The psychological effects of disaster by Dr Paul Lee, Deputy Director, Department of Child & Adolescent Psychiatry, Monash Medical Centre Even though Australia is a lucky country, disasters (both natural and man-made) occur frequently enough to warrant detailed study to find out the best ways to prevent, handle and manage a disaster when it happens. It is important to stress that each disaster is unique, e.g. the "Ash Wednesday" bushfires (February 1983); the Cyclone Tracy disaster (December 1974) and the Granville rail disaster (January 1977). How we handle each disaster is governed by several factors, including: A the disaster itself - the nature - the acuteness - the duration - the intensity. B our personality - previous exposure to a disaster - previous experience of losses - general coping ability in a crisis situation - our view of the disaster etc. C the environment - its pre-morbid nature - resources available after the disaster etc. This implies that the outcome (both physical and psychological) of a disaster is dependent on these factors and theoretically speaking, if we can alter any of these factors, we may alter the outcome of the disaster. A disaster creates significant stress on the people involved. The sources of this stress include: 1. life threat - helplessness - "this is it" - injury or death 2. loss threat - family, friends - property - sense of invulnerability, esteem 3. conflict threat - "did I do the right thing?" - guilt - "what if......?" 4. evacuation/separation - unfamiliar environments - separation from family and network Despite these various factors there are enough commonalities to generalise so the experience gained from one disaster can be transferred to another. It is the aim of this paper to discuss some of the common psychological effects of a disaster to both the victim and the helpers. Broadly speaking, there are 7 stages in the development of disaster situations. Obviously, not all stages have to occur and they do overlap considerably. The stages are: 1. warning 2. threat 3. impact 4. inventory 5. rescue 6. remedy 7. recovery The time of each stage varies. The level of functioning of the individual or group during these stages is best represented by the following diagram The disaster Our personality Environment Outcome 1. The warning stage Some disasters may strike without warning, but most natural disasters, eg bushfires floods and cyclones, warnings do occur well in advance. Perhaps it is human nature. The majority of us tend to ignore any warning and say to ourselves, 'she'll be right mate" or "it won't happen to us". As a result, we tend not to do anything to prevent or minimise a disaster. Some of us, especially those who had been through similar disasters before, may be acutely aware of the warning signals and are able to plan constructive ways to deal with the disaster when it arrives. 2. The threat stage As the threat approaches, we are forced to look more realistically into the situation in order to re-appraise our roles. Our anxiety and level of arousal are increased. We have to decide "fight" or "flight". This is the time when our adrenalin is really pumping. Our physical activities increase, eg building sand-banks to stop an impending flood; clearing all the shrubs around the house in case of bushfire, etc. We have internal images of the impending disaster and we prepare ourselves, both psychologically and practically. The images we hold are usually an underestimation of the dimension of the disaster. Reading and hearing about previous disasters is not the same as living through one. 3. The impact phase During the impact phase individual persons and groups are more or less isolated for a time; the usual structure of the community is fragmented. Rescue procedures (usually carried out by ourselves) commence but this may or may not be effective. Our skills and strengths are tested to the full. Family members may be separated and a great deal of fear and anxiety is generated. Confusion and panic may set in. At the peak of the impact phase, depending on our personalities and the degree of stress, several phenomena may occur: a. the sense of abandonment with its associated feelings of hopelessness. We may decide to give up because the stress is too great for us to cope. We may de-compensate and develop hallucinations and suicidal thoughts, b. the development of altruism and a feeling of invulnerable omnipotence. We become the super-person who is indestructible and who can save the world, c. the blocking off of emotion so that we continue activities coolly and calmly as if nothing has happened, d. the development of a total state of panic. 4. The inventory stage When the acute crisis is over, we may start taking inventory of the damages and losses. We are usually stunned by the degree of the destruction and feel a sense of numbness and disbelief - " the stunned mullet phenomenon". We may become depressed and tense, with frequent nightmares and sleep disturbances. We can't concentrate on our task because of frequent intrusive thoughts about the disaster. We become irritable and our mood fluctuates dramatically. We may feel angry towards other people, the government or God. We feel guilty about what we could have done to save the losses that occurred. We may feel guilty that we have survived the disaster whilst others have perished or sustained severe damaged. We are the "lucky ones', or are we? 5. The rescue stage The helpers start to arrive on the scene - usually far too late as far as we are concerned, but at the same time relieved that they are here. An assumption is made at this stage that the helpers can be so over-awed that they need help too. They are not omnipotent as we would like to see them, and as a result, we may feel angry towards them. 6. The remedy stage As the rescue stage proceeds, more and more helpers come along, providing us with physical, material and psychological supports. We feel grateful towards them. After all, they provide us with shelter, clothing, food, money etc. They try to put us back on our feet. However, we also become increasingly exposed. Our privacy is no longer ours if we want help; bureaucracy sets in with questionnaire, forms, vouchers etc. In fact we have lost our independence and our existence becomes entirely dependent on others. We, therefore, tend to view the helpers with a great deal of ambivalence. It is important to remember that remedy is instilled to replace what has been lost, but the replacement is never the same. Disasters do not simply return to their pre-disaster state. 7. The recovery stage There is some truth in the saying that "time heals". Certainly the time it takes for the victims of the disaster to recover is highly variable, dependent upon the pre-morbid personality of the individual, the experiences during the disaster, and the supportive network available to the individual. Some individual may develop post-traumatic stress disorder. The traumatic event is persistently re-experienced as recurrent and intrusively distressing recollection of the event; recurrent distress dreams of the event; sudden acting or feeling as if the traumatic event were recurring and intense psychological distress. There may be persistent avoidance of stimuli associated with trauma or numbing of general responsiveness. Individuals may have persistent symptoms of increased arousal, eg sleep disturbance, irritability, poor concentration and exaggerated startle response. If these symptoms persist for a prolonged period of time (greater that one month), psychological counselling may be required. The rescuers and the helpers From the helpers point of view, stress occurs during the initial stages, which includes frustration, over-commitment, guilt about those who could not be saved and about decisions of management; personal threat of danger to life in the disaster and massive encounter with death and the dead. Physical exhaustion complicates things further, with the result that these helpers may become victims themselves, a fact that is not usually recognised. A recent study has indicated that their family relationships may suffer as do their work efficiency during the initial and intermediate periods. Debriefing to the helpers is mandatory to reduce the incidence of psychological morbidity. Some of the problems facing the rescuers may be summarised: 1. problems of role stereotype 2. frustration and conflicts 3. "strained" feeling - sleep disturbance - tension - memories - conflicts - loss and grief 4. Specific nature of workers' experience - very intensive experience - "worthwhile" - special closeness - expectations - different roles 5. Effects on family life - strain - closeness Psychological debriefing of rescuers becomes an important part. During debriefings we have to consider: 1. review of role(+) - what was done? - what it meant? - frustration - implications for future 2. review of relationship with (-) - workers - victims - friends - close family In addition the workers will need to be allowed, and encouraged, to express their feelings. In summary, the psychological effects of a disaster are stress related. In order to help the victims and the workers, we need to understand the stages of disaster and also the sources of stress. The importance to realise the needs of the helpers is also discussed. We will also need to learn from the experience so that proper displan can be drafted then implemented when disaster strikes again.