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
May
2009
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.