HURRICANE ANDREW’S
CONTRIBUTION TO THE EMERGING KNOWLEDGE OF “POST TRAUMA
HUMAN REACTIONS” (Aug. 1992)
WHAT DID WE KNOW
RAQUEL E.
COHEN, M.D.
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
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
LESSONS LEARNED AFTER PARTICIPATING
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.
LESSONS LEARNED AFTER PARTICIPATING
“Andrew”
laid bare the capacity and vulnerabilities of
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.
MENTAL HEALTH RESPONSE PROGRAMS
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.
BIBLIOGRAPHY
Cohen, R.
E. and Ahearn, F. L. Handbook for Mental Health Care of Disaster Victims.
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.
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