Towards The Next Millennium: Disaster Mental Health - Learning From The Past And Planning For The Future
George W. Doherty
ABSTRACT
The twentieth century has produced many advances, miracles, and improvements, but
has also had many losses, traumas, and major disasters harmful to the human race. This
article presents a brief overview of articles in this Special Issue. It also suggests that
there is a need for a comprehensive, coherent body of knowledge which underlies and
defines a general model of Disaster Mental Health and calls for research to look at
each area of Disaster Mental Health and develop a general model or template which can
be tested through planning, application and outcome research.
*************************************
"It was the best of times. It was the worst of times." (Dickens, 1997). This opening line
from "A Tale of Two Cities" might be an apt description of the twentieth century. The twentieth
century has encompassed more within 100 years than any previous century in the history of
mankind. This century has seen the growth of major cities and economies; the development and
refinement of the automobile; safe and convenient air travel; instant world-wide communications;
space exploration (both manned and unmanned); major leaps forward in the medical professions
and treatments of the disabled; the almost complete eradication and control of a number of major
diseases; and increased ability to provide food for an increasing population world-wide (Malthus
notwithstanding). Advances in providing education have increased literacy levels world-wide.
There has been improved and more humane treatment for the mentally ill and significant attempts
directed at eliminating poverty. We have developed a new understanding of natural phenomena and
our world eco-system. Vastly improved methods for predicting weather and other natural events
have provided increased warning times helping to save lives. The development and multi-use of
television and radio, not only for entertainment and news, but also for educational, business
and other purposes has led to increased understanding and communication of ideas world-wide.
Uses and continued development of the computer, not just as a computational device, but also as
an informational and communication resource and tool, has opened up potential for a world-wide
net of ideas, information, communication and correspondence. This is beyond the wildest dreams
of those in previous centuries.
Many, many more developments in the sciences, arts, politics, social sciences, medicine,
business, international relations, cross-cultural understanding, human rights, etc. have made
the generations of the twentieth century the most prolific in history. There are people yet
alive today who began their lives in a horse and buggy world and have lived to see men and
women in orbit and walking on the Moon. All these have contributed to the general overall
welfare of the human race. Compared to previous centuries, the twentieth century stands alone
as one in which mankind has made many giant leaps forward.
The Downside
While the twentieth century has produced many advances, miracles and improvements, it
has not been without losses, trauma, major disasters (natural and man-made), setbacks
and other critical events harmful to the human race. One could probably make a good case
for the twentieth century producing more disastrous events that have affected more people
than any previous century.
The positive and the negative effects of the twentieth century experience have affected
the psyche and philosophical foundations of all cultures and societies. For example, as
a direct result of man going into space, we now are able to literally and figuratively look
back upon ourselves with an outside perspective - a perspective not yet fully realized, but
with enormous implications and potential for the future of the human race.
Disasters of the Twentieth Century
The Nineteenth Century ended with the Spanish-American War which propelled the United
States onto the world scene as a power to be reckoned with. The Twentieth Century began
with a hurricane which devasted Galveston, Texas in 1900 and took over 8,000 lives (Table 1).
In 1906, an earthquake of very significant magnitude all but destroyed San Francisco,
California. It was one of the most destructive in the recorded history of North America.
The earthquake and fire that followed killed nearly 700 people and left the city in ruins.
The quake was estimated to have been 8.3 on the Richter Scale. It destroyed most of the
city and left over 250,000 homeless. Table 2 lists some of the major earthquakes that have
occurred around the world from 1970-1990 and the number of deaths associated with each of
them.
The Twentieth Century has seen many more traumatic events and disasters that have stuck
in the memories of individuals as well as society and the human race in general. Some have
caused the loss of a significant number of lives, others have caused major economic, social
and emotional losses, and still others have changed the course of history. All were remembered
by survivors and living victims throughout their lives. Table 3 lists many of these major traumatic
events and disasters.
In the second half of this century, since the end of World War II, the United States has developed
improved methods for dealing with disasters and responding to them domestically and world-wide.
Between 1984 and 1994, there were 285 Presidentially declared disasters in the United States
(Young, Ford, Ruzek, Friedman, & Gusman, 1999). According to FEMA (1995), they provided
funding to 553,835 disaster victims in this period. In the period 1996-97, there were no less
than 118 Presidentially declared disasters and 8 National Emergencies within the United States.
Meichenbaum (1995) estimated there are about 17 million people in North America alone
who are exposed to trauma and disaster each year. Of those who are exposed to unusual
traumatic events, a significant number develop chronic PTSD or other psychiatric disorders
(Yehuda et al, 1994). These events include disasters, violence, combat, and accidents.
Following Hurricanes Andrew and Hugo, interest in providing disaster mental health services
increased. Research, training, education and planning has resulted in a number of approaches
and agreements for providing such services before, during and following disasters of many
kinds. While these groups focus on working with victims and with disaster/trauma workers,
each has a slightly different approach and even different definitions of disaster and the types
of interventions suggested in different time frames. There is a need to pull together the current
body of knowledge and possibly suggest a template or general model which can be tested and
revised in order to develop a common approach to disaster mental health which is supported by
empirical evidence as well as tried and tested methods.
Definitions
The Federal Emergency Management Agency (FEMA) has defined 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).
Taylor (1999) initially defines disaster as "a sudden or great misfortune, an event of ruinous
or distressing nature, a calamity; suffering death, injury, ruin, etc., as a result of an event,
circumstance, or oppressive or adverse impersonal (or interpersonal) agency". He defines victim
initially "as a person suffering death, injury, ruin, etc., as a result of an event (or) circumstance".
The definition offered by FEMA is one of an operational nature which suggests a programmatic
approach to addressing the disaster. It identifies specific types of disaster and is useful as a
governmental yardstick. As an operational definition for use in providing governmental aid, it is
useful. Taylor's definitions of disaster and victim are more general, more encompassing and tend
to better lend themselves to a psycho-social response to disasters and trauma.
Taylor (1999), however, goes on to make a good case for even more inclusive definitions of
disaster and victim. In his paper on classification of disasters and victims, he defines disasters
as "catastrophic events which seriously overtax the resources of individuals, their families,
their communities, the organizations in which they work, and sometimes threaten their vital
cultural traditions." Likewise, he re-defines victims as "people whose lives have been affected
adversely by their direct or indirect exposure to catastrophe, whether or not they might have
contributed to their misfortune."
Using the above definitions, Taylor develops a classification schema which attempts to pull
together disparate phenomena related to disasters and research on different kinds of disasters
which had been widely scattered both conceptually as well as graphically. His suggested schema
came about as a result of his work on the 1979 DC-10 crash on Mt.Erebus in Antarctica (Taylor,
1987). His classification schema for disasters and victims provides a useful model for
conceptualizing previously unrelated phenomena related to both. Certainly, it deserves attention
as a method for integrating disaster studies. A general working model of disasters and victims
can provide a framework within which disaster mental health research and practice can be used
as a coherent body of knowledge to build upon in the future.
State of Disaster Mental Health
With the above definitions and discussion in mind, and using it as a brief historical
perspective and suggested framework, this Special Issue presents a number of articles
on Disaster Mental Health from various perspectives and levels. In an inspirational
"foreword" to this issue, Garfinkel (1999a) presents events and responses from the
1996 Valuejet and TWA Flight 800 airplane crashes from a personal perspective in "The
Poetry of Recovery". In setting the tone for this issue, she discusses how small events
can take on large meanings and how the emotional life at the site of an airline disaster
has a language and rhythm of its own.
Taylor's (1999) article on classification provides an overview of disasters and victims.
Rose (1999) presents a provocative review and discussion of evidence based practice and
psychological debriefing. She discusses the use of evidence based practice in evaluating
the efficacy of psychological debriefing, citing information gathered from continuously
updated systematic reviews such as the Cochrane Database of Systematic Reviews. She
discusses the strengths and the weaknesses of evidence based practice. Following a
systematic review of the literature, she questions, given current evidence, whether
psychological debriefing should continue. Rose (1998) in a previous review on the
variability and potential negative impact of debriefing has also highlighted the problem
that what is called "debriefing" may quite often be poorly defined. The need for universally
accepted operational definitions for "debriefing" in different settings, under different
circumstances, and with different goals and/or expected outcomes seems apparent.
Smith and Suda (1999) provide a review of Mowrer's Two-Factor theory and its application
to acute intervention following trauma. They identify conditioned fear as variable rather
than universal or automatic. They suggest that acute post-traumatic interventions should
remain flexible while assessing and addressing the different types and levels of problematic
and adaptive reactions. Their discussion presents an interesting application of a behavioral
model for debriefing. Given an assessment and understanding of the contingencies surrounding
an individual conditioned fear response, a debriefer using this model would be able to provide
an individualized intervention to address specific conditions.
Post traumatic stress disorder is a psychological consequence of a traumatic event. Sivak,
Swartz & Swenson (1999) advance a hypothesis that suicidal thinking often increases when
individuals are afflicted with PTSD. They present information from a descriptive study conducted
at the Twin Ports VA outpatient clinic with both combat and non-combat veterans suffering from
PTSD. This study examines the prevalence and frequency of suicidal cognitions and their relation
to suicidal attempts. They also analyze Counter Suicidal Cognitions (CSC) which they define as
the thoughts and related interventions which individuals use to recover from episodes of suicidal
ideation. They maintain that a strong focus and distinct understanding of chronic suicidal ideation
and CSC in PTSD can assist mental health professionals in the assessment and development of
prophylactic interventions with this sequelae of PTSD.
At 9:02 AM on the morning of April 19, 1995 the world changed for the people of Oklahoma
City. In an article providing clinical information about the post-traumatic impact and counseling
interventions following the bombing of the Alfred P. Murrah Federal Building, John Jones (1999)
presents a very unique therapeutic approach which is of great value to other clinicians. He
describes the use of art therapy as an intervention with victims and survivors of the bombing.
His method and insights provide a valuable guide for clinicians who may work under similar
conditions with the victims and survivors of other disasters and tragedies. His method also lends
itself to use with other trauma victims.
Delamater and Applegate(1999) present a study which examines post-traumatic stress
disorder (PTSD), behavioral adjustment, and developmental outcomes in preschool children
who had been exposed to Hurricane Andrew in 1992. Their study measured mothers' self-reports
of their child's symptoms of PTSD. They present useful conclusions of major interest to
clinicians and practitioners in the field of Disaster Mental Health. They conclude that many
young children can be expected to exhibit PTSD symptoms and other behavioral disruptions for
at least 18 months following exposure to a natural disaster. Their study demonstrated that
preschool age children exposed to the stress of a major hurricane were more likely to exhibit
symptoms of PTSD than a comparison group who were less exposed. Children with PTSD at 12
months were reported as being more likely to be developmentally delayed at 18 months and
those with PTSD at 18 months were also likely to be delayed. They suggest the children are
at risk for failure to achieve normal development in cognitive, social and emotional skills and
conclude that children with PTSD are at risk for developmental delays. This study is one of the
first to examine the effects of PTSD on the general development of young children and presents
information that will require further study in this important area.
Another clinical approach to post-traumatic intervention is presented by Dahlen (1999). She
provides a succinct overview of dreams and trauma as a result of disaster. She describes a
stimulating and interesting clinical intervention for nightmares and traumatic dreams following
trauma. This article provides a stimulus for research into when and how dream defusing might be
useful in the treatment of post traumatic stress. Other research suggested by this article
includes methods of slowing down recall in a manner that would enable the individual to
re-experience the trauma therapeutically.
Garfinkel (1999b) provides an account of two studies of elderly civilians living in nursing homes
and how they coped with months of Scud Missile attacks on civilian populations of Israeli
cities during the Gulf War. These attacks should have led to increased sickness and death
rates. However, she presents information from two studies that found the opposite to be the
case. Not only were morbidity and mortality not increased, but levels of cooperation, empathy,
and civility were seen to increase. She reports that the studies examined elements of staff
behavior, public policy, communications, formal and informal support, all of which fostered
psychological resilience and effective coping when facing a mass threat. She discusses how
these elements and principles could be taught and how they could be integrated into disaster
preparation, disaster response, and staff training.
Giving a different perspective on psychosocial intervention in emergency situations, Martel (1999)
provides a background of emergency events in Quebec, Canada from 1984-1992. He goes on to
describe the levels of intervention and coordination within the health and social services
sectors in Quebec. Emergency measures psychosocial interventions in Quebec are outlined
and include an integrated approach, a training program, a tool kit and a practical intervention.
Two major elements are discussed involving a psychological-educative approach and an emotional
reactions normalization message. Martel presents an impact model which deals with physical,
psychological, living environment and general environment factors. He identifies phases of
psychosocial emergency intervention, different clientele groups (Primary, Secondary, Tertiary)
affected by the event, a psychosocial emergency services planning process, a grieving process,
objectives of the intervention and activities, major characteristics by age group, outline of
training program for CLSC psychosocial workers (an 8 module program), practical applications
of incident debriefing sessions and examples of how these have been implemented in major
events in Quebec.
Summary, 2001 and Beyond
Disaster Mental Health is in need of a comprehensive model with smaller diverse models
to help develop focused local and national approaches to interventions and follow-ups.
The literature contains a wealth of information with many varied approaches. A
comprehensive, coherent body of knowledge which underlies and defines a general model
with tested planning, approaches, and interventions can help improve upon an already
useful and helpful field. We need to look at the research in each area of Disaster Mental
Health and use it to develop a general model or template. We then need to test that model
through planning, application, and outcome research. A synthesis can then be developed as
we follow a plan of action similar to that used by Emergency Planners: Plan how to respond
- Respond - Evaluate our response - Plan to respond using new insights and information.
Really, it is the same scientific method approach to hypothesis testing we all learned in
Graduate School.
With a new century and a new millennium soon to be here, Disaster Mental Health has a
great opportunity to learn from our past and make informed, educated, balanced, and
innovative decisions and plans for the future. The articles in this issue are a step in that
direction of integrating research and practice. A general model is presented and a specific
behavioral model is suggested. Following articles review the literature and anecdotal
information about past experiences. They provide some suggestions about future planning.
A programmatic approach is outlined and one suggestion about follow-up therapy is
discussed.
Where do we go from here? What will be the state of Disaster Mental Health in 2001? In
2010? In 2025? In 2100? And beyond? Are we learning from our past?
George W. Doherty
O'Dochartaigh Associates
P.O. Box 786
Laramie, WY 82073-0786
Email: larlion@usa.net