The interaction of gender and various social/family factors highlights the interconnectedness of vulnerability factors. While men typically cope using individual and immediate decision-making, women use their social network to process and work through problems (Kawachi and Berkman, 2000; Taylor, Klein & Lewis, 2000). After a disaster, changes often occur in one’s social network (Kaniasty & Norris, 1997). In a study with victims of Hurricane Andrew, Norris, Perilla, Riad, Kaniasty & Lavizzo (1999) noted that nearly all of the events that were experienced in common by the sample were related to changes in the social environment. Womens’ PTSD symptoms have been shown to increase as their available social supports decrease, a finding that was not true for men (Pulcino et al., 2003). Change in the social network, which may involve a decrease in available social support, may be more devastating for women than for men due to its negative effect on their coping ability.
Traditionally, women have been assigned the role of caregiver, a role that may lead to increased stress levels in the aftermath of a disaster. First, for women who are primary caretakers, the extra stress of caring for children and the home may fall disproportionately on them. Norris et al. (2002a) noted in their review of disaster studies that being a parent, especially a mother, was associated with higher disaster-related distress. In a study with survivors of the 1999 earthquake in Turkey, a higher percentage of women than men reported that their first thoughts were of their family (Yilmaz, 2004). Second, women may be more likely to provide care for others affected by disaster (Kaniasty & Norris, 1995; Solomon, Smith, Robins, and Fischbach, 1987). In a study with vicarious victims of the September 11th attacks, more than twice as many women than men reported engaging in collective helping behavior (Wayment, 2004). When women offer support to other people, not only can they be further exposed to the trauma through contact with others, but they also may be burdened by the stress of providing support in times of need (Solomon et al., 1987). A particularly devastating situation may be the one in which a woman provides support services to others in the aftermath of a disaster, but does not receive an equal amount of social support back, especially in light of our previous discussion on coping styles.
There may be something about the traditional caregiving role that leads to vulnerability. A brief investigation of gender, ethnicity and this role will again highlight the complexity of the interaction between vulnerability factors. Studies with members of varying cultural groups have suggested that the gap between PTSD symptoms in men and women is higher in societies that are more traditional (Norris et al., 2002a). Norris et al. (2001) conducted a study using a sample of non-Hispanic White and Black Americans affected by Hurricane Andrew and Mexicans affected by Hurricane Paulina. In all cultural groups, women reported more PTSD symptomology than men. However, this gap was widest in the Mexican sample and smallest in the Black sample. Since, when compared to non-Hispanic White American culture, Mexican culture is understood to be more traditional in its adherence to gender roles (Chia, Wuensch & Childers,1994; Davenport & Yurich, 1991), and Black American culture is understood to be more egalitarian in its gender role definitions (Davenport & Yurich, 1991; McAdoo, 1988), the results suggest that women who assume the traditional female role are most vulnerable to post-disaster psychopathology.
Minority or third world ethnicity. Norris et al.’s study with Americans and Mexicans brings us to our consideration of a second vulnerability factor, ethnicity. Post-disaster effects in developing countries tend to be greater than in the U.S. (Norris et al., 2002a), and within the U.S., adult members of ethnic minority groups are more negatively affected by disasters (Norris et al., 2002a; Perilla, Norris & Lavizzo, 2002). Differential exposure to disasters may account for some of these differences. For example, in the U.S., ethnic minority members are often concentrated in the lower income strata and are more likely to live in less safe homes and at risk areas (Quarantelli,1994), increasing their trauma exposure.
Factors beyond the amount of exposure to disaster-related trauma are likely in operation as well. Again, poverty leads to lower access to post-disaster resources for minorities (Kaniasty & Norris, 1995). Also related to low socioeconomic status is a higher pre-disaster exposure to community violence. Similarly, immigrant members of minority groups or individuals who live in developing nations may live or have lived in cultures where they are likely to have experienced trauma. This could include the community or personal violence that is common in countries characterized by political or social unrest. Previous exposure to community or personal trauma increases the risk of post-disaster psychopathology. For example, Perilla et al. (2002) found that the incidence of neighborhood and personal trauma was higher among the Black and Latino participants in their study, and that the severity of their exposure accounted for much of their higher rates of PTSD post Hurricane Andrew.
There may also be culturally-influenced ways of interpreting or expressing distress that account for the vulnerability of minority groups. Members of an ethnic minority group may have experienced prejudice, discrimination or oppression. These experiences can result in psychological vulnerability in general, but could also be related to the way trauma is expressed. African-Americans, for instance, may, because of experiences of oppression, become hypervigilant to perceived threats and this in turn could result in the expression of certain post-traumatic symptoms (Allen, 1996). The Latino concept of susto, which refers to an experience of fright, is often to what Spanish-speaking individuals attribute any symptoms they experience (Hough et al., 1996; Kirmayer, 1996). The incidence of a disaster is consistent with this cultural concept, as it represents a singular traumatic event to which one can attribute distress. In this way, the expression of PTSD in response to a disaster is quite culturally consistent.
In certain cultures, such as African-American and Latino ones, family ties are emphasized and there is a strong reliance on the family for social support (Chia et al, 1994; Hatchett & Jackson, 1993; Sabogal, Marin & Otero, 1987). As in the discussion of women, disruption to the family or social network that can occur post-disaster can lead both to a loss of available support for minority group members (Kaniasty & Norris,1997) and to increased stress that comes with the obligation of tending to others’ needs. In addition, such a family-orientation can also result in less receipt of outside sources of support (Kaniasty & Norris, 2000).
Fatalism, the tendency to attribute the causes for things to a higher power, such as nature or God, is associated with Latino culture and sometimes with African-American culture (Pepitone & Triandis, 1987). Such a worldview can lead to poor psychological outcomes in response to distress because one’s personal power is perceived as minimal (Mirowsky & Ross, 1984; Wheaton, 1982). In an interesting study with children affected by Hurricane Andrew, Lee (1999) found that African-American and Hispanic students often received information about the cause of the hurricane that was inconsistent with Western science, and sometimes consistent with fatalism.
To summarize these vulnerability factors, like features of disasters that contribute to psychopathology, they seem primarily related to the extent of stress experienced, before, during, and after the disaster, and the available resources to deal with it. We have cited, for instance, the findings that both women (Pulcino, et al., 2003) and minority victims (Perilla, et al., 2002; Quarantelli, 1994) may have experienced more trauma before or during the disaster than white males . Resources include material resources, like money and infrastructure of a western vs. third world culture, social resources, like social networks and the way these may impact males and females differently, and coping style resources, which may vary by gender and culture. Understanding risk factors can assist us in designing interventions, both at the individual and community level, for survivors of a disaster.
Psychological Interventions for Victims
Numerous individuals and organizations have written about disaster planning and interventions from a psychological perspective (e.g., Ehrenreich, 2001; Jacobs, 1995; Roberts, 2000; SAMHSA, 2000). In the panoply of ideas and techniques put forward, a valuable model for looking at psychological interventions for disaster victims is that provided by Caplan (1964), the father of community psychology, who developed the model of prevention of mental disorder. If, as the community psychology model posits, stress is the major cause of psychopathology, the best way of preventing psychopathology is to reduce the stress of the environment. This is primary prevention, and as it applies to disasters, primary prevention places psychology squarely in the process of emergency preparedness. Psychologists, might for instance, help develop campaigns to persuade the public not to build houses in a flood plain, or find ways to increase the public's emergency preparedness through education, or influence legislation that requires insurers to provide disaster insurance or prompt payment of benefits after a disaster. Because psychology has so much to contribute to education and policy development, it is important for emergency managers to involve psychology in all their planning efforts.
Secondary prevention in the Caplan model involves identifying people at risk, and intervening to assist them. As applied to disasters, secondary prevention requires psychologists to conduct rapid screening after disasters and to begin interventions as soon as possible. Again, emergency managers need to include psychologists in the immediate aftermath of a disaster.
This type of prevention is often labeled crisis intervention, an attempt to reduce the stress of a crisis at the time it occurs. Lindemann's (1944) ground-breaking research at the Cocoanut Grove nightclub fire, mentioned earlier, involved helping survivors and the bereaved express their grief, in the belief that this would reduce their later symptoms. Caplan (1964) proposed that a crisis is a turning point, and that individuals in crisis can either cope successfully and thereby enhance their ability to cope, or they can make maladaptive attempts to cope, and thereby decline in their psychological functioning.
As we have noted in the section on vulnerability, the availability of resources is critical to postdisaster adjustment, and Caplan idenified the providing of resources as a major form of crisis intervention. Resources include material resources (for instance, helping victims locate temporary housing after a flood, or locate missing family members) and social resources (for instance, providing emotional support to an individual who lost a family member in the flood, and locating other individuals who can provide support). Social resources may be especially critical for female victims, as we have mentioned. Psychologists should be involved in the allocating of resources after a disaster by emergency managers.
Helping deal with coping resources is another form of crisis intervention. While many models of crisis counseling have been proposed and discussed (e.g., McGee, 1992; Roberts, 2000), most tend to be solution focused, with an emphasis on the victim's strengths and finding appropriate solutions to the problems they face. In general, active problem solving strategies are more effective than passive ones (e.g., Lazarus & Folkman, 1980) One issue for psychologists applying crisis intervention to disasters is that often there are not good solutions to the crisis, regardless of the individual's coping strengths.
One type of crisis intervention, critical incident stress debriefing (CISD), has received a great deal of attention of late. Developed by Jeffrey Mitchell (1982), the model has a strict format and is applied to victims, family members, and especially rescue workers, including fire and police personnel.. It is conducted in groups, and includes seven phases: 1) introduction; 2) facts about what happened in the crisis; 3) thoughts about what happened; 4) feelings about what happened; 5) symptoms; 6) teaching/information about stress and stress management; and 7) re-entry (Mitchell & Everly, 2000). In the next section, we will discuss the effectiveness of CISD.
Traditional psychotherapy falls into the category of secondary prevention. A number of interventions have been developed for victims with PTSD. Similar to strategies for other anxiety disorders, therapists use exposure (e.g., Foa & Kozak, 1986) to require clients to revisit the trauma of the disaster experience. The theory is that in dealing with a traumatic event, we use avoidance strategies to reduce the pain, and these avoidance strategies are part of the symptom picture. More psychodynamic therapists may work to have disaster victims confront their feelings about their experience, using different labels from the behaviorist, but doing similar work.
Usually, cognitive restructuring is also a part of therapy for individuals with PTSD. We have mentioned that disasters lead to a shift in cognitions (Janoff-Bulman and Frieze) and victims of disaster often have distorted beliefs regarding their safety, the likelihood of another disaster, their personal worth, etc.
Many forms of therapy, too numerous to list, have been developed for other disorders, such as depression and anxiety, which may result from disasters. These therapies are not specific to the treatment of postdisaster survivors. It is important that emergency managers be able to provide some forms of therapeutic intervention to victims and responders after a disaster.
Tertiary prevention in the Caplan model involves preventing further deterioration of those already emotionally disturbed, and is less relevant to disaster work. It might apply to long-term victims of disaster, like Vietnam veterans, whose problems persist, and who may need new and as yet undeveloped forms of treatment.
Evaluation of psychological interventions for disaster victims.
Psychology has a long history of evaluation research, again making it an important partner for emergency managers who need to assess the effectiveness of their planning and interventions. Psychologists have investigated the effectiveness of therapeutic interventions for disaster victims with mixed results.
Using the Caplan model for looking at psychological interventions is useful because it provides perspective on the multitude of interventions that are included. Recent focus on the efficacy of Critical Incident Stress Debriefing has taken emphasis away from the many efficacious types of intervention that mental health fields have developed, and perhaps represents a backlash against an overly enthusiastic application of the CISD model. There was little empirical investigation of the efficacy of CISD in its early days. More recently, CISD and other debriefing approaches have been scrutinized intensely. Here again, the approaches are under investigation for their efficacy with many types of victimization, not just disasters. Mitchell and Everly (2000) argue that the findings are mixed because of the variability of the training and skill of the provider. Many studies, however, have found no positive results beyond that of a placebo condition (Humphries & Carr, 2001; Rose, Brewin, Andrews & Kirk, 1999) or no treatment (Conlon, Fahy, & Conroy, 1998; Kenardy, Webster, Lewin, Carr, Hazell, & Carter, 1996). Some studies with randomized assignment to groups have actually found that trauma victims who underwent debriefing showed higher levels of symptoms than those who did not (Bisson, Jenkins, Alexander, & Bannister, 1997; Mayou, Ehlers, & Hobbs, 2000). This issue has even reached the popular press: an article in the New Yorker focused on the lack of benefit of debriefing for individuals suffering from reactions to the September 11 attack on the World Trade Center (Groopman, 2004), and the New York Times featured an article about the inappropriateness of psychological help for non-Western victims of disasters (Satel, 2005). A number of reviews (Arendt & Elklit, 2001; Ehlers & Clark, 2003; Emmerik, Kamphuis, Hulsbosch, & Emmelkamp, 2002; Litz, Gray, & Adler, 2002; Raphael, 2000) conclude that the lack of benefit for debriefing after disasters means it should be used cautiously, never be compulsory, and that further research is necessary.
Since CISD has been the primary technique used post-disaster, these findings have thrown the whole issue of psychology's ability to understand and help disaster victims and responders into question. It is important to note that psychotherapy itself is effective (Lambert and Ogles, 2004), and has been effective in treating PTSD (Marks, Lovell, Noshirvani, Lavanou, & Thrasher, 1998). There are several possible explanations for this disparity between the effectiveness of CISD and psychotherapy in treating PTSD. 1) CISD may be too short-term and unfocused to have enough of an impact. 2) Psychotherapy may need to be adapted to the particular situation of disaster victims 3) There may be characteristics of disaster that are different from other traumatic stress, making intervention more difficult. We will take each of these explanations in order.
CISD is an extremely short-term form of treatment. Reviews which compare debriefing with cognitive behavioral therapy (CBT) (Litz, et al., 2002; Ehlers & Clark, 2003) show that CBT is more effective in ameliorating trauma symptoms, perhaps because it is longer term and more focused on symptoms.
CISD is also a treatment provided mainly by other disaster workers, trained in the process, rather than by professional psychologists, although professionals certainly sometimes provide CISD. Barker & Pistrang (2002) argue convincingly that the processes of social support and psychotherapy are overlapping and should be conceptualized in similar ways. For instance, the outcome of professional helping seems to be no more helpful than paraprofessional helping (e.g., Faust & Zlotnick, 1995). Hogan, Linden and Najarian (2002) review 100 studies on social support intervention and conclude that they in general are helpful, although we do not know which kinds of interventions work best for which problems. It seems logical to suppose that there are disaster interventions that would be helpful when administered at the time of the crisis by paraprofessionals, although further refining of approaches is obviously necessary.
New approaches to disaster are being developed. A relatively new and controversial therapy for PTSD is Eye Movement Desensitization (EMDR), which involves controlled eye movements back and forth while the client is thinking about the trauma which occurred. Empirical findings are mixed (e.g., Taylor, Thordarson, Maxfield, Federoff, Lovell, & Ogrodniczuk, 2003). The explanatory mechanism for why the technique should work is involved and many psychologists find it unconvincing. For victims of fire, Krakow, Melendrez, Johnston, et al. (2002) described a sleep dynamic therapy, involving psychoeducational approaches about sleep, and found that both sleep disturbances and other anxiety and depressive symptoms lessened. Basoglu, Livanou & Salcioglu (2003) report that a single session with an earthquake simulator diminished symptoms of traumatic stress in earthquake victims. Smyth, Hockemeyer, Anderson, et al. (2002) administered the task of writing about victimization experiences in Hurricane Floyd, and found that it reduced the relationship between intrusive thoughts and symptoms, not as dramatic a finding as that of Pennebacker and Harber (1993) who had earlier reported that writing down one's feelings about a disaster can ameliorate symptoms. Lange, Rietdijk, Hudcovicova, van de Ven, Schrieken, & Emmelkamp (2003) have incorporated writing tasks into an Internet treatment for posttraumatic stress, which they report as successful. Newner, Schauer, Klaschik, Karunakara and Elbert (2004) describe an effective narrative exposure therapy for PTSD in Sudanese refugees, in which participants replayed the events of their life until they formed a coherent narrative. Pitman, Sanders, Zusman, et al. (2002) report that propranolol administered to victims of trauma interferes with memory of the event and ameliorates the potential for PTSD.
The issue of special characteristics of disaster which make psychological interventions more problematic should be addressed. Individuals in a disaster are more likely to see their needs as physical and real rather than as emotional, especially in a non-Western culture (Satel, 2005). Emotional problems may only emerge years later, as with many Vietnam veterans. It may be that psychologists, in their work with other emergency managers, need to educate individuals about possible emotional reactions, rather than stepping in to try to intervene too quickly with those who are not in search of services.
We have already noted that most psychological efforts are directed to helping individuals develop active coping strategies, rather than passive, fatalistic ones. It is sometimes the case in disaster, however, that there are no active strategies to take. One issue which has not been sufficiently discussed is that of individual styles and needs. Fullerton, Ursano, Vance, & Wang (2000) reported that female emergency workers were three times more likely than males to seek out debriefing. Our previous discussion of gender differences in vulnerability would suggest that women may be in special need of social support services postdisaster. Roth and Cohen (1986) discuss the fact that individuals seem to have preferred styles for either avoiding or approaching stress, and that these styles are difficult to change. Both avoidance and confrontation can be helpful depending on the circumstances. Most psychologists, going back as far as Lindemann, assumed that individuals need to confront the trauma of a disaster. It may be that enabling individuals to avoid effectively is just as useful, especially when the trauma is severe and there is little that can be done to change the situation.
Another issue is the perception that needing and taking help from a psychologist is stigmatizing. Jenkins (1998) reports, for instance, that co-workers were the most frequently sought out resource (by 94% of emergency workers dealing with a mass shooting) and the most consistently useful source of emotional support. Although counselors were equally effective, only 50% of victims sought them out. Again, education from psychologists about the possible emotional consequences of disaster could normalize this process, and make it easier for victims to seek help. It may also be that forms of paraprofessional intervention, other than CISD, need to be developed.
Gray, Maguen and Lidz (2004) point out that current crisis interventions focus on PTSD and its prevention, and that the wide range of victim responses, which we have reviewed earlier, demands a more nuanced and individuated range of treatments. Few interventions have been tailored to the needs of children (Wooding & Raphael, 2004), and it is possible that many interventions for children need to be addressed to their parents (Norris, 2001).
In summarizing psychology's achievements in understanding and dealing with disaster, the following seem clear. Disasters can cause severe psychological disturbance, with many victims experiencing PTSD, depression and anxiety. More research is needed to determine the entire range of disorders and the frequency of their occurrence after disaster. The severity and duration of the disaster will predict much of the extent of the reaction. Vulnerability factors in the individual do play a part, with gender, age, previous level of psychopathology, poverty, ethnicity and social support correlating with extent of post-disaster psychopathology in victims. These variables interact in complex ways. Mental health fields intervene both pre-disaster in emergency planning and post-disaster in crisis intervention, debriefings, psychotherapy, and evaluation of emergency management efforts. Recent research has questioned the usefulness of single session debriefings, but there is support for longer-term interventions and there is the promise of new types of interventions for disaster victims.