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.
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.
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.
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.
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.
All survivors should be given educational information to:
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).
The variety of appropriate follow-up activities may include education, screening, referral, and treatment.
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.
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.
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.
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.
Experience indicates that relatively few survivors of many types of trauma make use of available mental health services. This may be because survivors:
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.