Suffering breaks our world.
Like a tree struck by lightening —splintered, shaken, denuded
Our world is broken by suffering, and we will never be the same again.
                    ...Nathan Kollar

In just the past few months, we have witnessed two major hurricanes in the Gulf States and now a massive earthquake in India, Pakistan and Afghanistan. Thousands of people have been killed, others have been left homeless without possessions, towns and cities. The massive evacuation of people in anticipation of Katrina and Rita in Alabama, Louisiana, Mississippi and Texas disrupted the lives of thousands of residents. People were often given little warning when told to evacuate. They left homes, pets and possessions behind and put lives and businesses on hold to avoid the path of these natural disasters. Some returned to intact homes, others to shambles, rubble or debris. Hurricane and earthquake survivors, witnesses and evacuees have been left dazed, tired, angry, confused and devastated. Their lives have been shattered, like the tree struck by lightening, and they may never be the same again.

Natural traumatic events—hurricanes, fires, earthquakes, tsunamis, tornadoes and floods—are strong reminders of how vulnerable we are to the powerful unexpected forces of nature. Whether the loss of a home, or the loss of a loved one, sudden traumatic events shatter a person's world, destroy what was once familiar and upset the normal sense of safety and stability. Viewing images of destruction, waiting and worrying about safety of family and friends in these areas, have left many witnesses, observers and others feeling shaken and unsure. Survivors are left splintered, shaken and denuded.

Equally damaging has been the result on the overall health and well being of survivors to these disasters. The emotional impact of a traumatic event may be felt for years, and for many whom have lost everything—a lifetime. This article provides survivors and professionals who may be treating survivors with information to understand traumatic events, the resulting normal responses and coping strategies to start restoring their health, so disrupted by these unexpected events.

Understanding Traumatic Events

A traumatic event is "an experience that causes physical, emotional, psychological distress, or harm," (1) or "an event, or series of events, that causes moderate to severe stress reactions." They are characterized by a sense of horror, helplessness, serious injury, or the threat of serious injury or death. (2) A traumatic event is perceived and experienced as threat to one's safety or stability. It may involve experiences, changes or emotions, such as: physical injury or illness, separation from parents (perceived abandonment), death of a friend, family member, or pet, violence of war, terrorism or mass disaster, divorce, loss of trust, a move to a new location, hospitalization, anxiety, fear or pain. (1)

Devastating, natural trauma—hurricanes, earthquakes, fires and floods—can significantly impact a person's overall health and wellness. (3) The effects of a natural disaster can be long lasting. Traumatic events affect those who have been directly affected by suffering injuries or loss(es) (primary survivors). They can also affect people indirectly, those who have witnessed the events either firsthand or on television (secondary survivors). Additionally rescue workers, emergency and medical personnel, counselors, relief work volunteers, chaplains, friends and relatives of victims who have been involved may also be impacted by the traumatic event as secondary survivors.

Focusing on the Basics of Coping
When helping traumatic event survivors, their physical and safety needs must be addressed first. Surviving the first 72 hours can be difficult and chaotic. Survivors may need to be reminded to simply care for themselves and attend to the basic survival needs of the body. Focusing on the basic necessities—personal safety, basic health needs, eating and sleeping—can help to re-establish some sense of control, in coping with events that may been beyond anyone's control. (4,5)

Initially, survivors need to:
1. Take it one day at a time.
2. Eat a well balanced diet.
3. Drink plenty of water.
4. Avoid using excess alcohol, medications or drugs to mask the pain.
5. Try to keep up basic hygiene. Remember basic grooming and appearance.
6. Get enough sleep or enough rest.
7. Get some kind of exercise. Even walking can help relieve stress and tension.
8. If at all possible try and maintain some type of a normal routine, such as sleeping and eating at your regular times.
9. Talk to others, especially those who have lived through and survived similar experiences.
10.Remember healthy coping strategies you have used to survive past challenges. Draw upon these inner strengths and skills again.

More Suggestions for Living Through a Traumatic Experience
After tending to the basics necessities, survivors can focus on a bit more. Additional suggestions for coping during traumatic times are found in the table below. They are developed from Dr. Mark Lerner, clinical psychologist and traumatic stress consultant and President of the American Academy of Experts in Traumatic Stress.

Common Normal Responses Following a Traumatic Event
The recent series of natural disasters have served as powerful reminders that we cannot control the events in our lives. We can, however, control how we will respond in difficult times and choose to view traumatic events. Gaining knowledge and understanding the common responses that occur following a traumatic event can return a sense of control over the chaos and seemingly random occurrences that result in the aftermath of a natural disaster.
 

The stress reactions and grief responses that follow a traumatic event are normal and very common. Many survivors have lost loved ones, their homes and worldly possessions, experiencing multiple traumas and multiple losses.
 

Traumatic events impact physical, emotional, psychological, behavioral, social, spiritual, environmental and financial well being, disrupting the survivor's normal balanced state of wellness. (3,5) Grief is the normal reaction to loss. Grieving is the process a person goes through while restoring the balance to his or her health and life.

Some of the common reactions that occur include fear, anxiety, numbness, sadness, depression, anger and rage. Other reactions include:

• Negative view of the world

• Moodiness

• Impatience or irritability, feeling jumpy

• Startling with loud noises

• Changes in appetite—eating too much or not being hungry

• Problems concentrating

• Difficulty in school

• Wanting to be alone more often than usual, or not wanting to be alone at all

• Re-experiencing the trauma—in daymares, nightmares or flashbacks

• Increased use of alcohol/drugs to cope with traumatic event, impairing recovery

• Tearful at unexpected moments, crying more easily or wanting to cry all the time

• Avoidance of situations that remind the survivor of trauma—places, time of day

• Difficulty sleeping, nightmares

• Loss of interest in previous activities

• Plans for the future no longer matter (7)

Common physical responses include nausea, diarrhea, stomachache, headache, dizziness, rapid heart rate, lightheadedness, allergies, rashes, grinding of teeth, increased colds and flu-like symptoms.(2, 7)

Understanding the normal responses that may result following a traumatic event can help survivors realize that certain responses may even be expected; they are normal reactions to a major loss.

It helps survivors to know that they are not “losing it” or “going crazy,” rather what they are experiencing are normal responses to an abnormal event. Survivors need to take care of themselves and understand that these normal responses and feelings are their body's way of coping with a major life-altering event. This knowledge can make physical and emotional responses less disturbing and overwhelming. (3,4)
 

When to Seek More Support
Most people who have been directly involved with a painful, extraordinary stressful, traumatic event will be affected in some way. Many will require some form of assistance, whether financial, environmental, physical, emotional or psychological. How a survivor reacts to a traumatic event depends on that person's perception of the events, his/her previous experiences with prior challenges or traumas, his/her coping abilities and the level of available existing support.

In general, the intense physical and emotional responses start to lessen within two weeks and often disappear within four to six weeks as life continues and the survivor's attention becomes focused on other things.

Many people feel better within three months after the event, but others recover more slowly, and some do not recover without help. Much depends on the survivor's coping skills, prior state and the nature and the extent of the losses sustained. Someone who has experienced multiple major losses e.g. loss of home or possessions, death of a loved one or multiple traumas may take longer to recover. Research indicates that 20-30% of persons directly affected by a major traumatic event will require some type of long-term emotional support such as counseling. (2,7)
 

Any trauma survivor feeling or showing any of the following symptoms should seek professional help.

• Prolonged agitation or anxiety

• Depression or extreme hopelessness

• Impaired daily activities or job function

• Suicidal thoughts or ideation

• Prolonged, inhibited or absent grieving

• Extreme physiologic or psychological reactions

• Substantial guilt

• Substance abuse – alcohol or drug use

• Psychotic states

• Uncontrolled rage

Various supportive resources that survivors may find helpful include: emergency response teams, counselors, social workers, physicians, nurses, healthcare professionals, clergy, therapists, support groups and leaders, mental health professionals and other survivors.

Helping the Survivors
The Center for Disease Control’s Emergency Preparedness & Response Disaster Mental Health Resources offers ways for healthcare providers to address the emotional needs of survivors and help them cope with the traumatic event: (2)

• Identify concrete needs and attempt to help. Traumatized persons are often preoccupied with concrete needs (e.g., How do I know if my friends made it to the hospital?).

• Keep to their usual routine.

• Help identify ways to relax.

• Face situations, people and places that remind them of the traumatic event— not to shy away.

• Take the time to resolve day-to-day conflicts so they do not build up and add to their stress.

• Identify support sources, i.e., family and friends. Encourage talking about their experiences and feelings with friends, family, or other support networks (clergy and community centers).

Making Sense of Loss & Picking up the Pieces
Trying to make sense of or find meaning sudden catastrophic losses can be difficult. Natural disasters such as hurricanes Rita and Katrina, the Asian earthquake, or last Christmas' tsunami are beyond anyone's control; they are reminders of how susceptible we are to the whims of nature. Natural disasters cause sudden, devastating, insensible losses that cannot be explained. Witnesses are left with the realization that life is not always fair and that sometimes bad things happen to good people.

We are left asking the poignant question "Why?"

It is human nature to want to answer the questions "Why?" "Why me?" and "Why did this happen?" yet it may be impossible to ever find an answer. Asking "Why" may be counterproductive, especially when working on recovering and rebuilding. Perhaps the more worthwhile question to ask is, "How do I pick up the pieces and go on living as meaningfully as possible?"

Picking up the pieces of a shattered life and finding ways to keep on living is a challenge. Many survivors discover an internal core of strength, others rely on their faith, and still others cope by making sense of or finding personal meaning in the events. They view the event as a chance to be reborn, a turning point or a wake-up call in their life.

Realizing that Life Goes On
Dr. Elisabeth Kübler-Ross said of mourning, that "it usually ends when people realize that they can live again, that they can concentrate their energies on their lives as a whole…". In time survivors come to cope with the difficulties and the challenges, integrate the loss, and begin to rebuild a new life—a life forever change by the events. Integrating traumatic events into a new life involves giving up on old dreams and not spending a lifetime mourning what might have been. Survivors learn to accept what their life is now.
 

The destruction caused in a few hours by hurricanes Katrina and Rita or the Asian earthquake may take years to repair. Yet in the midst of the destruction there are signs of life. Les Brown once offered the wise words, "Change is difficult but often essential to survival."

Although the setbacks from Rita were difficult, residents of these states are changing in order to survive. They are living by the words "Laissez les bons temps rouler," "The good times will roll again."

Slowly, survivors start to live again. In time, they begin living a new life, believing that life is worth living and that most of all, despite tragedy...life goes on.

21 Things You Can Do While You're Living Through A Traumatic Experience (6)
	Take immediate action to ensure your physical safety and the safety of others. If it’s possible, remove yourself from the event/scene in order to avoid further traumatic exposure.		Traumatic stress may compromise your ability to think clearly. If you find it difficult to concentrate when someone is speaking to you, focus on the specific words they are saying.  Work to actively listen. Slow down the conversation and repeat what you have just heard.
	Address your acute medical needs (e.g., if you’re having difficulty breathing, experiencing chest pains or palpitations, seek immediate medical attention).		Don’t make important decisions when you’re feeling overwhelmed. Allow trusted family members or friends to assist you with necessary decisionmaking.
	Find a safe place that offers shelter, water, food and sanitation.		If stress is causing you to react physically, use controlled breathing techniques to stabilize yourself. Take a slow deep breath by inhaling through your nose and then exhale slowly through your mouth. Upon exhalation, think the words “relax,” or “let go.” Repeat this process.
	Become aware of how the event is affecting you (i.e., your feelings, thoughts, actions; your physical and spiritual reactions).		Realize that repetitive thinking and sleep difficulties are normal reactions. Don’t fight the sleep difficulty. Try the following: Eliminate caffeine for 4 hours prior to your bedtime, create the best sleep environment you can, consider taking a few moments before turning out the lights to write down your thoughts, thus emptying your mind.
	Know that your reactions are normal responses to an abnormal event. You are not “losing it” or “going crazy.”		Give yourself permission to rest, relax and engage in non-threatening activity. Read, listen to music, consider taking a warm bath, etc.
	Speak with your physician or healthcare provider and make him/her aware of what has happened to you.		Physical exercise may help to dissipate the stress energy that has been generated by your experience. Take a walk, ride a bike, or swim.
	Be aware of how you’re holding up when there are children around you. Children will take their cues from the adults around them.		Create a journal. Writing about your experience may help to expose yourself to painful thoughts and feelings and, ultimately, enable you to assimilate your experience.

Try to obtain information. Knowing the facts about what has happened will help you to keep functioning.

If you find that your experience is too powerful, allow yourself the advantage of professional and/or spiritual guidance, support and education.

If possible, surround yourself with family and loved ones. Realize that the event is likely affecting them, too.

Try to maintain your schedule. Traumatic events will disrupt the sense of normalcy. We are all creatures of habit. By maintaining our routines, we can maintain a sense of control at a time when circumstances may lead us to feel a loss of control.

Tell your story. And, allow yourself to feel. It’s okay not to be okay during a traumatic experience.

Crises present opportunities. Cultivate a mission and purpose. Seize the energy from your experience and use it to propel you to set realistic goals, make decisions and take action.

You may experience a desire to withdraw and isolate, causing a strain on significant others. Resist the urge to shut down and retreat into your own world.

References
1. Medline Plus. 2004. Medical Encyclopedia: Traumatic events. Available at: http://www.nlm.nih.gov/medlineplus/ ency/article/001924.htm
2. CDC. 2003. Coping With a Traumatic Event: Information for Health Professionals. Emergency Preparedness & Response. Available at: http://www.bt.cdc.gov/masstrauma/ copingpro.asp
3. Stebnicki MA. 2002. The Psychological Preparation for Extraordinary Stressful and Traumatic Events. East Carolina University Off of Enviro Health/Safety. Available at: http://www.ecu.edu/oehs/EmergencyProcedures/ psyprep.htm
4. Dyer KA. 2002. Dealing with Sudden, Accidental or Traumatic Death. Basics on Coping for the Survivor. Available at: http://www.journeyofhearts.org/jofh/grief/accident2
5. Dyer KA. 2004. Enhancing Well Being by Understanding Grief and Taking a Loss History. Medical Wellness Journal. At: http://www.medicalwellnessassociation.com/docs/ medwellnessjourn_vol2.pdf
6. Lerner MD. 2005. 21 Things You Can Do While You're Living Through a Traumatic Experience. Available at: http://www.aaets.org/column5.htm
7. Dyer KA. 2001. Health Concerns for Witnesses to the
Events. Available at: http://www.journeyofhearts.org
8. Lerner MD. 2005. How Can We Help Grieving Individuals
in the Wake of Hurricanes Rita and Katrina? Available at:
http://www.aaets.org

Emergency Preparedness Resources
1. The Department of Homeland Security: http:// www.ready.gov/index.html
Includes information for putting together a disaster kit of emergency supplies and creating a family plan.
2. Federal Emergency Management Agency: http:// www.fema.gov/preparedness/community_prepare.shtm Includes Community and Family Preparedness
3. Red Cross: http://www.redcross.org/services/ disaster/0,1082,0_501_,00.html
Includes Disaster Services and Disaster Safety.
4. Hurricane Awareness: http://www.redcross.org/news/ ds/0305hurricane/index.html
5. CDC Emergency Preparedness & Response Site: http:// www.bt.cdc.gov/
Includes various resources for coping with different agents, diseases and other threats.
6. San Francisco, Office of Emergency Services and Homeland Security: http://www.72hours.org

Disaster Mental Health Resources
1. CDC Emergency Preparedness & Response Site: http:// www.bt.cdc.gov/mentalhealth/
Includes an extensive section on Disaster Mental Health.
2. The American Academy of Experts in Traumatic Stress: http://www.aaets.org
3. Acute Traumatic Stress Management: http://www.atsm.org