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Managing the After-effects of Disaster Trauma – The Essentials of Early Intervention
A Proposed Five-step Model Sense of Safety
There is no evidence-based consensus with regard to effective Adverse stress reactions tend to persist under conditions of ongoing
interventions for use in the immediate, early and mid-term post- threat.
18,19
It is essential to bring disaster victims to a safe place that is
disaster phases.
7
For example, two recent assessments of the effect of free of threats to life and exposure to witnessing horrors. For example,
early interventions after potentially traumatic events of large and small in a study of Norwegians who survived the South-East Asian tsunami
magnitude confirm that the available evidence is weak or lacking.
8,9
of 2004, we noted an accumulated risk of stress complaints six months
For many years ‘acute stress debriefing’ was the intervention of choice post-disaster when a victim was both exposed to personal danger and
for disaster survivors. However, research about its efficacy has failed to witnessed horrors such as deceased victims or abandoned children.
20
show any positive outcome.
10,11
The recent work by Hobfoll et al.
12
tries to achieve consensus in a field
that has been plagued by controversy. In this work, an expert panel of
There is no evidence-based consensus
mental health professionals from a broad range of disciplines draws
with regard to effective interventions
attention to some central elements or principles of intervention,
for use in the immediate, early and
ranging from prevention to support to therapeutic interventions. The
authors make it clear that their recommendations are evidence- mid-term post-disaster phases.
informed rather than evidence-based. Their five intervention principles
are to promote a sense of safety, calming, a sense of self- and
collective efficacy, connectedness and hope. These interventional Some disaster situations allow for an escape only to relative safety,
principles have been criticised as being too ambitious in their provision such as in a war zone or the after-shocks of an earthquake. Even a
of detailed public health intervention. The critics state that for many relative sense of safety can buffer the risk of developing PTSD.
21,22
practical circumstances there seems to be a gap between what is Failure to feel safe may be caused by untreated physical injuries,
desirable and what is feasible.
13
In our opinion, although practical uncertainty about loved ones and feeling responsible for the search
work has to be adapted to available resources as well as to local and rescue of other victims at the expense of personal safety.
context and culture, we think that the five intervention principles serve
as general aims for intervention strategies.
14
Priority should be given to reuniting family members and providing
information about missing next of kin because the safety of loved ones
Components of the five intervention principles are relevant to the entire is just as important, or even more important, than the safety of
disaster population. Everyone can benefit from certain aspects of these oneself.
12
When such ongoing stressors are resolved, most survivors
principles. Indeed, most post-traumatic stress reactions are normal – and experience an immediate sense of relief, a sort of ‘let-go’ reaction,
sometimes adaptive – during the early aftermath of disaster, and these with trembling, tearfulness and an understanding that the real danger
reactions will often gradually disappear.
6
There is a risk that early has passed. This cathartic reaction, which can be facilitated by
interventions unintentionally disrupt the normal recovery and processing intervention, has been shown to predict a positive prognosis.
23
In many disaster situations it is important to have a family focus.
More than any other type of help-
Particularly with children, perceived safety is associated with the
giving, disaster interventions need to
assurance of continued contact with parents or other familiar care-
givers. In the past, well-intended measures such as the evacuation of
be highly organised and co-ordinated,
children to safety have inflicted separation trauma.
24
It is also
and they should be conducted in a important for adults to be around someone they trust. Sense of safety
collaborative atmosphere.
can be either promoted or undermined by group processes.
25
Reliable information is important, ideally from an authority, in order
of events. During the early aftermath, ‘watchful waiting’ may be the to neutralise rumours. Media may sometimes enhance anxiety and
recommended strategy.
13
This is the approach favoured by the UK’s uncertainty by conveying information in a dramatic way. Many studies
National Institute for Health and Clinical Excellence.
15
For those who do have demonstrated that viewing television coverage of traumatic
not improve, subsequent targeting is necessary. While the triage of events has been associated with later psychological distress among
physical injuries must be immediate, mass psychiatric screening has a both children and adults.
26–28
It is important to tell parents to restrict
longer time-frame; that is, a larger window of opportunity. Screening can children’s television viewing because children have less capacity to
be accomplished by identifying high-risk disaster exposures and understand the immediacy of threats.
29,30
For example, some
vulnerable individuals/families/communities, or by measuring post- Norwegian children who experienced the 2004 tsunami believed that
disaster stress responses, all of which predict long-term psychopathology. there had been several tsunamis because of repetitive presentations
Questionnaire screening followed by clinical interviews will help to on television.
identify high-risk cases.
16,17
Calming
In the following, we briefly review the five intervention principles The psycho-physiological and neurobiological reactions that are activated
listed above, as well as some evidence for an additional principle: by extreme stress – the fight, flight or freeze reactions – are deeply
controlled exposure. embedded in the brain and not easily switched off. The accompanying
EUROPEAN PSYCHIATRIC REVIEW 67