Using the Internet to Assist Disaster Mental Health Efforts
by Storm A. King
March, 1996
Cite as:
King, S. A. (1995). Using the Internet to assist disaster mental health efforts Retrieved [fill in todays date here] from the World Wide Web: http://www.concentric.net/~Astorm/suicide.html
When disaster strikes, first aid teams rush to the site, ready to give aid to the injured. Modern science has recognized the need to address the psychological harm incurred by victims of a disaster. A quick response, by trained psychologists and mental health workers, has been shown to decrease psychological damage, and may mitigate or even prevent the later development of Post Traumatic Stress Disorder (PTSD) (Linton, 1995). The importance of this work is reflected in a recent action taken by the American Psychological Association (APA). In 1992, the APA formed the Disaster Response Network (DRN), which currently has 2,000 psychologists associated with it (Aguilera, 1995).
One method of administering this fast application of psychological first aid is Critical Incident Stress Management (CISM). Originally developed to treat public service workers exposed to extreme levels of trauma, it is currently finding widespread application in a variety of settings for treating anyone exposed to natural or manmade disasters, such as war, earthquakes or hurricanes (Jacobs, 1995). One purpose of the CISM team is to provide Critical Incident Stress Debriefing (CISD). This is most often a structured, group session that offers educational information and psychological assistance designed to counter the effects of the trauma caused by the disaster experience. An important element of successful CISD is a sufficient level of social support for the victim, following the disaster (Cook, 1989; Boscarino, 1995; Flannery, 1990).
The Internet is opening up new, unique opportunities for people to receive social and emotional support (Sproull & Keisler, 1995; Wellman & Gulia, 1995; King , 1994; Rheingold, 1994). Virtual communities are forming to discuss every imaginable topic(Cutler, 1994). These are loose knit social networks where members exchange ideas and information. There are particular factors about computer mediated communication that make it a possible useful addition to the treatment of disaster trauma. This paper will examine the current theory and practice of Disaster Mental Health (DMH) efforts, and suggest possible ways of including the use of the Internet.
The Importance of Social Support in DMH
When normal, well adjusted people experience the extreme stress and trauma of a disaster, they may develop symptoms of psychopathology. These include anxiety, depression, sleep disturbances and a profound sense that the world is unsafe. The role that social support plays in diminishing these symptoms has only recently been studied in an empirical manner. Cook and Bickman studied the psychological aftereffects of a disastrous flood that occurred in western Virginia in November, 1985. Using scales from the Brief Symptom Inventory (BSI), they assessed 94 subjects for levels of somatization, depression and anxiety. Using the Interpersonal Support Evaluation List (ISEL), they also assessed for levels of perceived social support. Each subject was assessed five times, first at one week after the flood, and then every five weeks after that. Results indicate that subjects reporting in the low category for perceived social support had significantly higher levels of psychological symptomatology (Cook, 1997). There was a downward trend for both groups, as the effects of the trauma wore off over time. At the end of the 21 week assessment period, there was still more symptomology in the low social support group. It is noteworthy that no attempt was made to measure actual levels of social support. It was the individuals subjective evaluation of having adequate support or not was the factor found significantly correlated with symptoms. One way to easily, cheaply and quickly increase peoples perceived level of being connected to others and of having a social support system would be to get them join an Internet discussion group set up as a self help group for the victims of that particular disaster. "Many clinicians and researchers in the trauma field have intuitively understood the importance of social support in trauma and it's role in recovery" (Flannery, 1990), but there have been few empirical studies to support this belief. In a review of the findings of an associative relationship between social support and psychological trauma, Flannery describes two formats in which social support is preceived. He refers to networks as the "social structures in which a persons life is embedded." This is one's family, friends, co-workers and community links. Buffers are social exchanges that cushion or mitigate the negative effects of life stresses. They may or may not be found in ones social network. He recommends that in treating trauma victims "the development of networks and buffers should be a specific treatment goal, not a hoped for by-product" (Flannery, 1990). The Internet represents a means of expanding the social network one is embedded in. For disaster victims, this could represent a means of finding buffers that were not available. One of the factors that has been shown to be a large buffer for trauma victims is contact with others that experienced the same trauma (Boscarino, 1995). In the case of survivors of a plane crash or a train wreak, the victims most often return home to widely separated locations. The establishment of an Internet link, for the exclusive use of those survivors, would greatly improve their ability to debrief each other as to their personal outcomes from that disaster, and supply each other with a unique buffer against the effects of the trauma.
A number of studies have researched the effect of disasters on the public health workers tasked with providing emergency care. One aspect of this issue that has received very little research attention is the bonding that occurs between such workers. "The development of close relationships through disaster work is inevitable" (Armstrong, 1991). Many Red Cross workers are brought in from disparate locations to do disaster relief. When the work is done, they go back to their locals of origin. A continued connection, established over the Internet, would allow these workers to retain important social ties easily, just at the time they are being tasked to deal with the stress of the trauma they experienced.
Using New Technology in DMH
E-mail is a form of communication that is increasingly becoming a part of peoples normal lives. There is a lower sense of social presence using email. The lack of tactile sensory feedback and the privacy of being in ones own home contribute to a different sense of being connected socially than even the use of the phone. This "makes it easier to contact strangers because there is less concern about rude intrusion or interpersonal risk" (Wellman, 1996; Stoll, 1995). The ability to find ones peers, no matter how esoteric the topic of interest is, is causing an explosion in the number of and uses of virtual communities (King, 1994). Both these factors make email self-help discussion groups viable and useful, as well as therapeutic. DMH workers could be prepared to enter disaster work sites with the information about available Internet sites already set up, ready to go.
"Electronic technology may open a variety of strategies to deal with disasters. Communication could be enhanced (a) through portable cellular equipment including telephone, fax, and memo; and (b) through linkages to centralized data sources by modem. The availability of educational material, for example, has been largely through next-day delivery services and has yet to use computer bulletin boards. Electronic linkages will enhance the use of disaster consultants who may be geographically removed from the incident site. Research or other data relevant to specific disasters would become immediately available (Aguilera & Planchon, 1995).
In the immediate wake of a large disaster, information is at a premium. The uncertainty as to the extent of the disaster is a major stress for people who have loved ones in the crisis area. In the wake of the Northridge earthquake in 1994, thousands of people used the Internet and commercial interactive services such as America Online and Prodigy to keep each other informed and to seek information about loved ones. Every major natural disaster since that time has caused a huge increase in the use of interpersonal computer mediated communication, as members of virtual communities shared with each other the nationally felt sense of grief and shock. There are no studies I am aware of that document this phenomena. After the bombing in Oklahoma City in April, 1995, the World Wide Web ( at http://www.cpb.uokhsc.edu/okc_bomb/okc_bomb.html) was used to provide information about the current state of disaster relief work, victim identification, and the status of the investigation into the cause of, and the perpetrators of, the explosion. Usage of this web site peaked eight days after the bombing at 30,000 "hits" (number of times the web site was accessed) per day (see appendix 1 or look up http://www.disaster.net/historical/ok/usage.html)An Internet Relay Chat (IRC) channel (a live, real time connection where information is sees as soon as it is posted) was set up the morning of the bombing. The records from that channel, which quickly became the Internet's source of official information, were kept and are still available on the Web (at http://www.disaster.net/historical/ok/procyon.html. This is a record of that channel for the two days following the bomb attack. From Wed. April 19, 12:15 am to Friday, April 21 12:15 (am or pm is uncertain) there were 78,137 words posted to just this one virtual forum. Many of those words were regularly repeated messages about where to go on the net for additional information, but most were comments and transcribed news reports. This appears to have been a grassroots efforts that became the site for official information due to moderators that attempted to allow only people to post that were monitoring TV news, radio sources or other official information. Following is a sample from that transcript (the logon names have been changed to protect the anonymity of the poster):
john - cnn just reported only 41 dead
joe - Headline News reports 53 dead
george - the FBI is studying videotapes of security cameras that were placed around the federal building.. the VTR's were located in the Phone Co's office across the street
george - KWTV reports 52 dead
joe - bloodied baby's image has come to symbolize the OKC tragedy...
george - ... Southwestern Bell Telephone parking lot
george - THey showed some video that was taken looking up from near the blast crater.. you can see the indentations in the concrete where rebar was ripped out
john - Yeah, that was a BIG bomb
george - estimated at 1,000 lbs plus of explosive
george - The vehicle that delivered the bomb is believed to be a large van
george - update of dead is 52 officially, 12 are children
john - REMINDER: this channel is intended for NEWS and UPDATES only.. please keep talk to #oklahoma1...Since this time, Internet resources for disaster related information have grown considerably. There is now a centralized Web site with links to sties on the Web that are maintained by over a dozen different official emergency organizations (see appendix 2 or look up http://www.vita.org/disaster/others.html). It can be seen from this example that there is a need to address the mental health aspects of a national disaster by means of the Internet. An email discussion group was formed around the topic of this bomb attack, but it was not done by any official disaster related organization.
Suggested Therapeutic Uses of the Internet in DMH
On-line virtual communities and activities expand the social contacts available to the participant. More relationships are possible, with people that are not available to share with any other way. "The number of and diversity of social contacts" can be greatly extended by computer social networks (Wellman, 1995). In times of great stress it is social contacts that people turn to, to get the buffering effect and the emotional support they need. Those people already connected on-line when a national disaster strikes are going to reach out to each other for information and support. There are ways that DMH teams can facilitate victims of disasters in using Internet resources to help cope with a tragedy. One of the main goals of CISD is to help the person in crisis to begin to normalize their experience. Mental health workers are trained to go into disaster sites and encourage victims to recount details of their experience, using therapeutic skills such as active listening, and cognitive reframing. They inform victims of the naturally occurring effects of traumatic stress, and reassure them that they are experiencing a normal reaction to an abnormal event. However, the number of such workers available for this pales in comparison to the number of victims in a large natural disaster. The average length of contact with a crisis victim is less than 10 minutes (Aguilera, 1995).
If an Internet forum was available that was monitored in times of crisis by trained mental health professionals, people from the disaster site could extend the amount of time they are able to get psychological help. The email address or password would be given to the CISM team, so that only people in the disaster site would receive it. This would assure the mental health professionals using the Internet that they were offering assistance to those truly in need, and would greatly extend the nature of and the time of the therapeutic contact. The kind of grassroots Internet efforts that have accompanied recent major disasters contain rumors, misinformation and even bad advice. This is a reflection of the of social exchange of information that occurs during such an incident off line, but the broadcast nature of virtual communities makes this problem more significant. If DMH organizations were prepared, official moderated IRC channels and email discussion groups could be created the moment a disaster strikes. This would not stop the grassroots efforts, but it would offer a needed alternative. Moderated groups (where messages must be approved before dissemination) are more consistent sources of both information and emotional support. Individuals in crisis from a disaster trauma that contacted a central clearinghouse staffed by trained professionals could be invited into a closed IRC channel for one to one counseling. It is reasonable to expect a counselor to be able to keep up with the typed messages and respond to 3 or 4 such channels at one time. Nightmares and sleep disturbances are an expected reaction to disaster trauma. The 24 hour availability of the net makes it a great resource for treating flare-ups as they occur. An additional benefit of an increased on-line therapeutic professional presence is the data such an effort would generate. A few of the research question in the field that are currently being explored include; Which groups of people are at highest risk for negative effects? What kinds of factors modify the impact of exposure to a disaster crisis? (Solomon, 1992). The messages generated in an official Internet therapeutic effort could be analyzed to see what they reveal about such issues, provided that the use of human subjects in such a virtual forum was done in an ethical manner (King, 1996).
Conclusion
PTSD is a serious, debilitating failure to cope successfully with overwhelming stress. The DSM - 4 lists the lifetime occurrence prevalence rates at 1% to 14%. In populations considered at risk, such as disaster victims, this rate is much higher. CISD is being used extensively to increase peoples ability to cope with the kinds of extraordinary stressful events that have been associated with he development of PTSD. The social support component of a successful CISD intervention can not be understated. Virtual communities are computer supported social networks that can easily provide "emotional support, companionship, information and a sense of belonging from the comfort of ones own home" (Wellman, 1995). The therapeutic value to participants of such virtual forums designed to give and receive emotional support has been documented (King, 1994; Finn, 1994).
The APA has over two thousand psychologists already on it's DRN. The American Association of Behavioral Therapists has formed a special interest group, to educate psychologists about the use of computers in psychology. There are many efforts in progress in the social sciences to evaluate the psychology of the use of computers, and the interpersonal dynamics of virtual social networks. Internet access is b y no means universal at this point. Possession of a home personal computer is out of reach for many, and will remain so for some time. However, the trend is clear. In time, communicating over the Internet will be part of most peoples' daily life. Some natural disasters leave people temporally without electricity. There is a need to have mobile communication systems in place. Advances in wireless, portable personal communication devices will allow people made homeless by a disaster to contact their virtual communities from a first aid station, decreasing the stress on themselves and others by reassuring loved ones they are a survivor. The kind of Internet provided professional therapy advocated here has it's own set of ethical and legal dilemmas. The nature of the therapeutic alliance that can be formed by the exchange of text is unstudied at this point. There are certainly drawbacks, but the advantages mentioned here deserve to be examined. Recent advances in technology have allowed the creation of new forms of social interaction. This demands a corresponding reevaluation of the means by which large scale, emergency mental health efforts can be conducted.
References
Aguilera, D. M. & Planchon, L. A. (1995). "The American Psychological Assoication - California Psychological Assoication Disaster Response Project; Lessons from the Past, Guidelines for the Future."
Professional Psychology Research and Practice 26, 6, 550-557.Armstrong, K., O'Callahan, W. & Marmar R. C. (1991. ) "Debriefing Red Cross Disaster Personal: The Multiple Stressor Debriefing Model." Journal of Traumatic Stress, 5,4, 581 - 592.
Boscarnio, J. A. (1995). "Post-Traumatic Stress and Assoicated Disorders Among Vietnam Veterans: The Significance of Combate Exposure abd Social Support." Journal of Traumatic Stress, 8,2, 317 - 336.
Cook, J. D. & Bickman L. (1989). "Social Support and Psychological Symptomatology Following a Natural
Disaster." Journal of Traumatic Stress.Cutler, R. (1994, Nov). "Self & Community in Cyberspace" Presented in panel at the 1994 Speech Communication Association, New Orleans, November 21.
Jackobs, G. A. (1995). "The Development of a National Plan for Disdaster Mental Health." Professional Psychology Research and Practice 26,6, 543-549.
King, S. A. (1994, July). "Analysis of Electronic Support Groups for Recovering Addicts" Interpersonal Computing and Technology: An Electronic Journal for the 21st Century, 2, 3, 47- 56. http://www.notredame.ac.jp/ftplib/Articles/CMC/King94.txt
King, S. A. (1996). Researching Internet communities: Proposed ethical guidelines for the reporting of the results. The Information Society, 12, 2, 119-127.
Linton, C. J. (1995). "Acute Stress Management With Public Safty Personnal; Opertunities for Clinical Training and Pro Bono Community Serviece." Professional Psychology Research and Practice 26, 6, 566-573.
Finn, J. & Lavitt, M. (1994). "Computer Based Self-Help Groups for Sexual Abuse Survivors". Social Work With Groups, 17, 21-46.
Sproull, L. & Kiesler, S. (1995). "Computers, Networks and Work". Scientific American, a special issue, "The Computer in the 21st Century."
Solomaon, S. D. & Green, B. L. (1992). "Mental health Effects of Natural and Human-made Disasters." PTSD Research Quarterly, 3, 1 p. 1.
Stoll, C. (1995). Silicon Snake Oil: Second Thoughts on the Information Highway. New York: Doubleday.
Wellman, B. & Gulia, W. (1995). "Net Surfers Don't Ride Alone: Virtual Communities as Communiteis." Communities in Cyberspace University of Californis Press.
Wellman, B. (1996). "An Electronic Group is Virtually a Social Network." Reasearch Milestones on the Information Highway.
Created and maintained by Storm A. King
last updated 01/2006
