How to Manage Traumatic Reactions to Disasters
When disaster strikes, people need psychological first aid
Posted August 30, 2011
In the days and weeks following the 9/11 attacks on the World Trade Center, a cadre of psychologists trained in disaster relief intervened to foster recovery among survivors and first responders. The unprecedented nature of this disaster, and the widespread reports of post-traumatic stress disorders (PTSD) that followed, stretched psychological knowledge to its limits in developing effective behavioral strategies. In the first few years following the attacks, researchers and clinicians attempted to estimate the prevalence of PTSD symptoms and develop effective behavioral strategies. Their work is summarized in an excellent article by psychologists Patricia Watson and colleagues in the September issue of the American Psychologist.
Surprisingly, despite the enormity of the disaster, approximately half of those exposed to it developed no more than one PTSD symptom. These "resilient" individuals seemed to benefit from a combination of many factors: adaptive personality traits, methods of coping with stress, biological propensity, the belief that they could cope successfully with stress, and - perhaps most importantly - social support.
The first lesson from 9/11, then, is that not everyone responds the same way to a disaster. For whatever reasons, those who qualify as "resilient" will recover on their own. It's those at risk for PTSD, however, who stand to benefit from psychological intervention.
When intervening in a disaster, it's crucial to distinguish between those who need help and those who will recover on their own. One of the mistakes made immediately after 9/11 was to provide the same treatment to all potential victims, without taking this resilience factor into account. In a New York Times interview, published at the time of the report, Watson noted that she couldn't tell if the providers helped people or not. The helpers felt better, but did those they were trying to help? They employed the standard of care known at the time of "psychological debriefing: to urge a distressed individual to talk through the experience and emotions. Unfortunately, this approach has the opposite effect on many people who become more depressed and anxious when reliving the trauma.
Instead of providing this single remedy fits all approach, Watson and her team recommend that disaster response teams limit their first response. "Psychological First Aid (PFA)" helps to stabilize survivors by promoting their safety, attending to their practical needs, enhancing their coping, and connecting them with additional resources. PFA is intended to be flexible, allowing responders to tailor their approach to the specific needs of each survivor.
After a month or more, however, survivors who are slower to recover need a different intervention strategy. The approach with the greatest empirical support is "Cognitive Behavioral Therapy" (CBT), which helps survivors understand and change their thoughts and beliefs to help alleviate their negative emotions. Though highly effective, CBT requires extensive training and isn't recommended for paraprofessionals. Instead, an approach known as "Skills for Psychological Recovery" doesn't require an advanced mental health degree. In this approach, you assist people showing moderate levels of distress by providing help with problem solving, scheduling time for positive activities, managing reactions, promoting helpful thinking, and improving social support by rebuilding healthy connections with others.
Psychologists also learned that to be most effective, they need to team with other service providers ranging from school personnel to first responders, public health and health personnel, volunteers, and spiritual providers. By training these individuals in principles of disaster relief, including the basics of CBT, psychologists provide a valuable role by expanding their reach beyond the victims who they can help.
There is much that psychology and other mental health and health professionals need to learn about how to help disaster victims. We have learned that not everyone reacts the same way, that immediate intervention should have a different set of goals then longer-term help, and that help is best provided via a multidisciplinary team. It's hard to conduct the best type of research to give the field a stronger empirical base. You can't study everybody prior to a disaster, put them into control groups when the disaster happens, and measure their response. All of this research is, by definition, non-experimental. However, certain principles, such as use of CBT for treatment of depression and anxiety, have a solid empirical and experimental base.
If you're called upon to help in a disaster, here are the 8 steps recommended by disaster behavioral health professionals:
1. Be prepared, pragmatic, and flexible. Know ahead of time what's going to be needed throughout the duration of the recovery period.
2. Promote a sense of safety. Give survivors a sense of calm, hope, connectedness, and boost their feelings of being able to cope with the crisis.
3. Do no harm. Know what strategies work and which do not. Take into account the resources available in the community. Be sensitive to cultural differences among victims and respect their rights. Be open to feedback on your effectiveness.
4. Build on community resources. Work with families, communities, schools, and friends and maximize the participation of everyone who's been affected.
5. Integrate with existing larger systems. Design programming that will reach as many people as possible and reduce the stigma of seeking help. Avoid building stand-alone programs that replicate other available services.
6. Provide "stepped care." Adjust the type of helping to the phase of the disaster. Early intervention calls for different strategies than later interventions.
7. Provide support that reaches out to the community. Help the community understand what you're trying to do, and frame your efforts in terms of the community's cultural, religious, memorial, and spiritual needs.
8. Provide a spectrum of services. Your intervention efforts should include assessment, Psychological First Aid, outreach, training, treatment for individuals showing signs of continued distress, and promotion of resilience.
On the whole, psychology receives a favorable score card in the post-9/11 decade. By acknowledging what works and what doesn't, we're expanding our knowledge of how best to help disaster victims, their families, and their communities.
Copyright 2011 Susan Krauss Whitbourne, Ph.D.
Watson, P. J., Brymer, M. J., & Bonanno, G. A. (2011). Postdisaster Psychological Intervention Since 9/11. American Psychologist. Advance online publication. doi: 10.1037/a0024806