Disasters, Ever Increasing, Take Their Toll on Mental Health

Obviously, natural disasters have been part of human existence since the dawn of civilization. But we're at a moment in time where they've been increasing at an alarming rate because of climate change.

Regardt J. Ferreira, PhD, is an assistant professor at the School of Social Work and the director of the Disaster Resilience Leadership Academy at Tulane University in New Orleans, Louisiana, and is also editor of the journal Traumatology. With more than 15 years of experience in disaster and trauma-related work, Ferreira specializes in the psychological trauma that disasters can leave in their wake, and in understanding the psychological toll inflicted on communities and individuals after disasters.

Medscape spoke with Ferreira about what communities face after they've been through a disaster, how healthcare professionals can help, and how to prepare for a world where these once-exceptional occurrences will become an everyday reality.

As Disasters Increase, So Too Does Research Into Their Psychological Impact

Medscape: I read that your academic interest in trauma is something of a family pursuit.

Ferreira: Yes. I'm a third-generation social worker and a second-generation PhD. My mother was dean at a school of social work at the University of the Free State in South Africa, focusing on trauma, grief, and bereavement. I guess the apple doesn't fall far from the tree.

Medscape: The study of the psychological impact of disasters is a relatively young field. What are its origins?

Ferreira: From a Western perspective, the first disaster research study was done by Henry Samuel Prince. He looked at the 1917 Halifax explosion (in which a munitions ship exploded, killing nearly one quarter of the city's population). He provided very in-depth notes, which eventually became his book Catastrophe and Social Change,^[1] on the effect to the community and how they recovered. So for 100 years, we've been having a go at disaster research, even though folks have been experiencing trauma for ages.

Medscape: Did the field grow in relation to similar high-profile disasters throughout recent history?

Ferreira: There was definitely an uptick in research after the Vietnam War, which is more related to trauma than disasters to per se. More recently, there was a lot of interest with Hurricane Andrew in 1992, and certainly around September 11 and then Hurricane Katrina. And when you think about technological disasters, the Exxon Valdez oil spill in 1989 led to a spike. Big events always pique interest.

But of late, especially in the past 3-4 years with the increase in significant large-scale disasters, there's definitely more interest out there and more studying coming about.

Ethical Dilemmas of Working in a Disaster Area

Medscape: A lot of your work has focused on the ethics surrounding disaster research. What are the some of the difficulties and missteps that have taken place in this field?

Ferreira: As disaster research has increased, there is a need for ethical guidelines on how to conduct it. The mere fact that we're at that stage basically shows that there's been an uptick in it.

One of the main ethical conundrums one is faced with is, when is the right time to start with a study and to whose benefit is it at the end of the day? The researcher? The community?

There's a lack of cultural humility where folks literally parachute in, and they leave and never bring the results back to the community members, who often don't know what the purpose is. There's a distrust of the research community, which has cascading effects within these communities that are already under stress.

There's also a general notion that certain areas are being overexposed to disaster research, which is something we've seen here in southeast Louisiana.

Keeping a Community Together After a Disaster

Medscape: Do communities respond differently to separate types of disasters?

Ferreira: There's no clear-cut answer, and we have a golden rule in this field never to compare disasters or groups with one another, because we all experience a disaster in a different way, even though what's underlying it is sometimes the same.

However, if it's a natural disaster, a lot of communities, especially those that are fairly religious like here in southeast Louisiana, attribute it as an act of God. Then we had the Deepwater Horizon oil spill, where it's clear that there's human negligence; then there's actually someone we can blame.

We've also seen that with natural disasters, everyone is on more equal footing. However, with technological disasters, such as chemical spills or infrastructure problems, we see communities get fractured, because not everyone will get benefits in terms of insurance buyouts post-disaster.

It becomes very complex when socioeconomic status comes into play. Like with Hurricane Katrina, those who were more affluent often had insurance. Although they also experienced mental health issues, they were able to come back more easily than those from a lower socioeconomic status.

I think technological disasters also create more severe mental health issues, because there's a lot of uncertainty. For example, after the Deepwater Horizon oil spill, many people didn't know whether the drinking water or consuming seafood was safe.

What Predicts Resiliency?

Medscape: You've done research into the domestic abuse as well.^[2,3] Is that something you see increasing after these events?

Ferreira: I've done a few studies that indicated domestic violence does increase postdisaster. We found that in Hurricane Katrina and then also with the Deepwater Horizon disaster, several communities experienced an uptick in domestic violence. Then in several communities, substance abuse oftentimes is correlated with domestic violence.

Obviously, a lot of domestic violence comes about owing to stress within a relationship. So there's the precondition, and you can imagine the stress increases with disasters, where there's possibility of not having a roof over your head or not being able to go to work. You have kids who need childcare. So it's just compounding factors that come into play.

Medscape: You've researched the predictors of resiliency for individuals in postdisaster settings.^[4] What characteristics seemed most relevant?

Ferreira: A positive for resilience is definitely social support—if you have networks that you can rely on, access to resources, and are prepared for disasters. Females also tend to be more resilient, though this is not to say men are not. It's very context-specific in terms of gender. Level of education is correlated with resilience too, which connects back to having more resources and higher income.

Conversely, if you're looking to identify patients who may be in need of more care, you'd flip those indicators.

Medscape: Your research has also focused on the experience of children after disasters.^[5] What has that shown?

Ferreira: I should say that it's obviously difficult to access children after a disaster, because there's reasonably a lot of measures put in place to protect them, such as when you go through an institutional review board at universities. Although it's complex, it's very important to know what they're going through.

Bringing it back to Hurricane Katrina, we had a lost generation in terms of school performance. Children are very vulnerable postdisaster, and one thing that's very important is to get them back to a sense of normalcy. Our priority with disaster recovery should be to get children back into their school systems and into their routine as soon as possible. Otherwise, mental health issues could develop.

Bracing for a Dire Future, but Not Succumbing to It

Medscape: In the past few months, there have been several high-profile reports offering dire projections for the decades ahead if climate change is not addressed, most prominently by the United Nations' Intergovernmental Panel on Climate Change^[6] and the US government's National Climate Assessment.^[7] Given the seriousness of what they predict, how do you expect your field to evolve?

Ferreira: One thing we definitely need to do in response to that is ask whether we are going to still focus on our research in terms of disasters or in terms of climate change, because they are different.

I'm from South Africa, originally. I was in Cape Town for the recent water crisis. Just talking to local practitioners in Cape Town, you would hear that there was an upsurge in folks seeking mental health treatment, and there's a concern this might happen again.

I do expect there will be a paradigm shift in this field to focus more on the mental health impact of climate change in general, rather than solely disasters.

A Role for Medical Professionals

Medscape: Our readership of clinicians is geographically diverse, and undoubtedly some already have experienced or will experience the effects of a disaster. What advice do you have for them in terms of the role they can play in the immediate period after a disaster?

Ferreira: At a minimum, medical practitioners should be aware of what services, policies, and procedures exist so they can then give that information to their patients, because that form of preparedness bolsters resilience. This can sound simplistic, but just knowing where shelters are or who folks can go and see in terms of mental health providers would be beneficial. There's a role for them to play in connecting their community to these resources. Usually, families get assigned a disaster case manager who attends to their needs if they qualify, with whom they can work in collaboration with.

So all together, it means creating something like a predisaster type of plan that they can give to their clients to ensure they're prepared. Because it's just a matter of time when their clients will experience disaster, not if.

Medscape: In the longer term, after a disaster has occurred, what can healthcare professionals do to support their communities?

Ferreira: Be aware that someone can be on autopilot for months or years, and then there could just be a day where there's a trigger that brings it all back. For example, there were reports last year of people here in Louisiana experiencing posttraumatic stress disorder just by being exposed to media images of Hurricane Harvey, which brought back memories of Katrina.

Medscape: Many people feel a sense of helplessness when it comes to climate change, and healthcare professionals aren't immune to that. Is there an active role they can play to offset that feeling?

Ferreira: We do need a better policy response in terms of mental healthcare. One thing that's the issue in the West is that we're very materialistically driven, in that after a disaster we're much more concerned about bringing back infrastructure than looking at mental health aid. The human element is often forgotten.

We really are in trouble with climate change, whether we want to admit it or not, and I don't think the mental health community is efficiently prepared. Just look at the Federal Emergency Management Agency in 2017. They couldn't respond to all the disasters, and our resources are tapped out. The mental health system in the United States is already overtaxed, and during a disaster there are not enough resources.

But there's a clear need for education from practitioners, as well as policymakers and politicians. I know we're in a difficult situation in this country in that regard, but we all need to educate people that yes, you might not be feeling the tangible impacts of climate change now, but you will certainly experience it down the road.

There's a fine line to walk there. Don't come with scare tactics or cry wolf tactics. Raise awareness, but not fear.

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