During the Gulf War, Iraq fired Scud missiles at Israeli cities, aimed at terrorizing and harming the civilian population. This study examined the public health, interpersonal, cultural and individual methods by which a very vulnerable subset of the population - elderly nursing home residents - coped with the extraordinary stress of those attacks. _________________________________________________________________________________________________ Surviving Disaster: What We Can Learn from Elderly Civilians' Surprisingly Successful Coping With Missile

The history of psychology in this century include advances in the theoretical and empirical study of human beings’ responses to major national and international catastrophes. From Anna Freud’s studies of children under the bombing of London to the seminal examinations of survivors of Hiroshima and Viet Nam, we have observed the components of strength and weakness in human nature under siege.

Although the elderly have, of course, been affected by the crises of wars and their aftermaths along with the rest of the population, they have not been the focus of research attention. We have no systematic understanding of the role of historical memory and the value of a long-life perspective on the older person’s response to disaster. We have a growing understanding of the ways in which older people cope with personal stresses: death of a loved one, relocation, disability. We even have clinical insight into the adaptation required to cope with personal- crisis-once-removed, such as the breakup of an adult child’s marriage. Examination of the ways in which older adults cope with a mass emergency and the effect it has on them will help our understanding of the factors that facilitate or hinder adaptation and survival in the face of mass threat.

This paper reports observations of nursing home residents in a city subjected to missile attacks by a hostile enemy. Israel was a noncombatant in the Gulf War. Although not at war with Iraq, Israeli cities suffered frequent destructive missile attacks in densely populated residential areas. The missile attacks were accompanied by the threat of chemical warheads. This national trauma had two dimensions characteristic of severe stress; it was prolonged and it was unpredictable. The crisis contained elements of personal, familial and national threat. Every part of the society was affected by the trauma. We expected the frail, elderly population of a nursing home to be at particular risk from stress of this magnitude.
 

THE STUDY

We examined the experiences of residents of a small, proprietary nursing home in Jerusalem, and supplemented our observations by telephone contact with nursing home administrators in larger facilities in the Tel Aviv area. The 25 residents of the target nursing home had a mean age of 83, range 74-87. They had an average of 3 chronic illnesses, and had been living at the nursing home from one month to two years.

Anticipation

The missile attacks differed from many other types of mass emergencies because of the opportunity for preparation. As the deadline for Saddam Hussein to withdraw from Kuwait approached and the Middle East prepared for the eventuality of war, there was much speculation and anticipation in Israel. Anxiety rose when Iraq threatened to “burn half of Israel” and gas masks were distributed to the entire population. Gas masks can be frightening to wear; they hamper breathing and restrict peripheral vision. Public discussion aired private memories of the horrors of mass gassing of Jews in World War II. The nursing home residents, along with the rest of the country, had the opportunity to become apprehensive, but also, perhaps, to work through some of their feelings. Physical preparation for the possibility of attack included “gas-proofing” a room in the facility by sealing it with plastic sheeting and masking tape, and donning a gas mask. Outside of the facility the country prepared by calling up reserves in civil defense units. Television news showed hospitals rehearsing disaster plans. Within the facility management and some staff volunteered to spend the nights in order to be on hand if there were an attack.

In compliance with civil defense directives to avoid gathering large groups of people together, communal meals were suspended and the residents were served meals in their rooms.

Air raids occurred at night. The highest risk hours for Scud attacks were between 11PM and 4AM. At the siren’s wail, the population was directed to move quickly to their sealed rooms, don gas masks, and tune in to their radio to await instructions. The First Air Raid. Among the 25 residents there were several episodes of agitation on the first night, including violent acting-out by a confused resident who had had previous episodes of violence. He was a Holocaust survivor. During the first missile attack the population spent four hours in sealed rooms wearing gas masks and waiting to find out what had happened. Tension built as the minutes passed. Agitation and restlessness, anger and fear increased with the time spent in confinement.

As the attacks continued, adaptations were made. Structures and Interventions Supportive of Coping. Israeli society was mobilized to facilitate healthy adaptation to extraordinary stress throughout society, and the elderly were included. Among the interventions were the following:

1. Quick, clear, authoritative communication during the missile attacks. Military and civil defense authorities broadcast on television and radio within 10-20 minutes with credible and complete information (given security concerns). This virtually eliminated rumors and the chaos and anxiety they generate.

2. Families stayed together, which reduced worry about the safety of absent family members. Most significantly, schools were closed (again, avoiding the risk of large gatherings being hit), and children accompanied their parents to work or workers were excused to stay home with their children.

3. Television and radio increased their daily broadcast hours and included programming about mental health under the circumstances. Call-in shows enabled the airing and sharing of feelings. Experts discussed and advised methods of helping others, children in particular, cope with the situation. Television personalities and other celebrities participated. The “Big Bird” of Israeli Sesame Street took calls from the smallest children.

4. The amount of time spent in the sealed rooms was reduced. The experience of the first night indicated that severe stress was induced by prolonged confinement. Efforts were made to inform the population quickly that it was safe to leave the sealed rooms.

Coping Styles

After the first night, the most common methods of coping observed among the residents were expressions of cooperation and mutual support, information seeking, minimizing and intellectualizing. Religious and historical sources were drawn upon heavily to provide a context for comfort. Procedures were followed with flexibility and tolerance of individual needs. The confused, agitated Holocaust survivor who acted out violently at the first air raid was kept constantly at the administrator’s side during subsequent attacks. His security assured, there were no further episodes of acting out. One resident, a survivor of the London Blitz of WWII, refused to participate in defensive actions. She sat out the air raids alone in an open sitting area, protected only by her stiff upper lip.

The attacks triggered emotional episodes for several residents in which their earlier traumas and personal losses were reexperienced. This was most poignant in a resident who had survived the loss of two daughters and had lost a grandson in the Yom Kipppur War. Her grief expressed her personal tragedies and was perceived by others to express as well the pain of a nation who, although not at war, was once again in the victim’s role. Such emotional expression was tolerated, even respected by the staff, and elicited a great deal of support. But it was relatively rare.

Cooperation and Mutual Support. Disasters, crises, emergencies, or even just an unexpected event have been observed to engender neighborliness and social interaction in communities. New York City still marvels at its reaction to the great blackout of 1967! This seemed to be the case in the nursing home. Residents were distracted from their ordinary focus on issues of personal and physical concern during the national crisis. Residents became involved in the staff’s concerns for their own families. They became less demanding, more tolerant of delays and difficulties in service. Residents cut short visits with their own families, preferring that their family members be at home with their children in case of attack. Changes in routine were greeted cheerfully. Even the fairly dramatic change of having to eat their meals in their rooms rather than together was accepted gracefully, “Look at us, now we’ve got first class service! Private dining rooms!”

Minimizing. Complaints were discouraged by the other residents who seemed to feel that support and cooperation in this stressful time were patriotic necessities. This social norm was so powerful that Administration was surprised by the absence of complaints, difficulties and resistance to change.

Information-seeking. One method of gaining a sense of mastery in an uncontrollable situation is to be well-informed. Nursing home residents, along with everyone else, stayed constantly in touch with the news. Discussion, debate, political prediction and second-guessing was a favorite topic of conversation.

Intellectualization. Anxiety was kept at bay by placing the missile attacks in a larger perspective in an attempt to find meaning or understanding. The larger perspective that was brought to bear included history, geopolitics and religion. This context-creation and attribution effectively prevented despair despite 3 months of missile attacks and the debilitation of disrupted sleep.

Health Effects

We had expected to find health effects of the chronic stress punctuated by frequent sleep disruption, uncertainty, and acute public losses. We examined the following measures of deteriorated health: reduced function, more calls to nursing, more visits to the doctor, and increased mortality. We found no significant changes. Six months after the Gulf War ended, no increase in any of these variables was observed. Using the current paradigms of stress, coping and adaptation, we predicted long-term deleterious effects of the prolonged stress of bombing in this group of frail elderly. We found no such effects.

CONCLUSION

The stress and coping literature indicate that prolonged stress punctuated by unpredictable acute episodes that can neither be controlled nor mastered present the most severe challenge to coping. We hypothesized that three months of missile attacks is just such a stress for a civilian population. We predicted that a frail nursing home population would have difficulty dealing with the immediate onslaught, and would demonstrate long-term health and psychological effects of exposure to the stress. Although we found some adverse initial reactions among our subjects, we were surprised at their overall ability to adjust to the bombing period. No long-term health or behavioral effects were found.

Nursing home administration speculated that the coping methods used, especially mutual support and minimizing, repeated throughout the society, helped cushion the impact of the stress. In addition, the historical and religious context was felt to be a source of comfort and meaning. Furthermore, the relationship between expectation and reality may have worked to enhance the outcome in this case. The worst case scenario had been considered: that Iraq might use poison gas warheads. Relative to that horrifying possibility, the actual loss suffered was judged to be miraculously light. In the end, the triumphant outcome probably exerted a salutary effect. Finally, these were a group of people who had survived earlier wars, and worse. The unexpected resilience of these elderly people to intense stress perhaps demonstrates that the fittest survive.

The apparently successful cushioning of the impact of severe stress in this nursing home has implications for other disasters besides war. Some of the techniques applied here translate well. In emergency situations it is easy for communication to be intermittent and inconsistent, shared only in a partial, fragmented manner. Timely, credible and repeated information from a single authoritative source is both comfort and strength. Mutual support is found not only in small groups, but also through radio and television, call-in shows and hotlines that validate feelings and share experiences along with practical advice. Finally, it appeared that models of adaptive coping were reinforced by peer expectation. The adaptive model combined minimization of difficulties (not denial) with acceptance of intense emotional expression.
 

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Renee Garfinkel, Ph.D.
Visiting Scholar
Institute for Crisis, Disaster and Risk Management
School of Engineering and Applied Science
George Washington University
Washington, DC
Editor, Adoption Quarterly
2515 K Street, NW, Suite 403
NW Washington, DC 20037
Email: reneeg@erols.com