First, do no harm, Part 1
In addressing the psychological aftermath of a disaster, good intentions alone aren't enough, and less is often more.
It's been more than a quarter century since the collapse of a pair of suspended walkways traversing the lobby of Kansas City’s Hyatt Regency Hotel killed 114 people and made the impact of a mass disaster on community mental health a central focus in planning and response. More by happenstance than by any pre-incident design, a great deal of attention was placed on helping the community to wend its way through the processes of mutual support and collective recovery.
There was little guidance in 1981 regarding best practices in disaster mental health and virtually no empirical evidence on which to base approaches. The efforts undertaken were the products of common sense, practical experience and informed guesswork. The overall effort appeared reasonably effective in mobilizing emotional solace and instrumental support; it also provided an opportunity to suggest some working hypotheses regarding principles for community intervention (Gist & Stolz, 1981). These, in turn, facilitated our first forays into melding what pieces of empirical theory and research were available across several disciplines into a preliminary picture of evidence-informed practice (Gist & Lubin, 1989).
According to the reported activity of various training groups, there must now be more than twice as many trauma counselors in the United States as there are dentists.
Science, it's been said, progresses at one of two speeds: tectonic for most things or, when accelerated due to extreme urgency, glacial. Science is conservative, tedious and sometimes quite overly cautious. Clinical applications tend to be bolder and less averse to risky shifts; the urgency of relieving suffering and limiting morbidity often motivates practitioners to try new ideas and approaches before science has had the full opportunity to test their safety and efficacy. Accordingly, it’s not at all uncommon to find today’s "drug du jour" the subject of tomorrow's recall after controlled clinical testing finds that unforeseen risks outweigh demonstrable benefit.
Psychological interventions, especially those with primarily preventive intent delivered across large populations, are notoriously difficult to evaluate. They often take shape as social movements rather than through carefully controlled sequences of planned clinical trials. The objectives tend to be sweeping and amorphously defined, while the outcomes are vague and general. They are typically delivered with the best of intentions propelled by the fervor of true commitment. Providers come to believe strongly in their importance and their impact; they often react with stunned resistance when empirical research questions the usefulness of their efforts.
The lobby of the Hyatt Regency Hotel in Kansas City, Mo. is pictured on the 25th anniversary of the collapse, July 17, 2006. (AP Photo/Charlie Riedel)
Psychological intervention at disaster scenes grew to become so prevalent that counselors clamoring to provide assistance began to outnumber victims seeking help. One reporter who researched the response to Manhattan following the 9/11 attacks noted that 9,000 counselors reported being present in New York, outnumbering known victims by at least three to one. She also observed that, according to the reported activity of various training groups, there must now be more than twice as many trauma counselors in the United States as there are dentists (Kadet, 2002).
At the same time, though, accumulating empirical evidence has revealed increasingly circumspect assessment of the actual benefit of these interventions. Worse, some of the most frequent and visible approaches (such as critical incident debriefing) have been disturbingly associated with paradoxically negative impacts for at least some recipients (see McNally, Bryant, & Ehlers, 2003, for a definitive review).
Though rushing to provide mass psychological prophylaxis through “instant intervention” has proved to be a path that should be taken only with caution (Gist & Devilly, 2002), there’s no doubt that helping those in affected communities to support one another remains a needed and worthwhile undertaking. A recent report from a number of leading researchers in the community impact of disasters is noteworthy for the extent to which it reiterates most of the basic premises that drove our earliest efforts almost three decades before. Hobfoll, et al, (2008) list what they contend to be five essential elements of appropriate community assistance, informed by the now substantial empirical literature in disaster mental health:
1. Restoring a sense of safety;
2. Calming (reducing anxiety and agitation);
3. Establishing a sense of community and self-efficacy;
4. Building connectedness; and
5. Facilitating hope.
These are not, the astute community leader will quickly note, typical clinical objectives to be carried out by counselors through psychological intervention. They involve instead the sorts of factors that flow from the actions taken by those who represent a community’s formal and informal leadership.
Rather than importing counselors by the drove to communities experiencing disasters or exhorting anyone connected to the event to gather for quasi-therapeutic intervention groups, psychologists can do our best work by quietly helping to advise those whose duties place them closest to the consequences of disasters. Over the next several installments, I’ll review what current evidence tells us about these matters and explore the latest in evidence-informed best practices to support community recovery.
Gist, R., & Devilly, G. J. (2002). Post-trauma debriefing: The road too often traveled? The Lancet, 360, 741-742.
Gist, R., & Lubin, B. (Eds.). (1989). Psychosocial aspects of disaster. New York: John Wiley & Sons.
Gist, R., & Stolz, S. B. (1982). Mental health promotion and the media: Community response to the Kansas City hotel disaster. American Psychologist, 37, 1136-1139.
Hobfoll, S. E., Watson, P. J., Bell, C. C., et al. (2008). Five essential elements of immediate and mid-term mass trauma intervention: empirical evidence. Psychiatry, 70, 283-316.
Kadet A. (2002, June). Good grief! Smart Money, 11(6), 108–114.
McNally, R. J., Bryant, R. A., & Ehlers, A. (2003). Does early psychological intervention promote recovery from posttraumatic stress? Psychological Science in the Public Interest, 4(2).