PTSD: National Center for PTSD
Helping Survivors in the Wake of Disaster
Helping Survivors in the Wake of Disaster
The Impact of Disasters on Affected Individuals
Disaster survivors exhibit a wide variety of reactions and patterns of change over time. A significant proportion of those exposed to disasters will experience immediate intense reactions, which decline over time (e.g., 1-4). The proportion of survivors who develop chronic long term problems is generally less than 10%, and rarely exceeds 30% (5-7). For instance, in one review of the literature (8):
- 50% of the disaster studies indicated moderate effects in their cohorts, (increased or prolonged stress but little enduring psychopathology).
- 24% of studies showed severe effects.
- 17% of studies indicated very severe effects (25% - 50% + prevalence of clinically significant distress or psychological disorder).
- Reactions were most likely to be apparent in the year following the disaster, with 70% of the samples showing improvement past that time.
The majority of disaster survivors will not typically require the attention of mental health professionals. While there have been few longitudinal studies, in one multi-site trial following survivors of both natural disasters and a terrorist attack over time (1): Approximately 10% had few symptoms of distress both immediately following the disaster, and for months afterwards.
- Approximately two-thirds had initial mental health problems or psychological distress, but showed resilience or recovery in the following months.
- Approximately one-fourth showed chronic dysfunction.
What are some common, expectable stress reactions following disasters?
Most individuals involved in disasters experience stress reactions. These reactions may last for several days or even a few weeks or months, and may include:
- Emotional reactions: shock; fear; anxiety grief; anger; guilt; shame; feeling helpless or hopeless; feeling numb; feeling empty; diminished ability to feel interest, pleasure, or love, perceived stress, demoralization
- Cognitive reactions: confusion, disorientation, indecisiveness, worry, shortened attention span, difficulty concentrating, memory loss, unwanted memories, self-blame
- Physical reactions: tension, fatigue, edginess, insomnia, bodily aches or pain, startling easily, racing heartbeat, nausea, change in appetite, change in sex drive, physical health problems and/or somatic concerns, poor sleep quality, increased activation of the autonomic nervous system and hypothalamic-pituitary-adrenal (HPA) axis
- Interpersonal reactions: distrust, conflict, withdrawal, work problems, school problems, irritability, loss of intimacy, being over-controlling, feeling rejected or abandoned
What are more severe reactions to a disaster?
Prolonged distress and impairment in functioning lasting more than a few months are the hallmarks of potential need for more behavioral health interventions (8). Of those individuals exhibiting more severe reactions following disasters, the effects most commonly observed are:
- Acute stress disorder
- Posttraumatic stress disorder (with intrusion and arousal symptoms more often prevalent and avoidance symptoms less common)
- Severe anxiety (debilitating worry, extreme helplessness, compulsions, or obsessions)
- Severe depression (loss of the ability to feel hope, pleasure, or interest; feeling worthless)
- Increases in the use of alcohol or drugs
- Physiological indicators of stress such as physical pain
- Complicated grief, which presents as a combination of grief and PTSD symptoms, causing greater psychological distress and for a longer period of time than when death is due to natural causes
What do we know about risk factors?
Many factors influence the impact of a disaster on affected individuals. While methodological challenges in disaster research make it difficult to definitively assign weights to these factors, the risk factors that have consistently and most strongly influenced the likelihood of serious or lasting psychological problems following disasters and mass violence are (8-12):
- Severity of exposure to the event (especially injury, threat to life, and extreme loss)
- Post-event stresses and adversities
For instance, in one review of literature, in the first year after a disaster, prevalence of PTSD depended on exposure to the disaster (13):
- Between 5% and 10% in the general population
- Between 10% and 20% among rescue workers
- Between 30% and 40% among direct victims
Other risk factors that have emerged from empirical literature include (e.g., 5,8,14-17):
- Female gender
- Ethnic minority group membership
- Age in the middle years of 40 to 60 or over sixty five (if sick, economically disadvantaged, or frail)
- Poverty or low socioeconomic status
- Presence of children in the home
- Little previous experience in coping with disasters
- Psychiatric history
- In children, reactions of parents, separation from primary caregiver, and exposure to media
A number of post-event risk factors hold particular relevance for intervention, such as: Absence of social support (e.g., 18,19).
- Higher levels of life stress and ongoing adversity (19,20)
- Lack of or loss of both practical and social resources (21-24)
- Negative coping strategies, such as self-blame (25)
- Negative appraisals, including appraisals about the event, personal role in the event, reactions, and potential future risk (12,25,26)
What do we know about resilience factors?
A number of unique predictors of a resilience following disasters have emerged, including (5,22,27,28):
- Social and emotional resources
- Personality traits such as low negative affectivity and capacity for positive emotions
- Optimistic attributional style
- Perceived coping self-efficacy
- Range of demographic and biological factors such as male gender, older age, and greater education
How do risk and resilience factors inform disaster response?
From the literature on risk and resilience factors, we know that:
- Many individuals will have recurring stress reactions that fluctuate in severity, even years later.
- Acute distress reactions should not necessarily be regarded as pathological responses or even as precursors of subsequent disorder.
- Most individuals are likely to need social support and provision of resources, rather than clinical treatment.
- Some individuals, especially those with the highest exposure to traumatic and loss stressors, may require more intensive intervention.
What are best practices for assisting disaster survivors?
Interventions should address not only risk factors and acute distress reactions, but also foster provision of resources and other protective factors. Searching for a single solution to fostering resilient recovery might not be responsive to the way risk and resilient patterns vary across situations and timelines (29). Additionally, because resilient individuals appear capable of coping effectively on their own, it has been suggested that global interventions for everyone might undermine some individual's natural coping abilities (30).
A multifaceted approach is recommended, with a number of different interventions that are sensitive to the cultural and event context, as well as to differential exposure levels and unique reactions of affected individuals. Experts have recommended that five empirically-supported intervention principles be used in situations of both disaster and ongoing mass violence. These principles are: (a) promoting a sense of safety, (b) promoting calming, (c) promoting a sense of self- and community-efficacy, (d) promoting connectedness, and (e) instilling hope (22).
A number of studies and reviews have concluded that psychological debriefing cannot be endorsed, particularly for use with disaster survivors (31-35). Interventions for those in distress in the early aftermath, such as Psychological First Aid (PFA), should focus on reducing ongoing adversity, promoting safety, attending to practical needs, enhancing coping, stabilizing survivors, and connecting survivors with additional resources, to help mitigate the consequences of traumatic events. PFA models aim to reduce distress, foster short- and long-term adaptive functioning, and link distressed or at-risk survivors with additional services. PFA is designed to be tailored to the specific needs of each disaster survivor (22,36).
While some individuals will require more intensive interventions, and some level of screening for predictors of continued distress is recommended, besides symptom severity at 1-2 weeks post-trauma, there is no algorithm to predict persisting distress (32). Trying to create a simple conceptual framework of risk factors might obscure the important nuances and complexities of a disaster's consequences (37).
Outreach to other service providers and systems (including spiritual leaders, school personnel, first responders, public health and health professionals, employee assistance programs, and volunteers) is recommended to support the integration of mental health principles into all phases of disaster management and response and to counter the many barriers to care that may present themselves after disasters (i.e.,33,38-40).
Early clinical intervention should be offered, as it yields success in those who complete treatment, and results in markedly greater overall population impact (41-44). However, the decision to implement early versus intermediate clinical intervention should be determined not by the length of time after an event, but rather by the extent to which a sense of threat persists for survivors, and the extent to which survivors have sufficient resources to engage in the intervention (36). Additionally, monitoring and follow up of those offered early intervention may be necessary, as longitudinal follow up of individuals offered early interventions has shown that they may still suffer from PTSD and other symptoms years later (45).
Cognitive behavioral interventions delivered to disaster survivors and first responders have yielded significantly greater reductions in PTSD, depression, and anxiety compared to control conditions. There has been acknowledgement that CBT requires resources and motivation on the part of survivors, and may not be appropriate for all survivors at all times. (e.g., 46-50). Because of this, more flexible CBT models exist tailored to the post-disaster setting and have yielded positive results (e.g., CBT-PD, 51; STAIR/MPE, 52; the Screen and Treat Approach, 18,53; a brief CBT disaster intervention, 54; Problem Management Plus, 55; Skills for Psychological Recovery (SPR), 56; an internet-based screening and education intervention, 57).
- Norris, F. H., Tracy, M., & Galea, S. (2009). Looking for resilience: Understanding the longitudinal trajectories of responses to stress. Social Science and Medicine, 68, 2190-2198. doi:10.1016/j.socscimed.2009.03.043
- Bonanno, G. A., Ho, S. M. Y., Chan, J. C. K, Kwong, R. S. Y., Cheung, C. K. Y., Wong, C. P. Y., & Wong, V. C. W. (2008). Psychological resilience and dysfunction among hospitalized survivors of the SARS epidemic in Hong Kong: A latent class approach. Health Psychology, 27, 659-667. doi:10.1037/0278-6184.108.40.2069
- Bonanno, G. A. (2004). Loss, trauma, and human resilience: Have we underestimated the human capacity to thrive after extremely aversive events? American Psychologist, 59, 20-28. doi:10.1037/0003-066X.59.1.20
- Galea, S., Vlahov, D., Resnick, H., Ahern, J., Susser, E., Gold, J., Bucuvalas, M., & Kilpatrick, D. (2003). Trends of probable post-traumatic stress disorder in New York City after the September 11 Terrorist Attacks. American Journal of Epidemiology, 158, 514-524. doi:10.1093/aje/kwg187
- Bonanno, G. A., Brewin, C. R., Kaniasty, K., & La Greca, A. M, (2010). Weighing the costs of disaster: Consequences, risks, and resilience in individuals, families, and communities. Psychological Science in the Public Interest, 11, 1-49. doi:10.1177/1529100610387086
- DiGrande, L., Neria, Y., Brackbill, R. M., Pulliam, P., & Galea, S. (2011). Long-term posttraumatic stress symptoms among 3,271 civilian survivors of the September 11, 2001, terrorist attacks on the World Trade Center. American Journal of Epidemiology, 173, 271-281. doi:10.1093/aje/kwq372
- Bonanno, G. A., Galea, S., Bucciarelli, A., & Vlahov, D. (2007). What predicts psychological resilience after disasters? The role of demographics, resources, and life stress. Journal of Consulting and Clinical Psychology, 75, 671-682. doi:10.1037/0022-006X.75.5.671
- Norris, F. H. (2005). Range, magnitude, and duration of the effects of disasters on mental health: Review update 2005. Research education disaster mental health, 1-23.
- Neria, Y., Gross, R., Marshall, R. D, & Susser, E. D. (2006). 9/11: Mental health in the wake of terrorist attacks. Cambridge: Cambridge University Press.
- Norris, F. H., Friedman, M. J., Watson, P. J., Byrne, C. M., Diaz, E., & Kaniasty, K. (2002). 60,000 disaster victims speak: Part I. An empirical review of the empirical literature, 1981-2001. Psychiatry: Interpersonal and Biological Processes, 65, 207-239. doi:10.1521/psyc.220.127.116.1173
- Palinkas, L. (2012). A conceptual framework for understanding the mental health impacts of oil spills: Lessons from the Exxon Valdez oil spill. Psychiatry, 75, 203-222. doi:10.1521/psyc.2012.75.3.203
- Goldmann, E., & Galea, S. (2014). Mental health consequences of disasters. Annual Review of Public Health, 35, 169-183. doi:10.1146/annurev-publhealth-032013-182435
- Neria, Y., Gross, R., Litz, B., Maguen, S., Insel, B., Seirmarco, G., Rosenfeld, H., Suh, E. J., Kishon, R., Cook, J., & Marshall, R. D. (2007). Prevalence and psychological correlates of complicated grief among bereaved adults 2.5-3.5 years after September 11th attacks. Journal of Traumatic Stress, 20, 251-262. doi:10.1002/jts.20223
- Pietrzak, R. H., Van Ness, P. H., Fried, T. R., Galea, S, & Norris, F. H. (2013). Trajectories of posttraumatic stress symptomatology in older persons affected by a large-magnitude disaster. Journal of Psychiatric Research, 47, 520-526. doi:10.1016/j.jpsychires.2012.12.005
- Brymer, M. J., Steinberg, A. M., Watson, P. J., & Pynoos, R. S. (2012). Prevention and early intervention programs for children and adolescents. In J. G. Beck, & D. Sloan. (Eds.), The Oxford handbook of traumatic stress disorders. (pp. 381-392). New York: Oxford University Press.
- Goenjian, A. K., Walling, D., Steinberg, A. M., Karayan, I., Najarian, L. M., & Pynoos, R. S. (2005). A prospective study of posttraumatic stress and depressive reactions among treated and untreated adolescents 5 years after a catastrophic disaster. The American Journal of Psychiatry, 12, 2302-2308. doi:10.1176/appi.ajp.162.12.2302
- Pfefferbaum, B., Nixon, S. J., Tivis, R. D., Doughty, D. E., Pynoos, R. S. , Gurwitch, R., & Foy, D. W. (2001). Television exposure in children after a terrorist incident. Psychiatry: Interpersonal and Biological Processes, 64, 202-211. doi:10.1521/psyc.18.104.22.16862
- Brewin, C. R., Fuchkan, N., Huntley, Z., Robertson, M., Thompson, M., Scragg, P., d'Ardenne, P., & Ehlers, A. (2010). Outreach and screening following the 2005 London bombings: Usage and outcomes. Psychological Medicine, 40, 1-9. doi:10.1017/S0033291710000206
- Brewin, C., Andrews, B., & Valentine, J. (2000). Meta-analysis of risk factors for posttraumatic stress disorder in trauma exposed adults. Journal of Consulting and Clinical Psychology, 68, 748-766. doi:10.1037/0022-006X.68.5.748
- Neria, Y., Nandi, A., & Galea, S. (2008). Post-traumatic stress disorder following disasters: a systematic review. Psychological Medicine, 38, 467-480. doi:10.1017/S0033291707001353
- Hobfoll, S.E. (2012). Conservation of resources and disaster in cultural context: The caravans and passageways for resources. Psychiatry, 75, 227-232. doi:10.1521/psyc.2012.75.3.227
- Hobfoll, S. E., Watson, P. J., Bell, C. C., Bryant, R. A., Brymer, M. J., Friedman, M. J., Friedman, M., Gersons, B. P. R., de Jong, J. T. V. M., Layne, C. M., Maguen, S., Neria, Y., Norwood, A. E., Pynoos, R. S., Reissman, D., Ruzek, J. I., Shalev, A. Y., Solomon, Z., Steinberg, A. M., & Ursano, R. J. (2007). Five essential elements of immediate and mid-term mass trauma intervention: Empirical evidence. Psychiatry, 70, 283-315. doi:10.1521/psyc.2007.70.4.283
- Kaniasty, K. Z., & Norris, F. H. (2009). Distinctions that matter: Received social support, perceived social support, and social embeddedness after disasters. In Y. Neria, S. Galea, & F. Norris (Eds.), Mental health consequences of disasters. (pp. 175-202). NY: Cambridge University Press.
- Neria, Y., Olfson, M., Gameroff, M. J., DiGrande, L., Wickramaratne, P., Gross, R., Pilowsky, D. J., Neugebaur, R., Manetti-Cusa, J., Lewis-Fernandez, R., Lantigua, R., Shea, S., & Weissman, M. M. (2010). Long-term course of probable PTSD after the 9/11 attacks: A study in urban primary care. Journal of Traumatic Stress, 23, 474-482. doi:10.1002/jts.20544
- Ehlers, A., Clark, D. M., Hackmann, A., McManus, F., Fennell, M. J. V., Herbert, C., & Mayou, R. A. (2003). A randomized controlled trial of cognitive therapy, a self-help booklet, and repeated assessments as early interventions for posttraumatic stress disorder. Archives of General Psychiatry, 60, 1024-1032. doi:10.1001/archpsyc.60.10.1024
- Holman, E. A, & Silver R. C. (2005). Future-oriented thinking and adjustment in a nationwide longitudinal study following the September 11th terrorist attacks. Motivation and Emotion, 29, 389-410. doi:10.1007/s11031-006-9018-9
- Hobfoll, S. E., Stevens, N. R., & Zalta, A. K. (2015). Expanding the science of resilience conserving resources in the aid of adaptation. Psychological Inquiry, 26, 174-180. doi:10.1080/1047840X.2015.1002377
- Neria, Y., Galea, S., & Norris, F. H. (2009). Mental health and disasters. Cambridge: Cambridge University Press.
- Luthar, S. S., Cicchetti, D., & Becker, B. (2000). The construct of resilience: A critical evaluation and guidelines for future work. Child Development, 71, 543-562. doi:10.1111/1467-8624.00164
- Bonanno, G. A., Westphal, M., & Mancini, A. D. (2011). Resilience to loss and potential trauma. Annual Review of Clinical Psychology, 7, 511-535. doi:10.1146/annurev-clinpsy-032210-104526
- Gray, M. J., & Litz, B. T. (2005). Behavioral interventions for recent trauma: Empirically informed practice guidelines. Behavior Modification, 29, 189-215. doi:10.1177/0145445504270884
- 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, 45-79. doi: 10.1111/1529-1006.01421
- Rose, N., Hughes, P., Ali, Sh., & Jones, L. (2011). Integrating mental health into primary health care settings after an emergency: Lessons from Haiti. Intervention, 9, 211 - 224. doi:10.1097/WTF.0b013e32834e0061
- Van Emmerik, A. A., Kamphuis, J. H., Hulsbosch, A. M., & Emmelkamp, P. M. (2002). Single session debriefing after psychological trauma: a meta-analysis. The Lancet, 360, 766-771. doi: 10.1016/S0140-6736(02)09897-5
- Sijbrandij, M., Olff, M., Reitsma, J. B., Carlier, I. V., & Gersons, B. P. (2006). Emotional or educational debriefing after psychological trauma. The British Journal of Psychiatry, 189, 150-155. doi:10.1192/bjp.bp.105.021121
- Bryant, R. A., & Litz, B. T. (2009). Mental health treatments in the wake of disaster. In Y. Neria, S. Galea, & F. Norris (Eds.), Mental health consequences of disasters (pp. 321-335). New York: Cambridge University Press.
- Galea, S. (2012). Simplicity, complexity, and conceptual frameworks. Psychiatry, 75, 223-226. doi:10.1521/psyc.2012.75.3.223
- Jaycox, L. H., Cohen, J. A., Mannarino, A. P., Walker, D. W., Langley, A. K., Gegenheimer, K. L., Scott, M., & Schonlau, M. (2010). Children's mental health care following Hurricane Katrina: A field trial of trauma-focused psychotherapies. Journal of Traumatic Stress, 23, 223-231. doi:10.1002/jts.20518
- Laor, N., Wiener, Z., Spiriman, S., & Wolmer, L. (2005). Community mental health in emergencies and mass disasters: The Tel-Aviv model. Journal of Aggression, 10, 681-694. doi:10.1300/J146v10n03_02
- Boscarino, J. A., Adams, R. E., Foa, E. B., & Landrigan, P. J. (2006). A propensity score analysis of brief worksite crisis interventions after the World Trade Center disaster: Implications for intervention and research. Medical Care, 44, 454-462. doi:10.1097/01.mlr.0000207435.10138.36
- O'Donnell, M.L., Lau, W., Tipping, S., Holmes, A.C.N., Ellen, S., Judson, R., Varker, T., Elliot, P., Bryant, R. A., Creamer, M. C., & Forbes, D. (2012). Stepped early psychological intervention for posttraumatic stress disorder, other anxiety disorders, and depression following serious injury. Journal of Traumatic Stress, 25, 125-133. doi:10.1002/jts.21677
- Shalev, A. Y., Ankri, Y. L. E., Israeli-Shalev, Y., Peleg, T., Adessky, R. S., & Freedman, S. A. (2012). Prevention of posttraumatic stress disorder by early treatment: Results from the Jerusalem Trauma Outreach and Prevention Study. Archives of General Psychiatry, 69, 166-176. doi:10.1001/archgenpsychiatry.2011.127
- Zatzick, D. F., Rivara, F. P., Jurkovich, G. J., Russo, J. E., Trusz, S. G., Wang, J., Wagner, A., Stephens, K., Dunn, C., Uehara, E., Petrie, M., Engel, C., Davydow, D., & Katon, W. J. (2011). Enhancing the population impact of collaborative care interventions: Mixed method development and implementation of stepped care targeting posttraumatic stress disorder and related comorbidities after acute trauma. General Hospital Psychiatry, 33, 123-134. doi:10.1016/j.genhosppsych.2011.01.001
- Zatzick, D. F. (2012). Toward the estimation of population impact in early posttraumatic stress disorder intervention trials. Depression and Anxiety, 29, 79-84. doi: 10.1002/da.21912
- Shalev, A. Y., Ankri, Y., Gilad, M., Israeli-Shalev, Y., Adessky, R., Qian, M., & Freedman, S. (2016). Long-Term Outcome of Early Interventions to Prevent Posttraumatic Stress Disorder. The Journal of Clinical Psychiatry, Advance online publication. doi:10.4088/JCP.15m09932
- Basoglu, M., Salcioglu, E., & Livanou, M. (2009). Single-case experimental studies of a self-help manual for traumatic stress in earthquake survivors. Journal of Behavior Therapy and Experimental Psychiatry, 40, 50-58. doi:10.1016/j.jbtep.2008.04.001
- Difede, J., Cukor, J., Jayasinghe, N., Patt, I., Jedel, S., Spielman, L., Giosan, C., & Hoffman, H. G. (2007). Virtual realityexposure therapy for the treatment of posttraumatic stress disorder following September 11, 2001. Journal of Clinical Psychiatry, 68, 1639-1647. doi:10.4088/JCP.v68n1102
- Duffy, M., Gillespie, K., & Clark, D. M. (2007). Post-traumatic stress disorder in the context of terrorism and other civil conflict in Northern Ireland: Randomised controlled trial. British Medical Journal, 334, 1147-1150. doi:10.1136/bmj.39021.846852.BE
- Jarero, I., & Uribe, S. (2012). The EMDR protocol for recent critical incidents: Follow-up report of an application in a human massacre situation. Journal of EMDR Practice and Research, 6, 50-61. doi:10.1891/1933-322.214.171.124
- Jarero, I., Artigas, L., & Luber, M. (2011). The EMDR protocol for recent critical incidents: Application in a disaster mental health continuum of care context. Journal of EMDR Practice and Research, 5, 82-94. doi:10.1891/1933-3126.96.36.199
- Hamblen, J. L., Norris, F. H., Pietruszkiewicz, S., Gibson, L., Naturale, A., & Louis, C. (2009). Cognitive behavioral therapy for postdisaster distress: a community based treatment program for survivors of Hurricane Katrina. Administration and Policy in Mental Health and Mental Health Services Research Special Issue: Disaster Policy and Research, 36, 206-214. doi:10.1007/s10488-009-0213-3
- Levitt, J. T., Malta, L. S., Martin, A., Davis, L., & Cloitre, M. (2007). The flexible application of a manualized treatment for PTSD symptoms and functional impairment related to the 9/11 World Trade Center attack. Behaviour Research and Therapy, 45, 1419-1433. doi:10.1016/j.brat.2007.01.004
- Brewin, C.R., Scragg, P., Robertson, M., Thompson, M., D'Ardenne, P., & Ehlers, A. (2008). Promoting mental health following the London bombings: A screen and treat approach. Journal of Traumatic Stress, 21, 3-8. doi:10.1002/jts.20310
- Bryant, R. A., Ekassawin, S., Chakkraband, M. L. S., Suwanmitri, S., Duangchun, O., & Chantaluckwong, T. (2011). A randomized controlled effectiveness trial of cognitive behavior therapy for post-traumatic stress disorder in terrorist-affected people in Thailand. World Psychiatry, 10, 205-209. doi:10.1002/j.2051-5545.2011.tb00058.x
- Sijbrandij, M., Farooq, S., Bryant, R. A., Dawson, K., Hamdani, S. U., Chiumento, A., ... & van Ommeren, M. (2015). Problem Management Plus (PM+) for common mental disorders in a humanitarian setting in Pakistan; study protocol for a randomised controlled trial (RCT). BMC Psychiatry, 15, 232. doi:10.1186/s12888-015-0602-y
- Berkowitz, S., Bryant, R., Brymer, M., Hamblen, J., Jacobs, A., Layne, C., & Watson, P. (2010). Skills for psychological recovery: field operations guide. Washington (DC): National Center for PTSD (US Department of Veterans Affairs) and National Child Traumatic Stress Network (funded by US Department of Health and Human Services and jointly coordinated by University of California, Los Angeles, and Duke University). Available on: www.nctsn.org and www.ptsd.va.gov.
- Ruggiero, K. J., Resnick, H. S., Acierno, R., Carpenter, M. J., Kilparick, D. G., Coffey, S. F., Ruscio, A. M., Stephens, R. S., Stasiewicz, P. R., Roffman, R. A., Bucuvalas, M., & Galea, S. (2006). Internet-based intervention for mental health and substance use problems in disaster-affected populations: A pilot feasibility study. Behavior Therapy, 37, 190-205. doi:10.1016/j.beth.2005.12.001