DEVELOPMENTAL PHASES OF INDIVIDUAL REACTIONS
FOLLOWING NATURAL DISASTERS - 1984
Raquel E. Cohen, M.D., M.P.H.
Mental health professionals are increasingly becoming aware of the number and variety of catastrophic events affecting the lives of individuals. The sources of stressors are being generally categorized into man-made (radiation leaks, chemical pollution, terrorism) and natural disasters (earthquakes, tornadoes, volcanoes). The need to plan, develop and offer assistance to the victims of these injurious events is prompting further study into the human health and mental health consequences and sequelae. This is highlighted by the fact that the Diagnostic and Statistical Manual of Mental Health Disorders of the American Psychiatric Association (1980) has reinstated the diagnostic category of "Post-Traumatic Stress Disorder" and defines it as follows:
"The essential feature is the development of characteristic symptoms following a psychologically traumatic event that is generally outside the range of usual human experience.
The characteristic symptoms involve re-experiencing the traumatic event; numbing of the responsiveness to, or reduced involvement with, the external world; and a variety of autonomic, dysphoric, or cognitive systems." (236)
As one analyzes the clinical and behavioral depictions of human reactions to dramatic events found in the literature, one finds complex descriptions that involve the biological, psychological, interpersonal, behavioral and social perspectives. (2) To develop an understanding of individual variability in the reactions of post-traumatic behavior, it is necessary to find a conceptualization that combines knowledge and semantics originating from a large number of diverse professional disciplines -- sociology, psychology, biology. This necessity presents a novel situation to traditional, clinically trained mental health professionals. Not only do they need to expand their understanding of how multivariate circumstances unleashed by the dramatic events affect individual but, in addition, they must devise a new interventive approach to develop psychotherapeutic techniques that take all these new concepts into account. This, in turn, will influence his role as a member of the disaster assistance team. To make these changes the clinical mental-health professional needs to acquire a body of knowledge which includes awareness of the changing reactions of individuals through time and relocation sites.
This paper has the primary aim of describing observed behavior after disasters. These post-traumatic human reactions are conceptualized across time phases using a developmental frame of reference described by Tyhurst(3). The organization of these reactions includes associated findings in the bio-psycho-social expressions of individual reactions. The selection of the various descriptions of observed and documented human reactions after disasters are sketchy and fragmented because they are the recompiled efforts gathered during various experiences of different authors and professionals who have reported them in their own style and perspectives. They have tended to perceive these experiences through their own "lens" and have chosen to report key observations as expressions of what they thought was important in understanding the individual and his/her situation.
The method chosen to present key reactions identified in publications plus personal experiences was, to sort out, on a brought organizing grid, a group of specific categories of human reactions. On the vertical frame, the categories are listed according to identified professional perspectives - biologic, psychologic/emotional, interpersonal and socio-cultural. The horizontal categories include the sequential periods before and after the disaster strikes. In this way, we can identify groups of expected human reactions, during one of these periods and conceptualize the individuals experience through a specific frame of reference. For example, we find in the "Recoil" period and the "Interpersonal Perspective" an increase in competitive behavior (possibly stimulated by the anxious need to obtain a fair share of the scarce resources available following disaster relief operations).
Obviously, there are overlapping descriptions of human reactions that cannot clearly be differentiated through the use of descriptive discriminating variables, due to our lack of a solid research knowledge base. This chapter is an effort to compile documentation to assist and to achieve a preliminary approach to help disaster-relief workers. It will allow them to organize their own increasing understanding of the behavior observed and continue to document their own experience using their own professional point of view and theoretical preferences. The author is suggesting one approach to conceptualize a variety of reactions of this complex human syndrome. By using the time frame structure across time phases to underline the developmental nature of these behavioral patterns, the need to take this into account when trying to ascertain and diagnose the severity of post-traumatic syndromes will become clearer.
There is a relation between the approaches by which problems are defined and the interventions chosen and translated into action. Mental health problem definitions reflect inferences and assumptions about the causes of the problem. In the case of post-traumatic stress reactions and behavior, one conceptualization that can be used based on the bio-psycho-social model is as follows: the human crisis reaction that occurs in an individual following the disaster impact is related to 1) the personality structure of the individual; 2) age, sex, ethnicity, economic status; 3) usual coping (adaptive defense) styles; 4) intensity of stressor; 5) available and appropriate "fit” between individual need and support systems; 6) extent of personal loss suffered; and 7) availability of relief and community disaster assistance resources (4). Using these knowledge components, the problem definition of the situation in which the victim finds himself (the way we organize and relate all these characteristics, their hypothetical interactions and influences on the individual's health and personal functioning) offers guidance in which way a mental-health worker can assist a victim (5).
The body of knowledge selected to highlight the characteristics of human reactions in the aftermath of the disaster are not all-inclusive but are presented in figure 1 as a method of systematically ordering data and including some inferred understanding of the adaptive defenses available to individuals. These adaptive defenses are defined as follows: an existing human characteristic (health, age), process, activity, or social support skills that act as a barrier, regulatory system, or "filter" to modify the impact of this dresser so as to resist, to deter or to self-correct the effects of the reactive psycho/physiologic disorganization of the organism faced with traumatic after effects of a disaster.
HUMAN REACTIONS TO SEVERE CATASTROPHIC DISASTERS:
Modern technology has developed the capability of forecasting many natural disasters. The use of weather satellites, radar, radio signals are able to track storms, hurricanes, tidal waves and other devastating disasters. The one disaster that cannot be predicted is the earthquake. The use of visual and audio media has developed methods to prepare and alert that the population for an imminent impact. These emergency signals and messages prepare a population for the possibility of potential danger. This initiates the stage known as the “Threat Phase”. This phase is absent in the sudden impact of an earthquake. There are no reports or studies on the biological response to the “alert” signaling through auditory or visual stimuli. We could infer an increase in a variety of levels of anxiety and other physiologic responses based on fear reactions (6). These reactions may vary according to the experiences of the inhabitants of the region affected, the cultural tradition and the level of expectation of certain known disasters endemic in certain countries.
It has been observed that following the media forecast people are more concerned to hear the latest reports and organize their daily routines in such a way that they can be close to a radio or TV. Rumors are constant sources of distorted information which flows through informal communication networks. Reactions to the many "bits of knowledge" passed along, varies from individual to individual - some respond rapidly with planned and appropriate, responsible actions, while others who deny the possibility of the disaster occurring postpone plans to take care of their property or themselves (7). Some of the behavioral responses appear to convey the individual’s belief that "it cannot happen to me" (sense of invulnerability) or "it cannot strike here". There also appears that type of attitude that appears to relinquish responsibility to the "powerful" governmental systems who "should take care of us" and so a passive-aggressive stance is chosen. Humor prevails in many jokes circulate among the group. All these types of expressions are influenced by cultural and social customs. No report on how children react has been documented.
The adaptive defenses that have been reported to be predominantly used in this phase are psychological in nature. We have identified the following: denial (affecting the perception of external reality and is closely associated with sensory experiences); repression (withholding from conscious awareness ideas and feelings that are painful/frightening); reaction-formation (the expression of feelings like fear, is manifested in paradoxical forms. This is observed in people who plan and attend “hurricane parties”).
As the knowledge of imminent danger pervades the community and intensity of emotions heightens nervous tension, the relationship between people take on different patterns of relating. Family members contact each other and plan together for helpful and supportive actions; there is increased shopping activity for essential articles; an increased number of groups and meetings are convened for a variety of preparatory family activities that are anticipatory to prearranged task assignments. This increased family agitation and rehearsed activity can be equated to the reports on the utility of “worry-work” done by individuals and investigated by Janis. (8)
The socio-cultural types of community activities which parallel the initial, individual prepatory phase, also begins to influence the type of changes observed in personal reactions. For example, planning religious meetings may be influenced by the religious customs, rituals and other characteristics of the traditional social systems of the affected community. All cultural and social environmental influences have an impact on how individuals behave and react under threat of an imminent disaster.
The effect following a few hours or days after the impact of the disaster and the consequences of traumatic after-effects (stressors) on the biological reactions have not yet been researched or reported. Descriptions of self-observed reactions have been made by some individual victims. These findings allow us to infer (also based on findings in animal stress reaction research) that there are changes in the neuro-chemical levels of the Central Nervous System associated with stress reactions that may affect the immune responses (4). Complaints of constant or intermittent fatigue, exhaustion and differing levels of restlessness have been observed accompanied by changes in appetite and sleep (5).
Psychological and emotional reactions ranged through all levels of anxiety. Fear, worry, shame and guilt are experienced as changes in the way people perceive themselves are noticed. Changes in the usual ways are reacting in behaving toward their novel situation add to their difficulties in adapting and coping.
Some important psychological and emotional reactions that have been observed are:
Emotions of fear,
anxiety, apprehension and demoralization “wash over” victims like waves,
sometime stronger, sometimes weaker, but constantly for a period of time. Lifton has added two
concepts to the reactions after a major stressor in his work studying the
victims of the
A group of adaptive defenses have been observed during this phase. Psychological mechanisms like “denial” serve as a mechanism to adapt and cope with the painful and unbelievable change in the individual's life. The following dialogue between a mental health worker and the victim shows how denial is useful to assist in control of emotions:
Health Worker: it must have been a
very frightening experience for you to see the water rising and no one
available to rescue you?
Victim: well, it was quite an experience, like adventure, they going to the movies in seeing a scary picture. I knew someone would come and I waited. It wasn't too bad.
Another manifestation that shows the need to control emotions is the degree of docile and passive obedience to the commands, orders or regulations that have to be given by the rescue authorities. In contrast, there are others who become rebellious, antagonistic to any rules, showing a wish to be in charge of their own routines in the disaster shelters. This behavior exemplifies the need to control situations so as to avoid being overwhelmed by feelings that are painful and intense.
In the interpersonal relations between victims and the first group of helpers that appear in the scene, it has been observed that individuals behave in the helpless, docile, dependent, indecisive way while others demand, complained, and express a sense of entitlement or scapegoat the authorities for the consequences of the disaster. A small percentage of the victims isolate themselves, and are uncommunicative. Some express guilt feelings about the fact that others were less fortunate after the impact (6). For example, if their house was less damaged or they suffered fewer losses of loved ones, they seem to need to perform actions symbolizing atonement while expressing defensive explanations of the fact that they were spared a worse fate than their neighbors.
The observed adaptive defenses that appear to help individuals initiate the necessary coping activities that has to continue through many of the troubled days ahead ranges, on one hand, from rigid obsessive behaviors in their interaction with other individuals, the other extreme, vacillating, changing their minds, going along with any suggestion. Some form groups easily and extend individual support towards helpers or victims. At times, the support behavior is inappropriate and is resented. All these individual efforts, to either relate with each other or to isolate themselves, seem to assist the individual to be able to deal with the sense of crisis, mercy, threat, and unfamiliar world into which the victims have been plunged.
The community, in
different degrees of geographical extent and social cohesiveness, is changed
after the impact of the disaster. Its
pre-impact socio-cultural characteristics will continue to have an impact on
the individual behavior according to previous characteristics and available,
organized resources - both supportive and for relief operations (7). For instance, it was reported to the author
that following the
As time passes,
the biological somatic reactions become manifested and there is more
documentation by the medical profession of increasing psychosomatic complaints,
increased interference with usual biologic functions and emergence of acute
flaring of chronic somatic conditions.
Cardiovascular problems have been reported and conditions that have been
controlled (e.g., blood-pressure and diabetes) need readjustment medication
(report to the author for medical professionals in
The psychological-emotional reactions that are manifested as the individuals return to their neighborhoods and for the first time visualize and realize the consequences of the impact of the disaster varies. As they begin to ascertain what it will take to begin the reconstruction of their lives, we have seen reactions ranging through all the known manifestations of grieving, mourning and despair, familiar to mental health professionals. Anecdotes, observations and documentation (9) describe vividly the range of manifested and reactive emotions that are part of the” working through” of loss. The task of achieving resolution and resignation to accept their fate makes life for the victims a series of painful days.(10) The very difficult need of dealing with personal emotions, interpersonal relations while at the same time having to attend to daily living tasks presents, at times, moments of intense feelings of helplessness. Levels of vulnerability are manifested, tending to strip individuals of their usual coping, adaptive defenses (11). Their usual psychological mechanisms, at times fail, so that individual finds it very difficult to deal with the multiple demands of making decisions that are needed to reconstruct their lives. Sometimes these behaviors interfere seriously with the task of dealing with disaster assistance agency staff that are brought into the site to assist in the “relief operations”. These workers, who have to clean after the devastation has destroyed the structural physical settings of streets and houses, will need some interaction with citizens. They have to use equipment so that roads get cleaned, trees uprooted have to be hauled away, water pipes have to be fixed, electric wires reconnected. To do all this, the relief workers will intrude into “living spaces” of the victims and we have seen emotional and violent reactions resulting from misunderstandings between victims and workers. In addition to these interactions, decisions have to be made, negotiations with plumbers, architects, banks and others whose assistance is needed to return the household to normal. These tests require from the victim a certain ability to solve problems through clear thinking and emotional stability. Both of these characteristics, however, may be, to varying degrees, impaired at these crucial moments.
In this period, feelings are easily hurt, conflict arises from the need to ask for help; a sense of humiliation and pride has to be suppressed. The awareness of having lost the known sense of security and independence without knowing if one will ever regain it adds to the bitter pain of these moments.
A mixture of behavioral patterns appears as interpersonal relations are studied during this phase. We have observed a mixture of different approaches to behaving in groups. Again, many paradoxes appear. Some individuals who had first tended to be within groups, in the early phase, following the disaster will shift their behavior and tend to isolate themselves, showing rigid independence reactions. They will have difficulty in interchanging efforts and resources, sharing the materials supplied by the rescue workers (12). There appears to be increasing difficulty in sustaining steady, expectable relations between individuals. People get angry easily, feel her, discriminated against for not receiving their fair share of the “relief” resources and blame others for their fates or feel guilty and greedy. A percentage of the population, in areas of scarce resources, develop a “victim” role with its accompanying expression of entitlement, learned helplessness, expectations of assistance and reactions of depression when frustrations begin to accumulate.(13) The increasing intrusion of the events that follow the aftermath of the disaster (stressor) with accompanying loss suffered, makes the individual as he negotiates with others feel like a failure, ruminating about the fact that he now has “proof” that he is not strong, able and in control, and has to depend on others. These reactions begin to alter distort relationships between individual and his/her support system (14). They avoid getting involved with other individuals as a method of not “losing control”. Their behavior compounds are difficulties in dealing with the crisis situation because to resolve their problems they have to interact with many people. For most individuals whose feelings of self-disparagement slowly disappear and there is a re-emergence of characteristic personality traits and social skills.
Within the socio-cultural community, activity efforts exerted by groups or individuals emerge. This aides in revitalizing the community social structure and helps return all the affected social agencies to function more effectively. All the social structures, where individuals and victims, who are back to some sense of normality, take on the functions ascribed to governmental, religious, social and human services return slowly to usual practices. A sense of competence is regained and continuation of functions to assist victims takes over from the outside "relief operations" staff who are beginning to leave the community. Religious organized activity continues in many of the community groups, at times, with increased celebration of reactivated and re-established rituals, including thanksgiving for the living and prayers for the dead (15). Explanatory stories emerge to put in perspective the traumatic events produced by the act of the nature. At the end of this period we begin to observe diminution of the outpouring of community supports. It had been at its height, just after the impact phase with its heroic, altruistic and loving acts of generosity shown by the community itself and the outside world. Occasionally, this outpouring of objects and give adds another aspect of trouble to the distribution and apportioning to the affected groups by officials trying to exert fairness and appropriateness in choosing the recipients of the gifts.
all the events and reactions that appear in this period is spotty in the
literature and few observations are reported.
The study reported by Ahearn and Rizzo was able to relate some of the
effects of the
Some accounts of
documented psycho-physiologic reactions to traumatic “signal” stimuli like the “pattern
of rain” on the roofs of the town in Buffalo Creek, or a radio, TV announcement
of tornadoes, or in the rumble of noise from a train that's a similar to
earthquakes. Some accounts of persistent
ruminations, obsessive memories, traces and sudden appearance of remembrances
have been told to the author by victims of a previous earthquake that preceded
An increased and continuous use by the victim of their support systems appears to be present for a long time following a disaster. There's a need to ventilate for a long time, to have others “acknowledge” how traumatic the event was and to receive acceptance of behavior that still “feels” alien to individual many months after the event. The event becomes a milestone that bonds individuals and allows them to share sense of history, unique to the survivors.
An attempt has been made to organize, describe, and report human/social reactions across time frame transitional phases after a natural, catastrophic disaster. The classification has been based on four categories of reactions - biologic, psychologic-emotional, interpersonal and socio-cultural.
The selection of a number of “key” reactions has been chosen to highlight the most often and documented the phenomena. They are based on anecdotal, studied and participatory reporting. They are not all-inclusive and many of the descriptive terms are not self-contained, non-overlapping categories. This has been an initial attempt to sort out reactive patterns following developmental sequences, as the effects of the disaster (stressors) interplays with all the adapting efforts available to human beings in their need to cope with new unfamiliar, uncontrollable circumstances. Although the language used and selected track to keep it in the descriptive field of the biologic and behavioral sciences, it is evident that the objectives of separating each description for sorting purposes is artificial. The genuine purpose of trying to understand the victims, their suffering, what they have gone through, with they face, what are their present problems and what they face in the near future, is a unique, sobering and incredibly challenging human experience.