Psychological Aspects Of Disasters.pdf

Renal Failure

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Psychological Aspects of Disasters Brian W. Flynn To cite this article: Brian W. Flynn (1997) Psychological Aspects of Disasters, Renal Failure, 19:5, 611-620, DOI: 10.3109/08860229709109027 To link to this article: https://doi.org/10.3109/08860229709109027

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Renal Failure, 19(5), 61 1-620 (1997)

SYMPOSIUM PAPER

Psychological Aspects of Disasters Brian W. Flynn, EdD Chief Emergency Services and Disaster Relief Branch Center for Mental Health Services U.S. Public Health Service Rockville, Maryland 20857

ABSTRACT This article describes several topics necessary for understanding the psychological impact qf disasters. fiipics discussed include characteristics of disaster that impact psychological response, stages of response, ,factors in@encing individual anti collective trauma, and important aspects ofpsychological interventions. The author shures several conclusions about the nature of people, culture, and society based on his many years of work in disaster mental health.

INTRODUCTION How individuals respond psychologically to a disaster experience is a complex topic. Individual response is the product of many variables including the nature of the disaster, the nature of the survivors' exposure to the disaster, individual health and mental health status, and nature of the collective trauma in which individuals find themselves. Signs of disaster-related stress differ among individuals and people typically demonstrate different responses as a function of their stage of recovery following a disaster. Beyond the identification of psychological response, the availability and appropriateness of psychological and psycho-educational interventions will play a significant part in the course of psychological recovery. Address correspondence 2 0 : Brian W. Flynn, EdD, Chief, Emergency Services and Disaster Relief Branch, Center for Mental Health Services, Room 16C-26, 5600 Fishers Lane, Rockville, MD. Fax: (301) 443-8040. Presented at the International Conference on Renal Aspects of Disaster Relief, Ohrid, Former Yugoslav Republic of Macedonia, May 24-26, 1996.

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DISASTER PSYCHOLOGY Current knowledge about disaster psychology is the product of both research and practice. Conducting research on psychological response to disaster is extremely difficult and has produced many mixed findings (1). For the past 22 years, the United States has conducted a government-sponsored program to provide crisis counseling and training services following large-scale disasters. A description of that program, as well as guidance based upon the experience of the program, is available (2,3).

Disaster Characteristics In an article particularly relevant to our understanding of how event characteristics influence psychological response, Green (4) describes several factors that impact psychological response. These include: threat; physical harm or injury; exposure to the grotesque; sudden violent loss of a loved one; witnessing or learning of the violent death of a loved one; learning of exposure to a noxious agent; causing death or severe harm to another; and intentional injury or harm. From both research and practice in the disaster mental health field, certain event characteristics can be identified that increase the probability of adverse psychological consequences. These include: 1. LittZe or no warning. Warning allows individuals to take psychological and physical protective action, allows the activation of psychological defense mechanisms, and permits cognitive structuring of the impending events. In other words, warning provides some level of (at least perceived) control over the destructive event. A lack of warning deprives the victim of this opportunity and therefore reduces perceived control and increases the sense of helplessness, vulnerability, and disequilibrium. 2. Serious threat to personal safety.Exposure to risk with respect to personal health and safety is associated with future psychological symptomatology. 3. Exposure to grotesque situations. Those exposed to particularly gruesome scenes, especially if that exposure is prolonged, are at increased psychological risk. This means that not only are survivors at risk, but those who are involved in event response, rescue efforts, body recovery, and body identification are at particular risk. 4. Diminished health status. The psychiatric literature has long shown that individuals who suffer from reduced health status are at increased psychological risk. Disaster survivors are often faced with long-term medical care, prolonged pain, physical rehabilitation, and multiple surgical interventions. One can easily understand how and why so many of these individuals become psychological casualties. 5. Potential for reoccurrence. In natural disasters we have learned that the potential for reoccurrence is an important predictor of the magnitude of adverse psychological response. In disasters such as earthquakes, the aftershocks are a constant reminder to survivors of the potential for reoccurrence. 6. Potential unknown health effects. We learned from the Three Mile Island nuclear accident that the most significant long-term health effect of that occurrence was anxiety caused by the potential for long term and unknown health effects. The recent work by the U.S. Agency for Toxic Substances and Disease Registry (ATSDR) with people living at or near hazardous waste sites reinforces the strength of this concern. If people fear for the future effect of exposure on their own health, or on future generations, they are at signifi-

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cantly increased psychological risk. As the world contemplates biological, chemical, and nuclear terrorism, this risk factor becomes particularly significant.

Stages of Psychological Response The psychological impact of disasters occurs i n stages or phases. What is happening to people psychologically, and therefore what services they need, is very different 6 days after a disaster than 6 months after. There is a predictable sequence of phases people go through, but this progression is not linear and it is affected significantly by what is happening in an individual’s community and the nature of the event. Is this a one-time event or is there a high probability (real or perceived) of reoccurrence a day, a week, or a month afterward? Several discussions of disaster phases are available (3,5-7). When and if warning occurs, psychological defenses are activated and people respond in a wide variety of ways consistent with their coping style and social context. This phase is sometimes followed by an alarm that usually heightens anxiety, resulting in various psychophysiological reactions. At impact, there is frequently a relatively short stun reaction. During this phase, there are often deeds involving great heroism. Following impact, there is usually an inventory and rescue phase in which people may experience many affective extremes depending on their experience and loss. Typically joy, relief, fear, grief, and other very individualized responses are seen at this time. Communities and individuals frequently enter a “honeymoon” period at this point, during which there are expressions of appreciation, relief, and gratitude for the sparing of those people and community elements not killed or destroyed. Following this period, there is almost always a period of anger and disillusionment. People come to fully appreciate the magnitude of their loses, recovery does not occur with the rapidity expected, and people become angry with insurance companies and relief agencies for their failure to meet expectations. Finally, there is typically a resolution phase when people incorporate the disaster experience and loss and move ahead with their lives. Some are left with the psychological scars of the experience, some emerge about the same as they were prior to the disaster, and some appear to become stronger and better able to cope in the future.

Factors Influencing Individual Trauma In his study of the dam failure at Buffalo Creek, West Virginia, Kai Erikson (8) described two types of trauma that occur following disaster. The first is individual trauma, defined as “a blow to the psyche that breaks through one’s defenses so suddenly and with such brutal force that one cannot react to it effectively.” The second is collective trauma defined as “a blow to the basic tissues of social life that damages the bonds attaching people together and impairs the prevailing sense of community.” The factors that may be determinants of the severity of response (in addition to the usual factors such as coping skills, prior trauma history, etc.) include: 1. Gradient ofexposuru. Disaster research is consistent in the finding that the closer or more directly impacted an individual is to the traumatizing agent, the higher the probability for the development of psychiatric symptomatology. As a result, some of the most serious responses can be expected in those most directly exposed and those who are involved in protracted, particularly difficult, or failed resource efforts.

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2. Magnitude of the loss and impact. Loss has many meanings. While those who lose family members or close friends and colleagues are typically and appropriately identified as those who have lost most and whose grief is often most visible, there are other types of loss. These may include loss of physical abilities due to injury, loss of employment resulting from destroyed businesses, and loss of economic and social position resulting from death, injury, or unemployment. While intervention research is minimal, the experience with providing disaster services seems to indicate that important mitigating factors include: early and skilled intervention, intactness of an individual’s support system (including school, family, church, and work), and the abilities of individuals to cognitively structure the event in a way that provides meaning to their loss. Following the April 19,1995, bombing in Oklahoma City, many survivors are assisting in efforts to improve architectural design and materials to better withstand a terrorist attack. In these efforts they are helping to give meaning to their loss and pain.

Factors Influencing Collective Trauma Several factors influence collective trauma. These include: 1. Degree qf community disruption. Not all disasters tear apart the social fabric of a community. For example, tornadoes frequently are very destructive to a defined area of a community but leave the basic social and governmental infrastructure undamaged. At the same time, many large-scale disasters destroy entire communities. The more a community’s fabric is tom or destroyed, the greater the collective trauma seems to be. 2. Predisaster stability. Both families and communities that were strong and healthy prior to the disaster seem to do better following the disaster. Families and communities where there was preexisting serious tension, conflict, or other difficulties, seem to fair less well. 3. Role of community leadership. The extent to which leaders in communities (government, clergy, elders, etc.) are able to continue to perform their role in facilitating community cohesiveness, seem to lessen collective trauma. 4. Sensitivity of recovery. Many communities experience large-scale destruction as evidenced by such factors as the relocation of many people or the need to reconstruct homes and communities. The sensitivity with which those activities are undertaken is a significant factor in mitigating collective trauma. When people are allowed and encouraged to maintain preexisting social and community groupings, collective trauma is reduced. Unfortunately, people are too often relocated without these factors taken into consideration, and religious, ethnic, socioeconomic affinities are not sufficiently respected.

Signs of Disaster Stress The symptoms of major disaster-related conditions such as post traumatic stress disorder (PTSD), major depressive episodes, and acute stress disorder are easily identified (9) and well known to most mental health practitioners. What may be less apparent to disaster survivors, and those who serve them, are the signs of disaster-related stress that frequently exist at a subsyndromal level (2). These may include:

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1. Physical signs such as increased heartbeat and blood pressure, nausea, sweating or chills, tics, fine motor tremors, tunnel vision, headaches, lower back pain, feeling a “lump in the throat,” exaggerated startle response, fatigue, decreased resistance to infection; 2. Behavioral signs such as a change in general activity level, decreased efficiency, difficulty communicating effectively, inability to rest, changes in eating or sleep patterns, changes in patterns of intimacy or sexuality, increased use of alcohol/ tobaccoldrugs, social withdrawal, proneness to accidents; 3. Cognitive signs such as reduced attention span, difficulty concentrating, difficulty making decisions, anomia, slowness of thinking, blaming, inability to stop thinking about the disaster; 4. Emotional signs such as crying easily, mood swings, inappropriate affect, feeling invulnerable, anxiety, anger, irritability, guilt or “survivor guilt,” hopelessness, apathy. Longer-term signs may include decreased job or school performance, marital problems, substance abuse as a form of self-medication, and recurring nightmares.

Important Aspects of Psychological Intervention Although the research with respect to psychological consequences of disasters is incomplete, the research on effective interventions is nearly nonexistent. No controlled studies in refereed journals could be found. Ursano et al. (10) provides a well thought through model for incorporating patient care, community consultation, and preventive medicine. Early service experience (ll), as well as current practice, points to several important counseling intervention characteristics. Assume Competence A guiding principle of disaster mental health is that, from a psychological perspective, we are dealing with normal response to abnormal situations. It is very important, until shown otherwise, to assume that people have the skills and ability to cope (given information, support, and assistance) with what they have experienced. This is a very different approach from many traditional mental health interventions where the first role, and goal, is to provide a diagnosis. Most individuals (at least adults) have gone through some type of very difficult traumatic event in their life and have made it through psychologically intact. It is important for counselors to elicit this history and try to reconnect those successful coping mechanisms. Normalization Normalization of psycbological sequelae to disasters is a significant part of successful intervention. The previous section discussed a fairly predictable menu of cognitive, emotional, behavioral, and physical consequences to disaster exposure. Helping people understand that what they are experiencing is normal is, in itself, a very significant intervention. Experienced disaster mental health workers have all heard people make statements like, “I can deal much better with this now that I know I am not going crazy,” or, “I really didn’t associate what I am experiencing now with what happened to me in that hurricane 6 months ago. Now that I understand what is going on, I can cope better.”

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Directive Care Giving After a disaster, many people respond well to very directive care giving. Most mental health professionals were trained not to be directive in care giving. Most disaster survivors are not looking for insight or assistance with existential issues. They want concrete assistance with very specific types of problems. In addition, the crisis counselor may have the opportunity to see the person only once or twice. The disaster crisis counselor needs to regear and rethink approaches to individuals and find clear and innovative ways to provide often very proscriptive direction to disaster survivors. Organizing Tasks Assistance in organizing tasks is an example of nontraditional assistance. There are enormous numbers of tasks to be accomplished after one’s house has been destroyeddealing with governmental agencies, insurance companies, contractors, banks, etc. It is easy to see how people can be stressed, even to the point of immobilization, by the immensity and complexity of the tasks. A significantrole for interveners, in the psychological sense, is to assist people in organizing and prioritizing these tasks. This type of assistance is a significant stress reducer. Active and Repeated Listening When interveners listen to repeated accounts of a survivor’s experience, a marked therapeutic, cathartic, and healing effect is often seen in the survivor. Active listening to what happened is a way to normalize the experience and to bring the experience under better control for the survivor. Discouraging Blame Discouraging blame is important to assist survivors as they progress through the phases of disaster response. People seem to move through these early phases much more slowly if they become fixated on who is to blame and who is responsible for the loss that they incurred. There may be important differences between natural and human-caused disasters in this area. In human-caused disasters, litigation often follows. It may be in the best interest of the successful litigation to keep the notion of blame alive through the several years it may take for cases to come to court. In this situation, what is in an individual’s best legal interest runs contrary to what is in their best psychological interest. Realistic Expectations It is very important to keep survivors’ expectations reasonable. In well-intended, but naive efforts to comfort, many people make promises to disaster survivors. Many of these promises are never realized. Besides breeding distrust, unfulfilled promises can jeopardize an entire program of services. People often expect to be restored more quickly and more fully than reality permits. Referral The establishment of a working referral system is important. Disaster service programs need established referral systems with resources such as health professionals, mental health professionals, and social services. Much disaster response and recovery service is provided

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by individuals and groups who come from outside the disaster area to assist. Even those who are from the area may be engaged in disaster recovery activities on a time-limited basis. It is extremely important that planners and providers of mental health services understand that others will often be left with ongoing cases when mental health interventions cease or constrict. It is important both clinically and politically that those who assist in mental health interventions work in a close and sensitive way with those professionals who will remain when services stop. Several types of disaster mental health services have been shown to be most helpful: 1. Outreuch. lntervention programs must be outreach oriented. Traditional officebased services and those that rely on the patient or client to seek services simply do not work for disaster survivors. Mental health professionals who wait for people to come to them, and see people only in their offices, are likely to experience little or no disasterrelated work. Services are best provided where people work, live, or gather, such as at schools, churches, homes, and shelters. 2. Consultation. Appropriate interventions, in addition to counseling, include consultation. Local governmental components such as Zoning Boards, City Councils, Boards of Selectmen, and Health Departments all make decisions having an impact on peoples’ lives. 3 . Education. Targeted education, for example to primary care physicians (12), is important. Information geared toward the general public is essential. Contrary to reported experience outside disaster mental health, the media can be invaluable in helping individuals understand what they are going through and how and where to get help. Providers of Service With respect to the service providers themselves, the consistent experience in the United States government-funded crisis counseling program has shown that a blend of professionals and trained nonprofessionals is the most effective mix. The “mantra” of disaster mental health is that disaster counselors are primarily dealing with normal people, responding normally, to very abnormal situations. While the mental health professional involvement is critical, much of the front-line work does not require the full armamentaxiurn of a mental health professional. Trained nonprofessionals who are mature, comfortable with an outreach model, know the community and its culture, and know community resources, can perform much of this work very well. This blending of professional and trained nonprofessionals may be especially applicable in less developed countries and/or very rural environments where the availability of mental health professionals is minimal. Three components are required to make this mixed model work. First, nonprofessional workers must be trained well and trained throughout the program period. Second, mental health professionals must supervise the nonprofessionals. Finally, nonprofessionals must have easy access to a smooth functioning referral system to handle those cases that are beyond their level of training.

ADDITIONAL LESSONS LEARNED Much of the past 17 years of my 25-year mental health career have been spent dealing with the psychological sequelae of either refugees or survivors of natural disasters. The years spent in disaster mental health work have been among the most educational and rewarding. These years have produced a number of observations.

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The Resilience of the Human Spirit Above all else, I am struck by how people survive extreme adversity. I have seen extreme loss and personal devastation and have been amazed at the almost miraculous ability of people not only to survive, but to proceed with their lives and often be strengthened by the adversity.

The Centrality of Blame When terrible things happen to us there seems to be an almost universal need to assign blame. This is probably, in my view, an attempt to gain psychological control of the event by placing it in an explainable context. Since most people find it personally and culturally unacceptable to blame God for these events, blame is frequently shifted to other authority figures. In many cases, this means government officials that survivors believe (nearly always unrealistically) could or should have prevented the loss or are involved in the response and recovery following a disaster.

The Cultural Expectation of Immediate Gratification It has been disturbing to see first hand how ill-prepared, at least in the United States, we are to cope with even temporary disruption of basic infrastructure support (water, food, electricity, etc.) and how unrealistic expectations are of their immediate reestablishment following a major or catastrophic disaster. Our tolerance for inconvenience is both minimal, unrealistic, and perhaps even arrogant.

The Quality of Disaster Workers In my years of disaster work, I have come to view my colleagues in this area as among the finest people with whom I have had the privilege to work. Setting aside the occasional exceptions found in any group, I have found those who respond to emergencies and disasters to be consistently motivated to help others even at the expense of their own wellbeing, dedicated to the work sometimes beyond what is good for themselves and their families, and often seemingly immune to compassion fatigue. Working with these people has been one of the great privileges of disaster mental health work.

The Value of Religion A consistent theme across disasters has been the comfort that people receive from their religious beliefs and the support of their religious groups. This observation is consistent across religious groups. Religious beliefs appear not only to provide a context in which to view the disaster event, but a cause for hope in the future at a time when, for many, the future appears very bleak. The rare exceptions to this observation are the occasional extreme fundamentalist religious groups that view disasters as punishment for individual or collective perceived transgressions. They attempt to add guilt to the already heavy psychological burden borne by disaster survivors.

The Numbers of People Living on the Margin I have been struck by the number of people in the United States who live on the margin (in almost every sense of the word) and become visible for the first time following a disaster

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when they are pushed beyond their remaining capacities. I refer here to people who have been barely making it psychologically, as families, financially, socially, and medically; for whom a disaster is their “last straw.” Often these people have never come to the attention of public service agencies and now find themselves relying heavily on these external and public resources to survive. Because they may appear to be functional before the disaster and in the early aftermath. they are often overlooked when initial planning occurs.

The Importance of Symbolism and Ritual I believe that we often underestimate the symbolic importance of what is lost or destroyed in disasters and fail to fully appreciate the importance of symbolism and ritual in the healing and recovery process (13). On the smallest level, the loss of a grown child’s baby photos or the widow’s loss of her deceased husband’s pocket watch are more than the loss of paper and steel. They are losses of a symbolic link to history. As an example on a larger scale, the bombing and loss of the Murrah Federal Building in Oklahoma City (a government building symbolizing stability and strength) was a major contributor to the psychological impact of that event. We also seem to underestimate the healing value of largely symbolic and ritualized events such as memorial services, the reopening of a damaged school, and anniversary commemorations.

Our Ignorance About Mental Health I have been discouraged by our ignorance about what makes and keeps people mentally healthy. I have been in awe over the years at how well people cope with adversity and how easily and dramatically most people can be helped if they receive the right kind of assistance, at the right time, and in a manner that they can accept. It has demonstrated to me that while, as a field, we are making significant improvements in our understanding of the nature of mental illness, we are not making the same magnitude of commitment to better understand what makes and keeps people healthy. As practitioners, few of us are prepared to do this type of work. We are trained to seek out pathology and hopefully treat it. While this is a defensible approach when one assumes the presence of psychopathology, it is an unhelpful and stigmatizing way to approach disaster survivors. Until we begin to seek out health in those we serve as much as we seek illness, and until disaster research begins to examine nonpathological outcomes, we are limited to seeing only a portion of the entire picture of the psychological sequelae of disasters and our picture will remain terribly distorted.

ACKNOWLEDGMENTS I would like to note thi: rather extraordinary nature of the fact that a presentation on disaster mental health has been included in an International Conference on Renal Aspects of Disaster Relief and has been included in this special issue of Renal Failure. The inclusion of this topic represents, in my view, a profound acknowledgment that quality medical care must address the total needs of the patient and that medical personnel must look beyond a single organ system or single medical specialty to understand and meet the needs of patients. It is hoped that other medical specialties will be inspired and motivated to follow the lead of Nephrology.

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