April's Fury 2011, mental health, natural disasters, posttraumatic stress disorder (PTSD), prolonged grief disorder (PGD), psychological first aid (PFA)



  1. Wynn, Stephanie T.


ABSTRACT: Natural disasters leave survivors suffering physically, psychologically, and spiritually. An EF4 tornado on April 27, 2011, in Tuscaloosa, Alabama, known as April's Fury, raised the question of how mental health practitioners (MHPs) might respond to address psychological needs, rather than being exclusively assigned to offer physical support immediately following a disaster. This article proposes planning ahead for MHPs to provide psychological first aid (PFA) in the immediate aftermath of a catastrophe. Combating psychological issues early will hopefully help reduce the development of posttraumatic stress disorder (PTSD) or prolonged grief disorder (PGD) in survivors.


Article Content

Sadly, news of devastating natural disasters is commonplace. After catastrophic events, survivors suffer physically, psychologically, and spiritually. As a mental health practitioner, I witnessed the chaos that transpired immediately following the EF4 tornado known as April's Fury, which caused much injury, death, and destruction on April 27, 2011, in Tuscaloosa, Alabama. The results of this natural disaster were heartbreaking. The disaster left many healthcare providers in the area asking how mental healthcare professionals might respond to help survivors of a natural disaster immediately following the traumatic event.

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.
Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.


By their character, traumatic events are dangerous, frightening, and unpredictable. Without warning, survivors are exposed to horrendous suffering and threat to life that cause feelings of panic, terror, and vulnerability. A natural disaster can compromise the person's precrisis level of functionality, from the initiation of the threat until the capability to cope efficiently is resumed. The profound and enduring effects on mental health and psychosocial welfare can considerably impact social and economic development, as well as recovery efforts (Weissbecker, 2009). Therefore, following the immediate physical and medical necessities that occur with a traumatic event, such as a natural disaster, is the need for mental health services. Whether functioning in a role as a psychologist, psychiatrist, psychiatric nurse, or psychiatric nurse practitioner, MHPs have an opportunity to serve in fundamental roles in trauma identification, first response, and recovery.


However, many professional disaster-training programs are focused on providing information on physical actions to take if a natural disaster occurs. During a tornado, people encounter the danger of being struck by flying or falling objects as a result of extreme winds. Other medical hazards occur from being moved by the force of the wind or structures collapsing on individuals. As with any natural disaster, first responders focus to mobilize, establish safety, and supply essential emergency relief aid to survivors (Grigg & Hughes, 2010; Shughart, 2011). Many evidence-based disaster plans include elaborate steps for implementation after a natural disaster (Auf der Heide, 2006), yet few, if any, include the assessment of mental health status. As a result, the emphasis of care is on the medical and physical issues associated with the catastrophe. The impersonal trauma caused by the destruction is not a priority during a natural disaster; thus, the psychological effect on survivors often is overlooked (Weissbecker, 2009). MHPs have an essential role in assessing, diagnosing, and managing the treatment of emotional distress, as well as prevention of further distress, caused by the unwelcome trauma of natural disasters.


All traumatic experiences associated with natural disasters should be noted as life-changing events that disrupt the lives of many. Although there is a lack of specific research evidence about the mental health of those impacted by tornados, some studies have proven the stress reactions caused by natural disasters can lead to lasting posttraumatic stress disorder (PTSD) (Drescher & Foy, 2009). Research suggests that greater than a third of survivors of natural disasters suffer from PTSD (Warsini et al., 2014). Noteworthy is the increase in the development risk of other psychological issues, including suicidal ideation found in survivors of traumatic events (Bergh-Johannesson, 2010). This risk not only affects the survivors of the disaster but surrounding family and friends.



The majority of psychological reactions to natural disasters are typically abrupt, mild, and temporary. For several days to weeks, survivors may struggle with sleeping, planning, concentrating, making decisions, and setting priorities. Weeks to months after a natural disaster, survivors may experience intense grief and sadness. Anxiety and depression disorders have been noted in survivors for several years, following a natural disaster (Hussaina, Weisaetha, & Heira, 2011). PTSD, a Trauma- and Stress- or Related Disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition: DSM-5 (American Psychiatric Association [APA], 2013a), develops in response to actual or threatened death, serious injury, or sexual violation. Using DSM-5 PTSD criteria, the individual must either directly experience the traumatic event, witness the traumatic event, learn the traumatic event occurred to a close family member or friend, or experience first-hand repeated or extreme exposure to disturbing details of the traumatic event (APA, 2013b). Thus, the potential is high for developing PTSD following a natural disaster.


Posttraumatic stress disorder lasts at least 1 month and is characterized by symptoms in four areas. First is reexperiencing spontaneous memories of the traumatic event, possibly with recurrent dreams, flashbacks, or other psychological distress. Second is avoidance or flight from distressing memories, feelings, or external reminders of the traumatic event. Third is negative cognitions and mood, where the person may have persistent and distorted thinking, such as inappropriately blaming self or others for what happened, estranging from others, disinterest in activities, or inability to remember key things about the traumatic event. Fourth, hyperarousal is characterized by a fight reaction, where the individual is hypervigilant. He or she engages in aggressive, reckless, or self-destructive behaviors, and experiences sleep disturbances (APA, 2013b). In summary, the person experiences clinically significant distress or impairment in social interactions, capacity to work, or other important areas of functioning.


Often, PTSD symptoms are accompanied by an emotional state of anxiety and depression, social alienation, and mistrust of family, friends, and social systems (Shakespeare-Finch & Green, 2013). The depression may be a result of prolonged grief disorder if the feelings of disbelief, anguish, and bitterness over the loss do not diminish after 6 months, and if problems with normal functioning remain. Mental health practitioners should be positioned within the community immediately following a natural disaster, for early identification of psychological reactions by survivors.



Mental health practitioners (MHPs) possess the skills to assist survivors to return to normal functioning as soon as possible by providing information on practical problem solving, social support, and education pertaining to normal and abnormal stress reactions, as well as promoting hope. After the initial shock, MHPs must be positioned throughout the affected community to implement mental health assessments. Training by MHPs on managing stress, as well as the provision of information on available resources throughout the community, should occur in shelters, churches, libraries, and other public facilities.


After April's Fury, the few available MHPs were assigned, alongside other professionals, to exclusively attend to the physical needs of survivors. Time constraints did not afford the MHPs an opportunity to adequately assess the mental status of the survivors. As healthcare professionals with mental health expertise, the MHPs voiced the need for a separate area to implement mental health assessments and psychological interventions. Eventually, a site was designated where storm survivors could voluntarily come to receive mental health assistance. However, research has shown traditional, office-based interventions are ineffective after crisis situations. Given the impact of the tornado on the community, only a small number of persons sought treatment from the MHPs; interventions should have been at the community level (Weissbecker, 2009). MHPs are needed after a natural disaster to provide the survivors with evidence-based psychological care.


Psychological first aid (PFA) is an evidence-informed modular approach, recommended as an early intervention to assist survivors in the immediate aftermath of a disaster (Lewis, Varker, Phelps, Gavel, & Forbes, 2013). The technique is used to care for survivors of disasters experiencing a wide range of early reactions related to physical, psychological, behavioral, and spiritual well-being. Some of these reactions may cause anguish that interferes with adaptive coping; recovery may be assisted by support from kindhearted disaster responders with mental health backgrounds. Although PFA is not designed as a professional behavioral therapy, or to deal with underlying personality issues, correct use of PFA technique decreases the initial distress caused by traumatic events and promotes short- and long-term adaptive functioning and coping.


As PFA includes the utilization of basic information-gathering techniques, the mental health status of survivors should be assessed by MHPs immediately following a disaster. The survivors' behavioral and cognitive functioning, which includes descriptions of appearance and general behavior, mood and affect, level of consciousness, motor and speech activity, cognition, and thought patterns should be evaluated. The findings of this rapid assessment are used to implement supportive activities in an accommodating manner. Overall, the execution of the mental health status examination should model healthy mental and emotional responses as any emergency first aid; it must be calm, courteous, organized, and helpful.



Guidelines for delivering PFA include interventions that promote safety, calmness, connectedness, self-efficacy, and hope (U.S. Department of Veterans Affairs, 2014). For the most part, a feeling of safety for the survivors is delivered through food, water, and medical attention. The provision of shelter and clothing addresses the needs and comfort of the survivors. MHPs should be friendly and compassionate while actively listening to survivors who decide to share stories and emotions. To assist in comprehension of the situation, the MHP should provide the survivor with accurate information about the disaster and relief efforts underway. Emphasis should be placed on reconnecting survivors with family and friends (Usher & Grigg, 2011). Consider practical suggestions that engage people in meeting their own needs. MHPs need to be familiar with the types and locations of services (governmental and nongovernmental) available to assist survivors. The overall plan of PFA is to reduce anxiety, fear, or depression while assisting survivors in returning to precrisis life roles. MHPs elevate the level of care provided to survivors of natural disasters by including PFA techniques to help ease painful emotions while promoting hope and healing.


The recommendations provided in the PFA Manual (U.S. Department of Veterans Affairs, 2014) proved to be effective caring for a survivor whose wife died as a result of the April's Fury tornado. As the widower spoke with an MHP, the concern for his children's emotions was apparent. The MHP instructed the man to think of times when the children would possibly miss their mother the most (e.g., mealtime and bedtime). The father was instructed to say something similar to, "It is hard not to have Mommy here with us right now," in an effort to acknowledge and decrease the feeling of discomfort, and to assist in coping with the loss. The father also was educated to assess for sudden changes in the children (e.g., sadness and anger). If he suspects these emotions are a result of missing their mother, he should make a statement such as, "Sometimes I am sad about Mom, too. It's okay to tell me when you are feeling sad so possibly I can help," to suggest the acceptability of those feelings. In addition, the father was taught therapeutic nonverbal communication techniques, such as sitting quietly with the children, and touching and hugging them, especially during times of sadness.


Mental health practitioners must also be aware of techniques to avoid, when offering PFA (U.S. Department of Veterans Affairs, 2014). Survivors must never feel compelled to tell their stories, especially personal details. Avoid reassurance statements such as, "You'll feel better soon" or "You are strong enough to deal with this." In addition, do not criticize survivors for their reactions related to their emotions, thoughts, or actions. It is contraindicated to offer reasons for survivors' suffering based on personal behaviors or beliefs, such as "God is in control." It's important not to speak poorly about or condemn existing relief services or activities in the presence of survivors. It's critical to not make promises that cannot be kept; survivors need as much stability as possible. In general, the MHP has the responsibility to use only evidence-based techniques to protect survivors from unnecessary exposure to trauma reminders.



The known qualities of MHPs are vital resources in assisting survivors in recovery from traumatic exposure and loss. Provider characteristics such as good listening skills, empathy, and trustworthiness are essential for survivors, following a natural disaster. The MHPs are most effective when being patient, caring, culturally competent, and nonjudgmental. Nonetheless, the MHP must be flexible and able to tolerate chaos (Usher & Grigg, 2011). Overall, good people skills are a requirement for MHPs to provide psychological aid after a natural disaster.


To facilitate the interventions of the MHP following a natural disaster, several additional resources, such as community leaders and the media, are essential. Trustworthy community leaders possess the ability to advise cooperative behavior and teamwork from their members that, at times, the government may lack (Patterson, Weil, & Patel, 2010). Because rumors are notorious during emergent situations, community leaders can help manage speculations by providing facts to survivors. The media are needed to accurately broadcast the availability and location of mental health resources; therefore, the accessibility of journalists, editors, and publishers is vital during this time (Miller & Goidel, 2009). Community leaders and the media assist survivors of natural disasters in making informed decisions through objective provision of information.



Survivors of a natural disaster often are interested, even more willing than normally, to include spirituality and religiosity in their thinking, responses, and coping mechanisms (Aten, O'Grady, Milstein, Boan, & Schruba, 2014). At this time, the opportunity exists for MHPs to incorporate positive religious coping methods, such as spiritual support from God or a higher power. Religious rituals are known to promote coping (Koenig, King, & Carson, 2012). Faith offers explanations and fosters belief that better times are ahead, assists in combating hopelessness associated with the devastation and gives inspiration to make crucial adjustments to adapt in the aftermath of the disaster. Survivors may not mention a spiritual need, but questions about spirituality are usually welcomed (Putman et al., 2012). Mental health practitioners will want to ask survivors if they have any religious or spiritual issues to be addressed, or how their beliefs can be helpful at this time. Survivors may use religious language to share their circumstances or desire to engage in prayer or other religious practices (U.S. Department of Veterans Affairs, 2014).


Some survivors want responders to pray with them and for them. Hence, MHPs should become familiar with clergymen who are a part of the disaster response team, or with local religious organizations willing to accept referrals. Clergy are able to offer prayer and meditation techniques to instill hope in the survivors. They serve as reminders of "when the storm has swept by, the wicked are gone, but the righteous stand firm forever" (Proverbs 10:25, NIV). Local clergy may be beneficial in locating religious objects, such as sacred books or prayer beads that may have been lost or left behind during the storm. Faith-based organizations provide a sense of security and decrease emotional stress in ways exclusively understood by those who share their faith (Putman et al., 2012), and should serve as additional spiritual assets. Additionally, encourage survivors to record their thoughts and prayers through journaling (Putman et al.). As it is common for survivors of a natural disaster to rely on religious and spiritual beliefs/practices during the recovery process (Aten et al., 2014), MHPs should draw upon divine resources while delivering PFA.



After April's Fury, the majority of survivors displayed symptoms of psychological distress. However, in this disaster, the skills of the available MHPs were not used appropriately. Instead of using MHPs to provide PFA, MHPs were placed in positions to care for the physical needs of the survivors, leaving no time to address mental health concerns. At one point, a few of the MHPs attempted to provide psychological care for survivors at a designated site outside of the affected community; however, the intervention was ineffective and not well used by survivors. In hindsight, MHPs should have been situated to exclusively respond to psychological contacts initiated by survivors, or to initiate contacts in a nonintrusive, compassionate, and helpful manner.


Combating psychological issues early following a natural disaster will hopefully help reduce the development of posttraumatic stress disorder (PTSD) or prolonged grief disorder (PGD) in survivors. As community leaders, the media, and clergymen appear to meet the psychological issues of many survivors, MHPs should integrate their services with the provision of PFA. Spirituality can provide survivors meaning and coherence, which assists them with the eventual integration of the negative event into a positive worldview. Overall, the MHP has the skills to ensure an efficient, coordinated, and effective response to the emotional needs of survivors following a natural disaster. In the future, planning for, coordinating, and supporting PFA delivered by mental health practitioners should occur, to more effectively assist with imminent disaster responses.


American Psychiatric Association. (2013a). Diagnostic and statistical manual of mental disorders, 5th edition: DSM-5. Arlington, VA: Author. [Context Link]


American Psychiatric Association. (2013b). Posttraumatic stress disorder. Retrieved from[Context Link]


Aten J. D., O'Grady K. A., Milstein G., Boan D., Schruba A. (2014). Spiritually oriented disaster psychology. Spirituality in Clinical Practice, 1(1), 20-28. doi:10.1037/scp0000008 [Context Link]


Auf der heide E. (2006). The importance of evidence-based disaster planning. Annals of Emergency Medicine, 47(1), 34-49. doi:10.1016/j.annemergmed.2005.05.009 [Context Link]


Bergh-Johannesson K. (2010). Traumatic exposure, bereavement and recovery among survivors and close relatives after disaster (Unpublished doctoral dissertation). Uppsala University, Uppsala, Sweden. [Context Link]


Drescher K., Foy D. (2009). When horror and loss intersect: Traumatic experiences and traumatic bereavement. Pastoral Psychology, 59(2), 147-158. doi:10.1007/s11089-0090262-2 [Context Link]


Grigg M., Hughes F. (2010). Disaster mental health. In R. Powers & E. Daily (Eds.), Disaster nursing international (pp. 449-472). Cambridge: Cambridge University. [Context Link]


Hussaina A., Weisaetha L., Heira T. (2011). Research report: Psychiatric disorders and functional impairment among disaster victims after exposure to a natural disaster: A population based study. Journal of Affective Disorders, 128(1), 135-141. doi:10.1016/j.jad.2010.06.018 [Context Link]


Koenig H. G., King D. E., Carson V. B. (2012). Handbook of religion and health (2nd ed.). New York, NY: Oxford. [Context Link]


Lewis V., Varker T., Phelps A., Gavel E., Forbes D. (2013). Organizational implementation of psychological first aid (PFA): Training for managers and peers. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication. doi:10.1037/a0032556 [Context Link]


Miller A., Goidel R.(2009). Organizations and information gathering during a natural disaster: Lessons from Hurricane Katrina. Journal of Contingencies & Crisis Management, 17(4), 266-273. doi:10.1111/j.1468-5973.2009.00586.x [Context Link]


Patterson O., Weil F., Patel K. (2010). The role of community in disaster response: Conceptual models. Population Research and Policy Review, 29, 127-141. doi:10.1007/s11113-009-9133-x [Context Link]


Putman K. M., Blair R., Roberts R., Ellington J. F., Foy D. W., Houston J., Pfefferbaum B. (2012). Perspectives of faith-based relief providers on responding to the needs of evacuees following Hurricane Katrina. Traumatology, 18(4), 56-64. doi:10.1177/1534765612438945 [Context Link]


Shakespeare-Finch J., Green J. (2013). Feature story: Social support promotes psychological well-being following a natural disaster. National Emergency Response, 26(3), 14. [Context Link]


Shughart W. F. (2011). Disaster relief as bad public policy. Independent Review, 15(4), 519-539. [Context Link]


U.S. Department of Veterans Affairs. (2014). Psychological first aid: Field operations guide. Retrieved from[Context Link]


Usher K., Grigg M. (2011). Responding to traumatic events. Australian Nursing Journal, 18(9), 32-35. [Context Link]


Warsini S., West C., Ed Tt G. D., Res Meth G. C., Mills J., Usher K. (2014). The psychosocial impact of natural disasters among adult survivors: An integrative review. Issues in Mental Health Nursing, 35(6), 420-436. doi:10.3109/01612840.2013.875085 [Context Link]


Weissbecker I. (2009). Mental health as a human right in the context of recovery after disaster and conflict. Counseling Psychology Quarterly, 22(1), 77-84. doi:10.1080/09515070902761065 [Context Link]