DISASTERS AND MENTAL HEALTH--2003

 

Raquel E. Cohen

 

 

 

Disasters, whether natural or man-made, claim lives and property, devastating communities for long periods of life.  They are often events beyond our ability to predict, prevent and control.  Disasters impact on individuals to create survivors who must cope with trauma, loss and crisis to find the means to reconstruct their lives.  In afflicted communities large number of individuals are in the ranks of survivors and rescuers.

To design, organize and implement post-disaster crisis-oriented services, an integrated, interactive, flexible linkage system between the mental health organization and emergency management agencies needs to be established. It is important to realize that while mental health professionals organize to assist survivors, multiple activities are taking place within the other governmental/public system. Decision making about the ''life situation post-disaster” of the survivor in our care is also managed by other agencies. 

Identification of post-disaster need differences between groups of survivors is exemplified according to whether the physical impact of the disaster is direct or indirect:

Primary survivors- Those who have experienced maximum exposure to the traumatic event ( ).

 

Secondary survivors- Grieving close relatives of primary victims.

 

Third-level survivors- Rescue and recovery personnel, medical, nursing, mental health, Red Cross, clergy, emergency staff, firefighters, police, medical examiner, school personnel, administrators, children.

 

Fourth level victims- The community involved in the disaster – reporters, government personnel. 

 Fifth-level victims- Individuals who may experience states of distress or disturbance after seeing or hearing media reports (e.g., bodies of individuals falling down from the Towers after the terrorist attack in New York in September 2001).

 

Dividing and labeling timeframes in the sequence of a disaster is helpful to identify both the responses of survivors and programs that are organized to assist them.  Post-traumatic crisis has many of the clinical manifestations of loss, grief, bereavement, coping and adaptation. Although the reaction sequences are not of fixed duration there is a developmental process that has been identified and documented    Secondary events can influence these processes toward healthy resolution or  produce pathological syndromes. Observations of survivor behavior following a disaster are recorded in multiple types of media.  Variables like intensity of impact, extended geographical destruction, loss of life, loss of limb, rapidity of assistance are examples of modifiers that have emerged to categorize reactions to trauma. The inability to comprehend the reality of the destruction of the World Trade Center in New York following the terrorist use of commercial planes has been well documented by interviews of the mass media ( ).

 

Impact phase

Following the impact, the situation is dramatically and catastrophically experienced. Individuals in the affected areas will immediately mobilize themselves and participate with the efforts of rescue, shelter and safety for the citizens.  During these efforts, they will organize themselves in the areas of most trauma - dead, wounded, frail members of the community - and begin to apply their knowledge of first emergency aid while waiting for resources from the outside.

After the first days, when the issues of survival, shelter, food and water are the priorities, mental health issues present themselves as needing attention. The following list presents a summary of the key issues that need to be organized and operationalized to deliver a mental health program to mitigate consequences of the disaster in vulnerable populations.

 

Outreach 

These activities are organized in shelters or congregated groups in devastated communities.  They aim to provide emotional support during the acute period following a disaster. Individuals have a variety of emotions; feeling fear, shock, apprehension, confusion and disorientation. Outreach assists survivors in expressing and understanding disaster-caused stress, difficulty in sleeping, thinking clearly, and grief reactions, aiding individuals to return to a state of equilibrium and function.  Information is given to clarify that their reactions and behavior are normal and are expected due to the abnormal situation in which they suddenly find themselves ( ).

The emerging knowledge learned in disasters through the years helped professionals modify and reformulate intervention modalities to focus on the "person - situation configuration" as the unit of attention in post-disaster psychosocial treatment. This intervention post-disaster is now institutionalized. Post-disaster crisis counseling is defined as "a mental health intervention technique useful in post-disaster events that seeks to restore the capacity of the individuals to cope with the stressful situation in which they find themselves. It has three aims: a) Restoring capacity of the individual; b) Reordering and organizing their new world; and c) Assisting the victim to deal with the bureaucratic relief emergency program" ( ). The methodology to bring about these objectives varies according to the "school of thoughts" used by the professional. The reality circumstances mandate a short, flexible, creative adaptable approach compared to the usual organized, systematic clinical approach. This is an area where continued efforts to adapt clinical skills and modified approaches will be enhanced as professional learn from one disaster to the next. Differentiating variables like age, sex and cultural backgrounds point to the fact that both reactions and successful interventions differ in children, adults and the elderly of different cultures., tradition and religion.

 

Assisting families

When death occurs following the impact of the disaster, families need preventive mental health services, as they constitute a population at risk ( ).  The degree of loss, which includes loved ones, property, community, employment and unfamiliar surroundings, may overwhelm their coping capacity. 

Offering help in the morgue, near the common burial grounds (where victims may be buried due to fear of epidemics) is a proper function for mental health workers.  Collaboration with spiritual and religious representatives is very important.  This is especially poignant when the body cannot be found/rescued and no burial plan can be offered as occurs in aviation accidents or multi-building fires.

 

Assisting survivors in shelter

Intervention procedures are related to the assessment of the shelter survivor situation.     When this situation lasts more than a few weeks the survivors’ frustration can erupt in violence, anger and depression. The shelter mental health worker will have to ascertain how the condition of the survivor will impact on their ability to deal with problems, solving or coping with the challenges of the crowded environment found in countries with limited resources.  A triage method to apportion resources needs to be developed.  The ratio of needs and number of helpers will guide this procedure. Intervention objectives for the survivors in the shelter include helping them achieve physical comfort and increased capacity to organize their living area, as well as support to solve problems with the surrounding survivors.

Collaboration, education and consultation with medical emergency personnel dealing with wounded survivors will assist in the recovery toward a healthy outcome ( ).   A percentage of the population will be struggling not only with the impact of the disaster, but also with a myriad of health and mental health problem preceding the disaster. The need for referral or long term professional services may be needed. 

 

Short-term phase

The program objectives for consultation, education and assistance change during the weeks and months after the disaster.  The acute phase is over and now a new post disaster phase, that can last months, emerges with different problems facing the survivors.  Mental health disaster workers can be trained to identify the new problems, which include all the ranges of depression, anxiety and post-traumatic stress disorder (PTSD). Mitigation of further deterioration of the capacity of survivors can be achieved during this phase if preventive measures are taken. One important program that emerges is the school program for children, parents, teachers and administrators.  Due to the fact that these individuals are congregated in institutions to help with the education of children, the opportunity to assist them as a nuclear population appears very effective if they are educated about preventive mental health approaches ( ).   Women, as heads of households in underdeveloped countries, are an important group that needs assistance in their functions of caregiver and to help them obtain resources to reconstruct their lives.  

 

Another group that needs guidance are the survivors who have lost their homes and are frustrated in the lengthy rebuilding schedule of the country. Cases with diagnosable pathology increase and referrals to professionals need to be instituted. Professional capacity is needed to deal with post-disaster emotional disorders: severe acute stress, PTSD, depression and anxiety syndromes that increase in severity during this phase.  Other problems, like increased use of alcohol, will need therapeutic care.

 

Long-term phase

A program of support services needs to be extended to the traumatized individuals for longer periods of time than generally is expected ( ). When agencies are aware that a percentage of individuals at risk are unable to fend for themselves for a variety of reasons, their services can include assistance with finding shelter, employment and health resources.  This part of the preventive program is difficult for certain countries due to the lack of resources.

 

"Burnout syndrome" of caregivers

The mental health of rescue professionals following a disaster is an important component in emergency operations ( ). Their job can expose them to the most gruesome sights and smells. Even though they are prepared in their daily work as policemen, fire fighters, ambulance drivers etc. to come in contact with painful experiences, when this is multiplied by 100's or 1000's of bodies that have to be disposed of, the impact is severe. Nobody is prepared or immune to this devastating effect. Added to this, we need to consider fatigue, intense dedication to the task with reluctance to be relieved from duty, even for a short break.  This was exemplified by the angry reaction of the firefighters who battled with police when they were asked to stop working in the area of the remains of the World Trade Center disaster ( ). The basic components of the intervention consist of debriefing, identifying critical incidents, helping set the situation in perspective, and reinforcing the capacity and skill of the worker ( ).      

            

Utilization of paraprofessional workers

In some regions there is a need to develop a combination of professional and paraprofessional response teams to assist survivors. Professional and paraprofessional workers can combine efforts successfully to provide a disaster recovery response that is grounded in crisis theory and intervention techniques. "How can we help so many victims with so few mental health workers?"  Professionals have resorted to variations and experimentation utilizing a variety of human resources, according to availability. Certain conditions emerge as necessary to accomplish the objectives of successful use of paraprofessionals.  These include:

1) Individuals with some counseling experiences.

 

2) Individuals with communication skills and sensitivity to the ethnic, social and religious characteristics of the victim.

 

3) Training sessions and close supervision throughout the intervention program - Use of curriculum, video.

 

Private sector utilization

Recently the private sector of mental health services has increased its volunteer activity after catastrophic impact on citizens in urban settings. There are several problems that need resolution before a private psychiatrist can participate in these activities:

1) Knowledge of local post-disaster plans and networking with disaster agencies Example: Red Cross, government teams, clergy

 

2) Skills in crisis intervention, consultation and education.

 

Cross-cultural issues in disaster assistance

According to Robert Roth, from the Ohio State University, Response’s, ( ) that   although some involvement of the political institutions in disaster response is universal and, in many cases, extensive, the level at which the government becomes involved differs significantly among various societies. Disaster response in the United States is deemed primarily a local responsibility except when local resources are severely diminished by a direct impact. In other societies, however, disaster response is considered primarily a national responsibility of governmental involvement. In these pattern areas, the military is given not only a major supporting role, but also frequently a controlling role in disaster response activities.

 Religious institutions also differ in their involvement. In part, this is due to their degree of differentiation and institutionalization and to a certain extent, to their secularization and the extent of the scope of their pre-disaster activity. The clergy has an important mental health role following the tragedies of disasters, specially when there are large numbers of fatalities as exemplified by earthquakes in Armenia, (  ) or mud slides in Honduras (  ).

 

Education

Opportunities for media communication and dissemination of mental health information present themselves following a disaster. The human story in disaster is compelling and media professionals seek psychiatrists to interview - at a rapid pace. In the midst of community crisis, the impact of these messages exert a strong influence. There are two specific areas that offer objectives to be accomplished by educational methods. One area deals with our knowledge of how the population has been psychologically affected by the trauma and the sequences of the stress response to the disaster.

The other area is to offer knowledge of how the mental health system will respond and what professionals have to offer in post-disaster situations. Each of these areas has: a) methods; b) content; and c) structure, to disseminate knowledge. Disseminating information about the mental health services, including consultation and education, facilitates the actual operations of assistance.