INTRODUCTION
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.
SECTION
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.
STRESSOR
- STRESS RESPONSE CONCEPT
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.
SOCIAL
SUPPORTS CONCEPTS
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
POST-DISASTER
STAGE SEQUENCES
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
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
Conclusion
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.
Bibliografia
1, Lazarus,R.S., Folkman,
S, Stress. Appraisal
and coping.
2
Horowitz,
M. J., Stress response syndromes, 2nd
edition,
3
Caplan,
Gerald, Principles of Preventive
Psychiatry,
4 Cohen, R,
Salud Mental para Victimas de Desastres, Organizacion
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)