Everything You Ever Wanted To Know About Natural Disasters And Mental Health (Well, Almost)
By John R. Freedy, Ph.D. and Dean G. Kilpatrick, Ph.D.
NCP Clinical Quarterly 4(2): Spring 1994
Overview
Convincing the reader of the importance of this topic should not be difficult. Each year, several million American adults suffer injury or property damage due to natural disasters (1). In several large household probability samples we (together with colleagues) have found that approximately one-third of adults report exposure to a natural disaster during their life span (2,3). In addition, recent events confirm the potential impact of various natural disasters (e.g., the Great Midwest floods of '93; the Southern California fires of '93, Hurricanes Andrew '92, Iniki '92, and Hugo '89; the Oakland Hills fire '91, and the Loma Prieta earthquake '89).
Our personal and professional backgrounds provide us with insights concerning the mental health impact of natural disasters. On a personal level, we both lived in Charleston, South Carolina in September, 1989 when Hurricane Hugo devastated the area. We understand first hand what it is like to prepare for, survive, and clean up following a major natural disaster. On a professional level, we are part of a clinical research team that specializes in studying the mental health impact of various natural disasters. We have received National Institute of Mental Health funding to study the following events: Hurricane Hugo (September, 1989), the Loma Prieta earthquake (October, 1989), the Sierra Madre earthquake (June, 1991), and Hurricane Andrew (August, 1992). Our comments reflect a synthesis of out personal insights and research findings.
The goals of this article are basic: 1) to present a multivariate risk/resilience model that attempts to explain the connection between natural disasters and subsequent adjustment; 2) to discuss research-based support for the proposed model; and, 3) to provide recommendations concerning the clinical implications of our risk/resilience model. Our presentation will provide the reader with a sophisticated way of thinking about the mental health impact of natural disasters.
A Multivariate Risk/Resilience Model
Recent years have witnessed a increased interest in research concerning traumatic events (4). A number of credible research reports concerning the mental health impact of natural disasters have appeared (5). Despite this growing knowledge base, certain weaknesses exist in the natural disaster-mental health literature. The chaotic nature of natural disasters renders empirical studies difficult. Methodological weaknesses (e.g., non-representative samples, non-standardized measures) lessen confidence in some available knowledge (1,6,7). A related concern involves the need to develop conceptual models. We now turn our attention to describing a multivariate risk/resilience model being examined in our research efforts.
According to our model, adjustment is a complex process that unfolds across time. We conceptualize mental health risk/resilience factors according to three time phases: pre-disaster, within-disaster, and post-disaster. As presented in table 1, the potential contribution of a wide range of individual and environment factors are believed to influence adjustment. Both objective and subjective factors are considered as relevant to determining adjustment. A major weakness in prior natural disaster research has been the failure to assess the impact of a range of factors (across time) upon mental health adjustment.
It is beyond the scope of the current article to comprehensively review literature that is supportive of the proposed risk/resilience model. Support for the model has been detailed elsewhere (8). We will focus on noting several broad themes that are inherent in the proposed model.
Table 1: A Risk Factor Model Of Natural Disaster Adjustment
|
Pre-disaster
Factors |
Within-disaster
Factors |
Post-disaster
Factors |
Mental Health
Outcomes |
|
|
|
|
|
Demographic
Characteristics |
Disaster
Exposure |
Basic Needs
|
Depression
|
|
Mental Health
History |
|
Initial distress
level |
Anxiety
|
|
High magnitude
life events |
Cognitive
appraisal of
disaster exposure: |
Stressful
life
events |
Somatic
Complaints |
|
Low magnitude
life events |
*Low control |
Resource loss |
Substance
Abuse |
|
Low
predictability |
Coping
behavior |
|
|
Coping
Behavior |
high life
threat |
|
|
|
Social support |
|
Social support |
Positive
experiences |
The first theme concerns the importance of a disaster victim's prior history in determining their current adjustment. Too often, research concerning the mental health impact of natural disasters (or other traumatic events) ignores the role of previous personal and environmental characteristics in determining current adjustment. Extant research literature suggests that the following pre-disaster factors should be considered with regard to potential impact on recent adjustment: demographic characteristics, prior mental health problems, prior history of traumatic events, past year exposure to non-traumatic life events, social support, and prior skill in coping (8).
The second theme concerns the importance of acute stressors in determining adjustment. In particular, a dose-response relationship exists between level of event exposure and subsequent mental health problems (8). Examples of objective indices of exposure include: physical injury, experiencing intentional harm, deaths, witnessing grotesque sights, property loss, and information regarding exposure to noxious substances (9). Examples of subjective indices of exposure include: fearing death or serious injury, perceiving low control, or perceiving low predictability (8). Most extant research studies focus primarily upon the role of within-disaster exposure level in determining subsequent adjustment.
A third theme concerns the importance of ongoing, low grade stressors in determining post-event adjustment. Examples of post-event stressors include: disruption in basic needs (e.g., food, shelter, water, medicines), stressful life events (e.g., residential displacement, unemployment), or the loss of internal and external resources (e.g., sense of control, social ties) that are important predictors of adjustment even when the role of acute exposure (e.g., fear of death or injury) factors are statistically controlled (10).
A final theme requires the recognizing the nature of mental health adjustment following natural disasters. Adjustment will range from positive (e.g., experience of personal growth) to negative (e.g., severe depression or anxiety, substance abuse). Most adults will experience strong feelings before, during, and immediately following a major natural disaster (e.g., fear, sadness, anger). However, most adults (>90%) will not experience a major mental health disorder as a function of disaster exposure of subsequent ongoing stressors (11). In general, most adults will experience a full psychological recovery by 12 to 24 months following a major natural disaster (5). Of course, profound and lasting mental health effects may occur following extremely catastrophic experiences (e.g., deaths, serious injury, extreme community destruction).
Research Support For The Proposed Model
Our ongoing research projects were designed to test our proposed multivariate risk/resilience model. In general, findings have been supportive of the proposed model. Space limitations prevent a detailed review of our findings. Instead we will note general trends that have appeared within our data sets.
Our research findings have supported the importance of viewing the connection between natural disasters and mental health in a sophisticated fashion. Depending on the particular sample studied, some combination of pre-disaster, within-disaster, and post-disaster factors have been statistically significant predictors of mental health outcomes ranging from mental disorders (e.g., Post-traumatic Stress Disorder or Major Depressive Episode) to more general indices of psychological distress.
Table 2 presents factors that constituted risk factors for mental health problems in one or more of our samples. We suggest that the presence of one or more of these factors may be associated with an increased mental health risk within populations impacted by natural disasters. Professionals are advised to consider the presence of these factors as potential indicators of vulnerability to mental health problems following a natural disaster.
Table 2: Mental Health Risk Factor Profile
- Lower income
- Increasing age
- Prior mental health problems
- Prior violent crime victimization
- Prior history of other traumatic events
- Pre-existing non-traumatic events
- Intense initial emotional reactions to disaster
- Perceived threat of serious injury or death (to self or family) during disaster
- Higher post-disaster rates of non-traumatic events
- A lack of necessary resources in the post-disaster period (e.g., family stability, stable employment, social support)
- Higher rates of post-disaster coping behavior
Intervention Recommendations
Our personal insights and research data can be translated into practical actions. Towards this goal, we provide a series of guidelines directed at mental health professionals interested in addressing the psychological needs of natural disaster victims. In particular, we recommend the following:
1. Direct early relief efforts (3 to 6 months post-event) at assisting individuals and families in obtaining basic goods and services. Don't underestimate the importance of food, water, shelter, medicines, etc. to positive mental health. Maslow was right; there is a hierarchy of needs!!! Taking care of basic needs provides a bedrock for positive mental health.
2. To the extent possible, encourage people to become involved in collective self-help efforts. Continuing the pre-event norm of self-reliance is a set up for misery following a natural disaster. Family should help family, neighbors should help neighbors, and co-workers should help co-workers.
3. Watch out for forgotten groups. Certain groups may become isolated following a natural disaster. The elderly may become isolated. Rural areas may be late in receiving supplies or cut off from necessary assistance prior to the fullest recovery of the community. The poor may lack resources necessary to re-establish basic living conditions. The physically and mentally ill may suffer exacerbation of pre-existing conditions. Advocacy on the behalf of and direct service to such groups is indicated for humanitarian reasons. Remember, recovery from major natural disasters may require as long as 12 to 24 months for some individuals. In extreme cases, longer recovery periods may be required.
4. Actively educate the public regarding normal psychological functioning in the aftermath of a natural disaster. This can be accomplished in two manners: the aggressive use of media stories (newspapers, television, radio), and the use of group meetings (at shelters, community centers, work, churches, etc.) to: "debrief" citizens (one shot, 90 minute meetings) regarding normative stress reactions and available stress management tips. Encourage people to share their disaster related experiences with other people. It is usually very helpful to know that you are not alone in having certain experiences and feelings. It is reasonable to continue public education efforts for at least 6 to 12 months following a major natural disaster.
5. Expect largely pro-social behavior from the community in the weeks and months following a natural disaster. Large scale natural disasters typically bring out the "hero" in many community members. Following Hurricane Hugo, we observed much more good behavior from our community than problem behavior. However, be prepared for some increase in problematic behavior, such as: "price gouging", other crime, substance abuse, and family conflict (domestic violence/child mistreatment). The use of law enforcement and government ordinances may control some of these problems (prices, crime). Active efforts to educate the public (see #4) regarding the potential for increased substance abuse or family conflict may reduce the likelihood of such problems or encourage appropriate help seeking.
6. Be prepared to provide formal mental health services to individuals and families in need. If some form of psychological recovery is not significantly underway by 3 to 6 months following a natural disaster, a formal mental health evaluation may be indicated. In addition, the following personal characteristics/experiences may suggest increased vulnerability to develop serious mental health problems: prior mental health history, history of crime victimization or other traumatic events, high rates of negative events before or after the natural disaster, extreme initial psychological reactions (e.g., perception of threat to own life or life of family), lower income, a lack of resources (e.g., family stability, stable employment, support from other people), personal injury, or bereavement.
References
1. Solomon, S.D. (1989). Research issues in assessing disaster's effects. In R. Gist & B. Lubin (Eds.), Psychosocial aspects of disaster (pp. 308-340). New York: John Wiley & Sons.
2. Freedy, J.R., Resnick, H.S., Kilpatrick, D.G., & Saunders, B.E. (1993). Adult psychological functioning after earthquakes. Final report for NIMH grant no. R03 MH 49485, submitted to the Violence and Traumatic Stress Research Branch.
3. Freedy, J.R., Kilpatrick, D.G., & Resnick, H.S. (1993). The psychological impact of the Oakland Hills fire. Final report for supplement to NIMH grant no. R01 MH47508 01A1, submitted to the Violence and Traumatic Stress Research Branch.
4. Blake, D.D., Albano, A.M., & Keane, T.M. (1992). Twenty years of trauma: Psychological Abstracts 1970 through 1989. Journal of Traumatic Stress, 5, 1-8.
5. Solomon, S.D., & Green, B.L. (1992). Mental health effects of natural and human-made disasters. The National Center for Post-Traumatic Stress Disorder: PTSD Research Quarterly, 3(1), 107.
6. Baum, A., Solomon, S., & Ursano, R. (1987, Sept.). Emergency/disaster research issues: A guide to the preparation and evaluations of grant applications dealing with traumatic stress. Proceedings of the workshop on research issues: Emergency, Disaster, and Post-traumatic stress. Bethesda, MD: Uniformed Services University of the Health Sciences.
7. Raphael, B., Lundin, T., & Weisaeth, L. (1989). A research method for the study of psychological and psychiatric aspects of disaster. Acta Psychiatrica Scandinavia, 80(353), 1-75.
8. Freedy, J.R., Kilpatrick, D.G., & Resnick, H.S. (1993). Natural disasters and mental health: Theory, assessment, and intervention. Journal of Social Behavior and Personality, 8(5), 49-103.
9. Green, B.L. (1990). Defining trauma: Terminology and generic stressor dimensions. Journal of Applied Social Psychology, 20, 1632-1642.
10. Freedy, J.R., Saladin, M.E., Kilpatrick, D.G., Resnick, H.S., & Saunders, B.E. (in press). Understanding acute psychological distress following natural disaster. Journal of Traumatic Stress.
11. Summers, G.M., & Cowan, M.L. (1991). Mental health issues related to the development of a national disaster response system. Military Medicine, 156(1), 30-32.
John Freedy is Director of Training and Assistant Professor, Crime Victims Research and Treatment Center, Division of Department of Psychiatry and Behavioral Sciences, Department of Psychiatry and Behavioral Sciences Medical University of South Carolina, Charleston, South Carolina. Dean Kilpatrick is Director, and Professor, Crime Victims Research and Treatment Center, Division of Department of Psychiatry and Behavioral Sciences, Department of Psychiatry and Behavioral Sciences Medical University of South Carolina.
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