Disaster Mental Health:
Tropical storms, tornadoes, fires, floods, earthquakes, transportation accidents, mass murders, hazardous material spills, building collapses, nuclear plant malfunctions, terrorist bombings, and many other disasters occur throughout our country each year. In the wake of these events lies a wide path of catastrophic physical and psychological destruction. Many seriously traumatized people can be found there, struggling to recover from their losses and rebuild their lives.
Disaster mental health (DMH) is a growing field of practice designed to help the victims (and the relief workers who rush to their aid), learn to effectively cope with the extreme stresses they will face in the aftermath of a disaster. The goal of DMH is to prevent the development of long-term, negative psychological consequences of a disaster such as the development of PTSD. Victims and relief workers will be changed by their encounters with disasters, but the majority of them will not be damaged by those experiences.
Few mental health professionals have received training in crisis intervention, advocacy, mediation, education, psychological first aid, defusing, and debriefing - the primary skills used for DMH intervention. Social workers, for example, are mandated to provide appropriate professional services in public emergencies (see the NASW Code of Ethics), yet few social workers have the specific training/skills needed to serve as relief workers. Many undergraduate and graduate programs in social work, psychology, counseling, nursing, and psychiatry spend little time (if any at all) teaching the critical prevention and crisis intervention techniques needed for relief work.
Once a disaster occurs, folks look at a lot of things in a different way than they did before. Prior to the event, people have an order to their lives and they feel like they are in command. In the days and weeks following the disaster, they often feel they no longer have control over anything - the event has caused unexpected losses and has taken away their normal routines. They will find themselves awash in a sea of paperwork and bureaucracy (relief agencies and services, insurance claims, etc.) that many refer to as the second disaster. They soon begin to realize it will be some time before they will regain their former sense of stability and control.
Faced with so many changes, people begin to react with fear, anger, anxiety, and depression - all normal stress reactions under the circumstances. DMH workers do not expect people to feel well in the wake of a disaster, yet the victims will expect themselves to "get over it" and to feel better quickly. When they don't, they suddenly begin to fear they're weak or they're going crazy. DMH workers need to provide opportunities for offering education about "normal" reactions, stress inoculation about routine challenges of recovery, and support.
I strongly urge all mental health professionals to learn more about DMH. Read about it and consider attending a workshop. Talk to others who are helping with the many volunteer organizations active in relief efforts. Explore the things folks are doing to prepare for disaster events that commonly occur in your area. Within the next several pages, I've provided readers with detailed material about DMH and about volunteer opportunities with the Red Cross. Simply click the appropriate link selection at the bottom of this page to view more information about these topics.
Disaster Mental Health:
Assisting in the Aftermath of Disasters and Other Life Crises
John D. Weaver, LCSW
The following is a summary of disaster mental health (DMH) concepts and techniques. The material is drawn from my 1995 book, Disasters: Mental Health Interventions, my 1999 chapter for Innovations in Clinical Practice: A Source Book - Volume 17 (both published in Sarasota, FL, by Professional Resource Press; phone 1-800-443-3364), and several other, more recently published journal articles. Complete references for these can be found in the bibliography section of this webpage. Material is also cited from other publications as noted. This is copyrighted material and should not be reproduced without proper consent and references. DMH team members and volunteers who want more detailed explanations of this material are urged to read the original books, chapters, articles, etc.
The basic tenants of DMH begin with the central principle that the target population primarily consists of normal people who have been through an abnormally stressful disaster/emergency situation. Victims generally will not stop functioning, but they will react in fairly predictable ways (with some differences due to age/maturity). By using various crisis intervention techniques, outreach services, and psychoeducational approaches, the victims and relief workers can be quickly triaged and briefly counseled (or referred for formal services), so as to return them do pre-disaster levels of functioning as quickly as possible. The goal of DMH is to help assure that the victims become survivors, by doing whatever can be done to prevent long-term, negative consequences of the psychological trauma.
Phases of Rebuilding
Literature suggests that persons/communities struck by disaster will generally pass through four phases of response:
- Heroic phase - may begin prior to impact and last up to a week afterwards; people struggle to prevent loss of lives and minimize property damage;
- Honeymoon phase - may last two weeks to two months; massive relief efforts lift spirits of survivors and hopes of quick recovery run high, but optimism is often short lived;
- Disillusionment phase - may last from several months to a year or more; sometimes called the second disaster; the realities of bureaucratic paperwork and recovery delays set in; outside help leaves and folks realize they have lots to do themselves; and,
- Reconstruction phase - may take several years; normal functioning is gradually reestablished (Farberow and Gordon, 1981, pp. 3-4; Weaver, 1995, pp. 31-32).
Typical Reactions to Disasters
These are the common feelings and reactions that most victims will express and/or display: basic survival concerns; grief over loss of loved ones and/or prized possessions; separation anxiety and fears for safety of significant others; regressive behavior (e.g., thumb sucking in children); relocation and isolation anxieties; need to express thoughts/feelings about experiencing the disaster; need to feel one is part of the community and rebuilding efforts; altruism and the desire to help others cope and rebuild (Farberow, 1978, p.26; Weaver, 1995, p. 32).
Disasters often cause behavioral changes and regression in children. Many react with fear and show clear signs of anxiety about recurrence of the disaster event(s). Sleep disturbances are very common among children (and adults) and can best be handled by quickly returning to (or establishing) a familiar bedtime routine. Inability to do this often proves to be a major problem following major earthquakes, as frequent aftershocks and displaced residences make it difficult for anyone to return to regular sleep routines. Many families end up sleeping together in the same bed long after the main quake.
Similarly, school avoidance may occur and it can lead to development of school phobias, if children are not quickly returned to their normal routine of school attendance. In some disasters, the schools may be flooded (or damaged in another way), making them inoperable. This, and the need to be bused to other, unfamiliar buildings, will further add to the stresses on the children. The 1994 Los Angeles area earthquake and its aftershocks resulted in lots of children staying home for weeks, fearful to leave their parents' sides for the length of a school day.
Adults often report mild symptoms of depression and anxiety. They can feel haunted by visual memories of the event. They may experience psychosomatic illnesses. Pre-existing physical problems such as heart trouble, diabetes, and ulcers, may worsen in response to the increased level of stress. They may show anger, mood swings, suspicion, irritability, and/or apathy. Changes in appetite and sleep patterns are quite common. Adults, too, may have a period of poor performance at work or school and they may undergo some social withdrawal.
Middle-aged adults, in particular, may experience additional stress, if they loose the security of their planned (and possibly paid-off) retirement home (or their financial nest egg), and if they are forced to pay for extensive rebuilding costs. Older adults will greatly miss their daily routines and will suffer strong feelings of loss from missing friends and loved ones. They may also suffer feelings of significant loss from the absence of their home or apartment or its sentimental objects (especially items like paintings, antiques, family Bibles, photo albums, and films or videotapes), which tied them to their past.
Adults living in group residential rehabilitation settings (mental health, mental retardation, or drug and alcohol facilities) and institutions (prisons, hospitals, boarding homes, or nursing facilities) may react in the same ways others in the community react to the disaster. For these groups, there is often an overriding sense of isolation and dependence, which they may be made to feel even more strongly during the recovery period. Family members and friends are often lost, as actual casualties of the disaster itself, or as captives of the cleanup effort. Either way, the persons in the residential settings generally receive less social contact and will tend to feel more forgotten and alone.
Timing of onset of these changes varies with each person, as does duration. Some symptoms occur immediately, while others may not show until weeks later. Just about all of these things are considered normal reactions, as long as they do not last for more than several weeks (to a few months). Unfortunately, victims and relief workers who are unfamiliar with these normal feelings/emotions/reactions will often begin to fear they are losing it or going crazy from the disaster related stress.
Full recovery takes far longer to achieve than most people assume it will take. A nice way to explain it to others is to draw a parallel to the death of a close family member or friend. Most realize the recovery period will require at least one year (to pass each holiday, birthday, anniversary, change of weather and season, etc.) and the one-year anniversary of the loss (or the disaster event). It then can take several more years (some estimate 2 - 7 years) of repeating that cycle before folks really are comfortable with their losses and the resulting changes in their lives.
Bear in mind that the personal impact of disasters tends to be much worse whenever the disaster events are caused by intentionally destructive human acts than by natural causes (or pure accidents). Whenever inhumanity plays a major role in causality, survivors seem to need extra time to resolve their losses and move forward with their lives. This relates directly to the greater amount of anger involved, overexposure from repetitive media coverage, and the fact that any true sense of closure may not come until the perpetrator(s) are found and prosecuted.
People who have survived disasters tend to mark time differently, referencing things as being before or after the event, even when things appear to have been successfully resolved. Victims often report being stronger or more mature afterwards. Many have taken steps for future personal preparedness, to be ready for the next time something like that happens. They are often more sensitive to future disasters; many donate money and/or volunteer to help others who must now go through the same pain they experienced.
Key DMH Concepts
Here are some other "Key Concepts" from DMH literature that workers must keep in mind:
- ·Mental health labels should be avoided.
- People do not disintegrate.
- Victims (and relief workers) respond to DMH workers who show active interest and concern.
- Workers need to abandon traditional office-based approaches.
- Be sensitive to cultural, ethic, racial, and socioeconomic diversity.
- The disaster climate has a way of generating lots of rumors.
- Disasters bring out the best and the worst in people.
- Helpers are subject to a vast array of physical and emotional responses to crises, including burnout.
- Workers can find strength (and peer supports) in numbers.
- One DMH experience is enough to get you hooked - the work is highly addictive for many that volunteer (Weaver, 1995, pp. 41-45).
The screening process involves remaining calm and using interviewing basics such as active listening and a bit of "mental health" first aid. Here are the elements of mental health first aid:
- Remain calm - be an appropriate role model.
- Introduce yourself and your agency/services/role.
- Get needed demographic information immediately.
- Use active listening skills and allow plenty of time for ventilation.
- Giving process details helps lessen fear of the unknown.
- Be truthful about what you have to offer and be careful not to overstate it.
- Verify attentiveness.
- Usually, it is best not to stop any tears.
- Sometimes, giving a hug may help.
- Shun "superman/wonderwoman" urges and involve others.
- Learn to recognize and remember your own limitations (Weaver, 1995, pp. 64-68).
DMH Screening Techniques
Lots of DMH work is done while "hanging out" or what the Red Cross calls "schmoozing" with victims and other relief workers. Most interventions will be very brief contacts, many being 15 minutes or less in length. Those persons who are having more serious difficulties will need more careful attention and longer, more formal interviews.
The following material should help clarify some types of information that often must be gathered while screening persons with more significant, negative reactions:
- What drew special attention to this person?
- What are the person's presenting problems?
- How long have the problems existed?
- What help (support, education, and/or treatment services) has the person received and from whom?
- What medications, prescription and nonprescription (or over-the-counter), are being used by the person for physical conditions?
- What medication, if any, is the person taking for any psychiatric condition(s) for which he or she is receiving treatment?
- Is the person self-medicating (abusing street drugs, alcohol, prescription drugs, and/or nonprescription medications)?
- Has the person had a good, recent physical examination to rule out any physical problems that might be causing the current difficulties?
- Is there a family history of mental illness?
- What changes in mood, behavior, sleep, appetite, ability to concentrate, motivation, etc. are present?
- If depression is mentioned (or seems obvious), ask about current (and previous) thoughts of suicide and/or attempts.
- If anger and/or poor impulse control are issues, explore thoughts (and history of actions) of harming self or others.
- If the person is hearing voices, displays suspiciousness of others, sees things, feels odd sensations, believes he or she is being controlled by others or by the media, etc., these are often good indicators of serious illness (Weaver, 1995, pp. 86-89).
It is always a good idea to conclude any detailed screening interview with a general, open-ended question that will allow the individual to fill in any gaps. Say something like: Is there anything I did not ask you that might be important for me to know about how things are going with you since the disaster? Keep the possibility of abusive behavior in mind. Physical and/or psychological child abuse, spouse abuse, elder abuse, or other abusive relationships may worsen under the additional stress.
DMH workers need to get people talking, keep people busy, and begin problem solving. Talking things out can sometimes be structured by the formal or informal use of defusing and debriefing techniques. Familiarity with literature on Critical Incident Stress Debriefing and the Multiple Stressor Debriefing models will be extremely helpful. So too is familiarity and comfort with materials about (and experience with) handling loss, bereavement, and grieving. [Note: At the end of this page there is an internal page link to lots of additional information about defusing and debriefing, including a suggested handout.
As victims (and relief workers) share their stories, DMH workers need to provide support and normalize the experiences. At the same time, we must provide education about the challenges that lie ahead. This serves as a form of stress inoculation. Encourage victims to try to return to at least some of their normal pre-disaster routines (family meals, regular bed times, reading to children, etc.) as quickly as possible, to help them regain a sense of control of their lives.
Physical activity should be included in recovery plans, to help people deal with the adrenaline-rush portion of the typical stress response. It is important for folks to return to their damaged homes to confront the challenges that lie ahead. Have them spend some time working on cleaning up and/or salvaging whatever they can save. Another way to keep people busy and productive is to have them start to tackle the mountains of claim forms and other paper work they may be putting off.
Community Reactions to Disasters
Communities will experience disruption to physical and emotional environments as a result of most major disasters. Damage to roads and public buildings also causes a negative impact upon natural support systems (e.g., family gatherings, school and church attendance, and use of social/recreational facilities). Recovery efforts will be more successful as the community is able to return to fuller use of these support networks.
Most communities are blessed with considerable cultural, racial, religious, ethnic, and linguistic diversity. Workers need to be sensitive to the many screening and service delivery issues that can arise as a result of this diversity among our population and offer services in a sensitive and competent manner.
More About DMH Contacts
DMH contacts can be made at work locations such as disaster sites, staging areas, shelters, feeding locations, service centers, and so on. Workers need to work the crowds at congregate relief points, visit remote work sites, go out for home visits, and make condolence calls.
Outreach services and public education are also essential because only a small portion of those persons emotionally touched by disaster may seek direct-care services. Workers need to utilize print and broadcast media to broadly distribute timely information about the normal reactions people experience during the recovery (a period of time that will take far longer than many realize). Many excellent brochures are available to help spread the critical messages.
This copyrighted material is from: http://www.eyeofthestorminc.com