Provider Perspectives on Disaster Mental Health Services in Oklahoma City

Abstract

Seven years after the bombing of the Murrah Federal Building in Oklahoma City, 34 individuals affiliated with various organizations were interviewed about their experiences in providing disaster mental health services to victims and the community. Their perspectives elucidated the importance of preparedness, training and education, local control, interagency cooperation, and psychosocial support for providers. Significant conflicts emerged among providers about credentials, referrals, the quality of services provided, and the appropriateness, in this context, of basing services solely on a crisis counseling model. The lack of ongoing needs assessment or evaluation data further fueled the debates. On the basis of the findings, the authors outline several recommendations for planning mental health responses to future terrorist attacks.     

Ethical and methodological issues in academic mental health research in populations affected by disasters: the Oklahoma City experience relevant to September 11, 2001

Empirical data from research studies are vital to guiding mental health interventions following disasters. However, few data are available for this purpose. Important advances in policy and procedures for the conduct of organized research emerged from the Oklahoma City bombing, yielding cooperative working relationships among researchers and culminating in the ethical attainment of informative research data. However, the academic community was again caught off guard after the September 11, 2001, terrorist attacks. Suggestions to surmount these obstacles include incorporating research infrastructures into disaster preparedness plans in advance; organizing the community of researchers; and working closely with major funding organizations. Methodological issues pertaining to measurement of psychopathology include the importance of obtaining diagnostic data; interpreting the meaning of symptoms in the absence of a psychiatric disorder; differentiating preexisting symptoms from those that emerged after the disaster, and optimal timing of postdisaster assessment.     

Psychic aftershocks: crisis counseling and disaster relief policy

Though crisis counseling following disasters has become a commonplace in the 21st century, we have little to no sense of how and when it became part of federally supported disaster relief services. In 1974, as part of a broad overhaul of federal disaster policy, an authorization to fund counseling services, and mental health training to disaster relief workers, was inserted into the Disaster Relief Act passed in that year--despite little to no empirical evidence that such counseling was necessary or effective. As this article demonstrates, unlike the drive for community mental health programs at mid-century, federal support for disaster mental health did not come as a result of a long campaign waged from well-connected institutions. Rather, it was largely the result of local practitioners, informed by larger currents in thinking about crisis intervention, who discerned these needs in a spontaneous and ad hoc manner. Disaster mental health services came into being thanks to the flourishing of a broad network of therapeutic practitioners in places as far flung as Rapid City, South Dakota, Wilkes-Barre Pennsylvania, and Logan County, West Virginia, who implemented mental health pilot projects in response to disasters in the early 1970s. Their efforts caught the attention of journalists already attuned to therapeutic discourse, and to sympathetic national legislators, to whom the proposition that disaster victims would suffer from psychological damage simply seemed like common sense and a logical service to include as part of a general broadening of federal assistance to disaster victims.     

Mass traumatic terror in Oklahoma City and the phases of adaptational coping,part I: Possible effects of intentional injury/harm on victims' post-traumatic responses

The bombing in Oklahoma City shook the entire nation from “sea to shining sea.” This tremendous collective sensation was made even worse when available evidence revealed that this act of terrorism had not been committed by some terrorist from the Middle East but one from Middle America. The blast stunned the nation's sense of collective safety, while it raised serious questions about our ability as a nation to manage violence, and the profound feelings of discontent and narcissistic injuries among distressed Americans. Was it this failure to address chronic discontents that led to this tragedy of mass violence? These larger sociocultural and political issues are being debated in public and private forums throughout the nation, an activity that is likely to continue for some time to come. As these issues are debated in the public arena, victims' levels of psychological distress are expected to rise, as they attempt to process the traumatic shock in their minds and bodies. Specifically, this article has two parts and focuses on acute and post-acute psychophysiological traumatic stress responses in victims, as well as issues pertaining to assessment, prevention, and treatment. Part I addresses the nature of disasters, with a special emphasis on the victim's subjective evaluation (meaning) of the reality of a catastrophe caused by intentional human strategy. The article, additionally, discusses issues of epidemiology of stress reactions, post-traumatic stress disorder, co-morbidity, risk factors, and assessment and diagnostic considerations. Part II, to be published in the next of issue of the Journal, will focus on issues of prevention as well as post-disaster intervention. Prevention of chronic post-traumatic stress disorder after the Oklahoma City bombing is a critical objective by debriefers and mental health professionals. A proposed four-phase model called “self-efficacy adaptational coping” will be presented in Phase II as well. The present article is probably the first major discussion on the traumatic effects of the blast on individuals, families, and the communities of Oklahoma City, and the first to offer some broad guidelines to intervention. Since it predates future empirical studies, the author relies on his almost 20 years of experience in the field of traumatic stress, and on a review and integration of pertinent disaster outcome studies in the national and international literature.     

Structure and organization of research efforts following the bombing of the murrah building

Abstract

In the days and weeks following the Oklahoma City bombing on April 19,1995, Oklahoma state authorities, university faculty and staff, and leading experts from across the nation formed a coalition to address issues of clinical service delivery, educational intervention, and research. This article focuses on the centralized approach applied to the administration of research endeavors. This centralization was designed to minimize revictimization of both survivors and affected families, enhance the quality of data collected, and facilitate cooperation between participating investigators. The resultant set of projects includes a variety of research methodologies and study populations and will serve to significantly enhance understanding of the mental health sequelae of such disasters.     

The Role of Social Toxicity in Responses to a Slowly-Evolving Environmental Disaster: The Case of Amphibole Asbestos Exposure in Libby,Montana, USA

Experiencing a disaster has significant negative effects on psychological adjustment. Case study accounts point to two consistent trends in slowly-evolving environmental disasters: (a) patterns of negative social dynamics, and (b) relatively worse psychological outcomes than in natural disasters. Researchers have begun to explicitly postulate that the social consequences of slowly-evolving environmental disasters (e.g., community conflict) have their own effects on victims’ psychological outcomes. This study tested a model of the relationship between those social consequences and psychological adjustment of victims of a slowly-evolving environmental disaster, specifically those whose health has been compromised by the amphibole asbestos disaster in Libby, MT. Results indicate that experiencing greater community conflict about the disaster was associated with greater family conflict about the disaster which, in turn, was associated with greater social constraints on talking with others about their disease, both directly and indirectly through experiencing stigmatization. Experiencing greater social constraints was associated with worse psychological adjustment, both directly and indirectly through failed social support. Findings have implications for understanding pathways by which social responses create negative effects on mental health in slowly-evolving environmental disasters. These pathways suggest points for prevention and response (e.g., social support, stigmatization of victims) for communities experiencing slowly-evolving environmental disasters.     

Vicarious stress: patterns of disturbance and use of mental health services by those indirectly affected by the Oklahoma City bombing.

This study explored the intermediate psychological effects of terrorism on adults not directly affected by the Oklahoma City bombing by examining the course of PTSD and subthreshold PTSD symptoms over time and whether treatment affected this course. The respondents were interviewed at 3-mo. intervals for 18 mo. following an initial 6-mo. survey. Analysis suggested avoidance, re-experiencing, and increased arousal symptoms in this population were limited over time, declining with or without treatment between 6 and 9 mo. Conversely, victimization symptoms remained high without mental health intervention for the first year after the disaster. The study also examined the nature and occurrence of comorbidity in groups seeking and not seeking treatment.     

Lessons from the aftermath of Flight 232. Practical considerations for the mental health profession's response to air disasters

The fiery crash of a DC-10 at Sioux City, Iowa, on July 19, 1989, caused a crisis of major proportions, with attendant mental health needs. Various articles have described the need for psychological response teams in such crises. The present article provides practical guidelines for the preparation of a mental health disaster plan and for the coordination of a mental health team responding to a major air disaster. Such disasters can occur in any part of the country at any time. It is hoped that the suggestions in the present article will help teams that respond to future air disasters provide more rapid, effective, and efficient delivery of services to the survivors and their families, and the families of those who are killed.     

Coping Self‐Efficacy and Psychological Distress Following the Oklahoma City Bombing1

Findings from a study of 27 victims of the Oklahoma City bombing are reported. This research focused on the importance of subjective appraisals of coping self‐efficacy in predicting psychological distress following this tragedy. Results supported the hypothesis that judgments of coping self‐eficacy taken 2 months after the bombing added significantly to the explanation of general and trauma‐related distress after controlling for income, social support, threat of death, and loss of resources. Coping self‐eficacy judgments taken I year later were also important in explaining psychological distress after controlling for loss of resources and social‐support perceptions. Although coping self‐efficacy perceptions taken at 2 months were related to distress levels 1 year later, they did not remain significant in a regression analysis controlling for loss of resources and income. Implications of these findings for post‐terrorist bombing interventions are discussed.     

Psychological Impact of Terrorism on Children and Families in the United States

Summary

This article reviews the literature on the psychological impact of terrorism on children and families in the United States. It includes studies of the 1993 World Trade Center bombing in New York City and the 1995 bombing of the Alfred P. Murrah Federal Building in Oklahoma City, as well as the September 11 attacks. These studies explore the impact of various forms and degrees of exposure to terrorism on children across the development spectrum and on the relationships between parental and child reactions. The article concludes with a framework for future research on children's adaptation following mass trauma.     

The influence of culture on disaster mental health and psychosocial support interventions in Southeast Asia

Southeast Asia (SEA), which has borne the brunt of some of the most severe natural disasters in the past decade, has unfortunately, been largely under-represented in the world literature on disaster mental health. This article describes cultural factors that may inform the design and conduct of disaster-related mental health psychosocial support (MHPSS) interventions. Specifically, it discusses cultural nuances in emotional expression, shame, power distance, collectivism, and spiritual beliefs and their implications on providing post-disaster psychosocial interventions. It describes the MHPSS interventions implemented in the region using the Johns Hopkins Perspectives Model of Disaster Mental Health categories of resistance, resilience and recovery. Given the challenges on the delivery of MHPSS, there is a need for evidence-based interventions and to ensure that disaster responders in SEA understand the cultural factors that impact the delivery of MHPSS interventions.     

The medical student experience with disasters and disaster response

Medical students from New York City were integrally involved in the response by health professionals to aid the families of victims of the September 11, 2001, attacks on the World Trade Center. The present study was performed to investigate the emotional impact of this involvement on medical students from the Mount Sinai School of Medicine in New York City. One hundred fifty-seven students responded to a mail survey that explored their personal and professional involvement in the disaster as well as their psychiatric symptoms in the week after the event and at the time of the survey (3.5 months after the event). Findings suggested a differential emotional impact on female students and on students involved in less supervised and more emotionally intense activities. However, involvement in the relief effort, per se, did not contribute to psychiatric symptomatology. It may have been associated with enhanced professional self-esteem among the students. These findings have implications for future planning of psychiatric response to disasters.     

No Evidence of Suicide Increase Following Terrorist Attacks in the United States: An Interrupted Time‐Series Analysis of September 11 and Oklahoma City

There is substantial evidence of detrimental psychological sequelae following disasters, including terrorist attacks. The effect of these events on extreme responses such as suicide, however, is unclear. We tested competing hypotheses about such effects by employing autoregressive integrated moving average techniques to model the impact of September 11 and the Oklahoma City bombing on monthly suicide counts at the local, state, and national level. Unlike prior studies that provided conflicting evidence, rigorous time series techniques revealed no support for an increase or decrease in suicides following these events. We conclude that while terrorist attacks produce subsequent psychological morbidity and may affect self and collective efficacy well beyond their immediate impact, these effects are not strong enough to influence levels of suicide mortality.     

An investigation of the psychological effects of the September 11, 2001, attacks on New York City: developing and implementing research in the acute postdisaster period

The September 11, 2001, attack on New York City was the largest human-made disaster in United States history. In the first few days after the attack, it became clear that the scope of the attacks (including loss of life, property damage, and financial strain) was unprecedented and that the attacks could result in substantial psychological sequelae in the city population. Researchers at the Center for Urban Epidemiologic Studies at the New York Academy of Medicine designed and implemented an assessment of the mental health of New Yorkers 5-8 weeks after the attacks. To implement this research in the immediate postdisaster period, researchers at the center had to develop, in a compressed time interval, new academic collaborations, links with potential funders, and unique safeguards for study respondents who may have been suffering from acute psychological distress. Results of the assessment contributed to a New York state mental health needs assessment that secured Federal Emergency Management Agency funding for mental health programs in New York City. This experience suggests that mechanisms should be in place for rapid implementation of mental health assessments after disasters.     

If we had known then what we know now: a review of local and national surveys following September 11, 2001

There is little research on the consequences of large-scale violent disasters in a community despite their unfortunate prevalence over many decades. The primary source of epidemiological data for the greater New York community in dealing with the September 11, 2001, attacks was the Oklahoma City bombing. In the latter event, 45%; of directly exposed adults met criteria for a major psychiatric disorder 6 months later, including 34%; with posttraumatic stress disorder (PTSD). The first survey after the World Trade Center and Pentagon attacks, conducted within one week, revealed a remarkable degree of symptomatology across the nation in both adults and children. Forty-four percent of adults reported at least 1 of 5 PTSD screening symptoms in the 3-5 days after the attacks; 35% of parents reported children who had at least one symptom, and 47% of children worried about their own or someone else's safety. Coping behaviors were consistent with a community mental health model and included turning to open discussion (98%), religion (90%), and community activities (60%) in order to cope with their reactions. Rates of disorder were also high in a survey conducted 5-8 weeks later in Manhattan below 110th Street, with 38% saying they directly witnessed the World Trade Center attack. The current prevalence of new-onset PTSD was 7.5%, and of new-onset major depressive disorder, 9.7%. This translates into 67,000 persons with PTSD and 87,000 persons with major depression. This survey also found a significant increase in tobacco, alcohol, and marijuana use, but primarily among adults already using these substances. All surveys found strong associations between media exposure and symptomatology. The greatest need at this point in the literature is therapeutics research after such traumatic events.     

The Effects of Values on Worries Associated With Acute Disaster: A Naturally Occurring Quasi‐Experiment1

On April 12, 1995, a bomb exploded in Oklahoma City, Oklahoma, destroying a federal office building, killing 168 people, and upending American notions of safety and security in the heartland. Using data collected before, immediately after, and 1 year after the bombing from 3 samples living within 25 miles of the explosion in a naturally occurring quasi‐experiment, research examined effects of values on people's worries in the context of a macrolevel traumatic event. High self‐transcendence and conservation values correlated with higher macro‐worries immediately after vs. before the explosion, but these worries were lower 1 year later. Findings indicate that values emphasizing broader social perspectives were associated with higher macrolevel worries, while values emphasizing one's own life and welfare were not.     

Donating to disaster victims: Responses to natural and humanly caused events

The effect of the cause of a disaster, i.e. whether it was perceived to be caused by human or natural factors, on willingness to donate money to disaster victims was examined. In Study 1 (N = 76), the cause of a fictitious disaster was experimentally varied. In Study 2 (N = 219), participants were asked about their views regarding donations to two real‐life disasters, one of which was perceived to be naturally caused while the other one was perceived to be caused by humans. In Study 3 (N = 115), the cause of a fictitious disaster was experimentally varied, but this time measures of the proposed psychological mediators of the effect on donations were included, namely perceived victim blame and the extent to which victims were thought to make an effort to help themselves. A measure of real donation behaviour was also added. In Study 4 (N = 196), the proposed psychological mediators were manipulated directly, and the effect of this on donations was monitored. Across all studies, more donations were elicited by naturally caused rather than humanly caused disasters. This difference was driven by a perception that the victims of natural disasters are to be blamed less for their plight, and that they make more of an effort to help themselves. Implications for theory and practice are discussed. Copyright © 2010 John Wiley & Sons, Ltd.     

Fear Associated With September 11 Television Coverage in Oklahoma City Bombing Survivors

This study explored television viewing of the September 11 attacks in 99 survivors of the Oklahoma City bombing and examined the relationships of event-related television viewing with concerns about safety and danger in survivors with and without bombing-related posttraumatic stress disorder. The number of hours of viewing September 11 television coverage was related to worry about personal and family danger and to increased checking on loved ones but not to September 11–related posttraumatic responses. Some bombing survivors discontinued September 11 media contact due to fear. The findings suggest the importance of monitoring television viewing in survivors of prior incidents.     

Mental health care for ethnic minority individuals and communities in the aftermath of disasters and mass violence

Findings from research on psychiatric epidemiology, disaster effects, discrepancies in service use, and cross-cultural psychology are reviewed to generate guidelines for culturally responsive postdisaster interventions. Ethnicity and culture influence mental health care at various points: on need for help; on availability and accessibility of help; on help-seeking comfort (stigma, mistrust), and on the probability that help is provided appropriately. There are aspects of disaster mental health practice that may ameliorate many of barriers that contribute to ethnic disparities in service use. It is proposed that interventions should give greater attention to socially engaged emotions and functioning. To promote disaster recovery, practitioners are advised to: assess community needs early and often; provide easily accessible services; work collaboratively and proactively to reduce stigma and mistrust and engage minorities in care; validate and normalize distress and help-seeking; value interdependence as well as independence as an appropriate developmental goal; promote community action; and advocate for, facilitate, or conduct treatment and evaluation research. Notwithstanding the pain and stress they cause, disasters create opportunities to de-stigmatize mental health needs and build trust between providers and minority communities.