Ursano: Stopping post-traumatic stress disorder before it happens

Mental health professionals are aware of the importance of understanding the kinds of illnesses — such as depression and post-traumatic stress disorder (PTSD) — that can result from disasters both natural and human-made. But perhaps even more crucial, according to Robert J. Ursano, is that they understand the behaviors associated with such events.

That was the message of “Psychological and Behavioral Responses to Disaster,” a lecture in the social sciences given in the Radcliffe Gymnasium Tuesday (April 24) by Ursano, who is chairman of the Department of Psychiatry and director of the Center for the Study of Traumatic Stress (CSTS) at Uniformed Services University of the Health Sciences (USUHS) in Bethesda, Md. In addition to advising state and local governments — as well as federal and international agencies from the Department of Defense to the World Bank — CSTS, established in 1987 as part of USUHS’s Department of Psychiatry, conducts independent research, leads education initiatives, and trains first responders and other mental health workers on disaster preparedness.

Ursano began his talk by paraphrasing Neurosciences Institute founder and director Gerald Edelman’s statement that science is where imagination meets evidence. “The problem with science,” Ursano continued, “is that it often answers questions that are not the ones we want the answers to. It is only questions amenable to its tools that it can answer.” He then went on to outline the things he wouldn’t talk about, since science couldn’t measure them. Included were the “self-sacrifice, improvisation, creativity, dedication, and resilience” that go into any disaster relief effort, as well as the burdens disaster imposes on those who are already impoverished or disenfranchised, and the value of leadership and sufficient resources to recovery.

Over the years, “in working with people who had traumatic events,” Ursano said, “I noticed they had changed. They were one way before the events and another way after.” To understand why that is, he added, we must study the behaviors associated with disaster. Those behaviors include something as simple as teaching preschoolers to hold onto a red rope when they venture outdoors en masse — this is disaster preparedness. Wearing a seatbelt, he added, is a simple way to prevent PTSD, since the injured victims of motor vehicle accidents — as opposed to those who walk away unscathed — have the most severe responses to the trauma.

Ursano discussed how such principles can be applied to large-scale populations. It is critical, he noted, that we try to identify and act on “teachable moments” rather than waiting until disaster has struck. A public health campaign geared toward immunization against colds and flu, for example, might help head off a pandemic. A real-world precedent came during the 9/11 attacks. Fully 94 percent of the people in the World Trade Centers (WTC) at the time had never exited the building as part of a drill. After the first WTC bombing, in 1993, 30 percent of the workers decided not to evacuate and large groups — that is, 20 or more people — took an average of 6.7 minutes longer to leave the building.

“That’s not surprising,” said Ursano. “Large groups make decisions like committees, and operate on the same timetable.” Operational interventions such as appointing two group leaders for every floor could prevent such delays. “Having someone in charge of that decision could have protected 8,000 people,” he added.

“When disasters happen,” he said, “they open the fault lines in our society” — the areas we should not ignore until they are brought into relief by horrific events. The 2001 anthrax attacks, for instance, highlighted a problem that had been brewing for some time between management and labor at the postal service when employees — many of them African American — were given a less expensive prophylactic antibiotic. Though the drug was as effective as the pricier version — perhaps more so — employees felt they were being treated poorly, and racial tensions came to the fore.

When disaster does occur, Ursano pointed out, our responses are “more of a patchwork quilt than integrated.” In order for that to change, public health, medical care, and the emergency response system must work well not only internally, but with one another — and evidence-based interventions can be put to work in each area. “It’s difficult to do a double-blind, randomized trial during a disaster,” Ursano said, but prior knowledge and advance studies can help guide interventions for the primary victims, the bereaved, the first responders, and the community as a whole. For disasters are “multitrauma events,” according to Ursano. They “occur not only at the time of impact but following it. They are process events.”

The only way we can hope to break the chain of the process of trauma, Ursano made clear, is to build on the process of prevention.