Much emphasis has been placed upon acute interventions after a specific and circumscribed disaster affects a community. But in my opinion, there needs to be an increasing emphasis placed also on deepening our appreciation for the nature of a disaster, the nature of the affected community, and what the community response to a disaster entails, especially long-term.
My approach is to work within established procedures as a disaster mental health consultant and resource for the leadership of the affected community. However, at the same time, I function as a behind-the-scenes observer of sociological, historical, cultural, and mythological data and processes as well as an organizational psychologist. This sharpens my focus on the community’s reaction and the community’s needs after a disaster.
Over the years, my work has been informed by four guiding concepts.
Definition of disaster: Those who work in the disaster mental health field have traditionally used the term “disaster” to refer to a specific accident, or incident, or event—whatever the cause—which then leads to persons experiencing it as a traumatic event (hence, the condition “posttraumatic stress disorder”). I have my own working definition of a disaster: an unexpected event that occurs in one’s own life—as both outwardly lived and inwardly experienced—of such significance as to irretrievably alter both of those aspects of one’s own life and, as well, to leave one with both haunting and emotionally charged memories and with some extra degree of wariness about the future.
It is not only the nature of a disaster that defines our work. More importantly, it is the fact that individuals experience trauma in very private, idiosyncratic, and possibly cumulative ways.
Community and communality: A second principle is to look beyond the meaning of the word “community” when describing the effects of a disaster. Community can be looked upon as a collection of houses and buildings, organizations and businesses, roads and land, and cars, trucks and other means of transportation, and people who own, use, or inhabit these structures or things.
Kai Erikson (1976) provides a very valuable and illuminating discussion of how community differs from communality (the nature of the network of human interrelationships—the interpersonal underpinnings of a neighborhood, a region, a farm district or business district, a county, etc.). Reliance upon and responsibility for persons in a collective sense—of present, past, and future; of physical proximity and closeness; of shared cultural and ethnic strengths—is the communality that is especially strained and disrupted from an acute disaster. I believe that our biggest challenge in disaster response work is restoring communality.
From the moment I hear of an incident—a disaster—I think of both the physical community and the human communality that could be effected. The only difference between a motor vehicle accident with loss of life that occurs in a town and a jet airliner crash with complete loss of lives that occurs outside a major city is the size of the net that is cast over the community and communality.
The psychological, sociological, and mythological ramifications of a disaster that befalls or strikes a community can be long-lasting, subtle, and destructive. To use one analogy, it can be like termite damage to a house that goes unchecked, destroys the basic foundation of the house, and ultimately results in a sudden collapse or a need to completely destroy the house and begin rebuilding. This can come as a complete surprise, since the owners of the house may have kept it well painted and secure from the effects of weather. Unfortunately, the house looked nice to all observers and gave the appearance of a solid, enduring house and home.
The disaster-response-trained mental health care provider who by training and practice always looks beyond the individual to see the family and the group would be in an excellent position to monitor such a community closely after a disaster and to ensure the sense of communality is truly restored.
Nature of the disaster: A third guiding principle I use is that it is exceedingly important to have a conceptual grasp for distinguishing the nature of the acute incident. I categorize them as: natural disaster: accidental (technological, transportation, etc.) disaster: disasters caused by intent to harm others, with a corollary of chemical/biological/radiation attacks; business or industry workplace disasters; and disasters which directly or indirectly traumatize children and adolescents. The nature of the disaster has significant psychological implications for individuals, for the communality affected, and for interventions now and later. These types can be distinguished as follows.
Empathy and understanding: My fourth guiding principle emphasizes empathy and understanding. To be effective, it is so important to have a conceptual grasp and good fund of working knowledge about individual psychological responses to both the acute and chronic disaster conditions I described above and a personal and professional ability to truly listen to others and to communicate both empathy and/or sympathy, when appropriate
Lieutenant Commander Ed Simmer, MD, (a Navy psychiatrist and head of our SPRINT Team at Naval Medical Center, Portsmouth, Virginia), and I describe with much detail the types of group interventions that can be done in a community beset by a disaster. (See “When trauma affects a community: group interventions and support after a disaster,” in Group Psychotherapy for Psychological Trauma, edited by Robert Klein, PhD, CGP, and Victor Schermer, MA, Guilford Press, 2001). We discuss the important role for Critical Incident Stress Management (CISM), as well-described by Jeffrey Mitchell and George Everly (1996) and for the Community Crisis Response Team (CCRT) process, well described by the National Organization for Victim Assistance (Young, 1998), after an acute disaster. We also emphasize the various types of groups that can be done in the community over a short- or long-term basis, after an acute disaster. These include the standard support groups (which provide psychological education with emotional support as the primary function over weeks or months), the periodic topic groups (which provide recovery topic advice such as completion of paperwork for insurance claims and loans, how to pick a building contractor, etc.), and the event groups (which bring large groups of disaster survivors together on an as-needed basis to address an entire community’s needs, e.g., anniversary commemorative event) (Wee, 1994). The approach to planning for these types of groups and tailoring them to the community requires a knowledge of the past, present, and future aspects—strengths and weaknesses—of that community and communality.
It is important to understand that neither CISM, nor CCRT, nor any of the community groups we describe are forms of standard group therapy. The focus is not on changing the individual, but rather supporting and preserving the existing communality as it struggles to regain the sense of community it once embraced. Usually the persons who lead these groups are not mental health care providers, nor are they required to be. Rather, they come from a wide cross-section of trades and professions with a common denominator of being trained to be part of disaster response teams.
The individual mental health provider who wishes to play a helping role when a disaster affects a community, should obtain the requisite training in CISM/CCRT as a minimum and keep in mind—educate oneself and be educated—in the principles I set forth above. In the chapter Ed Simmer and I wrote, as well as in the invaluable resource provided by my colleague Diane Myers (1994), an emphasis is also placed on the mental health care provider’s need to consider his or her own physical and mental health, family situation, presence of other life stressors, and the nature of the practice and patients that he or she cares for, as real factors which modify the availability and participation of that provider on a disaster response team in the community.
Providers also need to consider what specific role(s) they are interested in playing: 1. member of a disaster response team that can deploy immediately out into the community or elsewhere to work either with (debrief) other disaster response personnel or with survivors; 2. member of a hospital-based stress debriefing team that can respond to tragedies in the hospital; 3. member of a mental health response emergency team, part of the hospital emergency services department, which can assist and take care of large numbers of mentally ill persons in the community, medically injured or not, who virtually flood the hospital emergency room or mental health clinics after a major disaster; 4.member of a mental health resource team that conducts long term support groups for hospital personnel or for members of the general community, after a disaster; or 5. member of community agencies or government (local, state, or federal) agencies tasked with disaster response planning and training and coordination with other agencies.
Further basic information on training done around the country is available from the International Critical Incident Stress Foundation, Ellicott City, Maryland, 410-750-9600, and the National Organization for Victim Assistance, Washington, DC, 202-232-6682. Local and state disaster response or emergency services agencies may also provide opportunities for training leading to certification in critical incident stress debriefing.
There are some excellent additional published resources on this field that include theory, training, management, and practice (Myers, 1994; Lystad, 1988; Young, et al., 1999). The National Mental Health Services Knowledge Exchange Network (PO Box 42490, Washington, DC 20015; 1-800-789-CMHS [1-800-789-2647]; firstname.lastname@example.org), sponsored by the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, provides numerous, free-of-cost, and excellent DHHS publications (e.g. Myers, 1994) and videotape programs on many aspects of disaster mental health services and programs; the Network will send a catalog from which orders can be made. But first, I advise anyone interested to read Kai Erikson’s books (1976, 1994,) for necessary perspectives which serve as a basis for everything else written or taught, cited below.
This article was published in the December 2001/January 2002 issue of The Group Circle.
Mark Dembert, MD, MPH, CGP, is a Captain in the U.S. Navy Medical Corps and Assistant Head of the Special Psychiatric Rapid Intervention Team 2 (SPRINT) based at the Naval Medical Center, Portsmouth, VA (NMCP). Director of the Group Psychotherapy Training and Practice program in the Navy Medical Center Department of Psychiatry, Captain Dembert also serves as Assistant Professor, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland, and Assistant Professor, Department of Psychiatry and Behavioral Sciences, Eastern Virginia Medical School, Norfolk, Virginia.
DiGiovanni C. Domestic terrorism with chemical or biological agents: psychiatric aspects. Am J Psychiatry 1999;156:1500-1505.
Erikson K. Everything in its path. Destruction of community in the Buffalo Creek flood. Simon & Schuster; New York, 1976.
Erikson K. A new species of trouble. The human experience of modern disasters. W.W. Norton; New York, 1994.
Holloway HC, Norwood AE, Fullerton CS, Engel CC, Ursano RJ. The threat of biological weapons. Prophylaxis and mitigation of psychological and social consequences. ??JAMA?? 1997;278, 425-427.
Lystad M, ed. Mental health response to mass emergencies. Theory and practice. Brunner/Mazel, New York, 1988.
McCaughey BG. U.S. Navy Special Psychiatric Rapid Intervention Team (SPRINT). Milit Medicine 1987;152:133-135.
Mitchell JT and Everly GS. Critical incident stress debriefing. An operations manual for the prevention of traumatic stress among emergency services and disaster personnel. 2nd edition. Chevron Publishing, Ellicott City, MD, 1996.
Myers D. Disaster response and recovery: A handbook for mental health professionals. DHHS Publication No. (SMA) 94-3010. Washington, DC. 1994.
Raphael B. When disaster strikes: How individuals and communities cope with catastrophe. Basic Books, New York, 1986.
Simon JD. Biological terrorism. Preparing to meet the threat. JAMA 1997:278, 428-430.
Wee D. Support groups in crisis counseling programs. Training handout volumes 1, 2, & II. Project REBOUND, Northridge Earthquake Crisis Counseling Assistance and Training, Regular Services Program. (FEMA 1008-DR-CA). Los Angeles, CA, 1994.
Young MA. Responding to communities in crisis. The training manual of the NOVA crisis repsonse team. 2nd edition. National Organization for Victim Assistance, Washington, DC, 1998.
Young BH, Ford JD, Ruzek JI, Friedman MJ, Gusman FD. Disaster mental health services. A guidebook for clinicians and administrators. National Center for Post-Traumatic Stress Disorder, Menlo Park, CA, Department of Veterans Affairs, 1999. (available online atwww.wramc.amedd.army.mil/departments/socialwork/provider/DMHS.htm