Raquel E. Cohen MD, MPH





Disasters, whether natural or man-made, claim lives and property, devastating communities for long periods of life.  They are often events beyond our ability to predict, prevent and control.  Disasters impact on individuals to create survivors who must cope with trauma, loss and crisis to find the means to reconstruct their lives.  In afflicted communities impacted by a terrorism attack a large number of individuals are in the ranks of survivors and rescuers.


What happens to people after a catastrophic event which rips asunder their expected daily life?  This paper will explore the data that supports the understanding and  methodology to assist  survivors  based on both research  and experiential  publications  worldwide.    


The paper will be divided in 2 sections.  The first section will present selected areas of basic knowledge that explores human behavior following a trauma.  The second section will identify the application of human behavior knowledge to program components used in most emergency mental health programs to assist survivors, families and helpers traumatized by different levels of impact, whether direct hit or indirect. 





Advances in the Behavioral Sciences that contributed to our Knowledge of Trauma Reactions


The behavioral sciences have contributed to our knowledge of post-disaster reactions and enriched the understanding of behavior phenomenology across time, following catastrophic events.


The fulcrum concept in psychic trauma effect is centered on the various expression of stress response.   Publications detailing this psychophysiology response ranges from lay magazines to specialized professional journals.


How did the evolving knowledge of variation in stress multifactorial response, influence the understanding of reactions following terrorism disaster events?


It guided professionals to shift their focus of conceptualization and assistance intervention methodologies.   It is well established now that victim populations undergo substantial stress and acute psychophysiology reactions, following a severe trauma but with differing types of long term outcome according to interacting variables unleashed by the terrorist attack (bombs, poisonous gas, germs).


What concepts are involved in post-disaster stress reactions? These concepts come out of a different theoretical base than psychoanalytic, dynamic or behavioral psychiatry.   It borrows its basic language from the bio-psychosocial sciences that offer a theoretical foundation to understand and assist the traumatized individual.  The following are signal behaviors observed in victims of traumatic events as they struggle for recovery.

Trauma responses, crisis reactions, stressor-stress reactions, coping mechanisms, use of support-networks, loss and bereavement processes, adaptation behavior. In each of these behavior components we have researchers like Lazarus (1), Horowitz (2), Caplan(3), who have published their research in the psycho-physiologic spheres of trauma and stress reactions.



The study of the influences of stress on the biologic sphere, as for example on the innmune system and on disease susceptibility is complicated by a number of factors. (4) One such factor is the difficulty in defining the relation between trauma and stress.  This has produced a plethora of divergent, often vague definitions as to what constitutes "stress." The term has been used to refer to the impact of an external event, how the event is perceived, the subjective experience of distress resulting from such factors as impact, the ability to cope with the event, the biological response, or the interaction and combination of these effects.  Following a terrorist attack the multiplicity of factors both of somatic, cognitive and psychological nature complicates our conceptualization on the types of reactions that will be produced.  The sequence appearance of these multiple definitions of "stress" in the literature complicates a review of the effects of ''stressful" stimuli originating not only from the traumatic disaster event but in addition to the emergence of a post disaster environment which can become chronic and unpredictable.


Signal anxiety and its relation To Stress-Response Concept


Research findings report the concept that fear and anxiety is a biologically adaptive inborn response to danger.


It is out of early traumatic experiences that we develop signal anxiety that gets reactivated by direct threats to learned or symbolic threats. This signaling system can be activated from inside by inner needs or outside by life situations in disasters. This presents to researchers the paradigm that in stressful situations the process encompasses meaning and reactive emotions that are individual and unique.



In his article "Psychosocial modifiers of Response to Stress, Jenkins (5) offers models to relate stress response outcome, in relation to quality of support systems so as to measure adaptive capacity of the individual. All these processes are examined at the biological, psychological, interpersonal and sociocultural levels simultaneously and successively.   Persons with a strong array of social resources are hypothesized to have less likelihood of having a given noxious circumstance override their defenses.



Success or failure to cope with a situation has been shown to depend among other factors on a person's ability to appraise the situation (6).

All the above items attest to the need that we have to increase our knowledge about these human responses and that further research should benefit from a revision of these concepts. It has become increasingly apparent that stress is not a specific unitary entity. It is a convenient code word, which subsumes a large variety of internal and external forces acting on the organism.




The concept of "labeling’ as victims or post-disaster patients and its impact on the course and prognosis of stress response, are appearing in our publications. It has been demonstrated that a ''label' that has negative social implications, can have long-term, debilitating impact on survivors. This present a challenge to mental health professionals in the post-disaster trauma work, who need to communicate dysfunction without "labels" associated with trauma responses. A dilemma is presented to professionals, who need to categorize behavior as symptoms to validate the expenditure of money and time.  They are trained to organize observations along clinical categories that serve as guidelines for intervention. This issue needs to be resolved by the funding authorities of their respective regions.  Survivors are not patients, they are traumatized individuals.  A small percentage may have a previous mental health diagnosis or develop a syndrome like PTSD, but the majority of affected individuals are responding in a normal way to an abnormal situation.










Knowledge of disaster reactions has been accumulated by worldwide experiences documented by professional publications.  Summarized key content will be presented within a “lesson” framework.  These summaries are a compendium of guidelines and principles accepted by a general consensus worldwide.


Lesson definition- Learned content based on observing, participating, experiencing or interacting with an individual impacted by a traumatic event. This content reappears in disasters, indicating robust concepts, forming repetitive patterns associated with similar events



Lesson 1- Sequence of Human Reaction after a terrorist attack

Observations of survivor behavior following an attack are recorded in multiple types of media. Continuous experiences in identifying the characteristics of survivor’s reaction during the last 20 years has improved our ability to describe in an increasingly precise, less anecdotal manner, the sequences and types of observed behavior across time phases. Variables that influence the expression of response to trauma – initial shock- intensity of impact - extended geographical destruction, loss of life, loss of limb, rapidity of assistance - are examples of modifiers that have emerged to categorize reactions to trauma. Contributions from the research of social scientists have reinforced our knowledge of the effect on individuals when the effect of reality sets in.  The inability to comprehend the reality of the destruction of the World Trade Center in New York following the terrorist use of commercial planes has been well documented by interviews of the mass media.


Observations and research, identifying them across time from the biological, psychological, interpersonal and social perspectives can group identifying behavior through stage sequences post-attack. Professionals keep adding new observations and in turn modifying their understanding and concepts as experiences accumulate following each terrorist event,  Regrettably in the last years we have seen an increase in terrorist events and are accumulating observations on their effect on individuals.


Lesson 2 - Outreach Crlais Intervention

The emerging knowledge learned in terrorist events through the years helped professionals modify and reformulate intervention modalities to focus on the "person - situation configuration' as the unit of attention in post-disaster psychosocial treatment. This intervention post-disaster is now institutionalized. Post-Disaster crisis counseling is defined as "a mental health intervention technique useful in post-disaster events that seeks to restore the capacity of the individuals to cope with the stressful situation in which they find themselves. It has three aims: a) Restoring capacity of the individual b) Reordering and organizing their new world, c) Assisting the victim to deal with the bureaucratic relief emergency program. The methodology to bring about these objectives varies according to the "school of thought’s used by the professional. The reality circumstances mandate a short, flexible, creative adaptable approach compared to the usual organized, systematic clinical approach. This is an area where continued efforts to adapt clinical skills and modified approaches will be enhanced as professional learn from one terrorist event to the next. Differentiating variables like age, sex and cultural backgrounds point to the fact that both reactions and successful interventions differed in children, adults and the elderly of different cultures.


Lesson 3 - Planning and Mobilizing Mental Health Intervention

To design, organize and implement post-disaster crisis-oriented services, an integrated, interactive, flexible linkage system between the mental health organization and emergency management agencies needs to be established. It is important to realize that while mental health professionals organize to assist survivors, multiple activities are taking place within the other governmental/public system. Many lessons have emerged out of these efforts. Decision making about the ''life – situation post-disaster” of the survivor in our care.  Identification of need differences between groups of survivors is exemplified according to whether the physical impact of the disaster is direct or indirect:


Primary survivors - those who have experienced maximum exposure to the traumatic event,  Example: Direct hit by the shrapnel of a bomb or being infected by the Anthrax germ

Secondary survivors- grieving close relatives of primary victims

Third-level survivors  -rescue and recovery personnel, medical, nursing, mental health, red cross, clergy, emergency staff, firefighters, police, medical examiner, school personnel, administrators, children

Fourth level victims  -the community involved in the event– reporters, government personnel 

 Fifth-level victims  - individuals who may experience states of distress or disturbance after seeing or hearing media reports


Private Sector Utilization

Recently the private sector of mental health services has increased its activity after catastrophic impact on citizens in urban settings. There are several problems that need resolution before a private psychiatrist can participate in these activities:


1) Knowledge of local emergency plans and networking with disaster agencies example: Red Cross, government teams, and clergy

2) Skills in crisis intervention, consultation and education.


Lesson 4- Consultation

Consultation methods are being used to 1) increase the capacity of emergency staff to manage the emergency assistance of a traumatized individual, and 2) increase the knowledge, procedures and methodologies used by post-disaster agencies.


Lesson 5 - Education


Opportunities for media communication and dissemination of mental health information present themselves following a disaster. The human story in disaster is very compelling and media professionals seek experts to interview - at a rapid pace. In the midst of community crisis, the impact of these messages exerts a strong influence.


There are two specific areas that offer objectives to be accomplished by educational methods. One area deals with our knowledge of how the population has been psychologically affected by the trauma and the sequences of the stress response to the disaster. The other area is to offer knowledge of how the mental health system will respond and what we as professionals have to offer in post-disaster situations. Each of these areas has a) methods b) content and c) structure to disseminate knowledge.

Disseminating information about the mental health services, including consultation and education facilitates the actual operations of assistance.


Lesson 6

 "Burnout Syndrome" of caregiver Post-Disaster

The mental health of rescue professionals following a disaster is an important component in emergency operations. Their job can expose them to the most gruesome sights and smells. Even though they are prepared in their daily work as policemen, fire fighters, ambulance drivers etc. to painful experiences when this is multiplied by 100 or 1000 body parts that have to be disposed of, the impact is severe, nobody is prepared or immune to its devastating effect. Added to this we need to add, fatigue intense dedication to the task with reluctance to be relieved from duty, even for a short break.  This was exemplified by the angry reaction of the firefighters who battled with police when they were asked to stop working in the area of the remains of the World Trade Center disaster in NY, Nov.2001.


Reactions with chronic sequel for these workers. Generally these highly trained and proud individuals don't attend to their psychophysiology response produced by the intensity of their task. The fact that these catastrophic experiences are confronted only a few times in their lives, doesn't prepare them for the suddenness of what they cannot "duck," which plunged them right into the middle of a nightmare.  Organized and systematic models of intervention are being designed in different regions. The basic components consist of debriefing, identifying critical incidents, helping set the situation in perspective, and reinforcing the capacity and skill of the worker.                   




Lesson 9 - utilization of paraprofessional workers

In some regions there is a need to develop a combination of professional and paraprofessional response teams to assist survivors. Professional and paraprofessional workers can combine efforts successfully to provide a disaster recovery response that is grounded in crisis theory and intervention techniques. "How can we help so many victims with so few mental health workers?"  Professionals have resorted to variations and experimentation utilizing a variety of human resources, according to availability. Certain conditions emerge as necessary to accomplish the objectives of successful use of paraprofessionals

1) Individuals with some counseling experiences

2) Individuals with communication skills and sensitivity to the ethnic, social and religious characteristics of the victim

3) Training sessions and close supervision throughout the intervention program - Use of curriculum, video

Lesson 10 - Cross-cultural Issues in Disaster Assistance           


Although some involvement of the political institutions in disaster response is universal and, in many cases, extensive, the level at which the government becomes involved differs significantly among various societies. In some societies, disaster response is considered primarily a responsibility of governmental involvement. In these pattern areas, the military is given not only a major supporting role, but also frequently a controlling role in disaster response activities

 Religious institutions also differ in their involvement. In part, this is due to their degree of differentiation and institutionalization and to a certain extent, to their secularization and the extent of the scope of their predisaster activity. The clergy has an important mental health role following the tragedies of disasters, especially when there are large numbers of fatalities as exemplified by the terrorist events in the US in 2001.



The need to assist large number of traumatized citizens following a terrorist attack is a new challenge to the mental health professionals.  Knowledge accumulated from the universal human response to trauma and loss needs to be adapted to the painful reality facing many nations worldwide.





1, Lazarus,R.S., Folkman, S,  Stress. Appraisal and coping.  New York, Springer. 1984


2        Horowitz, M. J.,   Stress response syndromes, 2nd edition, Northdale, New Jersey, Jason Aronson, 1986


3        Caplan, Gerald,   Principles of Preventive Psychiatry, New York: Basic Books, 1964


4   Cohen, R,   Salud Mental para Victimas de Desastres, Organizacion Panamericana de la Salud, Washington, USA, 1999 (Also an English Version)


5    Jenkins, C..D. y colaboradores,  Activity Surve, New York, Psychological Corporation, 1979                   


6    OP-den-Velde y colaboradores  International Handbook of Traumatic Stress Syndromes (pp 219-230) New York: Plenum Press 1991