, response, and recovery. A one-day Red Cross
training prepares licensed or certified psychologists, psychiatrists,
social workers, counselors, marriage and family therapists, and psychiatric
nurses to volunteer in their communities at local incidents and within
the Red Cross structure on larger disaster relief operations. They give
psychological support to individuals, families, community groups, and
other disaster responders, and make referrals to local mental health
agencies when further assessment or treatment is required. Mental health
workers help people to use adaptive coping mechanisms and provide information
about the psychosocial aspects of disaster. They advocate for clients
and workers, and help in problem solving. The interventions they use
are intended to alleviate distress by lowering physiological arousal,
clarify the current situation, and mitigate dysfunctional thinking.
Mental health professionals are present at most sites within a disaster
environment where they monitor and mitigate stress in other workers.
In 1991, the American Psychological Association
(APA) Disaster Response Network (DRN) was the first mental health organization
to sign a Statement of Understanding with the American Red Cross to
provide pro bono mental health services to disaster victims and relief
workers. It required participating psychologists to complete the Red
Cross mental health training, and recommended that they also take further
training (ARC, 1991). The DRN is a coalition of affiliated state and
local psychologists who are members of state and provincial psychological
associations and has an Advisory Committee of five members who serve
for a period of three years. The primary function of the national network
is to facilitate joint activities with the Red Cross. The DRN responds
to requests from the Red Cross to recruit members to assist at disasters.
On September 11, 2001, the New York State DRN chair was one of many
psychologists who arrived at the Red Cross Manhattan office. Her prior
training and experience enabled her to determine where psychologists’
services were most needed and organize mental health teams. By November,
the challenge of working in such a traumatic disaster was obvious to
30 New York DRN members who met to discuss ways of helping survivors
and how to help themselves deal with the trauma (APA, 2001).
Sometimes, disaster workers are overly
committed; it is easy for them to underestimate their own reactions
to the disaster. An important task for mental health workers is to be
alert to their own and other workers’ levels of stress and compassion
fatigue. As early as 1980, Cohen and Ahearn (1980) indicated that overwork
was a serious problem for disaster workers. In 1997, the Oklahoma City
Task Force recommended that mental health worker shifts be normalized
as quickly as possible to prevent unnecessary and potentially damaging
stress (APA, 1997). A lesson learned from Oklahoma City was that senior
managers should insist that workers leave at the end of their shift,
and then to leave themselves (MIPT, 2002). Ehrenreich (2005), citing
research based on international humanitarian aid workers, placed the
responsibility on the organization for preventing and mitigating stress.
“Although most agencies employing aid workers are aware that adverse
stress reactions are a risk for relief workers, psychological support
mechanisms for staff in their organizations are ‘underdeveloped’” (Ehrenreich,
2004).
Providing psychological assistance to
disaster survivors is one of the most challenging and most stressful
of psychological practices (Cohen and Ahearn, 1980). In a study that
compared disaster mental health workers with mental health professionals
who were not working in disaster mental health, Wee and Myers (1997)
found that increased levels of stress were associated with providing
mental health services to disaster victims during long-term recovery.
Few studies have investigated mental health staff providing post disaster
counseling or examined long-term effects of work related stressors (Myers
and Wee, 2005). Myers and Wee (2005) have emphasized the necessity of
pre-disaster stress assessment before assigning mental health workers
to a disaster setting, and for those already involved in trauma intervention,
they suggest assessing for compassion fatigue, burnout, and secondary
traumatic stress disorder as well as personal and job stress.
Psychological Responses to Disaster
and Traumatic Events
Most people exposed to a disaster do
well and experience only mild, transient symptoms (Ursano, et al., 1995).
Their responses are normal responses to “inordinate adversity” (Gray,
et al., 2004). Flynn and Norwood (2004) report that common physical
responses include fatigue, nausea, fine motor tremors, tics, paresthesias,
profuse diaphoreses, dizziness, gastrointestinal upset, heart palpitations,
and choking or smothering sensations, and cognitive responses include
memory loss, anomia, decision-making difficulties, confusing trivial
with major issues, concentration problems or distractibility, reduced
attention span and calculation difficulties. Emotional responses include
anxiety, grief, irritability, feeling overwhelmed and anticipating harm
to self or others, while behavior responses include insomnia, gait change,
hypervigilence, crying easily, gallows humor, and ritualistic behavior
(Flynn and Norwood, 2004).
“Most people are exposed to at least
one violent or life-threatening situation during the course of their
lives. Resilience is common and multiple pathways can lead to it” (Bonanno
2004). A number of prospective studies have demonstrated an association
between resilience to loss and the experience and expression of positive
emotion. Theoretical constructs can eventually lead to paradigm shifts.
In 1962, Schachter and Singer proposed that physiological arousal was
the same for all emotions but cognitive labeling was not. Their proposal
led to further studies exploring how feeling states or emotional behavior
impacts perceptions, thoughts and behavior (Charlesworth, 1982), and
how emotion has “more to do with how the individual relates past, present,
and future events to his or her goals and striving” (Roseman, 1979).
It is evident that theory and experimental research have influenced
the development of post-disaster interventions, and relate to the emphasis
on resilience and positive coping strategies for survivors of trauma.
Psychological Assessment Following
Disaster and Traumatic Events
Medical and physical needs should be
assessed before assessing psychological needs. Depending on the severity
and scope of a disaster, mental health needs vary, with some populations,
such as the bereaved, the mentally ill, and the disabled, more at risk
(Ritchie and Hamilton, 2004). The challenges of assessment accuracy
are due to bias, changes over disaster phases, unrealistic expectations
of follow-up from the assessment, and the personal danger to assessors
in post disaster chaos or violence (Ritchie and Hamilton, 2004). Evidence
based early interventions have been developed and although many people
exposed to large-scale disasters and traumatic events experience significant
psychological distress, this is not an indication of pathology (Gray,
2004). Early intervention policies should be based on empirically defensible
and evidence based practices and the use of ineffective or unsafe techniques
should be discouraged (National Institute of Mental Health, 2002).
Sometimes the enormity of an event is
overwhelming even to experienced and seasoned disaster mental health
professionals. Flynn (1995) wrote poignantly of his reactions and experience
during a visit to the site of the Alfred P. Murrah Federal Building
bombing in Oklahoma City, OK, and of the powerful emotions that enveloped
him. Sociologist Kai Erikson attended a post disaster gathering where
lawyers were collecting information from survivors of the Buffalo Creek
dam disaster. He recorded his observations, “The whole scene looked
as if it had been painted in shades of gray. The children neither laughed
nor played. The adults acted as if they were surrounded by a sheath
of heavy air through which they could move and respond only at the cost
of a deliberate effort. . . I felt. . . as though I were in the company
of people so wounded in spirit that they almost constituted a different
culture, as though the language we shared in common was simply not sufficient
to overcome the enormous gap in experience that separated us” (Erikson,
1978).
Author
Dr. Susan Hamilton is the Senior Associate
for Disaster Mental Health Services at the American Red Cross National
Headquarters. She has been active in setting up a Disaster Response
Network and active in the National Center on Disaster Psychology on
Terrorism.
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