There is a large literature on care to those affected by trauma, as well as a literature on the common effects of disasters, combat, and occupational critical incidents (see for example, Foa, Keene, and Friedman, 2000). The subspecialties of disaster psychiatry and psychology define the domains of knowledge from an epidemiological and preventive, as well as from a treatment, perspective for those most directly affected by crises of such magnitude. The literature on the treatment of post traumatic stress disorder (PTSD) has much to offer those involved in the care of the acutely traumatized. Additionally, professional organizations such as the APA, the American Psychological Association, the International Critical Incident Stress Foundation, Inc., and the American and International Red Cross offer training and logistical assistance for those wishing to help in disaster venues.

The literature on the effects of disaster exposure shows that a variety of posttraumatic reactions may be normative in the initial aftermath. Individuals’ reactions vary considerably to traumatic events like those of 9-11-01. There is a spectrum of normal acute reactions to trauma, some of which parallel those of the grief reaction caused by loss of a loved one. These symptoms may range in severity, intensity, and longevity in different people. However, most acute, normal trauma responses resolve within 1 to 3 months, although in some individuals, long-term minor symptoms may persist indefinitely.

Acute trauma response symptoms may include increased startle, anxiety, fears, phobias, sleep problems, numbness, intrusive thoughts or images of the trauma, mood changes, and changes in a sense of safety in the world (Marmar, Weiss, & Metzler, 1998). Children may be affected differently, depending on their developmental stage. Primarily, they respond with fears and regressions as well as anxiety and posttraumatic intrusions.

Risk factors for developing PTSD after a traumatic event include having been previously traumatized; life-threat during the trauma; prolonged, multiple violent and/or assaultive traumas; witnessing grotesque effects of trauma on others, such as people jumping from the World Trade Center; traumas occurring earlier in life; prior psychiatric disorder; poor social supports; dissociation (numbness, out of body experiences, visual changes, time distortion, memory loss) at the time of the trauma, and certain physiological reactions at the time of trauma such as rapid heart rate and lowered cortisol (Yehuda, 2000).

Disaster reactions may also follow a predictable sequence of phases for community groups. An initial “heroic” phase involves survival-based and altruistic concerns to help overcome acute reactions such as fear, anger, confusion, and psychic numbing. Following the initial reactions and coping efforts, a “honeymoon” phase may occur, characterized by outpourings of community and professional support and assistance. As the aftermath of the crisis extends in time, many sources of initial support may be withdrawn as agencies complete their initial missions and normal routines are reestablished. This has been identified as a “disillusionment” phase. This may be characterized by a loss of a sense of shared experience in the community, and a sense of a more pervasive disappointment, anger, resentment, and/or abandonment. The final phase of disaster adaptation is focused on the long term needs to rebuild and/or mourn what was lost, to reestablish relationships, and to resume a non-disaster focused existence. This work can extend for years, depending on the magnitude of the losses sustained by individuals and communities. Ironically, the honeymoon phase ends just at the point when persistent severe PTSD reactions would be likely to emerge: 1 to 3 months or so after the disaster.

Disaster Psychiatry has been defined as an epidemiological approach to understanding and treating the effects of mass casualty situations. (Norwood, Ursano,and Fullerton, 2001). It has been shown that the majority of persons exposed to disaster show only transient reactions. A subgroup, however, do develop psychiatric syndromes, including Acute Stress Disorder, PTSD, Depression, Adjustment disorders, and Substance Use Disorders. Rates of these disorders vary depending on the nature of the traumatic event (natural disaster vs. human-initiated), degree of exposure to traumatogenic stimuli, degree of personal relevance, degree of physical injury sustained, and level of social support (Marmar et. al., 1998). Ursano et. al. (2001) outlines common reactions to disasters. He reminds us not to forget that physical injuries related to the event may also have psychological ramifications.

Several studies have looked at psychiatric morbidity following terrorist incidents. Van der Ploeg et. al. (1989) found that one third of survivors of terrorist attacks in the Netherlands had adverse posttraumatic sequelae nine years later. Twelve per cent continued to require professional treatment. In another study of French survivors of terrorist attacks, rates of PTSD ranged from 8.3% to 30.7% depending on presence and severity of physical injury. 13.3% of all victims were suffering from major depression at time of the assessment. These rates of morbidity speak to the need for intervention by trained clinicians, as well as preventive interventions designed to target high risk groups. Ursano et al (2001) notes that disaster psychiatry encompasses both preventive interventions and community consultation, as well as direct patient care.

Supporters of the CISD model have responded with methodological critiques of this report (Everly, 1999). For example, heterogeneous populations were studied who varied widely in the types of interventions provided. However, it is clear that clinicians considering the application of structured group crisis intervention should give primary concerns to the selection of participants, the psychological readiness of the groups for intervention, and the appropriateness of group interventions given the individuals and the nature of the traumatic event.

In medical settings, a consultation-liaison outreach model has been advocated for addressing the psychiatric needs of injured disaster survivors. The identification of high-risk groups is one task of disaster mental health personnel. Children, the elderly, those with pre-disaster psychiatric conditions, and the acutely bereaved have been identified as being at highest risk for psychiatric sequelae following a disaster. As noted above, those with high levels of exposure and responsibility for responding to the traumatic event may also be at high risk.

In the acute aftermath of a disaster, initial interventions may be primarily practical and simple, depending on the need of those in crisis. Some of the most pragmatic and useful interventions are those of linking survivors to community resources for food, shelter, clothing and other forms of disaster relief. Initial psychological crisis intervention may involve stabilizing and preventing an escalation of the initial crisis reactions and symptomatology. Providing psychoeducational interventions regarding typical posttraumatic reactions may serve to normalize and reduce distress for some individuals. Providing support for the mobilization of coping strategies is a key intervention. Another central task is the identification of reactions that pose a danger to self or others, or are indicative of a much greater difficulty in coping (e.g., severe acute stress disorder symptoms such as amnesia, depersonalization, and alterations in state of consciousness).

Indeed, clinicians providing acute trauma services in a disaster may themselves become overwhelmed by caring for the acute survivors or by the effects of the trauma that they have suffered directly. Thus, medical, nursing, and mental health personnel must recognize their own vulnerability to the same reactions as those they are treating. Interventions for the acute care and support of these personnel themselves may become important in responding to a disaster and its aftermath.

Many clinical approaches for trauma-related syndromes have been empirically evaluated (see Foa, Keane, & Friedman, 2000). There is general consensus that a phasic model of treatment is the standard of care for most posttraumatic disorders. Most authors state that these can be reduced to a triphasic model (Brown, Scheflin, and Hammond, 1998). The first phase involves establishing safety in and out of the therapeutic relationship. If this phase is successfully negotiated, the therapeutic work may focus on directly processing the traumatic material itself, potentially at an affectively intense level at times. In addition, significant attention may be given to the grieving and mourning that often accompany the experience of trauma. Cognitive interventions may be vitally important in altering highly maladaptive posttraumatic cognitions and beliefs.

The final stage involves a process of reconnecting and reinvesting one’s energies into current life pursuits, relationships, and interests. To be sure, these phases are somewhat heuristic and, to some extent, work on each one may occur during the others.

It is important for all mental health professionals to become acquainted with the large and increasingly rigorous and empirically-based literature on trauma disorders. Training, supervision, and consultation are recommended and available readily in the Maryland area. Training in disaster response can be obtained through a variety of professional organizations. Emergency mental health skills are readily applicable to a variety of consultative venues, including schools, community organizations, religious organizations, and private industry. The opportunity for mental health professionals to help relieve human suffering and to be of service to the community in times of crisis is rewarding. At the same time, disaster mental health work challenges us to be flexible and creative in our application of mental health intervention and to maintain a high degree of personal and professional engagement and commitment.