The Role of Mental Health as a Therapeutic Agent in Traumatic Events
Raquel Eidelman Cohen, M.D., MPH
Lecture on the occasion of a tribute to the author during the IX Congress of Psychiatry and Mental Health of Children and Adolescents, Lima, Peru
Dear colleagues and friends,
I chose to present this topic because over 30 years of work, I have observed how the mental health component became a therapeutic agent in traumatic events. This role has evolved over the years, as advances in research on the reactions of victims continues to offer assistance for the prevention of chronic sequelae. Whether for professionals active in this field or citizens who find themselves in dangerous situations, knowledge acquired in this area can be very useful. These skills are important and should be disseminated.
I will present data that have led me to this view: 1. As a professional involved in this area; 2. Development of the role; and 3. Factors that give substance to the therapeutic effect of these interventions.
As a matter of time I will only present the role in events that affect large populations, although the same principles can be applied in traumatic situations like transportation accidents, violent crimes, child or sexual abuse, fires, etc.
How did I get involved in this area of professional activities?
Shortly after completing my Masters in Public Health and psychiatric residency in adult and child psychiatry, I was offered a position to develop a children’s community center where I learned the procedures necessary to serve a population. The concept of prevention has been a strong influence on all my work, so I began to develop methods in public health programs accelerating fast but effective systems for diagnosis, treatment for groups or parents, and helping families to rebuild their bonds with less chronic outcomes. Several years later I accepted the opportunity to participate in an academic program of Community Mental Health at Harvard Medical School. This course was organized to train mental health professionals in the methods and procedures needed to prepare leaders. The program developer, Dr. Gerald Caplan, an internationally recognized pioneer in this field, invited me to be the associate director of the program. Dr. Caplan’s studies on trauma, crisis, loss and grief, have been among the major contributions that have influenced my work and began to delineate the professional role in situations of trauma.
The possibility of developing preventive techniques for adults and children established and gave substance to the concepts that have guided my work in efforts to help survivors of traumatic events.
In 1970, during a visit to my parents in Lima, I spoke with the Minister of Health, Dr. Caravedo, who asked me for an advice about hundreds of children affected by the earthquake of Callejón de Huaylas in the Peruvian Andes. I had never thought how to help that large a group of children, much less in disasters of this magnitude; I had only done it with small groups. I was amazed by my own ignorance and do not remember what I said, but I went back to Boston for the purpose of finding the answer. I also contacted several colleagues and the head of the National Center for Mental Health in the U.S. asking for help, but I was informed that Peru had no funds for this project.
Two years later, I received the news of the earthquake in Managua, Nicaragua, and this time there was the possibility of forming several multidisciplinary and bilingual teams. I directed the first group, wrote the first curriculum and designed the project using all my knowledge gained in previous years, as well as experimenting with new procedures. Initially in Managua I was able to coordinate three types of activities based on my knowledge of community psychiatry --- as a trainer, clinician and consultant. Mental health professionals wanted instructions about how to help the survivors, the media -newspapers, radio and TV - wanted interviews on subjects relating to the disaster, and members of the government asked for guidelines to form government mental health programs. In addition to responding to these requests, I took the lead in providing clinical treatment to parents and children in tents outdoors.
A new U.S. law was enacted in 1974 that established mandatory mental health emergency and disaster assistance for survivors. Shortly after, the National Center for Emergency contracted me to train almost half of the national regions. This gave me the opportunity to produce a training program that is still expanding and developing as we acquire more knowledge in this area. This was the beginning of focusing my efforts more vigorously in the area of traumatic events. Over the years this area has grown significantly, fueled by the work and publications of many professionals worldwide.
More opportunities and invitations to help in other disasters began to appear alongside my professional responsibilities. I could always get permission from the university or the hospital to go and help. I participated with the Pan American Health Organization in its aid programs in El Salvador, Costa Rica, Honduras and Colombia, among many other countries during some of their disasters. Several of the experiences were in the US, including a blizzard and severe flooding in Boston, and many of the hurricanes in Florida (where I now live) in the last 20 years.
Due to my interest in helping traumatized people in catastrophic events, I also participated in programs for abused children, families who had lost a relative in an airplane accident, an episode of the hostages taken by terrorists from the residence of the Japanese ambassador in Lima, the orphaned Cuban children of Mariel that came to Miami, the terrorist attack on the Twin Towers in NY, the ravages of Hurricane Katrina and the last earthquake in the region of Ica, Peru.
Development of the Mental Health Role
The role of on mental health assistance in traumatic events focuses on the "here and now", using all necessary means to restore the survivor to functioning effectively. The procedures, techniques and methods are well known today. The acceptance of this role compared to traditional multi-teams of Red Cross, Civil Defense, and NGO emergency workers had a difficult start due to lack of understanding of the usefulness of their activities and the tentative format of its objectives, but little by little it has been embedded and incorporated into all levels of support in traumatic events.
During my first experiences I just focused my efforts on the survivors, but quickly learned that members of all groups of emergency workers also needed psychosocial support. Today, 30 years later, we put great emphasis on making every effort to ensure that emergency teams and first responders be as protected as possible. Not only is it necessary to respond to emergency teams working in very difficult situations, but that the knowledge of protective and preventive care should be shared with government representatives and the general public. In regions with a high risk of disasters, like Peru, it is necessary to disseminate knowledge that can protect the citizens as they do with other public health programs.
Experiences in many disasters have heightened the profile and configuration of the role. The role has 2 levels: 1) major assistance knowledge, procedures and techniques of our profession; and 2) the cultural, traditional and religious values of the affected population we are helping, in terms of modifying how we offer and they accept help.
As a Peruvian, knowledge of the social, economic and religious institutions of our country have served as a basis for understanding the differences with other populations and noting the importance in communication, tradition and values. As my experience grew, it expanded my knowledge and made me take notice of the number of facets that potentially could be ascribed to this role.
This role is one of the most difficult activities of our profession because the environment within which we must assist is usually a painful and stressful one for both the workers and survivors, not to mention often physically challenging. Generally in natural disasters, for example, there are very few amenities, and basic services such as water, safe shelter, food and electricity may be lacking.
There was another aspect of this work in which I had little experience - how to share private, confidential information obtained from survivors, while maintaing communication channels with members of civil defense, police, firefighters, representatives of the community, the military, funeral groups, lawyers, and so on. Each agency had its own objectives, jargon, and concerns other than mental health when dealing with the problems of the survivors.
During this same time period, new studies in the area of neuro-science on the effects of traumatic stressors and their impact on the biopsychic organism of the individual served to better explain and understand reactions and conduct in traumatic situations, increasing the possibility of therapeutic intervention. For those who read English books, I recommend two publications: Why Zebras Do Not Get Ulcers by Robert M. Sapolsky (3rd edition) and The Unthinkable by Amanda Ripley. To summarize their contents, comments and experiences of individuals who have been saved in disasters show similar patterns of behavior. Initial reactions are denial of the event with slow acceptance of the imminent danger. It is a defense that serves to automatically control the psychic disruption due to fear or anxiety in preparation to act rationally.
Following a few minutes to collect data, weigh the degree of risk, and identify "what is this about" before acting, the cognitive brain seeks confirmation. The individual needs to recognize and catalog the event before he can act. Finally, the individual recognizes he is at risk and acts to save himself. The degree of trauma, the quality of family support, and the group around him can increase or contain the effects of trauma. These brain processes are the cumulative result of the initial delay followed by anguish, fear, cognitive ability, the influence of the environment, and leadership.
Each of us has an individual way of reacting due to many factors, including our genetic heritage. Studies of the biologic component have shown progress in clarifying the reactions of stress produced by the effects of trauma. High levels of cortisol, a hormone associated with these reactions, can affect many physical functions such as the immunological system, regulation of blood sugar, blood pressure, and heart rate. If the individual does not receive aid, this situation could become a chronic stress with a high rate of disease.
As we increase our knowledge in three areas - social, biological, and psychological - we have better chances to intervene preventively and can help the survivor to regain their ability to adapt to the new environment. Using this knowledge, emergency preparedness programs throughout the world are developing new methods of preparation, training and support that are effective and appropriate.
Today we have the expectation that trained psycho-social professionals will be present in all types of traumatic events worldwide. As an example, we have the presence of military mental health teams assisting soldiers fighting in Iraq and veterans returning home, counselors during the current economic crisis helping workers who may lose their home or jobs, and teams ready to intervene in natural disasters, terrorist attacks, and crimes in schools and universities.
The role of professional assistance to traumatized individuals is established. The variety of activities that we undertake in our technological and global world presents difficult and sometimes dangerous situations that affect the stability of the bio-psychological systems of individuals. As we continue to increase our knowledge of how to assist in traumatic events, sharing knowledge is important at all levels so that citizens and professionals can help in these situations. I hope this presentation may be an initial appeal to the realization that each of us must stay informed about new knowledge in this field in order to insure there is help to preserve physical and emotional health when danger is imminent.