Disaster mental health: remembering the past, shaping the future

‘Progress, far from consisting in change, depends on retentiveness …Those who cannot remember the past are condemned to repeat it’ (Santayana, 1905, p. 172). Indeed, true innovation is most appreciated and most valuably constructed only in the context of that which has come before. Let us not forget the admonition of futurist Alvin Toffler who argued that if we do not shape the future, we shall be forced to passively endure it. This special issue of the International Review of Psychiatry will focus on the field of disaster mental health. In this issue, we will begin with a look at the foundations of the past before reviewing select innovations that may help shape the future.

In all of human experience there may be no more formidable force to alter the future than that of disaster. It does not have to be an event with the magnitude of the Chicxulub asteroid to change history. ‘A disaster is the consequence of an extraordinary event that destroys goods, kills people, produces physical or psychological harm but, above all, which overcomes the adaptive possibilities of the social group. Disasters have strong political background and consequences. They shake the life of a community and raise questions about safety, social organisation and the meaning of life’ (López-Ibor, 2006, p. 171). More specifically, and with regard to disasters and mental health, the implications are staggering, ‘Mental health has large intrinsic value as it relates to the core of what makes us human, thus anything that threatens the mental health of large numbers of people threatens the core fabric of society itself’ (United Nations, 2020, p. 5).

A brief retrospective on World War I may be instructive to illustrate this claim. The disaster of World War I changed history as any great war would be anticipated to do. The disaster of war is tragic enough, but the failure to consider how human beings respond to disaster can virtually guarantee a future that must be endured rather than charted. In this instance, the failure to understand how people were likely to respond to the stipulations of the Treaty of Versailles ending World War I in 1919 arguably contributed to, if not guaranteed, World War II. But even before the war ended, amid a raging disaster, the failure of those who crafted the Sykes-Picot Agreement of 1916 to consider the human response to redrawing international boundaries in the Middle East arguably contributed to further conflicts that endure today, with no end it sight (Fawaz, 2014; Willis, 2016).

More recently, for over two years, we have struggled to understand how to best respond to the physical public health challenges of a pandemic, while at the same time underestimating how the fear, frustration, and exhaustion of those affected would alter compliance, illness, and ultimately mortality. We seem to have learned little from history. To borrow a phrase, ‘And the beat goes on.’ While we do not yet possess the ability to prevent all disasters, we certainly must continue to improve our ability to anticipate and to some degree shape how individuals and communities both respond to adversity and ultimately move forward when disaster strikes. Albeit oversimplified, this is the quest of the field of disaster mental health, a field that remains in its infancy in relation to the need.

Birth of a field

There is no formally recognized set of rules governing the establishment of a new discipline or field of study. That said, it may be suggested that a field of study exists as a unique branch of knowledge. Supporting this assertion, one would expect there would be specialized and innovative textbooks (e.g., Dynes, 1970; Everly & Mitchell, 1997; Flynn, 2003; Hartsough & Myers, 1985; Mitchell & Bray, 1990; Raphael, 1986; Sowder & Lystad, 1985; Ursano et al., 2007), focussed conference presentations (e.g., VandenBos & Bryant, 1986), as well as formalized interest groups or professional societies largely dedicated to the study and practice of the discipline. Two such examples could be the International Society for Traumatic Stress Studies founded in 1985 and the International Critical Incident Stress Foundation founded in 1989. While neither of these non-profit open membership societies focussed solely on disaster mental health, it was a topic of increasing interest for their respective constituencies as floods, airline disasters, school shootings, the Gulf War of 1991, the Oklahoma City bombing of 1995, the terrorist attacks of September 11, 2001, the 2004 Indian Ocean earthquake and tsunami, Hurricane Katrina in 2005, and 2010 earthquake in Haiti, to mention only a few, were events that demanded attention and became harbingers of the future. Both organizations were accepted into special consultative status for the United Nations as non-governmental organizations.

The growth of the field took a quantum leap with the creation and mobilization of the disaster mental health initiative of the American Red Cross first fielded in 1992 and guided by its initial recommendations for psychological intervention contained in the training and procedures document ARC 3050 M (American Red Cross, 1991). If there was a defining moment of the field, mobilization of the Red Cross disaster mental teams in response to Hurricane Andrew in 1992 was likely that moment. Thus, from this perspective on the field of disaster mental health, 2022 marks its 30th anniversary. The Green Cross, another seminal disaster response organization of note was founded in 1995 largely to assist with the psychological impact of the Oklahoma City bombing.

It may also be suggested that a new discipline or field of study arises, not solely from the interest of scholars and researchers, but from a recognized and previously unmet need. Though the Red Cross had been providing physical disaster relief services since 1881, the expansion of services into disaster mental health in 1992 left the Red Cross ‘challenged like never before.’ ‘Exposure to a disaster is common, and one-third or more of individuals severely exposed may develop posttraumatic stress disorder or other disorders’ (North & Pfefferbaum, 2013, p. 507). It is now generally accepted that psychological casualties will surpass physical casualties, but this tenet was not always evident. Investigations of the large-scale psychological effects of disasters began to gain traction in the professional literature in the 1960s (Barton, 1969; Horney, 2018), but its seeds were sown by sociologists who pioneered some of the first systematic studies of the human impact of disaster, first during World War II. These pioneers orchestrated an institutional approach to the study of disasters with the establishment of the world’s first disaster research centre (DRC) at Ohio State University in 1963 (Dynes, 1970). The DRC later moved to the University of Delaware in 1985 (Quarantelli, 2002).

Disasters require innovation in intervention

Disasters require innovation; great disasters require great innovation. Interestingly, and as alluded to previously, much of the foundation of the field of disaster mental health can be traced to the two great world wars of the 20th Century. Field observations from World War I gave rise to the construct of ‘shell shock.’ Shell shock consisted of what was then termed a neurosis-like syndrome characterized by anxiety, withdrawal, hyper-arousal, and revivifications. Based on clinical observations of veterans of World War I and World War II, Abram Kardiner (1941) referred to the syndrome as a ‘physioneurosis.’ Kardiner chose the term in contradistinction to Freud’s psychoneurosis (Aktualneurose). The work of Kardiner can be seen as a precursor to the development of the diagnostic construction of posttraumatic stress disorder (PTSD).

Problematically, shell shock seemed recalcitrant to the traditional psychiatric interventions of the era, which were hospitalization far removed from the battle front in combination with multi-session psychotherapy (Artiss, 1963; Debenham et al., 1941; Solomon, 1917). Psychotherapy even appeared contraindicated for the acute distress associated with such experience (Debenham et al., 1941), a conclusion subsequently supported by evidence from the World Trade Centre disaster of 2001 (Boscarino et al., 2011).

To improve intervention effectiveness in those experiencing shell shock, French and English physicians adopted a new approach. In retrospect, we would conceptualize their approach as ‘psychological crisis intervention’ or perhaps the more recent moniker of ‘psychological first aid.’ Rapoport (1965) once noted, ‘A little help, rationally directed and purposely focussed at a strategic time, is more effective than extensive help given at a period of less emotional accessibility’ (p. 30). Solomon (1917), Artiss (1963) and Kardiner (1941) described the core psychological intervention processes as (1) proximity (treating soldiers in forward hospitals and sanitary stations), (2) immediacy (in close temporal relation to the precipitating incident), (3) expectancy (for both soldier and physician, the expectation that the reactions were characteristic of an acute psychological injury and that the soldier would return to combat), (4) simplicity (brief, practical interventions avoiding probing psychotherapeutic techniques), and (5) ventilation (the soldier was allowed to discuss the psychological injury, if desired). The implementation of these procedures was reported to dramatically increase the number of soldiers who returned to combat and to adaptive civilian life (Artiss, 1963; Crocq & Crocq, 2000; Kardiner, 1941; Solomon, 1917). Similar evidence was reported by Solomon and her colleagues during, and subsequent to, the Lebanon War (Solomon & Benbenishty, 1986). The beneficial effects of the interventions were reported to be sustained at least 20 years leading the authors to conclude, ‘Frontline treatment is associated with improved outcomes even two decades after its application. This treatment may also be effective for non-military precursors of posttraumatic stress disorder’ (Solomon et al., 2005, p. 2309). It should be noted, however, that not all observers acknowledge the utility of these intervention principles when applied to war (Jones & Wessely, 2003).

Extending the core military principles to civilian disaster mental health, we envision the current active mechanisms of psychological crisis intervention as (1) proximity (active outreach intervention in the field), (2) immediacy (surveillance and possible intervention as soon as there is any expectation of need), (3) expectancy (the notion that the experienced distress is a form of psychological injury most associated with the disaster rather than a form of mental illness), (4) simplicity (brief, practical interventions such as reassurance, anticipatory guidance, connecting with interpersonal support, stress management/self-care, and the instillation of hope; Bisson et al., 2007; Everly & Flynn, 2005), and (5) ventilation (disaster survivors are allowed, but not mandated, to engage in cathartic ventilation if desired). The ultimate, collective, goals of a psychological crisis intervention approach to disaster response would be (1) stabilizing acute distress, (2) mitigating acute distress, if possible, and/or (3) facilitating access to continued or advanced psychological support, as indicated (Everly et al., 2008; Everly & Lating, 2017, 2019). Such an approach is not a substitute for psychotherapy, however. Evidence suggests that a crisis intervention approach to reducing distress can be effective with civilian populations (Boscarino et al., 2005; Decker & Stubblebine, 1972; Despeaux et al., 2019; Everly, Lating, Sherman, & Goncher, 2016).

As asserted earlier, disasters can adversely affect the core fabric of a community. The principles of disaster mental health and psychological first aid can be applied at the community level, as well. Consider, for example, what occurred at the Cocoanut Grove, the most popular nightclub in Boston in 1942. On the evening of November 28, 1942, the nightclub was dangerously overcrowded with more than 1000 patrons. A fire started and spread rapidly. In the end, 492 people died and 166 were injured. This was the second deadliest fire in American history. The fire was not only traumatic for those in attendance but was traumatic for the entire community. Eric Lindemann (1944) made a significant contribution to the study of community resilience in the wake of disaster through his study of the trajectory of the grief process after that catastrophic fire. Spawned by this disaster, Lindemann was later joined by Gerald Caplan (1964) in the creation of a community mental health program that emphasized community outreach and crisis intervention in the Boston metropolitan area.

More recently, McCabe and colleagues have used psychological first aid training as a unique platform to proliferate public health planning and preparedness in the anticipation of community disasters (McCabe et al., 2014). In sum, ‘Psychological first aid (PFA) has become the flagship early intervention for disaster survivors, with recent adaptations for disaster responders, in the post-9/11 era’ (Shultz & Forbes, 2014, p. 3).

Expanding capacity

Surge capacity must be enhanced. In the wake of disaster, the surge for mental health services has historically exceeded mental health capacity. Norris and colleagues provide an exhaustive review of the psychological impact of disasters that serves to underscore the need for intervention services (Norris, Friedman, Watson, et al., 2002; Norris, Friedman, Watson, 2002). To meet these mental health demands, alternative approaches to psychological care and who delivers such care must be considered (Everly, 2020). The psychological crisis intervention and psychological first aid approach to responding to the distress of a disaster can be employed by mental health clinicians as well as those not trained in the mental health professions (Castellano & Plionis, 2006; Castellano, 2012; Wu et al., 2020). The American Psychiatric Association supported crisis intervention-based training and practice for disasters as early as 1954. ‘In all disasters, whether they result from the forces of nature or from enemy attack, the people involved are subjected to stresses of a severity and quality not generally encountered…It is vital for all disaster workers to have some familiarity with common patterns of reaction to unusual emotional stress and strain. These workers must also know the fundamental principles of coping most effectively with disturbed people. Although [these suggestions have] been stimulated by the current needs for civil defense against possible enemy action… These principles are essential for those who are to help the victims of floods, fires, tornadoes, and other natural catastrophes’ (APA, 1954, p. 5).

Survivors of disaster, including first responders and healthcare workers, likely see themselves as ‘normal individuals who are trying to adjust to extreme hardship’ (Lima et al., 1989, p. 74). As a result, they may see mental health providers as offering services that are unneeded and, perhaps because of stigma, undesired. Thus, they may seek psychological support from those whom they know, trust, or otherwise feel some connection. Friends, family, co-workers, and faith-based leadership are examples of those who might be approached more naturally for support in the wake of adversity. These ‘peer support’ programs can represent viable alternatives to the provision of acute mental health services. Arising from the community mental health movement of the 1960s, peer support may be thought of as the utilisation of anyone specially trained specifically in the provision of acute psychological support (typically psychological first aid and its derivatives), but who do not possess professional level training, certification, or licensure in one of the mental health disciplines.

Peer support has grown in recognition to the point that in November of 2021 United States President Joe Biden signed into law S. 3434, the ‘Confidentiality Opportunities for Peer Support Counselling Act,’ or the ‘COPS Counselling Act.’ Peer support specialists are defined as personnel who have received specialized training in peer support. The Act directs the Attorney General to develop a report on best practices and professional standards for peer support counselling programs for establishing peer support programs, training in peer support, certification, continuing education, and the creation of ethical guidelines for first responder agencies. Interestingly, guidelines for specialized training in disaster mental health have been previously offered by the American Schools of Public Health in conjunction with the United States Centres for Disease Control and Prevention (Everly et al., 2008), as well as the National Volunteer Organisations Active in Disaster (Everly et al., 2008). Thus, the foundation for such a bold initiative is already in place.

Finally, ‘A systematic approach to the delivery of timely and appropriate disaster mental health services may facilitate their integration into the emergency medical response’ (North & Pfefferbaum, 2013, p. 507). As recommendations for best practices in physical medicine would support a continuum of care, so too would a continuum of care approach appear to be useful in responding to the psychological distress associated with disaster (Everly et al., 2008; Paul & Blum, 2005; Ruzek et al., 2004; Sheehan et al., 2004).

Summary

At the tender age of 30 years, disaster mental health is a relatively new field of study and intervention born of a recognition of, and a compelling need to mitigate, a virtual tsunami of psychological distress that invariably resides in the wake of disaster and far exceeds and endures beyond property damage, physical injuries, and death. Arising largely from case study empiricism on the battlefield to become the subject of sophisticated epidemiological investigations and innovative clinical interventions, the field of disaster mental health is continually challenged to continue to innovate so as not to consist of a collection of passive observers of a future that must be endured. The cost of failure to adapt and innovate is simply too great. In this special issue we focus on recent innovations in this nascent field.

Acknowledgements

Gratitude is expressed to Zach Pocchia of Loyola University Maryland who provided invaluable editorial assistance and Sadie Thrift who offered patience and administrative support. The timely and useful feedback provided by the reviewers was essential in formulating this special issue. Lastly, a sincere thank you to the authors who contributed their time and most valuable insights creating this special issue highlighting select innovations in the field of disaster mental health…in the midst of a pandemic!

Disclosure statement

The author was co-founder of the International Critical Incident Stress foundation.