Mass Disasters, Trauma, and Loss

Disasters occur commonly, and affect individuals as well as their communities. They may be human-made, caused by deliberate intention, as with terrorism, civil unrest, and war experiences, or caused by people through mishap or neglect, such as a work accident or an apartment fire. In addition disasters may be caused by nature, including earthquakes, floods, wildfires, hurricanes, or tornadoes.

Often large numbers of people are affected and they share their experience of trauma and traumatic loss. Many losses may occur after a disaster, including loss of loved ones, coworkers, neighbors, and pets, and loss of homes, workplaces, schools, houses of worship, possessions, and communities. Survivors may also lose their routine way of living and working, going to school, and being with others. Some may lose their confidence in the future.

Some disasters, such as terrorism, continue over a long period. These may create an on-going insecurity and exposure to danger or threat of danger, which may make it more difficult for some people to function in their lives.

After a disaster, it is normal to experience a number of stress reactions that may continue for a significant period. And after the sudden, traumatic loss caused by disasters, it is normal for grieving and mourning to be uneven, more intensely felt, and extended over time. In all disasters, the experience of safety, security, and predictability in the world is challenged, and a sense of uncertainty becomes a part of life.

What can I expect after experiencing a disaster? 
Most child, adolescent, adult, and older adult survivors experience some of the following normal stress responses to varying degrees. They may last for many months after the disaster has ended, and even longer. Normal stress reactions include:

  • Emotional (feeling) reactions: feelings of shock, disbelief, anxiety, fear, grief, anger, resentment, guilt, shame, helplessness, hopelessness, betrayal, depression, emotional numbness (difficulty having feelings, including those of love and intimacy, or taking interest and pleasure in day-to-day activities)
  • Cognitive (thinking) reactions: confusion, disorientation, indecisiveness, worry, shortened attention span, difficulty concentrating, memory loss, unwanted memories, repeated imagery, self-blame
  • Physical (bodily) reactions: tension, fatigue, edginess, difficulty sleeping, nightmares, being startled easily, racing heartbeat, nausea, aches and pains, worsening health conditions, change in appetite, change in sex drive
  • Interpersonal reactions: neediness; dependency; distrust; irritability; conflict; withdrawal; isolation; feeling rejected or abandoned; being distant, judgmental, or over-controlling in friendships marriages, family, or other relationships.
  • Spiritual (meaning) reactions: wondering why, why me, where was God; feeling as if life is not worth living, loss of hope.

What factors increase the risk of lasting vulnerability? 
During or after massive disasters, many survivors may be directly exposed to or witness things that may make them particularly vulnerable to serious stress reactions.

Disaster stress may revive memories or experiences of earlier trauma, as well as possibly intensifying pre-existing social, economic, spiritual, psychological, or medical problems. While trauma reactions can become lasting problems, the shared experience of disasters and people’s resiliency can provide support. Being aware of risk factors is important. They include:

  • Loss of family, neighborhood, or community
  • Life-threatening danger or physical harm (especially to children)
  • Exposure to horrible death, bodily injury, or bodies
  • Extreme environmental or human violence or destruction
  • Loss of home or valued possessions
  • Loss of communication with or support from important people in one’s life
  • Intense emotional demands
  • Extreme fatigue, weather exposure, hunger, or sleep deprivation
  • Extended exposure to danger, loss, emotional/physical strain
  • Exposure to toxic contamination (such as gas, fumes, chemicals, radioactivity, or biological agents)

Studies show that some individuals are more vulnerable to serious stress reactions and lasting difficulty, including those whose histories include:

  • Other traumatic experiences (such as severe accidents, abuse, assault, combat, immigrant and refugee experiences, rescue work)
  • Chronic medical illness or psychological problems
  • Chronic poverty, homelessness, unemployment, or discrimination
  • Recent or earlier major life stressors or emotional strain (such as divorce or job loss).

What can survivors do to reduce vulnerability to serious emotional reactions and to achieve the best recovery from disaster stress? Observations by mental health specialists who assist survivors in the wake of disaster suggest that the following steps help to reduce stress symptoms and to promote post-disaster readjustment:

  • Protect: find a safe haven that provides shelter, food and water, sanitation, privacy, and opportunities to sit quietly, relax, and sleep, at least briefly
  • Direct: begin working on immediate personal and family priorities to help you and your loved ones preserve or regain a sense of hope, purpose, and self-esteem
  • Connect: maintain or re-establish communication with family, peers, and counselors in order to talk about the experiences. Survivors may want to find opportunities to “tell their stories” to others who express interest and concern and, when they are able, to listen to others as they tell theirs, in order to release the stress a little bit at a time and try to create meaning
  • Select: identify key resources such as Federal Emergency Management Agency (FEMA), the Red Cross, the Salvation Army, local and state health departments for clean-up, health, housing, and basic emergency assistance. Identify local cultural or community supports to help maintain or reestablish normal activities such as attending religious services.

Taking every day one at a time is essential in disaster’s wake. Each day is a new opportunity to take steps toward recovery. People affected by disasters should try to:

  • Focus on what’s most important to themselves and their families today;
  • Try to learn and understand what they and their loved ones are experiencing, to help remember what’s important
  • Understand personally what these experiences mean as a part of their lives, so that they will feel able to go on with their lives and even grow personally
  • Take good care of themselves physically, including exercising regularly, eating well, and getting enough sleep, to reduce stress and prevent physical illness
  • Work together with others in their communities to improve conditions, reach out to persons who are marginalized or isolated, and otherwise promote recovery.

How would I decide I need professional help?
Most disaster survivors experience many normal responses and for some, their personal resources and capacities may grow and their relationships may strengthen. However, many survivors experience reactions during and after disasters that concern them, often when the disaster was caused by human action or included horror or loss of life. Some problematic responses are as follows:

  • Intrusive re-experiencing (terrifying memories, nightmares, or flashbacks)
  • Unsafe attempts to avoid disturbing memories (such as through substance use or alcohol)
  • On-going emotional numbing (unable to feel emotion, as if empty)
  • Extended hyperarousal (panic attacks, rage, extreme irritability, intense agitation, exaggerated startle response)
  • Severe anxiety (paralyzing worry, extreme helplessness)
  • Severe depression (loss of energy, interest, self-worth, or motivation)
  • Loss of meaning and hope
  • Sustained anger or rage
  • Dissociation (feeling unreal or outside oneself, as in a dream; having “blank” periods of time one cannot remember)

If after the end of a disaster, these normal experiences do not slowly improve, if they worsen with time, or if they cause difficulties in relationships or work, it is helpful to find professional support. People who wish to consider therapy should select a trained mental health professional who is knowledgeable about trauma as well as natural- and human-caused disasters. A family doctor, clergy person, local mental health association, state psychiatric, psychological, or social work association, or health insurer may be helpful in providing a referral to a counselor or therapist.

Children and Trauma

What are traumatic life experiences?
Traumatic life experiences challenge a person’s normal coping efforts. For children and adolescents, traumatic experiences include such things as sexual and other physical abuse and neglect, peer or family suicide, dog bites, severe burns, natural disasters (e.g. floods, tornadoes, hurricanes, etc.), fires, and medical procedures.

It can be traumatic for children to witness or experience violent crimes (e.g., kidnapping, sniper fire, and school shootings) or vehicle accidents such as automobile and plane crashes. Witnessing assault, rape, or murder of a parent can also be traumatic for children.

Traumatic life events are fairly common in childhood. Research suggests that 14 to 43% of children have experienced at least one traumatic event in their lifetime.

What is the range of responses?
There is a wide range of responses to catastrophic events. Some children and teenagers experience temporary worries and fears that get better quickly.

Others experience long-term problems such as fear, depression, withdrawal, anger, haunting memories, avoiding reminders of the event, regressive behavior (acting younger than their actual age), worrying about themselves and others dying or being hurt, and irritability. Reactions can occur immediately after the event or weeks later.

Children who have had traumatic experiences may have difficulty sleeping or have nightmares. They may avoid activities, situations, thoughts, or conversations that may be related to the traumatic events, even if other people don’t perceive them as related (e.g., a child who was eating corn flakes on the morning of a terrible event may not want to eat corn flakes).

They may play in ways that repeat something from their traumatic experiences (e.g., twirling or hiding under things after exposure to a tornado). They may recreate aspects of the traumatic experience in their behavior (e.g., a child who was exposed to a fire may set fires).

They may not want to be with people as much as before. They may avoid school, have trouble with schoolwork, or feel unable to pay attention. They may not want to play as much, avoid certain kinds of play, or lose interest in things they once enjoyed.

They may be sad or seem to have less emotion or feel guilty about things they did or did not do related to the traumatic experience.

Young children (age 5 and younger) may experience new fears such as separation anxiety or fear of strangers or animals. They may act younger or lose a skill they have already mastered (such as toilet training).

Elementary school-aged children (6 to 11) may get parts of the traumatic experience confused or out of order when recalling the memory. They may complain of body symptoms that have no medical cause (e.g., stomach aches). They may stare into space or seem “spacey,” or startle easily.

Adolescents (12 to 18) may experience visual, auditory, or bodily flashbacks of the events, have unwanted distressing thoughts or images of the events, demonstrate impulsive and aggressive behaviors, or use alcohol or drugs to try to feel better. They may feel depressed or have suicidal thoughts.

What are the risk factors for long-term problems?
Children are at greater risk for developing problems if the traumatic event was very severe (death, injury, bloody scenes), if the child’s parents are extremely distressed in the aftermath of the traumatic event, or if the child was directly exposed to the event (versus hearing about it later).

In addition, risk increases if the event is an interpersonal trauma (caused by another person) such as rape and assault or if the child or adolescent has been exposed to numerous stressful life events previously or has a pre-existing mental health problem.

None of these risk factors means that the child will definitely have problems, but the risk factors increase the probability a child or teenager might develop problems after an extremely stressful event.

What can adults do to help?

  • Let the child know it’s normal to feel upset when something bad or scary happens
  • Encourage the child to express feelings and thoughts, without making judgments
  • Protect the child or adolescent from further exposure to traumatic events, as much as possible
  • Return to normal routines as much as possible
  • School can be a major healing environment as the child’s most important routine. Educate school personnel about the child’s needs. Reassure the child that it was not his or her fault, that adults will try to take care of him or her, etc.
  • Allow the child to feel sad or cry
  • Give the child a sense of control and choice by offering reasonable options about daily activities (choosing meals, clothes, etc.)
  • If the child regresses (or starts to do things he or she did when younger), adults can help by being supportive, remembering that it is a common response to trauma, and not criticizing the behavior

Adults can be most helpful if they take care of themselves and get help for their own distress, since children and adolescents may respond to adults’ feelings and reactions.

Most children and adolescents will recover within a few weeks with such support. However some children may require more help.

Responsible adults who are concerned about their child’s reaction to a very stressful event may want to consider seeking the help of a mental health professional who is trained in helping children with traumatic responses or post-traumatic stress disorder.

Therapies can be individual, group or family sessions that include talking, drawing and writing about the event. In some cases medication can be helpful.

A family doctor, clergy person, local mental health association, state psychiatric, psychological, or social work association, or health insurer may be helpful in providing a referral to a counselor or therapist with experience in treating children affected by traumatic stress.

When a Friend or Loved One Has Been Traumatized

Traumatic events are quite common. War, combat, civil unrest, disasters, and terrorism are some of these. Sexual assault, child abuse, and other domestic violence are other overwhelming situations. Most individuals experience several traumatic experiences and traumatic losses across their lifetime. These events not only affect individuals, but also their families, friends, coworkers, and neighbors. It is important for those who have experienced such events to have the support of their friends, family, neighbors, and others. It is also important that these supporters can understand their loved ones’ reactions as well as their own, so they can help them through the difficult times that accompany and follow traumatic events, and also take care of themselves.

Natural responses to traumatic events
It is natural for most people who experience traumatic events to have a variety of reactions. Among many responses this includes intrusive re-experiencing of memories, nightmares, or flashbacks; emotional numbing and avoidance of these memories; and hyperarousal and anxiety; and dissociation, or feeling of profound disconnection. These normal reactions can occur for a significant period of time and then begin to diminish. However, some may also experience significant distress and trauma reactions that don’t readily seem to lessen with time.

Some may be very upset, angry, or cry. Others may seem calm and composed or even numb, cold, and detached. They may want to talk about their traumatic experience or may wish to remain quiet. Some may want physical contact while others may not. They may have any number of emotions including feelings of fear, anger, guilt, sadness, and confusion.

In the immediate aftermath of traumatic events, it may be somewhat easier to see a person’s reactions to trauma. As time goes by, while the survivor may still be quite affected, it may be difficult to observe reactions and also not as easy to provide support. Some individuals who have endured traumatic situations, despite how they are feeling, may believe it is necessary to assure others that they are fine. They may not want to “bother” others with their continuing problems or may want to get “back to normal.” Some will use alcohol, drugs, promiscuity, overeating, or overworking to numb their feelings. Survivors may experience nightmares, insomnia or excessive sleeping, changes in eating, physical aches and pains, difficulty concentrating, and loss of interest in activities and in others. They may have frequent, disturbing memories of traumatic events. It is common for people to experience mood swings during this time, and survivors may misdirect anger toward others or toward themselves. They may feel dependent upon or become overprotective of others. Problems with trust and intimacy can be common.

These reactions are typical for victims of traumatic life events. However, each individual may experience unique reactions or may alternate among these reactions.

Reactions of friends and family
When an individual learns that a friend or loved one has been traumatized, he or she may experience a range of emotions that are similar to the emotions of the loved one. Some of these include feelings of helplessness and confusion, anger, guilt, fear, and depression. People often want to help, but may not know what to do, feel helpless and confused in the face of the pain, and also may get conflicting messages from the survivor. Learning about a loved one’s trauma can remind an individual of his or her own traumas or may overwhelm them as they imagine it as if it had been their own experience.

Frustration and impatience may also exist. Taking care of oneself allows an individual to be available to a loved one. Being able to share these responses with other supporters can be helpful and less lonely.

What can friends do if someone they care for has been traumatized? 
Offer support and listen: Offer support by listening to survivors and letting them talk about their experiences at their own pace. Be there for the survivor. Often, friends and family of the survivor will feel a need to “problem solve” or offer advice. However, physical presence and support are usually more valuable. It is helpful not to comment on what the survivor should have done or to tell him or her what to do now.

Provide safety to communicate about the traumatic experiences: Friends can let the survivor know that they are there to listen and give support when the survivor is ready. Believe the survivor and validate his or her feelings and reactions. Rather than minimizing what the survivor has been through, be clear that the traumatic experience was not the survivor’s fault. It is helpful not to question or judge what he or she did to survive. Friends can reassure the survivor of their love and concern. Friends can also communicate their support through their behavior. Small gestures of kindness can be very meaningful to survivors.

Provide another focus: Take a break from talking about the traumatic experiences. Follow the survivor’s lead on when to talk about it and when to leave it behind. Allow time for mutual relaxation and pleasant and comforting activities.

Broaden the social support network: Friends can encourage survivors to get additional support. This support may come from other friends and family members, religious institutions, support groups, self-help resources, crisis counseling agencies, or trained mental health professionals. Friends and family may also want support and may seek individual, group, couple, or family counseling if they are troubled by their trauma reactions. These include their own thoughts or images of what happened to the survivor, anxiety, depression, fears, anger, addiction, or relationship problems.

Help to return control: Friends need to respect the time and space it takes to heal. This requires patience. By respecting the survivors’ wishes and allowing them to make decisions, friends help return control to them.

Education: Educate yourself about trauma and the healing process. Learn about common reactions to traumatic experiences and about resources by attending classes, viewing films, reading books, searching the internet, or talking to a counselor.

The appreciation of survivors: Survivors will appreciate the support of friends and family, although they may not always be able to express it. Such support may be especially helpful in letting survivors know they are not alone, and that eventually, when they can more closely relate to friends and loved ones, they will be there.

Finding support
A family doctor, clergy person, local mental health association, state psychiatric, psychological, or social work association, or health insurer may be helpful in providing a referral to a counselor or therapist with experience in treating people affected by traumatic stress and their loved ones.

Post-traumatic Stress, Violence & Disaster

Research indicates a link between experiencing events like this terrorist attack and later mental health problems for many — especially those who were injured, directly witnessed the death of others, or experienced the loss of family members and friends. Rescue workers and caretakers of the injured and bereaved also may experience significant mental distress. Because these attacks were deliberate, extremely violent, and involved huge numbers of casualties, those who suffer lasting psychological effects may number in the hundreds of thousands. Even those who only watched the events unfold on TV may experience strong psychological reactions.

People’s reactions to violent events with loss of life vary greatly and there are no correct or incorrect responses. All survivors, including witnesses to the events, even those who only watched it on TV, may experience fear, disbelief, and helplessness in the initial days after the event. Over time they may experience, among other things, feelings of horror, anxiety, depression, and even numbness (lack of feelings). People may keep reliving images of the events (i.e., have “flashbacks”), have difficulty concentrating, not feel close to loved ones, and experience physical health problems. In the current tragedy, feeling of anger, blame, and rage may be common, along with feelings of irritability or even anger and violence against loved ones. Some may try to “calm down” by using alcohol or other substances. Children, like adults, may have difficulty sleeping or nightmares, and may avoid reminders of the events. They also may act out aspects of the events in their play, or avoid school, play, or being around other people.

There are no easy answers to these manifestations of suffering, but it can make a difference when people can help themselves by spending time with supportive friends and family sharing feelings and comforting each other. Taking care of one’s self is also advised: getting enough sleep, eating well, exercising, and limiting use of alcohol, caffeine, and cigarettes. It may help to offer assistance to others as well. Children can be helped to understand that it is normal to be upset, to express any feelings and thoughts about the events, and to return to normal routines as soon as possible. While some people recover on their own, or with the mutual help of beloved ones, given sufficient time, not everyone does. For this reason, some people may need professional help for posttraumatic stress reactions, depression, anger, or other trauma-related mental health problems. Research has shown that 20% or more of people exposed to traumatic events typically develop clinically significant psychological problems. Many more will experience less severe effects. If significant distress continues for many months, becomes more, rather than less, severe over time, or interferes with one’s daily ability to function, professional help should be considered.