RAQUEL E. COHEN, M.D.


Historical background of post-disaster human reactions

          Knowledge of human reactions following a catastrophic natural disaster has been documented and categorized for many years.  Based on the knowledge, intervention approaches to mitigate and assist individuals have been tried.  These approaches borrowed guidelines from the experiences of civil and the military models.  A solid content of knowledge supports many approaches that are beginning to be institutionalized in post-disaster programs of which NIMH and Red Cross are examples.

          How did the evolving knowledge of variations in stress response influence the understanding of reactions following disaster events? What concepts are involved in post-disaster stress reactions?  These concepts come out of a different theoretical base than psychoanalytic, dynamic psychosocial sciences. It is well established now that victim populations undergo substantial stress and acute psycho-physiologic reactions, following a severe trauma but with differing types of long term outcome. (Cohen and Ahearn, 1980)

 The formulations using the bio-psycho sociocultural principles offer a theoretical foundation to conceptualize the process of crisis theory, coping mechanism, support-networks, loss and bereavement process, adaptation behavior. This has guided professionals to shift their focus of conceptualization and assistance intervention methodologies. 

Post-disaster reactions are based on clinical descriptive studies, which present the nature of the symptom constellation found in survivors .  The knowledge acquired in disaster experiences aims at understanding the manifestations, reactions and its implication for helping the traumatized individual.

          These approaches to understand the impact of catastrophes producing traumatic effects on the individual had been labeled and associated with pathological diagnosis if it occurred without the effect of a disaster. Following a disaster these responses to traumatic experiences were categorized as “Lessons” by professional workers assisting survivors.  They were becoming aware of the behavioral manifestations and responses of individuals expressed during different phases following the traumatic impact and many of them disappearing after a certain time had elapsed.

Definition of Lessons – “Learned content based on observing, participating, experience or interacting with an individual impacted by a traumatic event.  This content reappears indicating robust concepts, forming repetitive patterns associated with similar events.  Many professional publications in the United States and worldwide  added content over the years to these lessons.  They are “universal reactions manifested according to culture.”

Knowledge based on clinical descriptive studies, presents the nature of the symptom constellation found in survivors of stress: and it aims at understanding the manifestations, reactions and guidance for helping the traumatized individual.

Lesson 1 – Sequence of Human Reactions After a Disaster (Cohen, 1985)

Observations of survivor’s behavior following a disaster are recorded in multiple types of media.  Continuous experiences in identifying the content of survivor’s reaction during the last 20 years has improved our ability to describe in an increasingly precise, less anecdotal manner, the sequence and expression of response to trauma – surprise – 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 “Issue of Social Life” and the “Prevailing Sense of Commonality” had been damaged by the collective trauma (Erikson, 1976).

Lesson 2 – Program for Assistance in “Special Populations

Awareness of need in planning within the area of mental health services emerged through “on-site” findings and learning in different disasters.

Examples deal with:

Medication for community placed mental health patients

Drug and alcohol for alcohol and drug addicted individuals

Aids Infected Patients

Health problems: epilepsy, miscarriage, heart conditions,  diabetes

Elderly and Displaced: loss of home and health care services

Lesson 3 – “Burnout Syndrome” In Post-Disaster Caregivers

The mental health of rescue and response team professionals following a disaster emerged through the years, as novel and important components in emergency operations.  Even though these workers are prepared in their daily work as policemen, fire fighters, ambulance driver etc. to painful experiences when 100 or 1000 survivors have to be helped, the impact is severe; nobody is prepared or immune to its devastating effect.  Added to this we need to consider fatigue, intense dedication the task with reluctance to be relieved from duty, even for a short break. 

Lesson 4 – Cross Cultural Issues In Disaster Assistance

Cross Cultural factors play a major role at every level of: 

1)     Assistance Programs –

a.      Agencies/Technology/Resources –

b.     Crisis Teams – Availability, preparation

2)     Crisis-intervention methodology



1.     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 disasters.  The effects and involvement of the military and governmental agencies was extensive post-Andrew and should be factored in when describing the disaster effects on survivors.  The following observations need to be added to our post disaster Lessons:

a.      Impact on the sense of identity of “belonging” to their community and sense of “loss” of survivor that have been displaced due to the destroyed status of their house structure.

b.     Relationship between intensity and duration of post-traumatic stress and the destruction of different geographical areas of the county necessitation displacement to seek shelter.

c.      That is, the shifts in living quarters to unfamiliar areas have created a community at risk for further traumatic experiences. The displaced population had to accommodate themselves to the loss of a way of life. The geographical demarcation of the impact of destruction in different parts of the county has highlighted the need to clarify the different populations affected in term of strength of impact and recovery.  It is evident that the differential capacity and skills to deal with the “second disaster” (Life necessities – water, electricity, clothing, shelter and security) became a priority for a population who had no resources to acquire them without the official government help. A “grid” of different populations needs has emerged with the accompanying emotional pain and suffering.  These groups are encountering differential pathways to recovery according to the fragmentation of support systems that they had in their neighborhood and the novel human assistance.

d.     Impact of the traditional family holidays timing and the phase of crisis resolution post-trauma.  Thanksgiving and Christmas coincided with the post-trauma and mourning phase of the trauma.  This superimposition on the time-frame post Andrew, (3 months) intensified many unresolved emotions, making it more difficult to deal with frustration and reality.

e.      The characteristics of the “second disaster” post-Andrew impact on mental health.-----All catastrophic disasters produce a secondary sequence of difficulties that survivors have to resolve.  “Andrew “has presented a series of problems that have adversely impacted on the mental health of survivors who were previously diagnosed as suffering from emotional problems.

f.       Serious disproportion between resources and needs – timing, amount, appropriate “fit”, placing of  resource distribution and bureaucratic barriers.

g.     Organization and deployment of adjustors, insurance agents and building professionals.

h.     Negative public opinion of the building quality of homes expressed through the media.

i.        Logistic reconstruction problems of communities and homes – tension between planners and home  owners.


Hurricane Andrew helped to clarify the relationship between mental health status and community actions to assist in the recovery – displacement, political, legal, building, insurance etc.  This points to the fact that assisting populations traumatized after a disaster is not the sole responsibility of mental heal professionals but all agencies-government, private, non-governmental, social, mental health--who participated in the reconstruction of the regions.



          “Andrew” laid bare the capacity and vulnerabilities of Miami-Dade County to respond to a disaster. When a crisis event becomes a disaster (when it outstrips the capacity of the society to cope with it), the society’s vulnerabilities are more noticeable than its capacities. The social, organizational, and motivational, attitudes of the South Dade County population have impacted on the disorganization/reconstructive efforts which in turn have impacted on individual mental/physical health.

Emerging Lessons after the impact of Hurricane Andrew

During my activities assisting survivors Post-Andrew I found the following factors affecting degree of impairment:

Degree of life threat: moderate

Degree of bereavement and mourning for community and home loss: high

Prolongation of suffering: moderate to high acute; high chronic

Amount of geographical displacement required: high

Proportion of the Dade community affected: moderate

Cause of the disaster: Natural and man made (home construction deficiencies)

Post-Traumatic Infantile Reactions

Relationship between event and other conditions

The occurrence of psychosomatic manifestations were higher if the child:

a)     huddled in a closet

b)    lost a pet

c)     home destroyed

d)    had to live in temporary housing

 Process trauma was associated with higher incidence of post-traumatic signs. There appeared to be a correlation between depressed mothers and children’s distress symptomatology. A correlation was noted between previous psychological difficulties of the parent and post-disaster level of distress. Impact of sudden changed, catastrophic impact on sensory systems – auditory, visual.




Lessons learned post-Andrew to respond to post-disaster human problems:

A)   Shift from uni-professional-mental health focus to multidisciplinary teams focus on human problems: approach – multilevel; interactive multiproblems approach team manned by all needed professionals

1)     Physical health – all disciplines participation

2)     Mental health – all disciplines participation

3)     Environment monitoring and control efforts

4)     Economic assistance to citizens

5)     Engineers, builders, contractors

Issues for team members to resolve

                   Focus of intervention – crisis situation

1)     Perspective and interpretation of problems

2)     Methodology of response and resources needed

3)     Philosophy of intervention

4)     Professional values, boundaries, techniques

5)     Senior Supervision of comprehensive, focused intervention


B)   Differential levels of skills in the affected population to obtain resources from disaster agencies – necessitates specific assistance from team members according to skills, resources, cultural barriers needed by survivors to obtain help and assistance. Variables that impact on ability to negotiate, obtain, “cajole”, advocate needed resources survivors may not know how to “navigate” through the system.

a)     experience

b)    socio-economic status

c)     citizen status (migrant, acculturation, immigrant)

C)   Trained Law Enforcement Squads to be prepared and ready to enter immediately into action to control and monitor “rip-off” behavior: price gouging, rebuilding thieves, looting.

D)   Long-term consequences of disaster – “second disaster” events – affecting the capacity of the survivor to return to functional psychological level – this may last years.

1)     The experience after “Andrew” has shown us that although:

The roofs are up

The roads are cleared

The debris mounds are beginning to disappear

The schools have opened

The period of recovery and healing has not ended and different impacted groups will have different length of sadness, despair and painful memories.



Cohen, R. E. and Ahearn, F. L.  Handbook for Mental Health Care of Disaster Victims.  Baltimore:  The Johns Hopkins University Press, 1980.


Cohen, R. E.,  Post-Disaster Mobilization and Crisis Counseling, in (Ed) Roberts, A. R.,  Crisis Intervention Handbook, Chapter 14, Wadsworth Co.  1990


Cohen, R. E. and Ahearn, F. L.  Handbook for Mental Health Care of Disaster Victims.  Baltimore:  The Johns Hopkins University Press, 1980


Erikson, Kai T.,  Loss of Communality at Buffalo Creek, American Journal Psychiatry 133:3, March 1976, pp. 302-305


Mitchell, JT, Helping the helper, in Role Stressors and Supports for Emergency Workers, (DHHS Publ No ADM 85-1908).  Edited by Lystad M. Washington, DC, US Government Printing Office, 1984, pp 105-118