Treatment for Survivors of Natural Disasters
Lauren T. Bradel, MA
Northern Illinois University
Kathryn M. Bell, PhD
Correspondence: Lauren T. Bradel, MA, Department of Psychology, Northern Illinois University, DeKalb, IL 60115. Email: firstname.lastname@example.org. Phone: 218-760-3387.
Correspondence: Kathryn M. Bell, PhD, Assistant Professor, Psychology Department, Capital University, Columbus, OH 43209. Email: email@example.com. Phone: 614-236-6439.
Natural disasters such as floods, earthquakes, tornadoes, and hurricanes can lead to significant psychological (and physical) impairment in populations both directly and indirectly exposed to the disaster. Although not everyone who survives a natural disaster responds aversively, a relatively large number of people do. In adults, stress reactions following a natural disaster may range from heightened anxiety and an increase in the frequency of nightmares to debilitating post-traumatic stress and severe depression. Of individuals exhibiting severe aversive reactions to natural disasters, many fail to utilize available mental health care services for one reason or another. Treatment approaches and strategies for enhancing treatment utilization among natural disaster survivors are discussed.
Keywords: trauma, natural disaster, PTSD, treatment
1. Raise the audience’s awareness of psychological problems commonly experienced by natural disaster survivors
2. Increase the audience’s knowledge of factors related to the development of psychopathology following natural disasters
3. Improve the audience’s understanding of treatment barriers for natural disaster survivors and provide suggestions for overcoming these barriers
4. Enhance the audience’s understanding of evidence-based approaches to treating survivors of natural disasters
Program Level: Beginners
Psychologists who currently work with or may in the future work with survivors of natural disasters According to the National Comorbidity Survey, nearly 19% of men and 15% of women report having experienced a natural disaster, or naturally-occurring catastrophe that is not man-made, at some point during their lifetimes (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). Research has indicated that, for survivors, natural disasters tend to result in slightly fewer negative psychological outcomes than man-made disasters, such as plane crashes and acts of terrorism (David et al., 1996). In spite of this, natural disasters have been shown to lead to significant psychological impairment in adult survivors. Multiple studies have shown an increase in psychopathology following natural disasters that may linger for years following the event (Boe, Holgersen, & Holen, 2010; van Griensven et al., 2006).
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Psychopathology Following a Natural Disaster
Post-traumatic stress disorder (PTSD) and posttraumatic stress symptoms have been shown to be one of the most prominent psychological conditions to develop following a natural disaster (David et al., 1996; Mason, Andrews, & Upton, 2010; Schoenbaum et al., 2009). PTSD and posttraumatic stress symptoms can result from exposure to a traumatic event and cause significant distress or impairment. PTSD is characterized by the development of intrusive recollections of the event, avoidance of stimuli associated with the event, and hyperarousal that persist for more than one month (American Psychiatric Association [APA], 2000).
Prevalence rates of PTSD and posttraumatic stress symptoms following a natural disaster vary across a number of studies. In a study by Tobin and Ollenburger (1996) , survivors of a flood were interviewed by telephone approximately four months after the natural disaster occurred. Nearly 71% of survivors reported experiencing some posttraumatic stress symptoms, with 25% of survivors reporting a high level of posttraumatic stress symptoms. Additional studies have also shown that individuals with preexisting psychological disorders may be at an increased risk for developing PTSD or posttraumatic stress symptoms following a natural disaster (Boe et al., 2010; McMillen, North, Mosley, & Smith 2002; Tobin & Ollenburger, 1996).
Research indicates that major depression often accompanies posttraumatic stress symptoms in survivors of natural disasters (McFarlane & Papay, 1992; North, Kawasaki, Spitznagel, & Hong, 2004). In a study conducted by Başoğlu, Kiliç, Şalcioğlu, and Livanou (2004), 16% of survivors who were at the epicenter of an earthquake in Turkey met diagnostic criteria for comorbid PTSD and depression. Ruminating, or constantly turning something over in one’s mind, related to symptoms of depression and posttraumatic stress has also been shown to increase the likelihood of developing depression following a natural disaster (Nolen-Hoeksema & Morrow, 1991). McLeish and Del Ben (2008) found that one month after Hurricane Katrina, depression scores in an outpatient population significantly increased, but PTSD scores remained unchanged.
Anxiety is another common psychological outcome following natural disasters, and it can come in several forms. In studying earthquake survivors in Turkey, Karanci and Rustemli (1995) found that survivors experienced a range of anxiety varying between phobic anxiety, somatization, and hostility, and many individuals’ symptoms were still chronic at a 16 month follow-up. Likewise, McFarlane and Papay (1992) found that survivors of a natural disaster experienced the development of both phobias and panic disorders following the event. Further, individuals suffering from high levels of general anxiety prior to the disaster were at an increased risk for experiencing higher-than-normal levels of post-disaster anxiety (Tobin & Ollenburger, 1996).
To date, research is inconclusive regarding how substance use changes in survivors of natural disasters, although many studies indicate that, as a whole, general substance use increases. For example, Parslow and Jorm (2006) found that survivors of a major bushfire in Australia significantly increased their tobacco use following the disaster—regardless of posttraumatic stress symptomology. Conversely, Beaudoin (2011) found that alcohol use following Hurricane Katrina significantly increased, but tobacco use did not. Beaudoin hypothesized that tobacco use did not increase because of the recent emphasis on publicizing tobacco’s adverse effects. In a third study, North and colleagues (2004) found no significant differences in pre- and post-disaster alcohol use in a sample of male flood survivors.
Although findings relating to natural disasters and substance use are relatively inconclusive, an abundance of research has supported the idea that surviving a traumatic experience, in general, is significantly related to increased substance use (Fetzner, McMillian, Sareen, & Asmundson, 2011; Khoury, Tang, Bradley, Cubells, & Ressler, 2010). Furthermore, Jacobsen, Southwick, and Kosten (2001) found that a diagnosis of PTSD often predicts substance use in trauma survivors. In a sample of individuals who had survived various traumatic experiences, Breslau, Davis, and Schultz (2003) did not find that PTSD preceded trauma survivors’ substance use, but they found that individuals did significantly increase nicotine use following the traumatic event. The authors hypothesized that PTSD and substance use disorders may be influenced by shared risk factors—other than trauma exposure—and this is why increased drug and alcohol use were not found to increase after the trauma.
Correlates of Psychopathology Following a Natural Disaster
Several factors have been shown to influence the impact natural disasters have on an individual. Exposure to the disaster may be one of the most important risk factors for developing posttraumatic stress reactions (Kessler, Galea, & Jones,2006). Multiple studies have shown that the greater the degree of exposure to a natural disaster, the more likely the development of negative mental health outcomes (Galea, Nandi & Vlahov, 2005; Nolen-Hoeksema & Morrow 1991; Rhodes et al., 2010; Thompson, Norris, & Hanacek, 1993). In a study focused on earthquake survivors, Bland, O’Leary, Farinaro, Jossa, and Trevisan (1996) found that individuals’ psychological outcomes were directly positively correlated to the magnitude of personal consequences relating to the earthquake.
Likewise, several studies have indicated that relocation is related to negative psychological outcomes. Weems and colleagues (2007) found that individuals needing to evacuate during Hurricane Katrina exhibited significantly more posttraumatic stress symptoms than those who did not relocate. Similarly, in a study conducted in the United Kingdom, Mason, Andrews, and Upton (2010) found that having to relocate following a natural disaster, in addition to suffering high levels of exposure to the disaster, was a significant predictor of the development of psychopathology. Specifically, individuals needing to vacate their homes were, on average, two times more likely to meet diagnostic criteria for PTSD, anxiety, and/or depression. Davis, Grills-Taquechel, and Ollendick (2010) report similar findings, noting that individuals displaced by Hurricane Katrina experienced significantly higher levels of psychopathology than non-displaced individuals. In fact, they found housing to be one of the top stressors related to the hurricane.
Loss may also play a role in the development of mental health problems following the disaster. For example, loss, in general, has been shown to be significantly related to an increased likelihood of suffering negative mental health outcomes (Mason et al., 2010). Similarly, in a study looking at flood victims, Tobin and Ollenburger (1996) found that temporary or permanent loss of employment due to the flood was significantly related to individuals experiencing increased levels of stress. Death of a loved one during the natural disaster was also shown to increase stress levels. Research following Hurricane Katrina also showed that watching exposure to the hurricane in the form of excessively watching television coverage of the disaster and a loss of electricity were predictive of negative psychological outcomes (McLeish & Del Ben, 2008).
Social support has been shown to be an important factor influencing the development of stress related to natural disasters (Galea et al., 2005; Lowe, Chan, & Rhodes, 2010). Kwon, Maruyama, & Morimoto (2001) found that low social support is associated with a higher likelihood of developing PTSD following a natural disaster. They also found that individuals perceiving greater social support prior to the disaster experienced less psychological distress, experienced fewer stressors, and perceived more social support following the natural disaster which, in turn, was related to lower post-disaster psychological distress. Subsequent to Hurricane Katrina, multiple studies reported that a high level of perceived pre-disaster support, emotional support throughout the disaster, and post-disaster companionship provided through sources such as churches and community centers were all predictive of fewer negative psychological outcomes as compared to individuals who did not receive those types of support (Ruggiero et al., 2009; Weems et al., 2007).
Preexisting Health Conditions
Natural disaster survivors with a prior history of trauma exposure or preexisting psychological condition may be more likely to develop PTSD than those with no preexisting trauma history or psychological condition (McMillen et al., 2002). For example, in a study conducted in the United Kingdom, flood survivors who had experienced a prior flood were at an increased risk of developing symptoms of posttraumatic stress and anxiety (Mason et al., 2010). The authors surmised that this relationship between prior disaster exposure and psychopathology may have been the result of the propensity of survivors to fear the reoccurrence of another exposure, and therefore, resulted in increased anxiety. Likewise, natural disasters can exacerbate pre-existing psychiatric symptoms and may also trigger the development of additional symptoms, such of depressive symptoms (McLeish & Del Ben, 2008; Schoenbaum et al., 2009). Similarly, individuals with poor physical health prior to the disaster may be as much as two to four times more likely to meet diagnostic criteria for PTSD, anxiety, or depression following exposure to a natural disaster than someone who was physically healthy prior to the disaster (Mason et al., 2010).
Gender has also been shown to be associated with the likelihood of developing stress reactions to a natural disaster, including PTSD. Mason and colleagues (2010) found that, on average, female survivors of natural disasters scored higher on PTSD, anxiety, and depression scales than male survivors. Preliminary research suggests that low-income single mothers may be particularly vulnerable to the development of stress reactions (Lowe et al., 2010). Studies have also shown that factors such as neuroticism, guilt, problems with concentration, and obsessive traits are directly positively related to the development of PTSD following exposure to a natural disaster (Carr et al., 1997; Chen et al., 2001; Kuo et al., 2003; McFarlane, 1988).
The tendency to interpret a disaster in a negative way has been shown to be related to negative psychological outcomes (Tobin & Ollenburger, 1996). In a study looking at risk and resiliency factors following a hurricane, Lowe and colleagues (2010) found that individuals who appraised the disaster negatively were at an increased risk for negative psychological outcomes following the disaster than those who did not evaluate the hurricane as negatively. In fact, appraisals of the event were stronger predictors of posttraumatic stress than exposure to the disaster itself. Similarly, Ruggiero et al. (2009) found that, in individuals affected by the 2004 Florida hurricanes, extreme fear during the hurricanes was a strong predictor of individuals’ overall health.
Notably, suicide is not among the prevalent psychological consequences of natural disasters. Research has shown that, although psychological distress may increase following a disaster, suicide rates do not necessarily increase as well (Kessler et al., 2006). For example, Krug et al. (1999) tracked suicide rates in various countries affected by natural disasters and found relatively no change in suicide rates. Similarly, Kessler et al. (2006) found that suicidality (ideation and suicide plans, but not attempts) was actually lower following Hurricane Katrina than before. Findings such as these suggest that factors other than just trauma exposure and psychopathology may play a role in individuals’ decisions to commit suicide. In fact, research on man-made disasters suggests that some aspects of post-disaster personal growth may actually be beneficial and protect against suicide in individuals with a clinically significant mental illness (Mezuk et al., 2009). Future research is needed to examine post-disaster personal growth and its impact on suicide risk among individuals exposed to natural disasters.
Factors Related to Treatment
Few studies have been conducted looking at mental health service use following natural disasters. Most existent research looking at treatment utilization focuses on service use following Hurricane Katrina. For example, in a telephone survey of Hurricane Katrina survivors by Wang and colleagues (2007), only 16% of respondents had used mental health services following the hurricane. Furthermore, only 4% of respondents were currently seeing a mental health professional whereas 11% were regularly visiting a general medical practitioner. In another telephone study, Wang and researchers (2008) found that 23% of respondents with preexisting mental health issues who used mental health services prior to the hurricane had either reduced or terminated treatment after Katrina. Of those individuals receiving treatment after the hurricane, nearly 65% were being treated by a general medical practitioner as opposed to a mental health professional. Polusny and colleagues (2008) report similar findings with tornado survivors, noting that participants were significantly more likely to seek treatment from a general medical practitioner than a mental health care professional.
Wang and colleagues (2007) report a dropout rate for psychotherapy of nearly 60% following Hurricane Katrina. Of those who sought treatment but discontinued, the authors found that drop out was for a number of reasons including financial limitations (22%); lack of enabling factors, such as transportation (42%); feeling their psychological concerns were not severe enough to justify seeking treatment (50%); and feeling as though their psychological concerns would resolve naturally over the course of time (52%). In a study of individuals with at least five symptoms of depression, Nutting, Rost, Smith, Werner, and Eliot (2000) reported similar findings with 57% of participants beginning treatment but only 17% completing treatment. Dissimilar to Wang and colleagues (2007), Nutting et al. (2000) attributed the high drop-out rate to severe physical problems that, likely, detracted from individuals’ interest in seeing treatment of psychological concerns.
Characteristics Influencing Healthcare Utilization Following a Natural Disaster
Various demographic variables have been shown to be related to the mental health services individuals receive following a natural disaster, including Hurricane Katrina. Studies looking at correlates of healthcare utilization following natural disasters have found that women are significantly more likely to seek services than their male counterparts (Rosen, Matthieu, & Norris, 2009; Roy-Byrne, Joesch, Wang, & Kessler, 2009; Wang et al., 2007; Wang et al., 2008). Furthermore, being a member of a minority group is related to significantly less healthcare use than White individuals, and being a member of a minority group has also been shown to be a significant predictor of treatment drop-out (Roy-Byrne et al., 2009; Wang et al., 2007). Multiple studies show that individuals who are middle-aged are the most likely age group to receive healthcare services following a natural disaster; the elderly and children are the least likely to receive proper healthcare (Rosen et al., 2009; Roy-Byrne et al., 2009; Wang, 2007). Additionally, individuals who are married, currently co-inhabiting with a partner, or have been married at some point in life are more likely to seek healthcare services than individuals who do not fall into one of those categories (Roy-Byrne et al., 2009; Wang et al., 2007).
Education and socioeconomic status are also significant predictors of healthcare service utilization after a natural disaster. Roy-Byrne and colleagues (2009) found that following Hurricane Katrina, individuals with a high school education and below were less likely to receive adequate healthcare services than those with more extensive education. Similarly, individuals with modest incomes prior to the hurricane were less likely to receive healthcare services than individuals with extremely low incomes or more substantial incomes (Roy-Byrne et al., 2009; Wang et al., 2007). Also related to education and income, individuals with no health insurance were less likely to receive healthcare than individuals who had coverage (Wang et al., 2007; Wang et al., 2008).
Research exploring pre-disaster health as a potential predictor of who will receive healthcare services—and specifically, physician referrals—following a natural disaster has been inconclusive. In a study by Rosen and colleagues (2009), results indicated that individuals who experienced significant disaster-related loss were more likely than those who had not experienced a significant disaster-related loss to receive referrals for healthcare services. Likewise, individuals who suffered from a disability prior to the natural disaster are often more likely to receive a referral than individuals who did not have a prior disability (Rosen et al., 2009). Conversely, Rosen and researchers (2009) found that individuals suffering from pre-disaster mental illness were less likely to receive a referral for post-disaster assistance than individuals not previously suffering from a mental illness.
Enabling resources are also important factors in determining whether or not individuals seek healthcare services after a disaster. Facilities must be available, individuals need access to transportation to make use of available services, travel times must be reasonable, and potential clients need to have the knowledge of how to use the services available to them (Wang et al., 2008). Given the risk for resource loss during a natural disaster (e.g., loss of electricity, telecommunications, transportation), it is no wonder that some survivors are unaware of available resources and/or may not have the means to access these resources even though they might otherwise be interested in utilizing these resources.
Not only do demographic variables and resources predict healthcare utilization, but attitudes towards healthcare services are also a significant predictor of use following a natural disaster. Low perceived need, or the belief that symptoms will diminish over time, is a common factor that prevents individuals from seeking post-disaster services (Wang et al., 2007; Wang et al., 2008). Similarly, individuals’ perceptions of their own symptoms and how they are still able to function may influence if they judge their problems as severe enough to require help from a mental health professional (Polusny et al., 2008). Stigma and the belief that treatment is useless—although this belief is less common than low perceived need—are other reasons that individuals may avoid seeking healthcare services after a disaster (Wang et al., 2007; Wang et al., 2008).
Specific psychiatric symptoms may also influence one’s decision to seek treatment and from whom they seek that treatment. For example, individuals suffering from PTSD Cluster C (avoidance) symptoms are more likely to use post-disaster healthcare than individuals suffering from other posttraumatic stress symptoms (Polusny et al., 2008). Findings also indicate that individuals may be more likely to seek services from a general practitioner rather than a mental health provider following exposure to natural disaster. Researchers from this study hypothesized that survivors experiencing a greater number of PTSD avoidance symptoms may avoid mental healthcare because they fear treatment will focus on the traumatic event (Polusny et al., 2008).
Current Treatment Methods
Critical Incident Stress Debriefing
Critical Incident Stress Debriefing (CISD), a group-based method of psychological debriefing (PD), has become common practice following various types of traumatic events. The goal of CISD is, generally, to minimize the adverse psychological impact of traumatic events through a brief intervention immediately following the event. Specifically, Mitchell (1983) explains that CISD is usually applied in seven phases: introduction, facts, thoughts/impressions, emotional reactions, normalization, planning for the future, and disengagement (as cited in Wei, Szumilas, & Kutcher, 2010). Recent research, however, suggests that this practice may be less beneficial and more harmful than originally believed.
Many mental health professionals are experiencing growing concern over the use of PD. Rose, Bisson, & Wessely (2003) articulate this concern in their review of PD procedures, referring to PD as an example of a commonly-used intervention that lacks the evidence to support its use. The authors identify an absence of randomized control trials examining group PDs, but note that the few studies that have investigated this intervention provide little evidence supporting the notion that PD is useful as an early psychological intervention or may help protect against psychopathology following trauma. Devilly and Cotton (2004) report similar findings, stating that there are no reliable studies demonstrating the efficacy of CISD and arguing that it is an ineffective response to critical incident. Indeed, Adler and colleagues (2008) conducted an empirical study of the effectiveness of CISD in veterans and found that CISD failed to reduce post-trauma symptoms relative to individuals undergoing no treatment.
Several factors may contribute to the possible ineffectiveness of PD including CISD. It has been suggested that debriefing may occur too early post-trauma to accurately predict morbidity. Research has indicated that debriefing may be associated with adverse effects for certain individuals because it may lead to secondary traumatization through its use of imaginal exposure shortly after the traumatic event (Rose et al., 2003). Debriefing may also increase survivors’ expectations of developing psychological distress to the traumatic event when, if not for the debriefing, they may have only experienced normal distress levels. In other words, debriefing may increase individuals’ awareness of their distress, and in turn, increase overall distress (Rose et al., 2003). Furthermore, Devilly, Gist, and Cotton (2006) suggest that debriefing may lead individuals to circumvent social support from family or friends because of the belief that professional help will be more beneficial to recovery. This is problematic because research has shown that inadequate levels of social support are related to poorer psychological outcomes following multiple types of trauma, including natural disasters (Kaniasty & Norris, 1995; Ozer, Best, Lipsey, & Weiss, 2003; Polusny et al., 2011).
Despite growing evidence that PD may do more harm than good, some individuals maintain their belief that PD is important to implement following a traumatic event. For example, Walsh (2009) supports the use of PD—specifically for workers assisting with relief efforts following a traumatic event. According to Walsh, PD provides a way for individuals sharing a similar experience to connect and support one another throughout the recovery process.
Cognitive-behavioral therapy (CBT) is another common treatment for survivors of natural disasters. In CBT, the client and therapist meet approximately 8-12 times to engage in various exposure, behavioral, and cognitive exercises to address the client’s maladaptive trauma-related beliefs and reduce the client’s emotional disturbance following trauma (Foa et al., 2000). Maladaptive trauma-related beliefs are inaccurate thoughts that may develop following exposure to a natural disaster, including those involving assimilation (i.e., altering new information about the traumatic event into preexisting beliefs, such as “Bad things only happen to bad people – therefore, I must be a bad person because this bad event happened to me.”) or over accommodation (i.e., changing one’s beliefs about the self or world to increase feelings of safety or control, such as “I must always be on guard to keep bad things from happening again in the future.”). A common goal of CBT is accommodation, in which the client balances beliefs with the reality of the traumatic event (see Resick, Monson, & Chard, 2007 and Sobel, Resick, & Rabalais, 2009 for further details).
There are several variations of CBT including: exposure therapy, systematic desensitization, stress inoculation training, cognitive processing therapy, cognitive therapy, assertiveness training, biofeedback and relaxation training, and different combinations of the methods listed above. Research has demonstrated that CBT is one of the most beneficial treatments for trauma survivors, with the exposure component, or imaginal exposure to the event itself, thought to be a large factor in its success (Foa, Rothbaum, Riggs, & Murdock, 1991; Foa et al., 1999; Foa, et al., 2000). Furthermore, studies show that CBT typically has the best outcomes when it begins two to six weeks following the trauma and is completed in five to nine sessions (Devilly et al., 2006).
Preliminary research suggests that CBT may be appropriate for the treatment of PTSD and posttraumatic stress symptoms (Hamblen et al., 2009). Specifically, Hamblen et al. (2009) conducted a study investigating the effectiveness of Cognitive Behavior Therapy for Post-disaster Distress (CBT-PD) following Hurricane Katrina, a ten session CBT intervention provided at least 90 days post-disaster to address the client’s cognitive, behavioral, and emotional reactions to trauma. The use of CBT-PD was related to significant reductions in participants’ distress and worked equally well for individuals suffering from both moderate and severe stress levels. The percentage of participants experiencing severe distress decreased from 61% (pre-treatment) to 14% (post-treatment). This reduction in stress was maintained at 5 months post-treatment when researchers followed-up with participants.
Suggestions for Treatment
Although there has been a significant amount of research conducted looking at psychological outcomes and treatments for survivors of natural disasters—especially following Hurricane Katrina in 2005—there is still much work to be done. Specifically, the efficacy of various treatments, such as CBT, need to be tested with survivors of natural disasters. Likewise, new guidelines must be established and implemented so that responses to natural disasters are quicker and more people have access to the necessary psychological services.
Eliminating Psychological Debriefing/Critical Incident Stress Debreifing
Currently, PD/CISD is the treatment that seems to receive the most criticism—primarily due to the lack of empirical evidence supporting its use (i.e., Devilly and Cotton, 2004). Belaise, Fava, and Marks (2005) propose moving beyond PD/CISD and, instead, focusing more on the potential effectiveness of well-being therapy (WBT) in which individuals learn to focus on incidents of emotional well-being. Specifically, he says randomized control trials are needed to test this therapy because, during preliminary investigations, trauma survivors have responded particularly well to the exposure and cognitive restructuring components of WBT.
Similarly, Tuckey (2007) suggests investigating other interventions that are financially and logistically feasible for organizations to implement as an alternative to PD/CISD. Wei and colleagues (2010) also suggest eliminating PD/CISD because of the lack of evidence supporting its effectiveness and, instead, implementing five empirically supported intervention principles: promotion of a sense of safety, promotion of calm, promotion of a sense of self- and community efficacy, promotion of connectedness, and promotion of hope.
Implementing PFA, or psychological first aid, is another alternative to PD/CISD that has been proposed (Vernberg et al., 2008; Wei et al., 2010). The PFA Guide is available to psychologists needing to provide relief for disaster survivors (see Vernberg et al., 2008 for a more detailed description of PFA). PFA is guided by the approaches most consistently supported by empirical research so that they can be disseminated, employed, and further studied. There are eight core actions outlined in PFA: (1) contact and engagement, (2) safety and comfort, (3) stabilization, (4) information-gathering, (5) practical assistance, (6) connection with social supports, (7) information on coping, and (8) linkage with collaborative services. PFA also discusses several implications for practitioners including how to utilize current knowledge, suggestions for working with various groups, the evolution of training and available materials, self-care of healthcare providers, the need to recruit PFA providers, and the importance of evaluating current practices.
Focusing on the Efficacy of Cognitive-Behavioral Therapy in Natural Disaster Survivors
Although numerous studies have supported the effectiveness CBT in treating trauma survivors (i.e., Foa et al., 2000), much more research is needed. Specifically, research must be conducted evaluating CBT’s effectiveness in survivors of natural disasters; most existent research focuses on assault survivors and, generally, survivors of violence. What little research on implementing CBT with natural disaster survivors does exist focuses on adolescent populations (i.e., Shooshtary, Penaghi, & Moghdam, 2008). Further research is needed to test the effectiveness of CBT in adult survivors of natural disasters.
Implementation of Telehealth
Telehealth is an emerging method of delivering long-distance healthcare to clients unable to access local healthcare services. Telehealth is being applied in a variety of settings including primary care and specialty consultation. It is also being implemented to assist with medical logistics, coordinating transportation, and monitoring remote patients (Simmons et al., 2008). In a study looking at adults diagnosed with depression, the use of telehealth was shown to significantly reduce symptoms of depression at 6 months as well as improve mental functioning at both 6 weeks and 6 months (Hunkeler et al., 2000). Assuming the infrastructure is available, this may be a beneficial approach to employ in disaster situations because it can make reaching survivors and providing services easier (Simmons et al., 2008).
Telehealth could assist aid workers in being able to provide resources sooner to survivors of natural disaster. Schoenbaum and colleagues (2009) suggest using telehealth to reach individuals affected by natural disasters immediately after the disaster. Using telehealth would allow for the provision of long-distance mental health services to shelters via working telephone lines. Likewise, telehealth would be useful when individuals are unable to or encouraged not to leave their homes (Simmons et al., 2008). However, this leads to the need to consider variables such as accessibility, affordability, and applicability of this type of assistance following a natural disaster (Devilly et al., 2006).
When treating individuals who have survived a natural disaster, mental health professionals need to distinguish between psychopathology and typical stress reactions (Ginzburg, 2008; Whaley, 2009). It is not uncommon for natural emotional distress to be mistaken for mental illness following a natural disaster. It is important that mental health professionals consider an individual’s overall functioning following the disaster to help guide decisions about diagnosing potential psychopathology (Whaley, 2009).
Likewise, mental health professionals must exercise caution not to “medicalise” distress symptoms. In other words, professionals should focus on not drawing unnecessary attention to symptoms that are typical of “normal” distress following a natural disaster. By drawing attention to symptoms unnecessarily, clients may become overly-focused on their symptoms and begin to experience more distress symptoms than they otherwise would have (Rose et al., 2003).
As Ginzburg (2008) points out, individuals who are diagnosed with a mental illness following a natural disaster may not have these diagnoses removed once symptoms begin to remit. As a result of maintaining their diagnoses, psychotherapy and/or medication may not be adjusted as necessary. This error can lead to the development of unnecessary distress once mental health relief workers begin to leave and mental health resources potentially become scarce. In order to avoid this unnecessary distress, it is important that mental health professionals are cognizant about re-assessing patients throughout the course of treatment to track the status of their disorder. Similarly, it is important that physicians treating survivors express the importance of frequently meeting with mental health professionals in order to receive the proper treatment following a natural disaster.
Rabins, Kass, Rutkow, Vernick, and Hodge (2011) recommend implementing advanced planning for responses to both natural and man-made disasters. Specifically, they recommend planning to first treat individuals who are particularly vulnerable to negative outcomes as a result of the disaster. For example, individuals who have preexisting mental health conditions and individuals reporting newly-emerging psychological symptoms should be treated before individuals not meeting those criteria. By implementing this advanced planning in the chaos following a disaster, mental health care providers would be able to systematically and efficiently triage care.
Implement Early Screening
The implementation of early screening, or looking for an illness that has not yet become apparent in a specific population, has been suggested by multiple mental health care professionals as a way to better-respond to the mental health care needs of natural disaster survivors. Others disagree with this recommendation, arguing that it will not be as effective as many individuals believe. For example, Brake and colleagues (2009) suggest that screening for adverse reactions, such as PTSD and acute stress, following a natural disorder is of no benefit. First, the authors state that early screening is futile because stress reactions within the first month after a natural disaster are “normal.” Furthermore, they allege that screening may lead to the “medicalization” of these normal stress symptoms. Additionally, Brake and colleagues (2009) state it is not cost-effective to screen natural disaster survivors, the literature has not yet identified an ideal time to conduct this screening, and screening is too inaccurate to be effective.
Contrary to the viewpoint Brake and researchers (2009) express, many mental health professionals view early screening following disasters as beneficial. For example, Ruggiero and colleagues (2009) recommend that disaster responders screen for depression as soon as survivors seek help for health-related concerns. Similarly, Koopman, Classen, and Speigel (1994) recommend using early screening measures that identify symptoms most predictive of future psychological disorders, such as dissociative experiences, immediately following the disaster. Preliminary research has supported the implementation of early screening procedures. In a study following survivors of an oil rig explosion in the North Sea, Holgersen, Klöckner, Boe, Weisaeth, and Holen (2011) concluded that an early screening intervention would have been able to identify survivors most at risk for developing long-term adverse effects.
In areas of trauma other than natural disaster, psychologists have begun creating measures to serve as quick, comprehensive ways to identify individuals who are most at risk for developing adverse reactions. For example, Winston, Kassam-Adams, Garcia-Espana, Ittenbach, and Cnaan (2003) developed the Screening Tool for Early Predictors of PTSD (STEEP). This instrument assesses individuals who have experienced a trauma, such as severe personal injury, within the past month. The STEEP is intended to help health professionals allocate resources, taking into account who has the greatest need for them. The measure was tested at a Level I trauma center, and was predictive of posttraumatic stress symptoms in approximately 90% of cases. Although this measure was not tested with a sample of natural disaster survivors, this is a type of early screening intervention that mental health professionals dealing with natural disaster survivors may want to consider creating and implementing in the future.
Get to Know Your Clients
The better a clinician can get to know his/her clients, the better he/she will be at providing the appropriate treatment for those clients (Ginzburg, 2008). Specifically, information on clients’ culture, including culturally-normative behavior, can be extremely valuable in determining a treatment path and making healthcare recommendations for clients. It is also important to be aware of the client’s personal needs and not make assumptions. For example, do not make assumptions that a client’s presenting problems will be directly related to the disaster he/she recently experienced. As advised by Whaley (2009), it may be beneficial to directly address any personal feelings of guilt or responsibility the client has relating to the event and help him/her reframe any events that were out of the client’s control. Once feelings of responsibility have been addressed, it may then be useful to get the client to focus on his/her own needs following the natural disaster.
Learning about a client’s family and friends can be beneficial in identifying a social support network following a natural disaster. Multiple studies have indicated that social support is an important factor for determining resilience following trauma (Galea et al., 2007; Lowe et al., 2010). Providing clients with information about where to connect with other survivors so they can communicate their feelings and responses to the disaster with individuals in similar situations can be important in helping them receive further support, learn self-help strategies, and develop contacts for further assistance (Devilly et al., 2006; Walsh, 2009).
To reiterate, it is crucial for the therapist to create a relationship with the client in which he/she feels comfortable revealing personal information that may prove useful during therapy. During Hurricane Katrina, some clinicians recommended that their clients stay with family to alleviate some of their stress (Whaley, 2009). However, this advice was often useless because many individuals’ families lived in close proximity to the disaster zone, and they, too, experienced a great deal of stress and loss. Had clinicians been more familiar with their clients, they could have provided more useful recommendations. However, instead of providing constructive recommendations, many clinicians only reminded their clients of the substantial loss they and their families were experiencing.
Consider the Health of Other Professionals—And Yourself!
Vicarious traumatization (VT), or the development of PTSD-like symptoms and changes in trauma-related cognitions in individuals not directly affected by a traumatic event, may develop among some professionals working with natural disaster survivors (as cited in Elwood, Mott, Lohr, & Galovski, 2011; Figley, 1995). VT can include general distress and a disruption of one’s beliefs and schemas (Farrell & Turpin, 2003). Symptomatic responses—especially intrusive thoughts related to the trauma—are more likely to develop than cognitive changes among mental health workers (Farrell & Turpin, 2003).
According to Figley (1995) VT is especially common in trauma-focused professionals, such as psychotherapists, but can affect anyone involved in helping an individual overcome a trauma including friends, family, and caregivers (as cited in Elwood et al., 2011). Research has indicated several predictors of VT including having a trauma history, experiencing life stress, suffering from mental illness, having a lack of social support, having achieved low educational attainment, being young, and implementing negative coping strategies, such as substance use (Lerias & Byrne, 2003). Argento and Ilaria (2011) found that role clarity and job support at one’s workplace were also inversely related to the development of VT in rescue workers.
Ginzburg (2008) noted the importance of paying attention to how fellow mental health professionals who are working with natural disaster survivors are faring. It is imperative to remember that professionals are also being exposed to and impacted by the devastating effects of natural disaster they are witnessing. Similarly, individuals in other service positions, such as police officers and firefighters, may display aversive reactions to the traumatic event (Ginzburg, 2008; Marmar, Weiss, Metzler, & Delucchi, 1996; Walsh, 2009).
According to data collected by Ginzburg (2008), several months after Hurricane Katrina, nearly 27% of firefighters contacted by the researcher’s team reported symptoms of depression, and 22% reported posttraumatic stress symptoms. Likewise, 26% of police officers reported depression symptoms and nearly 19% displayed posttraumatic stress symptoms. In a similar study following an earthquake in China, nearly 7% of military first responders met the diagnostic criteria for PTSD six months after the disaster (Wang et al., 2011). Walsh (2009) recommends that all organizations—both government and volunteer—provide trauma training for their workers who may someday respond to a disaster situation. For example, in a study by Fullerton, McCarroll, Ursano, and Wright (1992), firefighters reported significantly less stress responding to an emergency situation when they felt they had received the proper training prior to the event.
A lot about VT is still unknown, and further research must be conducted investigating predictors, symptoms, and prevention related to VT (Farrell & Turpin, 2003). Ellwood and colleagues (2011) recommend that employers work to provide more treatment options for trauma workers. They also recommended that trauma workers receive more training about how to respond to traumatic events, and they should also be more educated about VT.
Each year, natural disasters cause individuals significant emotional distress in the form of posttraumatic stress symptoms, depression, anxiety, substance use, and other adverse effects. Survivors of natural disasters who are women, suffer from preexisting mental health issues, interpret the disaster in a negative way, suffer extreme exposure to the disaster, and have low social support are the most likely to develop negative psychological outcomes following the event. Female Caucasian individuals who are middle-aged, have high or extremely low educational attainment, have access to transportation and technology, and do not hold negative attitudes towards mental healthcare are the most likely to receive treatment after a natural disaster.
Currently, there are two primary methods used to treat survivors of natural disaster who are suffering adverse effects: CISD/PD and CBT. Research exploring both therapies has consistently indicated that CBT is the superior treatment method, and several studies have even suggested that CISD/PD be abolished altogether. Furthermore, many mental health professionals believe that the current treatment methods, alone, are not sufficient. Researchers suggest that other treatments, such as WBT, PFA, and telehealth be explored further. Additionally, it is important for trauma workers to keep in close contact with their clients as well as pay attention for signs of VT in both themselves and other professionals. Much work is still needed in the area of psychological treatment for natural disaster survivors. Considering the large number of natural disasters occurring around the world in recent years, it is imperative that this area of psychology be given more attention than it has in the past. Consequently, new interventions must be implemented so that natural disaster survivors experience the fewest long-term negative psychological outcomes possible.
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Lauren T. Bradel, MA
Lauren is a fourth year clinical doctoral student at Northern Illinois University. Lauren received her Bachelor’s degree from the University of St. Thomas in St. Paul, Minnesota and her Master’s degree from Northern Illinois University. As an undergraduate, Lauren worked with Dr. Melissa Polusny at the Minneapolis Veterans Affairs Medical Center where she assisted with research focused on soldiers returning from Iraq and Afghanistan. At Northern Illinois University, Lauren has worked with Drs. Holly Orcutt, Kathryn Bell, and Alan Rosenbaum. Her primary research interests include identification of risk factors for intimate partner violence perpetration and the identification of risk factors for developing psychopathology following trauma.
Kathryn M. Bell, PhD
Dr. Bell is an assistant professor within the Psychology Department at Capital University. She received her doctorate in clinical psychology at Western Michigan University and completed her clinical internship in the Behavioral Sciences Division of the National Center for PTSD within the Boston VA Medical Center. Dr. Bell completed a two-year clinical research postdoctoral fellowship through The Warren Alpert Medical School of Brown University and served as an assistant professor for three years within the clinical psychology program at Northern Illinois University. She has published extensively in the areas of trauma and interpersonal violence.