Disaster Psychiatry Throughout the Americas
Raquel E. Cohen, M.D., MPH
Disaster Psychiatry: Intervening When Nightmares Come True
Ed. by Anand Pandya & Craig Katz (2004)
For many people, a disaster is an event witnessed on the news. For others, the event can have an immediate and unforeseen catastrophic impact on their lives. Disasters are most often natural, like earthquakes, hurricanes and tornadoes. Yet in our post-September 11 world, we have come to experience the devastation of man-made disasters that can be more destructive or frightening than anything nature has wrought. For millions of people, disasters are personal tragedies that create an unpredicted, immediate, and overwhelming loss. It may be the loss of a loved one, a home or personal possessions that make up a lifetime fabric of living. Today, as we face a time when we may often ask ourselves how we will be able to manage if or when we are the survivors of a disaster, it may be helpful to understand the reactions of survivors. Because through that knowledge, we can learn what to expect in the process, understand how our own emotional systems develop coping strategies, and recognize the importance of support systems that will strengthen our own mental health in crisis situations.
How do you cope when you are the survivor of a disaster? What happens emotionally when you are the survivor of a disaster? And how do you endure the overwhelming experience of loss and grief? These are the questions that I have sought answers to for more than 30 years as a psychiatrist in the field of mental health needs of disaster victims. When I began to work in this area, there was no "field" of disaster mental health. I had to develop a system based on my personal experiences in the field and my professional training in mental and public health. And, while over three decades we have been able to create a mental health system to respond to the needs of disaster survivors, each disaster is really a response to the hundreds and thousands of personal tragedies of each individual who is suffering tremendous change and loss.
I have often been asked how I became interested in the mental health of disaster survivors. As a native of Lima, Peru, I am sure my early experiences feeling the world tremble as an earthquake shook the foundations of our home gave me a predisposition to understand the fear of natural disasters. I left Peru to study medicine in Boston, first receiving my master's degree in public health from Harvard and then becoming part of the first class of women to graduate from Harvard Medical School. As a psychiatrist, my interest always focused on community mental health and public health issues. This public health orientation comes from a deep personal feeling that prevention is the best way to help people in need. I believe that these were the influences that motivated me to combine the mental health and emotional issues of individuals in crisis with the public health concerns of large populations of people in distress.
One of the first events that clearly provoked my interest in the mental health needs of survivors occurred in 1970 when I was visiting my family in Lima. A massive earthquake had recently killed more than 70,000 citizens in the Callejon de Huaylas, high up in the Andes Mountains. This catastrophic event left hundreds of young orphans stranded in the remote region. The minister of health, who was in charge of the rescue operations, asked me an important question: "What would be the best rescue plans for the children? Should we leave them in their hometown with their surviving relatives, who themselves were in dire need, or should we transport them to Lima and offer our urban resources?" The massive needs of the people and numbers of orphaned children left me speechless. I found little knowledge acquired during my training as a psychiatrist on which to base an intelligent answer. Intuitively, I suggested keeping the children in their town instead of removing them from their natural environment and adding to their losses.
I returned to my job in Boston, Massachusetts, challenged by this new awareness of mental health issues in disasters. I continued to ponder the questions raised in Peru and discuss them with colleagues such as Gerald Caplan, a pioneer in crisis intervention, and Eric Lindemann, a pioneer in community psychiatry. I had also contacted Bert Brown, then director of the National Institute of Mental Health (NIMH), to find out if we could send resources to assist the authorities in Peru. My petition was not successful. Although professionals in Washington, DC, were sympathetic, their lack of resources to respond to the situation was an obstacle to my efforts. Sadly, another disaster eventually created a new opportunity to respond to a catastrophe.
Two days before Christmas in 1972, a devastating earthquake struck the city of Managua, Nicaragua. More than 10,000 people were killed; the capital of Nicaragua was virtually destroyed. The United States and Nicaragua formalized an agreement to fund the efforts of bicultural and bilingual mental health volunteers. Professionals working in Washington who were linked with Nicaragua and NIMH representatives promoted the agreement. The agreement was reached through active negotiations between a Nicaraguan psychiatrist who traveled to Managua and established personal linkages with the Somoza government after the terror of the disaster. I was asked to be part of the volunteer team. After a brief training in Washington, we boarded a plane, organized into groups and planned our approach while flying to Central America. As the plane descended into Managua, I asked myself what I would find in the city and how I would be able to help. It is a question that still goes through my mind each time I face a new disaster situation.
At the airport, a representative of the minister of health received us. He briefed us on priorities for service and the arrangements for shelter and transportation. As we began to move through the city, the extent of the damage and overwhelming destruction was apparent at every turn. I remember the chilling sensation of seeing clocks on the buildings that were still standing all stopped at the same moment in time when the earthquake had struck. We set up in a kind of tent city established by the international rescue operations. As I began to develop a mental health outreach program, I was about to learn an important and lasting lesson about the emotional needs of rescue workers and caregivers in disasters.
I had been invited to make a presentation to a group of physicians. These professionals had been forced to leave their destroyed offices and hospitals and relocate to a nearby town. I prepared a science-based conference, thinking that these professionals would be best served by a technical presentation. Halfway through my presentation, as I was looking down on my notes, I heard a sob. I lifted my eyes and saw someone in the audience leave. As I looked around the audience, I could see the faces looking back at me were gloomy and sad. I then realized that they were experiencing the same pain and devastation that I had expected of their patients. I had defined them as health care professionals and expected that they would handle their emotions differently from the survivors that they were charged with treating. I then realized that they, and subsequently every caregiver affected by a disaster, were experiencing the same loss and emotional grief as any victim. I changed the tone of my presentation and suggested that if anyone wanted to see me individually I would be pleased to do so after the presentation. Many of them accepted my offer. This episode sensitized me to the effect of disasters on all persons and has continued to reinforce the individuality of needs of everyone who comes in contact with the tragedy of these events. I strongly support the research, development, and organization of mental health support programs to all the rescue and emergency personnel involved in disaster work.
New Federal Legislation Affects Disaster Relief Programs
Based on my experiences in Managua and work with other professionals in this emerging field, I was invited to a series of national meetings and planning activities designed to address U.S. programs for disaster relief. In 1974 the Disaster Relief Act (Public Law, Section 413) laid the foundation for systematic organized development of mental health activities that included the Crisis Counseling Assistance and Training Program. This program, which is jointly operated by the Federal Emergency Management Agency (FEMA) and the federal Center for Mental Health Services, funds short-term public education, outreach, crisis counseling services, and referral to other agencies for long-term treatment. The awareness of the psychological consequences of disasters emerged because of increased leadership in Washington, including the notoriety and publicity of a disaster that occurred in Buffalo Creek, West Virginia, in 1972 where the sludge accumulated from a coal mine caused a dam to collapse following a torrential rainstorm. Mass quantities of mud, rocks, and debris destroyed a number of small towns, killing adults and children. Class action litigation between the victims and the coal mine corporation resulted in the victims being compensated for the "psychic trauma" described by the lawyers.
This federal mandate for mental health assistance gave a strong impetus to train professionals to be prepared to assist in disaster situations. I was invited to be a member of the visiting faculty of the Staff College, a training arm of the NIMH. As I began to develop curriculum and train a number of professionals around the country, I adapted the research and literature on trauma, crisis, loss, bereavement, support systems, coping, and adaptation to the field of disaster mental health care. This collection of rather simple materials and articles has today grown to a worldwide rich, vast, and ever-growing body of disaster publications. To expand my own knowledge of the Emergency Response System, I invited representatives of every disaster-related system I could identify. Representatives from the Red Cross, FEMA, and civil defense agencies, as well as clergy and police, were asked to become the teachers in the presentations to the mental health professionals. Not only did I increase my knowledge from these experiences, but they also initiated a reciprocity by which many of these agencies began to invite mental health professionals to teach to their staff, something that had never happened before.
I still remember the puzzled looks of firefighters and police who were attending different training sessions in Emmitsburg, Virginia, the FEMA training facility. Their puzzlement also taught me an important lesson. One day, while I was eating in the staff cafeteria after presenting my work to a group of mental health professionals, one of the policemen asked why I was there. They wondered what a "shrink" could offer the emergency rescue efforts in disasters. It is a question that mental health workers have had to answer slowly, over time and through example. When people are addressing the immediate and painful needs of medical trauma, shelter, food and disease control, mental health may seem like a "soft" need. For many years, the public and survivors didn't and still don't see themselves as "mental health patients" in need of mental health assistance. That lesson was exemplified during the Great Storm of 1978 in Boston.
It started to snow one day that January, and then it seemed like it would never stop. When the storm ended, the city was buried in snow, communities were without power, and people were stranded. At that time, I was the superintendent of the Lindemann Mental Health Center, a comprehensive mental health, retardation, and drug abuse program. My responsibilities extended over part of Boston and several of the towns that bordered the Atlantic Ocean and were particularly devastated by the storm. This geographic area was part of the center's "catchment area," so I was able to mobilize a large number of resources to develop a mental health program focused on the event. Government leaders in Boston, who were interested and sensitive to the mental health needs of the survivors, assisted us in obtaining federal funding to organize several response teams. This opportunity to design, implement, and evaluate an intervention response taught me further how mental health programs need to be carefully integrated into the complex public and private agencies that assist victims.
I had advocated having a space in the FEMA center, where all the services were assembled in a large school gymnasium, called a One Stop Center. I assembled and organized a mental health team and we set ourselves up in the gym. Our table had a sign that said, "Mental Health." Because of the sensitivity of the content that the victims might want to reveal, I asked that the area should be curtained. We took our seats and waited. And waited. After several hours without any people stopping at our table, I decided to walk through the area where hundreds of individuals were forming long lines for Red Cross, housing, and loan assistance. As I walked through the large gym, watching anguished individuals negotiate their future, I realized that traumatized individuals do not see themselves as "patients" in need of mental health. They were traumatized individuals dealing with the immediate needs of survival. I recognized that survivors do not seek mental health assistance while they are struggling with survival needs.
In subsequent disasters, this awareness helped me learn to observe signs, expressions, thoughts, and behavior of survivors as normal expressions to cope with abnormal situations. I learned that their behavior in most of the cases were efforts to deal with the effects of the trauma events and were not expressions of psychopathology. This emerging awareness allowed me to conceptualize new ways of assisting them by focusing my interventions in supporting coping behavior and return of function. I also realized how the premise of community psychiatry, which recognizes the importance of coordination and collaboration with grassroots agencies, clergy, schools, and human service agencies, assisted in developing a well-designed emergency response program. During the activities in the Boston disaster I became aware of the well-organized programs of the Red Cross-to assist survivors. I developed good relations with many of their leaders, who asked me to add my knowledge to their training content. This collaboration grew through the years and resulted in their inclusion of mental health into Red Cross disaster manuals.
Cross-Cultural Issues in Disaster Relief
As a Peruvian and a psychiatrist with a specialization in cross-cultural communication, my knowledge and experience of cross-cultural universal human response to the tragic impact of disasters has expanded through my work in Latin America.
In 1980, South Florida became part of history as it responded to the Mariel Boat lift. This exodus of people from Cuba brought thousands to the shores of Florida. At the invitation of the University of Miami Medical School, which had received a grant from the federal government, I was asked to participate in the program to assist more than 1,000 Cuban children who arrived on the boatlift without parents or adults. This program consisted of housing them in three federal national camps, where they would be diagnosed, referred, and placed in appropriate sites throughout the country.
Again, all the accumulated knowledge of disaster guidelines was useful in designing this yearlong program. Because of the nature of the youths' ethnic and cultural background, their differing psychosocial development, and, in many instances, traumatized childhoods, the concept of populations at multiple risks presented a challenge to our techniques. Our first priority was to house them and establish a sense of safety and fairness in dealing with all their needs. During the next year we studied each child individually and recommended their future planning, which consisted of a variety of placements: foster care, group housing, special schools, hospitals, or finding relatives with whom they could stay.
My subsequent decision to accept a tenured professorship from the University of Miami Medical School as the head of child psychiatry training paved the way for me to work more closely with Latin American countries.
One night in 1985, as thousands slept in their beds, a major volcano erupted in Colombia. A riverbed guided an avalanche of mud and stones toward Armero, covering the city with millions of cubic feet of boiling mud and stones, killing more than 20,000 citizens. The number of deaths was painfully high because there was very little warning of the impending disaster. Rescue operations were impeded by torrential rain and the difficulty of driving emergency vehicles on the deep mud surface. Terrorized survivors held onto treetops or tried to stay above the mud that reached up to their chins. Eventually a small fleet of helicopters rescued some survivors, one by one, flying and dispersing them to hospitals all over the country. Many had to have their legs amputated because of the infection developed during hours of waiting to be rescued. When I became aware that a catastrophic disaster had occurred in Colombia, I asked the dean of the medical school to contact the minister of health and offer our help. A few hours later we received a telegram inviting me to fly over and assist the emergency mental health program. I packed my bags for departure, and, as always, as we approached the disaster site, I asked myself what I would find there and how I would be able to help.
The Colombian Emergency Committee assigned me the responsibility of training all their deployed emergency and hospital personnel on mental health issues to assist the survivors, both wounded and well. For this to happen they organized a systematic schedule and attended to the logistics, transportation, lodging and attendance of the personnel that had to be trained at the site. This experience was one of the most tragic—and educational—of my career. This was the first time I worked in hospital trauma wards dealing with physically (amputations) and psychologically intense distress in large numbers of patients. Long hours of training and debriefing were spent with the nursing staff, who were also tired, grieving, and overwhelmed by the tragedy. Difficult situations also appeared out in the rural areas because of the constant reminder of the possibility that the events would be repeated; we received daily reports of the volcano's continued eruptions. The emotions of fear and anxiety were pervasive. I clearly remember its impact on my emotional state of mind during one incident. After a long day of consulting and training, I looked forward to bedding down at the inn where we were living. Tension among the participants was heightened that day because of several alerts warning that the volcano was erupting again. People were advised to seek shelter up in the hills. While resting on my bed, I wondered how real these alarms were and had a fantasy vision of the next day's headlines: "Disaster Expert Succumbs Under Volcanic Lava." As I tried to laugh about my fears, the electricity was cut off—no light, no radio, no alerts. I panicked, grabbed my flashlight and gathered two of my colleagues. We hiked, guided by our flashlights in the dark, and slept in a tent high in the hills. I became intimately aware how denial is a helpful defense when working in painful situations, but at the same time, intelligent self-care is a necessary response as well.
In Armero, I also learned another important lesson about the importance of bereavement processes when the body of the deceased cannot be mourned or buried. Because such a large number of dead remaining under the tons of mud were never recovered, the families had a very difficult bereavement. It ranged from the obsessive belief that the loved one was somewhere in a hospital to the slow, but painful realization that maybe they had not survived. I have seen similar types of reactions from families whose loved ones have died in airplane crashes where the bodies could not be recovered. The inability to have the emotional closure of a burial process and ritual can cause additional emotional consequences. Families from different cultures mourn their loved ones observing traditional ceremonies, but their need of visually seeing the bodies are similar. When this is missing, the expression of pain needs support and assistance so as not to rely on pathological defenses. Techniques to confront slowly and then bear the reality of the loss are helpful in these instances. The assistance of spiritual or religious guidelines and support are used throughout this process.
The next disaster experience in which I participated struck close to home. In 1992, the Category 4 Hurricane Andrew made landfall in South Florida, destroying hundreds of homes and becoming one of the most costly disasters in U.S. history. I had been active with the Red Cross program in Miami and accepted an invitation to be part of the team at its emergency center. After I left the center the day after the storm, I was still uncertain how I made it back to my apartment. The world had been turned upside down, with boats strewn across the roadway like litter; familiar roads, street signs, and landmarks had disappeared. Like many of my experiences in preceding disasters, there were new lessons to learn. Two of them remain in my memory. The first was the change in the subtle but powerful social environment that enveloped our daily lives. Whether at work or in recreational or social situations, all our concerns were linked to the effect on our lives of the destruction around us. The number of dead and wounded was small relative to other hurricanes, but the physical destruction of homes, roads, and neighborhood infrastructure was massive. The disappearance of familiar surroundings plus the loss of physical landmarks had a powerful effect on our emotions.
The second experience was the effect of the disaster on organizations and institutions that have bureaucratic structures and well-defined guidelines for daily working activities. These include schools, businesses, and government agencies. One such experience presented itself when my employer, state attorney general Janet Reno, asked if I could help her 600 employees by informing them of the emotional consequences of post-disaster responses. I was the director of the Children's Center, a unit of the State Attorney Office in Miami, the function of which was to interview children who allegedly had been abused. The state attorney asked all her staff to attend these sessions. After introducing the basic knowledge about normal emotional response to abnormal situations, I opened the session to discussion of how to solve some of the problems of personnel who had been traumatized and yet were still expected to produce documents or meet deadlines for cases in the judicial and criminal system. There were many examples that highlighted what happened when the working product relied on a human team who, for the moment, had lost its efficiency. Discussion on how much tolerance, anticipation, support, and time allowance to finish briefs or to research and investigate crimes, were some of the issues raised by lawyers and clerical staff.
In 1998, Hurricane Mitch devastated the Central America countries of Nicaragua, Honduras, El Salvador, and Guatemala. Human losses were counted at 6,500. Almost 12,000 people disappeared, and more than 1 million lost their homes and were placed in shelters. Worldwide assistance responded generously, and several international teams for psychological help traveled to the affected areas. I was invited by the Pan American Health Organization to participate in training and consultation with the members of the Coordinating Government Committee established to deal with the mental health of the survivors. During one of my consulting appointments, I was taken by helicopter to a faraway region because the roads were nonexistent. The experience of that bird's-eye view of hundreds of houses filled with hard, drying mud that reached the second or third floor was painful. A vivid memory that remains is of a worker's reaction as we walked through a cemetery, and she realized that the coffin other grandparent had broken open and filled with mud. In that program, we worked with the director of mental health and the top representation of all the government ministries. Their dedication and interest in developing a good response enabled me to deliver and participate in an effective way. They organized each of the activities that consisted of daily training sessions, consultation to emergency teams, and information to government leaders. In addition they attended to logistic issues and gathered the members of the groups, which consisted of doctors, nurses, teachers, counselors, and students of all the disciplines. Their efforts reinforced my central belief that an effective disaster mental health program has to have the strong support and involvement of the top leadership in the devastated country.
Over the past 30 years, I have been a participant and a witness to the evolution of the field of mental health in disasters. From the time when I landed in Peru and advised the minister of health about the earthquake, I have learned important lessons with each experience and from the exceptional collaboration of disaster workers. I have seen the body of research and published literature expand so that today there is a well-developed understanding of the mental health needs of disaster survivors. Today we face new challenges. These are not natural disasters but man-made tragedies. In the post-September 11 world and with the growing threat of international terrorism, the impending mental health needs that may be created through the devastating effects of nuclear attacks, poisonous gas, and germ or biochemical warfare have strengthened the awareness of the professionals in our field. The need to prepare and organize large numbers of trained mental health personnel was painfully clear in the response to the Oklahoma City bombing and the terrorist attacks in New York and Washington, DC. As professionals grapple with the best intervention strategies and the need for scientifically based research, it is evident that finding answers will be a challenge. Another large question in need of an answer is which methods and techniques developed over the last 30 years are most useful to assist survivors of terrorism. Individual resilience and support systems that reinforce coping and adaptation may be an important area for future research that will offer hope and guidance to the next generation of mental health workers. Public health models may be most useful to assist and help large populations of survivors. As I participate in adapting our knowledge to the new, evolving training efforts that will prepare us to help victims of terrorism, my thoughts often come back to the questions I have asked myself every time I land at a disaster site: "What will I find? How can I help?" I believe that we will continue to seek answers to these questions as we aim to assist those who are affected by disasters and who lose so much of what is most important in our lives—home, health, loved ones, and community.