Disasters, A Psychological
Perspective

                                    Margaret Gibbs, Ph.D. and Kim
Montagnino, M.A.

Abstract

Psychological research has shown that disasters can cause serious mental
health consequences for victims. These consequences take the form of
Posttraumatic Stress Disorder and a variety of other disorders and
symptoms which have been less investigated. The more stress, defined in
a variety of ways, within the disaster, the more likely there are to be
emotional consequences. Vulnerability factors within the victim operate
in complex ways, but seem related to the extent of stress experienced by
the victim and the available resources, broadly defined, with which to
deal with it. The mental health profession has developed a variety of
strategies with which to ameliorate the effect of disaster. Although
recent research on single session debriefing has produced disappointing
results, many techniques and therapies have been validated as successful
interventions for disaster victims.

                   Unlike other disciplines, which have come more
recently to the study of disasters, psychology has concerned itself with
disasters\' impacts on victims for much of its own short history.  As
long ago as 1944, Lindemann published an observation of the
psychological aftermath of the Coconut Grove nightclub fire in Boston. 
Besides the obvious involvement psychologists have in attempting to
relieve distress of victims, disasters have a relationship to several
important psychological constructs.  Disasters allow psychologists to
perceive the operation of trauma on emotional functioning, an operation
which mental health practitioners as far back as Freud have been
interested in understanding.  Stress research is a central and crucial
explanatory factor in many fields of psychology, especially community
psychology, which considers stress the central ingredient to the
formation of psychopathology (e.g., Albee, 1997; Dohrenwend, 1998). 
There is an ethical limit to the extent that stress can be manipulated
in the laboratory, and disasters allow psychologists the opportunity to
observe how extreme stress impacts individuals and groups. 

                   Because of psychology\'s interest in trauma and
stress, its definition of disaster has differed somewhat from that
employed in other fields.  In the 1970\'s, after the Vietnam War and the
discovery of its impact on veterans, and after the discovery of the
long-term effects of child sexual abuse, the mental health field
conceptualized a disorder specifically related to the consequences of
trauma, Post Traumatic Stress Disorder (PTSD) (American Psychiatric
Association, 2000).  We will define PTSD later in the chapter.  Here we
are making the point that because of the interest by psychologists in
PTSD, there has been some blurring between the concepts of victimization
from any source and victimization from disaster.  For instance,
vulnerability factors to PTSD in victims of an earthquake may be similar
to vulnerability factors to PTSD in victims of rape, and effective
treatments may also be similar, so that studying a broader group of
victims may be useful in understanding disasters.

                    In spite of many differences in opinion (e.g.,
Quarantelli, 1998), the definition of disaster in use in this chapter
agrees with that of most psychologists (e.g., Barton, 1969; Norris,
Friedman, Watson, Byrne, Diaz & Kaniaty, 2002) who regard disasters as
involving an unexpected or uncontrollable event rather than a long-term
experience. That is, a disaster is something that could happen within a
war (e.g., My Lai, or many other less well-known examples) rather than
the war itself, or Three Mile Island rather than Love Canal.  These
examples illustrate the difficulty with the distinction, and some
researchers think that our concept of disaster should include chronic
disaster (Couch & Kroll-Smith, 1985).   Dynes (2004)  has argued that
social scientists need to expand their definition of disaster to
encompass events like war, genocide, and refugee experiences that are
critical in third world countries.     

                   Disasters are also usually viewed as a collective
experience, excluding personal disasters like sexual abuse or automobile
accidents, unless these involve a large number of people.  Again, the
dividing line can be unclear.  The type of event, with its various
dimensions, can affect our perceptions.  We might not consider an
automobile accident that killed 13 people to be a disaster, even if many
others were involved or witnessed it, but the killing of 13 in the
shootings at Columbine certainly qualifies.   

                   With the passage of time, study of disasters has
become less descriptive and more quantitative, attempting to resolve
some of the methodological problems of this research.  The focus has
moved from the question of whether there are significant long-term
psychological impacts of disasters, to studying the types of impact that
occur and what factors in the disaster and in the individual increase
the likelihood of emotional damage.  Interventions to assist victims
have been developed.  Most recently, there has been more focus on the
effectiveness of these interventions.  This chapter will explore in turn
each of these areas:  methodology of disaster research; extent of
psychological impact of disasters;  types of psychological sequelae;
damaging aspects of disaster; vulnerability factors; psychological
interventions for victims; and the effectiveness of these
interventions. 

[Methodology of Disaster Research]{.underline}

                   Early studies of disaster tended to be descriptive. 
Lifton (1967) described the emotional impacts of Hiroshima, Coles (1967)
portrayed the effect of political disaster on children (1967), and
Erikson (1976) painted the picture of  the aftermath of the Buffalo
Creek floods in West Virginia.  While some researchers (e.g., Edelstein,
2004) still favor a qualitative approach, most psychological disaster
research today tends to be quantitative.

                   Problems exist for the social scientist who wishes to
study disaster.  Experimental design requires random assignment of
participants to experimental and control conditions.  Even if a mad
scientist wanted to conduct such an experiment, controlling a disaster
is an oxymoron.  Disaster research can only attain the status of
quasi-experimental design, with comparison groups, not controls.  Since
disasters occur unpredictably, pre-test data on victims are usually not
available.  Psychologists called into a disaster are usually there to
provide help.  Researchers can seldom obtain access to the disaster at
its onset, and if they do find access, the exigencies of the situation
usually preclude administration of standard instruments in a
standardized fashion. Victims usually have no motive to participate in
research, and follow-up studies are often difficult to arrange.  Samples
of victims vary from those directly impacted, to rescue workers, to the
families of the bereaved.  It is difficult to compare Western victims to
those from third world countries, as their circumstances and resources
are so different, and for the same reasons it is difficult to compare
victims from different ethnic groups within a culture. 

                   Disasters also vary widely in the amount and the
nature of the stress they involve: duration; loss of life; personal
injury, or injury to loved ones; property damage; terror; helplessness;
gruesome sights, sounds and smells; dislocation from one\'s home;
availability of social support  -- all these factors may differ in a
flood as contrasted to an earthquake, or between one flood and another,
or between one victim\'s and another\'s experience of the same flood.  
One special differentiation between types of disaster is the natural vs.
the technological, or human-caused, disaster.  Natural disasters tend to
involve lack of control over natural forces, like wind, that we expect
to be uncontrollable, while technological disasters can be less defined,
especially if they include toxic exposure, and can involve a loss of
control over an area of life in which we expect control, like drinking
water (Baum, Fleming, & Davidson, 1983).  Terrorism is a special form of
technological disaster, and the most recent addition to the typology of
disaster (Ursano, Fullerton, & Norwood, 2003).

                   As psychologists conducted more disaster research,
they began to develop standardized measures, beginning with the Impact
of Events Scale (Horowitz, Wilner & Alvarez, 1979).  Many measures have
been devised to diagnose post-traumatic stress disorder (PTSD), one of a
number of psychological consequences of disaster.  The National Center
for PTSD (2003) currently lists 15 adult PTSD self-report measures, 4
interview measures, and 9 measures for children.  Obviously, many other
standardized measures of other types of psychopathology have been
administered.   Measures have also been developed to identify
vulnerability factors and intervening variables, e.g., the Peritraumatic
Dissociation Experiences Questionnaire  (Marmar, Weiss, Schlenger et
al., 1994), and World Assumptions Scale  (Janoff-Bulman, 1985). 

                   Comparison groups, if not actual control groups, were
introduced early into the research.  A step forward in the confusing
array of studies on different disasters with different samples and
different methods came with the meta-analysis of Rubonis and Bickman
(1991), which found small but consistent post-disaster effects on levels
of  psychopathology across different types of study and types of
disaster. 

                    Robins, Fischbach, Smith, Cottler, Solomon, and
Goldring (1986) seized upon a fortuitous (or infortuitous) series of
events at the Times Beach site in Missouri.  Interviews had taken place
in that area for the Epidemiological Catchment Area study which
documented the prevalence of psychiatric problems in the country.  Then
the area was struck both by floods and the discovery of dioxin.   This
allowed the comparison of the effects of a natural and a technological
disaster, with pre-test information available for a sample of the
victims, and documented that change had occurred. 

                   When Norris et al. reviewed the disaster literature
in 2002, she found six other studies that were able to obtain true
pre-test measures for their samples.  Comparison of types of disaster
exposure for the same sample remains rare.  Norris et al. also report
that many recent disaster studies used follow-up formats and probability
sampling methods.  In short, methodology has improved dramatically, and
conclusions can comfortably be drawn about the psychological impact of
disasters.

[Extent of Psychological Impact of Disasters]{.underline}

                   As noted, Rubonis and Bickman found in their 1991
meta-analysis consistent but small post-disaster effects upon
psychopathology.  Many other review chapters and articles have been
written (e.g., Gibbs, 1989, 1991, Green & Solomon, 1995; Katz,
Pellegrino, Pandya, Ng, & DeList, 2002; Sundin & Horowitz, 2003), 
concluding that post-disaster effects are greater and more pervasive
than Rubonis and Bickman\'s inferences.  The most thorough recent review
is that of Norris et al. (2002a).  The authors analyzed 160 different
disaster studies, with a total of over 60,000 participants, and did not
conduct a meta-analysis because of the difficulty in deriving effect
sizes from descriptive studies.  Using a rough four point scale to rate
level of pathology, they found that only about 10 of studies found
minimal impairment, about half the studies found moderate impairment,
and the remaining 40% found severe or very severe impairment.  Severe
impairment was equivalent to rates of psychopathology in the
participants of between 25 and 50%.

 For many years there has been a debate over whether the effect of
disaster on mental health was important. One side of the debate came
from the sociological point of view (e.g., Quarantelli & Dynes, 1985),
which focused on the adaptive nature of community response, both in the
immediate aftermath of a disaster and in most people\'s long-term
response. The majority of people function adaptively during and after a
disaster, and the old notion (Kinston & Rosser, 1974) that individuals
will experience panic, wander aimlessly and be dependent has been shown
to be untrue (Wenger, Dykes, Sebok, & Neff, 1975). But that is a
different matter from focusing on the toll that the disaster takes on
some individuals. There is so much evidence now of the damage to
individuals, that to our minds, the debate has been resolved.  Norris,
Friedman, & Watson (2002b) conclude that the field does not need new
studies indicating that disaster causes serious psychopathology; we know
this to be the case.  Instead, we should focus on understanding what
aspects of disaster are most devastating, and what characteristics of
individuals make them vulnerable, issues we will address later in the
chapter.

[Forms of psychopathology resulting from disasters]{.underline}.

                   If it is clear that disasters cause psychopathology,
it is less clear what form that psychopathology takes.  Since the mental
health profession developed the PTSD diagnosis, PTSD has been the main
focus of research on the aftermath of disaster.  The criteria for PTSD
include (APA, 2000):  1) having been exposed to a traumatic and fearful
event; 2) re-experiencing the traumatic event, usually in flashbacks or
nightmares; 3) avoidance of situations and stimuli that could reawaken
the trauma, for example,  numbing one\'s feelings or withdrawing from
others;  and 4) increased level of arousal, for instance, sleep
difficulties, irritability, and  concentration problems. 

                   Norris et al. (2002a) reported that 68% of their
research samples assessed for and found PTSD in disaster victims.  The
second most common psychiatric problem was depression, found in 36% of
the samples.  Anxiety in various forms was shown in 32% of the samples. 
Health concerns were also often present (23% of the samples).  It was
not usually clear whether victims\' health concerns were realistic, or
were based on somaticizing the stress of the experience (North 2002). 
Alcoholism and drug abuse were not often investigated but when they
were, levels of abuse have been found to rise after disasters. 

                   What is not clear from the above figures is what the
actual rate of various psychopathologies might be if each study had
assessed for all of them.  Norris et al. (2002b) recommend that all
disaster researchers use a standard measure of psychopathology so that
it can be more clearly determined which disorders are linked to
undergoing disaster.  

                   Victimization, primarily child physical and sexual
abuse, has been shown to lead to other diagnoses beyond the ones
investigated in disasters.  These include schizophrenia and other
psychoses (Neria, Bromet, Sievers, Lavelle, & Fochtmann, 2002),
dissociative disorders (Coons & Milstein, 1986) and borderline
personality disorder (Herman, Perry & Van der Kolk, 1989).  None of
these diagnoses has been investigated to see if higher rates result
after disaster, although dissociative symptoms have been reported during
and after some disasters (Marmar, C. R., Weiss, D. S., Metzler, &
DeLucchi, 1996; Weiss, Marmar, Metzler, & Ronfeldt, 1996) and can be
part of the avoidance criterion of PTSD (APA, 2000).  It would be
valuable to look at long-term vulnerabilities of childhood victims of
disaster to these disorders.   Little research of any kind has been
conducted looking at long-term consequences of disasters for children.

                   An issue that has been discussed in the literature is
whether symptoms of other disorders found after disasters are part of
the PTSD syndrome or whether they are independent consequences.  There
are several possible explanations for the overlap that often is
observed. Symptoms within diagnoses do overlap, symptoms of other
diagnoses could be sub-clinical cases of PTSD, PTSD could increase
vulnerability to other diagnoses, and other diagnoses could increase
vulnerability to PTSD (McMillen, North, Mosley and Smith, 2002). In
particular, the fact that depression and PTSD are both common
consequences of disaster is of interest. Greening, Stoppelbein, & Docter
(2002) conducted an interesting study in which they  looked at
attributions for the negative outcomes of the Northridge earthquake. 
Victims who made what have been labelled depressogenic attributions,
seeing negative outcomes as related to internal, stable and global
causes (Abramson, Seligman, & Teasdale, 1978), were more likely to
develop depressive symptoms, but not PTSD symptoms.  Livanou, Basoglu,
Salcioglu and Calender (2002) looked at PTSD and depression as outcomes
of the Turkish 1999 earthquake, and found that there were different
predictors for each.  Research into the relationship between different
outcomes of disaster is continuing, but the lack of solid findings
points out that we know little about the actual mechanism of how
symptoms are caused by disaster stress.                  

[Aspects of disaster which contribute to psychopathology]{.underline}  

                   In general, the nature of the disaster and the extent
of the trauma it wreaks are more predictive of the extent of
psychopathology that follows than are characteristics of the victims
(Sundin & Horowitz, 2003).  The more stressful the disaster experience,
it appears, the more negative the consequences, but it is not always
possible to identify which of the many factors within a disaster make it
more stressful. Theorists have identified the following as important
characteristics:  mass violence (Norris et al., 2002); the experience of
terror and horror (Bolin, 1985); duration of the disaster (Baum &
Davidson, 1985, Bolin, 1985); and the amount of unpredictability and
lack of control (Baum & Davidson, 1985; Thoits, 1983). 

First responders and disaster workers are at special risk for PTSD and
other negative emotional consequences of disaster (Gibbs, Lachenmeyer,
Broska, and Deucher, 1996; Norris, 2002a) . This vulnerability has
usually been perceived to be related to the experience of the work
rather than to any inherent vulnerability factors, as often people
choosing these professions have high levels of emotional hardiness.
Looking at disaster workers who dealt with the aftermath of the World
Trade Center disaster of September 11th provides an example. Working
with dead bodies and body parts after a major disaster is something that
almost everyone finds extraordinarily stressful, and perhaps the
experience could be said to define horror. Disaster workers\' experience
of the disaster is often more long-term than that of other victims, as
for instance the long term digging out after September 11th. In
addition, the experience of helplessness and lack of control is
prevalent, as workers searched for but were unable to find identifiable
bodies.

Psychologists have many theories about what causes the disorders of
PTSD, depression, anxiety reactions, etc. (e.g., Barlow, 2000), but
little conclusive about what it is exactly about a disaster that leads
to emotional damage. 

  As we have mentioned, most psychologists identify stress as a leading
cause of psychopathology, but theories as to how stress affects its
victims are varied.  Some focus on the physiological overload of stress
(e.g., Selye, 1976), some on the unpredictability and uncontrollability
of stress (e.g., Kelly, 1955) and some on the conditioning that takes
place between a frightening stressor and other aspects of life, with a
resulting avoidance of stimuli that are reminders (Mowrer, 1960). 
Losses in a disaster, of other people, of material goods, of one\'s own
health and security, are also critical (Nolen-Hoeksema, 1990).  Some
theorists focus on the shift in cognitions that take place after a
disaster.   Janoff-Bulman and Frieze (1983) speculated that cognitions
shift after a disaster.  The individual asks \"Why me?\" and the answer
involves a change in one\'s sense of invulnerability, in the world\'s
predictability, and in one\'s own worth.

[Vulnerability factors]{.underline}

Research has identified a number of characteristics of victims that make
them more vulnerable to disaster effects. Vulnerability factors include,
but are not limited to, socioeconomic status (SES), available resources,
previous level of psychopathology, age, social/family factors, gender
and ethnicity. 

Regarding SES, Norris et al. (2002a) found that thirteen of fourteen
samples which investigated socioeconomic status and disaster outcome
found lower socioeconomic status to be associated with increased
post-disaster distress. Studies included a wide range of disasters: an
air disaster (Epstein, Fullerton, & Ursano, 1998), an industrial
disaster (Vila, Witowski, & Tondini, 2001), floods (Ginexi, Weihs,
Simmens, & Hoyt, 2000), and an earthquake (Lewin, Carr, & Webster,
1998).   Individuals who live in poverty tend to have fewer resources
available to them to attenuate the effects of disaster. 

Pre-existing psychopathology is a risk factor for developing
psychopathology related to a trauma (Norris et al., 2002a) in that
individuals who suffer from a psychological disorder are more
susceptible to further distress in the aftermath of a disaster.  For
example, pre-disaster anxiety disorders (Asarnow et al., 1999),
depression (Knight, Gatz & Heller, 2000), and suicidal ideation
(Warheit, Zimmerman & Khoury, 1996) were found to increase the
likelihood of post-disaster psychopathology. 

In terms of age, Norris et al. (2002a) noted that middle-aged adults
appear to be the group most affected by disasters.  This age group may
have more burdens and stresses (Thompson, Norris & Hanacek, 1993), such
as caring and providing support for a family, that may be amplified in
the aftermath of a disaster. 

Social network characteristics influence vulnerability.  For example, a
lack of perceived (Bromet, 1982; Dougall, Hyman & Hayward, 2001) or
received (Sanchez, Korbin & Viscarra, 1995; Udwin, Boyle & Yule, 2000)
social support may lead to greater post-disaster distress.

These risk factors do not operate in isolation. Any single factor is
often interrelated with others.  We will illustrate this complex
interaction within the context of two variables: gender and minority or
third world ethnicity, both of which Norris et al. (2002a) in their
review cite as among the most robust of vulnerability factors. 

Gender.  Norris et al. (2002a) stated that in 94% of 49 studies which
investigated the issue, female survivors of disaster were more seriously
affected than were males.  There are several possible explanations for
this difference.  For example, as mentioned in the previous paragraph,
low socioeconomic status is a risk factor for post-disaster
psychopathology, and women more often live in poverty than men (Belle,
2000). 

The gender difference may be in part explained by differences we often
observe between the genders in the way psychological distress is
expressed.  In general, women are more likely than men to acknowledge
psychological symptoms and to report them (Nolen-Hoeksema, 1990).  After
a disaster, males may suppress feelings of psychological distress
because of the expectation that men must be strong and capable (Wolfe &
Kimerling, 1997).  As discussed in a previous section, the most commonly
investigated post-disaster reactions are PTSD, depression, and other
forms of anxiety. Substance abuse and other acting out behaviors, such
as interpersonal violence, are seldom assessed.  Men are more likely to
express psychological distress through these kinds of behaviors, rather
than reporting neurotic-type symptoms like depression and anxiety
(Myers, Weissman, Tischler, et al., 1984).            

Women have higher pre-disaster rates of depression and most anxiety
disorders than men (Myers et al., 1984), putting them at risk for
disaster-related distress.  Furthermore, there may be some experiences
that women are more likely to have that may contribute to the
development of PTSD post-disaster.  The experience of rape and sexual
assault is higher among women than men (Kessler, Sonnega, Bromet, Hughes
& Nelson, 1995), and it has been shown that when compared with other
forms of trauma, unwanted sexual contact is more likely to result in
PTSD ( Breslau, Davis & Andreski, 1997; Kessler et al., 1995).  Pulcino
et al. (2003) found that the experience of previous unwanted sexual
contact increased a woman's likelihood of endorsing PTSD symptoms after
the September 11th attacks by 33%. 

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]{.underline}

            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,]{.underline} 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]{.underline} 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]{.underline} 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.]{.underline}

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.

                                                                                              

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