Secondary Mental-Health Treatment Following Disasters
The aim of all disaster mental-health management should be the
humane, competent, and compassionate care of all affected. The
goal should be to prevent adverse health outcomes and to enhance
the well-being of individuals and communities. In particular, it
is vital to use all appropriate endeavors to prevent the
development of chronic and disabling problems such as PTSD,
depression, alcohol abuse, and relationship difficulties, and to
hasten the recovery of those that do develop problems.
Timing of Follow-Up Services
The timing of interventions is central to the concept of
secondary prevention of PTSD and other negative consequences.
Early intervention implies that services will be delivered
sometime before chronicity has developed. Unfortunately, almost
no research has examined the effects of differential timing of
treatment. Although it has been speculated that PTSD develops by
means of neurobiological changes that take place in the first few
days or weeks posttrauma, most theoretical models of PTSD do not
explicitly address the timing of intervention. It would be
helpful to examine how timing effects prevention and treatment,
specifically in relation to the processes of symptom worsening,
maintenance, and remission. Psychological models focusing on
processes of therapeutic exposure, cognitive restructuring,
social support, coping, rumination, "working through," and so on
have largely been mute as to whether there are critical periods
during which initial symptoms remit or become chronic.
In the Oklahoma City bombing, symptom onset of PTSD was rather
immediate, usually within one or two days; few other cases
developed after the first month. Because all the individuals in
closest proximity to the Oklahoma City bombing who reported
psychiatric symptoms also had PTSD, focusing on PTSD symptoms in
other traumatic situations could identify most individuals
needing referral to psychiatric care. This is consistent with
results from a small sample of self-referred patients following
the 1993 World Trade Center bombing in New York
1. These data indicate that avoidance and numbing symptoms may
efficiently identify those who may be at risk for PTSD and other
disorders. Early identification may be crucial, since data from
the Oklahoma City bombing suggest that, of those who were in
closest proximity to the bomb blast, 9 out of 10 individuals with
PTSD were still symptomatic 6 months after the disaster. This
indicates that the provision of ongoing treatment is
essential.
In the real world of service delivery, the timing of follow-up
will also depend on a variety of other factors, including
readiness of the survivor, the nature of the traumatic event and
its effects, and the nature of the service delivery setting.
Survivor readiness
Some survivors may not attend
preventive mental-health activities or pursue a mental-health
referral early in the recovery process. This may be because they
are busy coping with practical problems caused by the experience
(e.g., finding housing, pursuing insurance claims, or undergoing
physical tests and treatment) or because they do not feel ready
to face the emotions that discussing the trauma will bring up.
They may not recognize the need for services due to emotional
"denial" or a lack of information about the purposes and
practices of psychological counseling. Survivors also may not
recognize the need for services because they may expect that
their emotional reactions are short-term and will pass. Moreover,
they may not yet be experiencing significant impairment; some
survivors will experience a delayed onset of symptoms.
Mental-health practitioners should be sensitive to these
possibilities. Follow-up, re-screening, and repeated referrals
will help ensure that patients receive referral information when
they are better able to take advantage of it.
Nature of the traumatic event
The timing of
follow-up services will also be determined in part by the nature
of the trauma and its effects. For traumatic events that are
characterized by sudden onset and termination, services may be
delivered within a few weeks after the event and may be
supplemented by occasional longer-term follow-ups if they are
necessary and feasible. Other traumas involve extended periods of
continuing exposure to severe stressors or negative consequences
(e.g., loss of housing due to disaster, or medical treatment of a
serious injury). Optimally, follow-up in such cases should be
delivered for much longer than is necessary for the sudden onset
and termination events. When possible, follow-up services should
also correspond with times when trauma-related problems may be
exacerbated, such as on the anniversary of a traumatic event. For
example, episodes of terrorist violence often result in criminal
trials long after the violent event has ended. Because these
proceedings can be stressful reminders of the original event,
follow-up services delivered in conjunction with trial activities
may be helpful for survivors.
Nature of the setting
Posttrauma service
delivery settings vary greatly. MVA or assault survivors may be
seen in traditional medical settings; rape survivors may seek
help at community-based rape crisis centers; combat soldiers may
be offered "forward psychiatry" close to the scene of the trauma
itself; survivors of hurricanes or floods may be gathered
together at community shelters. The nature of the setting will in
part determine when, and with what intensity, follow-up services
may be delivered. In some environments, routine, systematic, and
adequately resourced follow-up with all survivors will be
feasible. The nature of the setting will also influence who
(mental-health professionals, medical personnel,
paraprofessionals, or others) will deliver mental-health-related
follow-up.
Who Should Receive Follow-Up Services?
All survivors should be given educational information to
(1) help normalize common reactions to trauma, (2) improve
coping, (3) enhance self-care, (4) facilitate recognition of
significant problems, and (5) increase knowledge of and access to
services. Such information can be delivered in many ways,
including through public media, community education activities,
and written materials. More intensive follow-up services should
target subgroups of survivors who are at heightened risk for
chronic or severe posttrauma problems. Such targeting is
warranted for two major reasons. First, resources will often be
limited, making it difficult to provide all survivors with costly
services. Second, immediate posttrauma distress will remit
naturally for many patients
2, and it may not be necessary to provide mental-health
services to everyone. Hypothetically, it is even possible that
too much focus on mental-health issues could induce iatrogenic
symptoms in some survivors. Centering survivors' attention on
symptoms and problems might make them believe that they are
receiving help because they have more problems than they
realize.
Ideally, by systematically screening all survivors,
mental-health providers will identify individuals at significant
risk for continuing problems. If such screening systems are not
in place, identification can be based on a number of criteria,
including: a referral by a trauma responder, self-referral, a
severe level of trauma exposure (e.g., exposure to death and
dying), a co-occurring injury, the level of co-occurring loss,
and the role of the survivor (e.g., a disaster worker responsible
for body recovery).
Content of Follow-Up Activities
The variety of appropriate follow-up activities may include
education, screening, referral, and treatment.
Survivor and family education
As mentioned
above, educating trauma survivors and their families may help
normalize common reactions to trauma, improve coping, enhance
self-care, facilitate recognition of significant problems, and
increase knowledge of and access to services. First, survivors
and families should be reassured about common reactions to
traumatic experiences and be advised regarding positive and
problematic forms of coping. Information about social support and
stress management is particularly important. Second,
opportunities to discuss emotional concerns in individual,
family, or group meetings can enable survivors to reflect on what
has happened. Third, education regarding indicators that initial
acute reactions are failing to resolve will be important, as will
education about signs and symptoms of PTSD, anxiety, depression,
substance use disorders, and other difficulties. Finally,
survivors will need information about financial, mental-health,
rehabilitation, legal, and other services available to them as
well as education about common obstacles to pursuing needed
services.
Follow-up screening
Early identification of
those at risk for negative outcomes can facilitate prevention,
referral, and treatment. Mental-health providers can screen for
current psychopathology and risk factors for future impairment by
using brief semi-structured interviews and standardized
assessment questionnaires. Screening should address past and
current psychiatric and substance use problems and treatment,
prior trauma exposure, pre-injury psychosocial stressors, and
existing social support. Event-related risk factors should also
be assessed, including exposure to death, perception of
life-threat, and peri-traumatic dissociation. Acute levels of
traumatic stress symptoms are especially important because they
predict chronic problems. For example, more than three-quarters
of MVA patients diagnosed with Acute Stress Disorder (ASD) will
have chronic PTSD at 6 months posttrauma
3. In follow-up appointments, it will be important to
continue to screen for PTSD and other anxiety disorders,
depression, alcohol and substance abuse, problems with returning
to work and other productive roles, adherence to medication
regimens and other appointments, and the potential for
retraumatization.
Referral
A crucial goal of follow-up activities
is referral, as necessary, to appropriate mental-health services.
In fact, the referral to and subsequent delivery of more
intensive interventions will depend upon adequately implementing
the follow-up screening. Screening, whether conducted in formal
or informal ways, is what identifies those who need a referral.
However, embarrassment, fear of stigmatization, and cultural
norms may prevent some survivors from seeking help or pursuing a
referral. Those making referrals can directly address these
attitudes and try to preempt the avoidance of needed services;
motivational interviewing techniques
4 may help increase the acceptance rate of referrals.
Treatment
Research suggests that relatively
brief but specialized interventions may effectively prevent PTSD
in some subgroups of trauma patients. Several controlled trials
have suggested that brief cognitive-behavioral treatments (i.e.,
4-5 sessions), delivered within weeks of the traumatic event and
comprised of education, breathing training/relaxation, imaginal
and
in vivo exposure, and cognitive restructuring, can often
prevent PTSD in survivors of sexual and nonsexual assault
5. Cognitive-behavioral treatments can also prevent
the occurrence of PTSD in survivors of motor vehicle and
industrial accidents
6,
7. Brief intervention
with patients hospitalized for injury has been found to reduce
alcohol consumption in those with existing alcohol problems
8. Controlled trials of brief, early intervention services
targeting other important trauma sequelae (e.g., problems
returning to work, depression, family problems, trauma
recidivism, and bereavement-related problems) have not yet been
conducted, but it is likely that targeted interventions will be
effective in these areas for at least some survivors.
Treatment of Acute Stress Disorder (ASD) is indicated for the
small proportion of people at risk for developing long-term PTSD.
While the field of treatment for ASD is still young, two
well-designed studies offer evidence that brief treatment
intervention, utilizing a combination of cognitive-behavioral
techniques, may be effective in preventing PTSD in a significant
percentage of subjects. In their study of a brief treatment
program for recent sexual and nonsexual assault victims, all of
whom met criteria for PTSD, Foa, Hearst-Ikeda, and Perry
5 compared repeated assessments with a Brief Prevention
Program (BPP) composed of four sessions of trauma education,
relaxation training, imaginal exposure,
in vivo exposure, and cognitive restructuring. Two months
posttrauma, only 10% of the BPP group met criteria for PTSD,
whereas 70% of the repeated assessments group met criteria for
PTSD. In a study of motor vehicle and industrial accident victims
who met criteria for ASD, Bryant, Harvey, Dang, Sackville, and
Basten
6 compared five sessions of nondirective supportive
counseling (which provides support, education, and
problem-solving skills) with a brief cognitive-behavioral
treatment (which involves trauma education, progressive muscle
relaxation, imaginal exposure, cognitive restructuring, and
graded
in vivo exposure to avoided situations). Immediately
posttreatment, 8% in the CBT group met criteria for PTSD versus
83% in the supportive counseling group. Six months posttrauma,
17% in the CBT group met criteria for PTSD versus 67% in the
supportive counseling group. One important caveat to this study
is that the dropout rate was high, and the authors concluded that
those with more severe symptoms may need supportive counseling
prior to intensive cognitive-behavioral interventions.
In addition to targeted, brief interventions, some trauma
survivors may benefit from ongoing counseling or treatment.
Candidates for such treatment include survivors with a history of
previous traumatization (e.g., survivors of the current trauma
who have a history of childhood physical or sexual abuse) or
those who have preexisting mental health problems. See our fact
sheet: Empirical Evidence Regarding Behavioral Treatments for
PTSD, for more information.
Maximizing Follow-Up Services
Experience indicates that relatively few survivors of many
types of trauma make use of available mental-health services.
This may be because survivors (1) are unaware that such services
are available, (2) do not perceive a need for them, (3) lack
confidence in the services' utility, or (4) have negative
attitudes toward mental-health care. Therefore, those planning
follow-up and outreach services for survivors must consider how
best to reach trauma survivors and how to educate them about
sources of help. It is also important to think about how to
market these services to the intended recipients.
In the chaos following some kinds of traumatic events (e.g.,
natural disaster), it is important that workers systematically
obtain detailed survivor contact information to facilitate later
follow-up and outreach. In addition, it is important that those
providing outreach and follow-up services actively approach
survivors wherever they congregate. Each contact the survivor has
with the system of formal and informal services affords
mental-health workers an opportunity to screen for risk and
impairment and to intervene appropriately. Settings that provide
opportunities for contact with survivors are diverse and include
remembrance ceremonies, self-help group activities, settings
where legal and financial services are delivered, and
interactions with insurance companies. For survivors injured or
made ill during the traumatic event, follow-up medical
appointments are also opportunities for reassessment, referral,
and treatment.
References
1.
Difede, J., Apfeldorf, W.J.,
Cloitre, M., Spielman, L.A., & Perry, S.W. (1997). Acute
psychiatric responses to the explosion at the World Trade Center:
A case series.
Journal of Nervous and Mental Disease 185( 8),
519-522.
2.
Blanchard, E.B., Hickling, E.J.,
Barton, K.A., Taylor, A.E., Loos, W.R., & Jones-Alexander, J.
(1996). One-year prospective follow-up of motor vehicle accident
victims.
Behaviour Research and Therapy 34(10), 775-786.
3.
Bryant, R.A, & Harvey, A.Gay.
(2000).
Acute Stress Disorder: A handbook of theory, assessment, and
treatment. Washington, D.C.: American Psychological
Association.
4.
Rollnick, S.,
Heather, N., Bell, A. (1992). Negotiating behaviour change in
medical settings: The development of brief motivational
interviewing.
Journal of Mental Health (UK), 1(1), 25-37.
5.
Foa, E.B.,
Hearst-Ikeda, D.E., & Perry, K. J. (1995). Evaluation of a
brief cognitive-behavioral program for the prevention of chronic
PTSD in recent assault victims.
Journal of Consulting and Clinical Psychology, 63(6),
948-955.
6.
Bryant, R.A., Harvey, A.G., Dang,
S.T., Sackville, T., & Basten, C. (1998). Treatment of Acute
Stress Disorder: A comparison of cognitive-behavioral therapy and
supportive counseling.
Journal of Consulting and Clinical Psychology 66(5),
862-866.
7.
Bryant, R.A., Sackville, T., Dang,
S.T., Moulds, M.L., & Guthrie, R. (1999). Treating Acute
Stress Disorder: An evaluation of cognitive behavior therapy and
supportive counseling techniques.
American Journal of Psychiatry 156(11), 1780-1786.
8.
Gentilello, L.M., Donovan, D.M.,
Dunn, C.W., & Rivara, F.P. (1995). Alcohol interventions in
trauma centers: Current practice and future directions.
Journal of the American Medical Association, 274(13),
1043-1048.
9.
Friedman, M.J. (2000). A guide to
the literature on pharmacotherapy for PTSD.
PTSD Research Quarterly 11(1), 1-7.
