Crisis Intervention and Disaster Mental Health Interventions.

Crisis Intervention

Adaptation and coping are a natural part of life. If children are protected from experiencing negative events and developing coping skills, they may be unable to cope and adapt to crisis situations in later life. Crisis occurs when there is a perceived challenge or threat that overwhelms the capacity of the individual to cope effectively with the event. A crisis disrupts the life of the individual experiencing the event.

In a crisis, the person’s habits and coping patterns are suspended. Often, unexpected emotional (e.g., depression) and biologic (e.g., nausea, vomiting, diarrhea, headaches) responses occur. Although a person may become extremely anxious, depressed, or elated, feeling states do not determine whether a person is in a crisis. If functioning is severely impaired, a crisis is occurring (Yeager & Roberts, 2003).

Crisis

A crisis is generally regarded as time limited, lasting no more than 4 to 6 weeks. At the end of that time, the person in crisis should have begun to come to grips with the event and to harness resources to cope with its long-term consequences. By definition, there is no such thing as a chronic crisis. People who live in constant turmoil are not in crisis but in chaos. A crisis can also represent a turning point in a person’s life, with either positive or negative outcomes. It can be an opportunity for growth and change because new ways of coping are learned.

Either internal or external demands that are perceived as threats to a person’s physical or emotional functioning can initiate a crisis. The precipitating event is not only stressful, but unusual or rare. Many life events can evoke a crisis, such as pandemics, natural disasters (e.g., floods, tornadoes, earthquakes) and manmade disasters (e.g., wars, bombings, airplane crashes) as well as traumatic experiences (e.g., rape, sexual abuse, assault). In addition, interpersonal events (divorce, marriage, birth of a child) may create a crisis event in the life of any person.

A crisis is not the same as a psychiatric emergency that requires immediate intervention. A person in crisis may not need an immediate intervention and should not be viewed as having a mental disorder (Roberts, 2005). However, if the person is significantly distressed or social functioning impaired, an Axis I diagnosis of acute stress disorder should be considered (American Psychiatric Association [APA], 2000). The person with an acute stress disorder has dissociative symptoms and persistently re-experiences the event (APA).

A. Historical Perspectives of Crisis

The basis of our understanding of the biopsychosocial implications of a crisis began in the 1940s when Eric Lindemann (l944) studied bereavement reactions among the friends and relatives of the victims of the Coconut Grove nightclub fire in Boston in 1942. That fire, in which 493 people died, was the worst single building fire in the country’s history at that time. Lindemann’s goal was to develop prevention approaches at the community level that would maintain good health and prevent emotional disorganization. He described both grief and prolonged reactions as a result of loss of a significant person. From those results, he hypothesized that during the course of one’s life, some situations, such as the birth of a child, marriage, and death, evoke adaptive mechanisms that lead either to mastery of a new situation (psychological growth) or impaired functioning.

In 1961, psychiatrist Gerald Caplan defined a crisis as occurring when a person faces a problem that cannot be solved by customary problem-solving methods. When the usual problem-solving methods no longer work, a person’s life balance or equilibrium is upset. During period of disequilibrium, there is a rise in inner tension and anxiety, followed by emotional upset and an inability to function. This conceptualization of phases of a crisis is used today. According to Caplan, during a crisis, a person is open to learning new ways of coping to survive. The outcome of a crisis is governed by the kind of interaction that occurs between the person and available key social support systems.

Gerald Caplan’s Four Phases of Crisis

Phase 1: A problem arises that contributes to increase in anxiety levels. The anxiety stimulates the implementation of usual problem-solving techniques of the person.

Phase 2: The usual problem-solving techniques are ineffective. Anxiety levels continue to rise. Trial-and-error attempts are made to restore balance.

Phase 3: The trial-and-error attempts fail. The anxiety escalates to severe or panic levels. The person adopts automatic relief behaviors.

Phase 4: When these measures do not reduce anxiety, anxiety can overwhelm the person and lead to serious personality disorganization, which signals the person is in crisis.

B.Types of Crises

Recent research has focused on categorizing types of crisis events, understanding biopsychosocial responses to crisis, and developing intervention models that support people through crisis (Stone & Conley, 2004).

Maturational Crisis – While Lindemann and Caplan were creating their crisis model, Erik Erikson was formulating his ideas about crisis and development. He proposed that maturational crises are a normal part of growth and development, and that successfully resolving a crisis at one stage allows the child to move to the next. According to this model, the child develops positive characteristics after experiencing a crisis. If he or she develops less desirable traits, the crisis is not resolved. This concept of maturational crisis assumes that psychosocial development progresses by an easily identifiable, orderly process.

The concept of developmental crisis continues to be used today to describe unfavorable person-environment relationships that relate to maturational events, such as leaving home for the first time, completing school, or accepting the responsibility of adulthood. The accomplishment of developmental tasks throughout the life cycle will impact the interpretation of crisis events during the transition of an individual from one stage of life to another.

Situational Crisis – A situational crisis occurs whenever a specific stressful event threatens a person’s biopsychosocial integrity and results in some degree of psychological disequilibrium. The event can be an internal one, such as a disease process or any number of external threats. A move to another city, a job promotion, or graduation from high school can initiate a crisis even though they are positive events. For example, graduation from high school marks the end of an established routine of going to school, participating in school activities, and doing homework assignments. When starting a new job after graduation, the former student must learn an entirely different routine and acquire new knowledge and skills. If a person enters a new situation without adequate coping skills, a crisis may develop, resulting in dissonance (inconsistency between attitude and behavior).

Situational Crises

Death of spouse

Divorce

Marital Separation from mate

Detention in jail or other institution

Death of a close family member

Major personal injury or illness

COVID-19

Marriage

Being fired at work

Marital reconciliation with mate

Retirement from work

Major change health/behavior of a family member

Pregnancy/Abortion

Adventitious Crisis – An adventitious crisis is initiated by unexpected unusual events that can affect an individual or a multitude of people. In such situations, people face overwhelmingly hazardous events that may entail injury, trauma, destruction, or sacrifice. Such an event involves a physically aggressive and forced act by a person, a group, or an environment. National disasters (e.g., racial persecutions, kidnappings, riots, war); violent crimes (e.g., rape, murder, and assault and battery); and natural disasters (e.g., earthquakes, floods, forest fires, hurricanes) are examples of events that precipitate this type of crisis (Hazelwood & Burgess, 2001). 9/11 is an example of an adventitious crisis.

C. Advanced Practice Psychiatric/Mental Health Nursing Management of Crisis

The goal for people experiencing a crisis is to return to the pre-crisis level of functioning. The role of the PMH-APRN is to provide a framework of support systems that guide the client through the crisis and facilitate the development and use of positive coping skills. The PMH-APRN must be acutely aware that a person in crisis may be at high risk for suicide or homicide. To determine the level of effectiveness of coping capabilities of the person, the PMH-APRN should complete a careful assessment for suicidal or homicidal risk. If a person is at high risk for either, the PMH-APRN should consider the possible need for the person to be referred for admission to the hospital. When assessing the coping mechanisms and ability of the client to use those mechanisms for adaptation, the PMH-APRN should assess for unusual behaviors and determine the level of involvement of the person with the crisis. In addition, assess for evidence of self-mutilation activities that may indicate the use of self-preservation measures to avoid suicide. It is critical to assess the client’s perception of the problem and the availability of support mechanisms (emotional and financial) for use by the person (Litz, Gray, Bryant, & Adler, 2002).

During an adventitious crisis (e.g., flood, hurricane, forest fire) that affects the well-being of many people, the interventions of the PMH-APRNwill be a part of the community’s efforts to respond to the event. On the other hand, when a personal crisis occurs, the person in crisis may have only the PMH-APRN to respond to his or her needs. After the assessment, the PMH-APRN must decide whether to provide the care needed or to refer the person to a psychiatrist.

Biologic Domain/Assessment – Biologic assessment focuses on areas that usually undergo initial changes. Eliciting information about changes in health practices provide important data that the PMH-APRN can use to determine the severity of the disruption in functioning. Biologic functioning is important because a crisis can be physically exhausting. Disturbances in sleep and eating patterns and the reappearance of physical or psychiatric symptoms are common. Changes in body function may include tachycardia, tachypnea, profuse perspiration, nausea, vomiting, dilated pupils, and extreme shakiness. Some victims may exhibit loss of control and have total disregard for their personal safety. The victims are at high risk for injury, which may include infection, trauma, and head injuries (France, 2002). If the victim’s sleep patterns are disturbed or nutrition is inadequate, the victim will not have the physical resources to deal with the crisis.

Any negative physiological responses should be treated immediately. Triage the victims according to the level of care needed. If the crisis involves a life-threatening physical injury, those types of injuries should be treated immediately. Throughout the triage process, the victims should be reassured that the caregiver is concerned and committed to providing quality nursing care. Be careful not to give unrealistic or false reassurances of positive outcomes over which you have no control. Make referrals as appropriate. Ideally, a PMH-APRN would be an integral part of the triage team. Pharmacologic interventions may be needed to help maintain a high level of psychophysical functioning. While medication cannot resolve a crisis, the judicious use of psychopharmacologic agents can help reduce its emotional intensity.

Psychological Domain/Assessment – Psychological assessment focuses on the victim’s emotions and coping strengths. In the beginning of the crisis, the victim may report the feeling of numbness and shock. Responses to psychological distress should be differentiated from symptoms of psychiatric illnesses of the victim. Later, as the reality of the crisis sinks in, the victim will be able to recognize and describe the felt emotions. The PMH-APRN should expect those emotions to be intense and will need to provide some support during their expression by that victim. At the beginning of a crisis, assess the victim for behaviors that indicate a depressed state, the presence of confusion, uncontrolled weeping or screaming, disorientation, or aggression. The victim may be suffering from loss of feelings of well-being and safety. In addition, panic responses, anxiety, and fear may be present (Hall, Norwood, Ursano, & Fullerton, 2003). The ability to cope by problem-solving may be disrupted. By assessing the victim’s ability to solve problems, the PMH-APRN can evaluate whether the victim can cognitively cope with the crisis situation and determine the kind and amount of support needed. The survivor of a disaster may experience traumatic bereavement because of feelings of guilt for survival of the crisis.

Safety interventions to protect the person in crisis from harm should include preventing the person from committing suicide or homicide, arranging for food and shelter (if needed), and mobilizing social support. Once the person’s safety needs are met, the PMH-APRN can address the psychosocial aspects of the crisis. Prepare the victims for recovery. Victims should be encouraged to report any depression, anxiety, or interpersonal difficulties during the recovery period. There may be a need for support groups to be established to help victims and their families deal with the psychological effects of the phenomenon (Dattilio & Freeman, 2007).

Counseling reinforces healthy coping behaviors and interaction patterns. Counseling focuses on identifying the victim’s emotions and positive coping strategies. Responses to crisis differ with individuals. Some victims may present with behaviors that indicate transient disruptions in their ability to cope. Others may be totally devastated (Bonanno, 2004). At times, telephone counseling may provide the victim with enough help that face-to-face counseling is not necessary. If counseling strategies do not work, other stress reduction and coping enhancement interventions can be used. For anyone who cannot cope with a crisis, the PMH-APRN should make referral to short-term psychiatric inpatient treatment.

Social Domain/Assessment – Assessment of the impact of the crisis on the victim’s social functioning is essential because a crisis usually severely disrupts social proficiencies. The PMH-APRN should assess the severity of the crisis to determine the capability of the individual or the community to respond in a supportive way. Assist the victims to maintain a calm demeanor, obtain and distribute information about the crisis and the victims of the crisis. Initiate attempts to reunite victims and their families. Shelter, food, and other resources may not be available. In a crisis, the first priority is to meet the basic human needs of the victims.

The nursing interventions for the social domain include the individual, the family, and the community. A crisis often disrupts a victim’s social network leading to changes in available social support. Development of a new social support network may help the victim cope more effectively with the crisis. Supporting the development of new support contacts within the context of available social networks can be done by contacting available local and state agencies for assistance as well as specific private support groups and religious groups.

Disaster Management

A disaster is a sudden ecological or man-made phenomenon that is of sufficient magnitude to require external help to address the psychosocial needs as well as the physical needs of the victims. Acts of terrorism present situations that mimic disasters; terrorism can be categorized as a type of disaster.

Although crises and disasters are usually viewed as survivors of disasters draw on resources that they never survivors of disasters draw on resources that they never realized they had and grow from those experiences (Walter & Berkovitz, 2005). However, the survivors of disasters may present with severe psychological problems that begin with expressed feelings of fear, anger, and distress that elevate to severe anxiety at the panic level with deterioration to more severe mental illnesses (Norris, Friedman, Watson, Byrne, Diaz, & Kaniasty, 2002). Unresolved crisis and/or disastrous events can lead to disorganized thinking and responses that are inappropriate and traumatic for the person experiencing the situation (Flynn & Norwood, 2004). In addition, the victims may experience the development of acute stress disorder (that has a strong emphasis on dissociative symptoms), and posttraumatic stress disorder (PTSD; Harvey & Pauwels, 2000).

A. Historical Perspectives of Disasters in the United States

Throughout history, disasters have been portrayed from a fatalistic perspective that humans have little control over catastrophic events. Some cultures contend that natural disasters are an act of God. Other cultures express their belief that natural disaster events can be attributed to gods dwelling within such places as volcanoes, with eruptions being an expression of the gods’ anger (van Griensven, et al., 2006). Although often caused by nature, disasters can have human origins. Wars and civil disturbances that destroy homelands and displace people are included among the causes of disasters. Other causes can be a building collapse, blizzard, drought, earthquake, epidemic, explosion, famine, fire, flood, hazardous material or transportation incident (such as a chemical spill), hurricane, nuclear incident, terrorist attack, tornado, or volcano eruptions. Often, it is the unpredictability of such disasters that causes fear, confusion, and stress that can have lasting effects on the health of affected communities and their sense of well-being.

In recent history, we have experienced several attacks of violence and terrorism that are unprecedented in North America. The bombing of the federal office building in Oklahoma City on April 19, 1995; the shooting massacre of Columbine High School students on April 20, 1999; the destruction of the World Trade Center in New York and the attack on the Pentagon in Washington, DC, on September 11, 2001; and later, the dispersal of anthrax spores in the United States mail shattered North Americans’ sense of safety and security (Miller, 2002; North et al., 2002).

Since September 11, 2001, the emergency response planning of federal, state, and local agencies has focused on possible terrorist attacks with chemical, biological, radiological, nuclear, or high-yield explosive weapons. Before September 11, government agencies and public health leaders had not incorporated mental health into their overall response plans to bioterrorism. In the aftermath of the mass destruction of human life and property in 2001, government and health care leaders have recognized the need for monumental mental health efforts to be implemented during episodes of terrorism and disaster. The psychological and behavioral consequences of a terrorist attack are now included in most disaster plans (Hall, Norwood, Ursano, & Fullerton, 2003).

The hurricane Katrina disaster 2005 highlighted the importance of government preparedness for natural disasters as well as terrorism. The lack of government response and breakdown in communication resulted in thousands of hurricane victims being displaced and injured. Consequences of Hurricane Katrina are still being felt today.

B. Phases of Disaster

Natural and man-made disaster can be conceptualized in three phases:

1. Pre-warning of the disaster. This phase entails preparing victims for possible evacuation of the environment, mobilization of resources, and review of community disaster plans.

2. Disaster event occurs. Here the rescuers provide resources, assistance, and support as needed to preserve the biopsychosocial functioning and survival of the victims.

3. Recuperative effort. The focus here is to implement strategies for healing the sick and injured, preventing complications of health problems, repairing damages, and reconstructing the community (Flynn & Norwood, 2004).

C. Advanced Practice Psychiatric/Mental Health Nursing Management of Disasters

PMH-APRNs encounter three different types of disaster victims. The first category is the victims who may or may not survive. If they survive, the victims often suffer severe physical injuries. The more serious the physical injury, the more likely the victim will experience a mental health problem such as PTSD, depress ion, anxiety, or other mental health problems (North et al., 2002; Pfefferbaum et al., 2001). Victims and families will need ongoing health care to prevent complications related to both physical and mental health.

The second category of victims includes the professional rescuers. These are persons who are less likely to suffer physical injury but who often suffer psychological stress. The professional rescuers, such as policemen, firefighters, nurses, and so on, have more effective coping skills than do volunteer rescuers who are not prepared for the emotional impact of a disaster (North et al., 2002). However, many professional responders have reported experiencing PTSD for many months following the traumatic event in which they were involved (Puig & Glynn, 2003).

The third category includes everyone else involved in the disaster. Psychological effects may be experienced worldwide by millions of people as they experience terrorism or disaster vicariously or as direct victims of the terrorism/disaster event (Hall et al., 2003). After an act of terrorism, most people will experience some psychological stress, including an altered sense of safety, hypervigilance, sadness, anger, fear, decreased concentration, and difficulty sleeping. Others may alter their behavior by traveling less, staying at home, avoiding public events, keeping children out of school, or increasing smoking and alcohol use. In a nationwide interview of 560 adults after September 11, 2001, 90% reported at least one stress symptom and 44% had several symptoms of stress (Schuster et al., 2001). In New York state, almost half a million people reported symptoms that would meet the criteria for acute PTSD. In Manhattan, the estimated prevalence of acute PTSD was 11.2%, increasing to 20% in people living close to the World Trade Center (Galea et al., 2002: Schlenger et al., 2002).

The interventions developed by the PMH-APRN in collaboration with the victim should address individual outcomes specific to that victim. Victims experiencing head injuries or psychic trauma after a disaster may have to be hospitalized. During a disaster, a victim with a mental illness may experience regression to his or her pretreatment condition and may require short-term inpatient hospitalization.

Biologic Domain/Assessment – The PMH-APRN should assess physical reactions that may involve many changes in body functions, such as tachycardia, tachypnea, profuse perspiration, nausea, vomiting, dilated pupils, and extreme shakiness. Virtually any organ may be involved. Some victims may exhibit panic reactions and loss of control and have a total disregard for their personal safety. The victims may be suicidal or homicidal and are at high risk for injuries that may include infection, trauma, and head injuries (France, 2002).

Any physiological problems or injuries should be treated quickly. During the emergency response, individuals will be triaged to the appropriate level of care (see Table – Triage Categories During a Mass Casualty Incident (MCI) below). Victims who are primarily distressed and may have somatic symptoms will be treated after those suffering from exposure with critical injuries. All patients need to be reassured of the caring and commitment of the PMH-APRN  to their safety, comfort, and well-being throughout the triage process. The PMH-APRN is an integral member of the triage team. Many of the same interventions used for persons experiencing stress or crisis will be used for these victims.

Triage Categories During a Mass Casualty Incident (MCI)

Triage Category	Priority	Color	Typical Conditions
Immediate: Injuries are life-threatening but survivable with minimal intervention. Individuals in this group can progress rapidly to expectant if treatment is delayed.	1	Red	Sucking chest wound, airway obstruction secondary to mechanical cause, shock, hemothorax, tension pneumothorax, asphyxia, unstable chest and abdominal wounds, incomplete amputations, open fractures of long bones, and 2nd/3rd degree burns of 15%–40% total body surface area.
Delayed: Injuries are significant and require medical care, but can wait hours without threat to life or limb. Individuals in this group receive treatment only after immediate casualties are treated.	2	Yellow	Stable abdominal wounds without evidence of significant hemorrhage; soft tissue injuries; maxillofacial wounds without airway compromise; vascular injuries with adequate collateral circulation; genitourinary tract disruption; fractures requiring open reduction, débridement, and external fixation; most eye and CNS injuries.
Minimal: Injuries are minor and treatment can be delayed hours to days. Individuals in this group should be moved away from the main triage area.	3	Green	Upper extremity fractures, minor burns, sprains, small lacerations without significant bleeding, behavioral disorders or psychological disturbances.
Expectant: Injuries are extensive and chances of survival are unlikely even with definitive care. Persons in this group should be separated from other casualties, but not abandoned. Comfort measures should be provided when possible	4	Black	Unresponsive patients with penetrating head wounds, high spinal cord injuries, wounds involving multiple anatomical sites and organs, 2nd/3rd degree burns in excess of 60% of body surface area, seizures or vomiting within 24 hr after radiation exposure, profound shock with multiple injuries, agonal respirations; no pulse, no BP, pupils fixed and dilated.

 Table is provided with permission by the United States military

Psychological Domain/Assessment – Therapeutic communication is key to understanding the extent of the psychological responses to a disaster and to establishing a bridge of trust that communicates respect, commitment, and acceptance. By developing rapport with the victim or victims, the PMH-APRN communicates reassurance and support (Flynn & Norwood, 2004).

The PMH-APRN should assess the victim for behaviors that indicate a depressed state, presence of confusion, uncontrolled weeping or screaming, disorientation, or aggressive behavior. Ideally, thePMH-APRN should assess the coping strategies the victim uses to normally manage stressful situations. The victims may suffer from loss of feelings of well-being and various psychological problems, including panic responses, anxiety, and fear (Hall et al., 2003). In addition, the victims may demonstrate behaviors indicative of acute stress disorder and PTSD. The survivors of the disaster may experience traumatic bereavement because of their feelings of guilt that they survived the disaster (Ozer, Best, Lipsey, & Weiss, 2003). Responses to psychological distress need to be differentiated from any psychiatric illness that the person may be experiencing. A response to a disaster may leave the person feeling overwhelmed, incapacitated, and disoriented.

The ABCs of psychological first aid include focusing on A (arousal), B (behavior), and C (cognition). When arousal is present, the intervention goal is to decrease excitement by providing safety, comfort, and consolation. When abnormal or irrational behavior is present, survivors should be assisted to function more effectively in the disaster and when cognitive disorientation occurs, reality testing and clear information should be provided. In the initial phases, the PMH-APRN should assist the victim in focusing on the reality of problems that are immediate, with specific goals that are consistent with available resources, as well as the culture and lifestyle of the victim.

After the initial interventions, the PMH-APRN should support the development of resilience, coping, and recovery while providing technical assistance, training, and consultation. During the treatment process, it may become necessary to administer an antianxiety medication or sedative, especially in the early phases of recovery (Centers for Disease Control [CDC], 2005; Dochterman, Butcher, & McCloskey-Bulechek, 2007). The goals of care include helping the victims prioritize and match available resources with their needs, and preventing further complications, monitoring the environment, disseminating information, and implementing disease control strategies (CDC, 2005; Noji, 2000).

Debriefing (the reconstruction of the traumatic events by the victim) may be helpful for some. Long ago a common practice, debriefing was believed to be necessary in order for the person to develop a healthy perspective of the event and ultimately prevent PTSD. However, current research does not support debriefing as a useful treatment for the prevention of PTSD after traumatic incidents; compulsory debriefing is not recommended (Rose, Bisson, Churchill, & Wessely, 2006). If the victim has symptoms of PTSD, referral to a mental health clinic for additional evaluation and treatment is important. The PMH-APRN  should prepare the victim for recovery by teaching about the effects of stress and helping the victim identify personal strengths and coping skills. Positive coping skills should be supported. The victims should be encouraged to report any depression, anxiety, or interpersonal difficulty during the recovery period. After most disasters, support groups are established that help victims and their families deal with the psychological effects of the disaster (Dochterman et al., 2007).

Women exhibit higher levels of distress than men after a disaster, especially older women (Norris et al., 2002). Assess the ages of the female victims, their capability to participate in problem-solving activities related to the devastation left by the disaster, and their level of self-confidence/self-esteem that would allow each to participate as a team member or a team leader in addressing the needs of others. This includes encouraging the victims to do necessary chores and participate in decision-making, and to take advantage of the opportunity to serve as a leader or team member, as dictated by their abilities.

Educating the public and emphasizing the natural recovery process is important. There are information gaps and rumors that add to the anxiety and stress of the situation. By giving information and direction, it will help the public and victims to use the coping skills they already possess. Initially, the event may leave individuals and families in a stage of ambiguity with frantic disorganized behavior. In addition, individuals and family members are concerned about their own physical and psychological responses to the disastrous event. Children are especially vulnerable to disasters and respond according to their age and family experiences (Davidhizar & Shearer, 2005; Hoven, Duarte, & Mandell, 2003). Traumatized children and adolescents are high risk victims of a wide range of behavioral, psychological, and neurological problems after experiencing various traumatic events (Caffo, Forresi, & Lievers, 2005; Davidhizar & Shearer, 2005).

When the PMH-APRN explains anticipated reactions and behaviors, this helps the victims gain control and improve coping. For example, after a major disaster, there may be excessive worry, preoccupation with the event, and changes in eating and sleeping patterns. With time, counseling, and group work, these symptoms will lessen. Active coping strategies can be presented in multiple media forums, such as television and radio (Hall et al., 2003). After the initial shock, victims react by trying to do something to resolve the situation. When victims begin working to appropriately remedy the disaster situation, their physical responses become less exaggerated and they are more able to work with less tension and fear.

Social Domain/Assessment – The PMH-APRN should assess the kind and severity of a natural or man-made disaster or terrorist act to determine the capability of individuals and communities to respond in a supportive way. The PMH-APRN should maintain a calm demeanor, obtain and distribute information about the disaster and the victims, and reunite victims and their families. In addition, there is a need to monitor the news media’s impact on the mental health of the victims of the crisis. Sometimes, the persistence of the news media diminishes the ability of the survivors to achieve closure to the crisis (Majer et al., 2002). Constant rehearsal of the disaster in the newspapers and on television can increase and prolong the severity or initiate feelings of anxiety and depression.

In a disaster, the victims may experience economic distress because of job loss and loss of other resources. This may ultimately lead to psychological distress. In addition, acts of aggression and other mental health problems may emerge (Dooley, Prause, & Ham-Rowbottom, 2000; Bonanno, 2004). Again, shelter, money, and food may not be available. The absence of basic human needs such as food, a place to live, or immediate transportation quickly becomes a priority that may precipitate acts of violence.

The nursing interventions for the social domain include the individual, family, and community. The individual should learn about the community resources that can be made available. Family support systems may need to be re-established. The health care community should actively reach out to the media and keep the press engaged. Direct attention to stories that inform and help the public respond should be encouraged. There are federal agencies that assist victims of disaster. This assistance is available for individual, families, and communities. One of those agencies is the Federal Emergency Management Agency (FEMA). When a disaster occurs, FEMA sends a team of specialists who review the devastation of disaster. They provide counseling and mental health services, and arrange for many of the victims to access other services needed for survival, including training programs. In addition, the Substance Abuse and Mental Health Services Administration (SAMHSA) of the Department of Health and Human Services (DHHS) are available to assist both victims of and responders to the disaster. When a disaster disrupts the victim’s social network, other resources must be made available for social support. The social support system provides an environment in which the victims experience respect and caring from the caregivers, the opportunity to ventilate and examine personal feelings regarding the tragedy, as well as the opportunity to begin the healing and recovery process (Everly, 2000). Supporting the development of more contacts within the social network can be done by organizing support groups within the area of the disaster that address grief and loss, trauma, psychoeducational needs, and substance abuse. In addition, the PMH-APRN may refer the victims to nearby support groups or religious groups that are appropriate to meet their needs (Herman, Kaplan, & LeMelle, 2002).

References:

1. American Psychiatric Association (APA). (2000). Diagnostic and statistical manual of mental disorders (4th ed.) Text Revision. Washington, DC: Author. 

2. Bonanno, G. A., (2004). Loss, trauma, and human resilience: How can we underestimate the human capacity to thrive after extremely aversive events? American Psychologist, 59(1), 20-28.

3. Caffo, E., Forresi, B., & Lievers, L. S. (2005). Impact, psychological sequelae and management of trauma affecting children and adolescents. Current Opinion in Psychiatry, 18(4), 422-428.

4. Centers for Disease Control (CDC). (2005, August 30). Disaster mental health for states: Key principles, issues, and questions.Department of Health and Human Services, pp. 1-4.

5. Dattilio, F. M.. & Freeman, A. (Eds). (2007). Cognitive-behavioral strategies in crisis intervention (3rd ed.). NY: The Guilford Press.

6. Davidhizar, R., & Shearer, R. (2005). Helping children cope with public disasters. American Journal of Nursing, 102(3), 26-33.

7. Dochterman, J., Butcher, H. K., & McCloskey-Bulechek, G. (2007). Nursing interventions classification (NIC) (5th ed.). St. Louis: Mosby.

8. Dooley, D., Prause, J., & Ham-Rowbottom, K. A. (2000). Underemployment and depression: Longitudinal relationships. Journal of Health and Social Behavior, 41(4), 421-436.

9. Everly, G. S. (2000). Crisis management briefings (CMB): Large group crisis intervention m response to terrorism, disasters, and violence. International Journal of Emergency Mental Health, 2(1), 53-57.

10. Flynn, B. W, & Norwood, A. E. (2004). Defining normal psychological reactions to disaster. Psychiatric Annals, 34, 597-603.

11. France, K. (2002). Crisis intervention: A handbook of immediate person-to-person help. Springfield, IL: Charles C. Thomas.

12. Galea, S., Ahem,J., Resnick, H., Kilpatrick, D., Bucuvalas, M., Gold, J., & Vlahov, D. (2002). Psychological sequelae of the September 11 terrorist attacks in New York City. New England Journal of Medicine, 346(13), 982-987.

13. Hall, M.J., Norwood, A. E., Ursano, R. J., & Fullerton, C. S. (2003). The psychological impacts of bioterrorism. Biosecurity & Bioterrorism, 1(2), 139-144.

14. Harvey, J. J. & Pauwels, B. G. (2000). Post traumatic stress theory: Research and application Levittown, PA: Brunner/Mazel.

15. Hazelwood, R.R., & Burgess, A. W. (2001). Practical aspects of rape: A multidisciplinary approach (3rd ed.). Boca Raton, FL: CRC Press.

16. Herman, R., Kaplan, M., & LeMelle, S. (2002). Psychoeducational debriefings after the September 11 disaster. Psychiatric Services, 53(4), 479-80.

17. Hoven, C. W, Duarte, C. S., & Mandell, D. J. (2003). Children’s mental health after diagnostics: The impact of the World Trade Center attack. Current Psychiatry Reports, 5(2), 101-107.

18. Lindemann, E. (1944). Symptomatology and management of acute grief. American Journal of Psychiatry, 101, 141-148.

19. Litz, B. T., Gray, M. J., Bryant, R. A., & Adler, A. B. (2002). Early intervention for trauma: Current status and future directions.Clinical Psychology: Science and Practice, 9, 112-134.

20. Majer,J. M., Jason, L. A., Ferrarie, J. R., Venable, L. B., & Olson, B. D. (2002). Social support and self- efficacy for abstinence: Is peer identification an issue? Journal of Substance Abuse Treatment, 23(3), 209-215.

21. Miller, J. (2002). Affirming flames: Debriefing survivors of the World Trade Center attack. Brief Treatment and Crisis Intervention, 21, 85-94.

22. Noji, E. K. (2000). The public health consequences of disasters: A review. Prehospital and Disaster Medicine, 15(1),32-53.

23. Norris, F. H., Friedman, M. J., Watson, P. J., Byrne, C. M., Diaz, E., & Kaniasty, K. (2002). 60,000 disaster victims speak: Part 1. An empirical review of the empirical literature, 1981-2001. Psychiatry, 65(3), 207-239.

24. North, C. S., Tivis, L., McMillen, J. c., Pfefferbaum, B., Spitznagel, E. L., Cox,J., et al. (2002). Psychiatric disorders in rescue workers after the Oklahoma City bombing. American Journal of Psychiatry, 159(5), 857-859.

25. Ozer, E.]., Best, S. R., Lipsey, T. L., & Weiss, D. S. (2003). Predictors of posttraumatic stress disorder and symptoms in adults: A meta analysis. Psychological Bulletin, 129, 52-71.

26. Pfefferbaum, B., North, C. S., Flynn, B. W, Ursano, R. J., McCoy, G., DeMartino, R., et al. (2001). The emotional impact of injury following an international terrorist incident. Public Health Review, 

27. 29(2-4), 271-280.

28. Puig, M. E., & Glynn,]. B. (2003). Disaster responders: A cross cultural approach to recovery and relief 

29. work. Journal of Social Service Research, 30(2), 55-66.

30. Roberts, A. R. (2005). Crisis intervention handbook: Assessment, treatment and research (3rd ed.). Oxford & New York: Oxford University Press.

31. Rose, S., Bisson,J., Churchill, R., & Wessely, S. (2006). Psychological debriefing for preventing post traumatic stress disorders. EMB Review: Cochrane Database of Systematic Reviews.

32. Schlenger, W E., Caddell, J. M., Ebert, L., Jordan, B. K., Rourke, K. M., Wilson, D., et al. (2002). Psychological reactions to terrorist attacks: Findings from the national study of Americans’ reactions to September 11. Journal of the American Medical Association, 288(5), 581-588.

33. Schuster, M. A., Stein, B. D., Jaycox, L., Collins, R. L., Marshall, G. N., · Elliott, M. N., et al. (2001). A national survey of stress reactions after September 11, 2001, terrorist attacks. New England Journal of Medicine, 345(20), 1507-1512.

34. van Griensven, F., Chakkraband, S., Thienkrua, W., Pengjuntr, W., Cardozo, B. L., Tantipiwatanaskul, P., et al. (2006). Mental health problems among adults in Tsunami-affected areas in Southern Thailand. Journal of the American Medical Association, 296(5), 527-548.

35. Walter, H. J. & Berkovitz, I. H. (2005). Practice parameter for psychiatric consultation to schools. Journal of the American Academy of Child & Adolescent Psychiatry 44(10), 1068-1083.

36. Yeager, K. R., & Roberts, A. R. (2003). Differentiating among stress, acute stress disorder, crisis episodes, trauma, and PTSD: Paradigm and treatment goals. Brief Treatment and Crisis Intervention, 3:1

Figures

1. Figure 1: Crisis. Retrieved March 9, 2011 from http://www.e-missions.net/ssa/teacher/webimages/logoBIG_CRISIS.gif

2. Figure 2: The World Trade Center on 9/11. Retrieved March 9, 2011 from http://www.dailymail.co.uk/tvshowbiz/article-523729/9-11-attacks--says-French-best-actress-Oscar-winner.html