Koenig, Harold G. MD
From the Department of Psychiatry & Behavioral Sciences, Duke University Medical Center, Durham, NC.
Reprint requests to Harold G. Koenig, MD, Professor of Psychiatry & Behavioral Sciences, Associate Professor of Medicine, Duke University Medical Center, GRECC VA Medical Center, Durham, North Carolina. Email: firstname.lastname@example.org
The nature and timing of psychological and social interventions depend heavily on how much time has elapsed since the disaster event. Survivors and family members go through distinct psychological phases after the onset of a disaster. Adachi and colleagues1 have divided the time periods following disaster into four phases, each with characteristic psychological needs1: impact phase,2 early aftermath phase,3 short-term aftermath phase, and4 long-term aftermath phase. Proper understanding of each phase will help the physician arrange the kind of support (psychological, social, or spiritual) most needed and appreciated by the patient. Besides time since the event, however, psychological needs will also depend on the type, severity, scope, and geographical location of the disaster and on the personality and baseline mental health of the disaster victim. Although the psychological needs associated with each phase may vary widely, certain characteristic patterns have been observed.
The period beginning immediately after the onset of a disaster and continuing until the physical damage ends is called the impact phase. Psychological reactions usually involve hyperarousal and alertness, accompanied by fear, shock, or numbness. Research has shown that while some individuals will experience immobility or panic, most people will proceed rationally to acquire information to maximize their chances of survival.2 This will depend to some extent on their psychological stability and on the quality of social support available. The primary psychological need of this phase is information on how to minimize injury of person or destruction of property.
The second phase is called the early aftermath phase. This is also called the “crisis” phase and begins when the physical damage is complete and extends throughout the time that rescue workers (police, firefighters, emergency medical technicians) are providing physical care to survivors. Physical needs are the priority, and psychosocial needs are often put on hold. Nevertheless, survivors frequently experience high levels of anxiety and demonstrate physiologic reactions such as shaking, increased pulse and blood pressure, urinary urgency, or diarrhea. As the shock and numbness begin to wear off, acute reactions to loss may occur. In both the impact and early aftermath phases, what victims need most are simple explanations, instructions, and reassurance that they are safe. Survivors at this time do not need advice or counseling. Instead, they need the companionship of someone who cares, will stand or sit silently with them, and will meet basic needs as they arise.
The third phase is the short-term aftermath phase—the time after rescue workers leave the scene and survivors begin to fully process what has happened and the implications of what life will mean for them in the future. This usually starts about a week to a month after the disaster event and may extend for 6 to 12 months. This is the phase when victims most need emotional and social support and are most receptive to such support. Psychological interventions by professionals may be needed to help survivors work through grief over losses of property, persons, or physical health. World views have often been shaken, and previous notions that the world is a safe place and that there is a caring God that controls and protects things may be challenged by disaster events. The result can be the loss of a basic sense of trust.
During this phase, survivors will seek explanation about why the disaster occurred to give them some sense of control and ways to prevent it from happening again. Even negative explanations—ie, that the disaster is God’s way of punishing them for their sins, or that it results from their bad karma—may serve an important purpose, since even seemingly unhelpful religious or cultural explanations are better than having no explanation at all. For this reason, health professionals should be slow to discount such explanations and rather try to understand the psychological purposes they serve.
Spiritual counseling can be particularly helpful during the short-term aftermath phase because survivors are often attempting to ascribe “meaning” to the event as they begin to reconstruct their world views. Over time, if world views are successfully reconstructed, spiritual and psychological growth may result. If not, then there is increased risk of developing a psychiatric disorder that may impair social and occupational functioning for years to come. Likewise, anger and bitterness over painful losses may prevent some victims from seeking spiritual support or rejecting spiritual counsel due to feelings of anger at God for punishing or abandoning them. The result can be a loss of faith and inability to access spiritual resources to help them cope. Anger at God or loss of faith, especially if prolonged, has been shown to result in poorer long-term psychological outcomes3 and may even affect physical health.4 Simple reassurance at this stage (ie, God loves you, is with you, is not punishing you, has a purpose in this, etc.), however, should be avoided and persons encouraged to work out their own spiritual solutions at their own pace in a safe and nonjudgmental environment. Verbalizing intense feelings of anger, disappointment, and frustration (often at God for allowing this to happen) may be important for recovery.
The fourth and final phase of psychological adjustment is the long-term aftermath phase, which begins about 6 to 12 months after the event, when most survivors have at least temporarily adjusted to the changes that the disaster has brought into their lives. Complete and full adaptation, however, may continue to occur for years depending on the magnitude of the losses and changes. During this phase, psychosocial interventions and professional counseling are usually slowly tapered off. Memorials and gatherings become particularly important on the anniversary of the event as emotions resurface and further adaptation occurs. Some individuals, however, are not able to move on with their lives and may experience distress and impairment for many years or even decades. Others may have delayed grief reactions during this phase. Many will need periodic emotional and social support for years. This is the kind of support that faith communities are ideally positioned to provide for those who have lost loved ones and other support networks. Religious communities may provide a substitute family and a way that survivors can participate in meaningful activities with others.
If the psychological trauma and loss are great enough, if survivors do not receive adequate support and counseling, and/or if they are psychologically fragile to begin with, then the result can be a crippling emotional disorder that lasts for years or even the rest of their lives. Research indicates that after natural disasters, approximately one in three survivors will develop post traumatic stress disorder (PTSD), and that many more may experience less severe anxiety disorders or depression lasting for years after the event.5 Similar results are found for survivors of terrorist attacks, even among those not directly affected by the event.6 At greatest risk for PTSD or depression are those who are younger, who are female, who have suffered concurrent traumatic events either related or unrelated to the disaster, who have less social support, and who have low self-esteem.6,7 Persons at risk for psychological problems after disasters include rescue workers. The prevalence of PTSD in firefighters varies from 7 to 37% (averaging about 16% following disasters).8
In summary, psychological morbidity is common among survivors of natural disasters or acts of terrorism and among rescue workers involved in these events. Psychological needs vary depending on how much time has elapsed since the event, and interventions (psychological and spiritual) should be tailored to address the unique needs of each time phase. If psychological, social, and spiritual needs are not addressed, long-term psychiatric disability may result.
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