Five Key Elements Should Underlie Disaster Planning
Life for survivors of disaster or mass violence would improve if interventions in the hours, weeks, and months after such events rested on a few basic principles, according to an international group of mass trauma specialists.
Intervention and prevention efforts should promote safety, calming, self- and collective efficacy, connectedness, and hope, wrote the 20 authors in an article in the winter 2007 Psychiatry.
Not all persons affected by a disastrous event develop pathological responses, but some short-term or late-onset distress may demand clinical or community intervention, wrote the authors.
“As such, most people are more likely to need support and provision of resources to ease the transition to normalcy, rather than traditional diagnosis and treatment,” they stated.
The psychological impact is often the most critical impact after a disaster, said lead author Stevan Hobfoll, Ph.D., distinguished professor and director of the Applied Psychology Center and Summa-Kent State University Center for the Treatment and Study of Traumatic Stress in Ohio, in an interview.
“That psychological effect is the fundamental goal of terrorism, but it is equally important, if unintended, after a natural disaster,” he said in an interview.
Because controlled trials of mass interventions are difficult to organize, the authors used the best available evidence to support the principles underlying specific interventions, said Hobfoll.
“I'd call it 'research-informed,'” he said. “Every recommendation had to have research behind it but not necessarily randomized, controlled trials. There is an ethical need to respond to society's needs without waiting for perfect evidence.”
The paper points the way to future research in addition to clarifying theoretical underpinnings for the field.
“The now-notorious history of critical-incident debriefing shows what happens when we fail to base decisions on the evidence,” co-author Robert Ursano, M.D., professor and chair of psychiatry at the Uniformed Services University of the Health Sciences (USUHS) in Bethesda, Md., told Psychiatric News. “In that case, many people ran ahead of the information and overstated its value.”
Essential Elements Noted
In brief, five “essential elements” should undergird disaster response planning, according to the article:
Safety: First steps after a disaster require the removal of actual or perceived threats to reduce the physiological responses to fear and anxiety. When needed, exposure-based therapies can help individuals“ interrupt the posttraumatic stimulus generalization that links harmless images, people, and things to dangerous stimuli associated with the original traumatic threat.” Accurate information on developments following a disaster can increase the sense of safety by explicating bad news and dispelling rumors. Professional organizations like APA should be on the alert to confront community leaders or media figures who exploit disasters for political gain or sensationalism, wrote Hobfoll and colleagues. | |||||
Calming:Anxiety and distress are common responses to disasters, but once the immediate danger has passed, heightened anxiety or arousal can become dysfunctional. Hobfoll and colleagues recommend individual techniques like breathing exercises or reminding survivors that they are no longer in danger and community-level approaches like psychoeducation to make clear that postdisaster reactions are understandable and expected. | |||||
Efficacy: Promoting self-efficacy can begin with restoring one's ability to regulate negative emotions and solve practical problems. It can also include community activities like mourning rituals, getting children back in school, or rebuilding economic infrastructure. “The more that victims of mass trauma are truly empowered, the more quickly they will move to survivor status,” said the authors. | |||||
Connectedness: Connecting children with parents and neighbors with neighbors provides social support and increases the chances for longer-term recovery. Temporary settlements for the displaced should be viewed less as refugee camps and more as villages, with town councils, meeting places, sports fields, and places of worship all run by their inhabitants. Hobfoll and his colleagues cautioned that division along ethnic, religious, racial, or other lines may turn “social support” on its head, decreasing trust and increasing intolerance. | |||||
Hope: For some—especially in Western societies—hope is a belief that one's actions will help bring about a better future. For other individuals and cultures, hope arises through belief in God, a responsive and responsible government (“a belief that may be diminishing,” said Hobfoll), or sheer luck. | |||||
Opinions Differ
The paper's origins lie in a meeting three years ago under the auspices of the Substance Abuse and Mental Health Services Administration, the National Institute of Mental Health, and the National Center for Posttraumatic Stress Disorder. Discussions at the conference were expanded with a review of the literature and edited through an “exhaustive and slightly painful process,” in Hobfoll's words. Everything included was backed by research, so it was important not to overqualify statements, he said.“ Sometimes you've got to stick your neck out.”
One commentary accompanying the article said the five-point paradigm may be fine for industrialized cultures well stocked with resources but would be hard to translate to much of the world. Sufficient trained therapists will not be available to apply suggested cognitive or behavioral treatments to large numbers of people if local community structures break down, wrote Simon Wessely, M.D., of the King's Centre for Military Health Research in London, and two co-authors.
Hobfoll disagreed, saying that the principles would work well in settings without great numbers of physicians or other highly educated personnel.
In another accompanying paper, Brian Flynn, Ed.D., an adjunct professor of psychiatry and associate director of the Center for the Study of Traumatic Stress at USUHS, welcomed the fact that Hobfoll and his team suggested responses to mass trauma that went beyond the traditional realm for behavioral health professionals.
“It does continue to reinforce a trend away from more intense individual and group psychological interventions except when clearly warranted,” wrote Flynn. “It helps legitimize... the natural healing and resilience process.”
Ideally, said the authors, these principles should lead to pilot programs, adapted to local cultures and customs, that can be tested and refined. Interventions need several layers, ranging from individual care for the most severely affected to broader community interventions that are less costly per capita.
“These principles don't define programs, but they should underlie supportive psychotherapeutic approaches for any stressful event,” said Ursano.
Flynn went a step farther to propose that behavioral health professionals should take an active, early role in policymaking to prevent or mitigate the effects of incidents before they occur.
Hobfoll hopes that the ideas his group has presented will ultimately become integrated into policy and practice.
“My fear, though, is that before that happens, we will have another Katrina, and all the problems will again be attacked piecemeal,” he told Psychiatric News.
Some ideas appear to be seeping into the all-too-real world of floods, hurricanes, and terror attacks, however.
“It wasn't that many years ago that we didn't address the behavioral health of disaster victims and their families,” said Ken Murphy, director of homeland security and emergency management for the state of Oregon and president of the National Emergency Management Association, in an interview. “In Oregon, we have created teams of credentialed mental health professionals to go out immediately after a disaster happens.”
He would like to develop more such teams and do more to educate the public, victims, and responders, in ways reflecting their differing perspectives on the event and its consequences.
“We're trying to target the 'hope' part and to help get people back to a new normal” after a disaster, said Murphy.
An abstract of “Five Essential Elements of Immediate and Mid–Term Mass Trauma Intervention: Empirical Evidence” is posted at<www.atypon-link.com/GPI/doi/abs/10.1521/psyc.2007.70.4.283>.▪
