I am writing this blog 12 days after the devastating earthquake in Haiti. We are seeing and hearing about the tremendous need for food, water, medical personnel and supplies. There are head injuries, broken bones with people dying of infections and other complications of their injuries as well as facing the prospect of starvation. We know from experiences in other disasters that there has to be fear, anxiety, depression and tremendous psychological pain among the people of Haiti. Thousands of people have been killed with unimaginable numbers of people injured, displaced from homes, separated from families, without food, water or shelter. There is great uncertainty about the future for these people and this alone will intensify their emotional reactions.
Is There A Role For Mental Health Professionals ?
Of course, at this time there is a need for psychiatrists and other mental health professional in Haiti. However, everything is relative. After the terrorist attack in New York on 9/11 there was an abundance of mental health experts immediately available. They were put to work on the Pier 92, which was where the services for the victims were being organized. They were not assigned to do psychological therapy but rather assisted in helping the stunned people to get food, shelter and assist them in finding what happened to their loved ones. Their psychological and interpersonal skills were no doubt helpful in carrying out these tasks even though most were not initially doing formal therapy.
Psychiatrists who have become involved in previous disasters often will write prescriptions for heart, thyroid, diabetic and mostly other non- psychiatric medications which people need and did not have . (See my previous blog on this subject) Psychiatrists may also participate in the delivery of general medical care or even assist in surgery during the early stages of a disaster response.
We would hope that the people organizing and delivering the immediate care to the victims in Haiti are sensitive to the psychological vulnerabilities of the victims, especially the children involved. The leaders of emergency services also need to understand how important it is to provide truthful information to the people involved without inducing additional fears and anxiety. There are special techniques to do these “risk communications”
In addition, the people doing death notifications to family and friends of those who died need to be knowledgeable and skilled in this difficult task. Psychiatrists and other mental health professionals can be very helpful in training emergency workers for these tasks but the best time to do it is during emergency planning and disaster preparedness.
Emotional Reactions in the Aftermath of Disaster
We all can imagine the fear and anxiety that people will initially feel when an earthquake occurs with immediate devastation. We can see the stunned look on the faces of the people in images from Haiti . It may take a while for the emotions to catch up with reality. In such a situation the people may become disconnected from their feelings (called dissociation).
Sometimes the people involved are actually denying the reality that has clearly occurred. In New York City immediately after the destruction of the World Trade Center thousands of people “disappeared”. So many people did not come home that night and were buried in the rubble. Once it was established missing people were not registered at local hospitals, it should have been obvious that these people had perished. However families began posting “missing persons posters” all around Manhattan with a picture and a description of the lost person with a phone number to call if the person were found. It took a week or two before the originators of most of these posters came back and changed the posters to memorials with people often putting flowers next to them. While this specific phenomena may not be occurring in Haiti, we can only imagine the difficulty that people are having adjusting to the sudden disappearance of important people in their lives. This is made even more difficult since, for most a funeral was not possible and for many the bodies will never be found.
It was estimated that 10,000 children were grieving after the loss of a parent or a close relative following the 3000 deaths in the New York tragedy in 9/11. In Haiti more than 150,000 people are estimated to have died in this disaster so you can do the math as to acute grief among adults and children. When people die violently, unexpected or when children are killed, the grieving that follows by their loved ones takes on special characteristics. It tends to be complicated by other psychiatric conditions such as post traumatic stress, major depression or even suicidal thoughts. Grieving in such situations tends to bring on alcohol and drug use in some people. It is more difficult to resolve all the powerful emotions especially the anger and the grief which can linger on for many years.
It is probably fair to say that the entire country of Haiti will be going through a prolonged grieving period but most people will not require psychological counseling even if it were available. The social networks including the church will provide most of the support. In fact, it has been shown that following most disasters the majority of people will have great resiliency and will bravely deal with the tragedy albeit with a heavy heart. Their lives will be changed forever and they will never forget what happened. There will be memorials and anniversary events, which will be helpful to the grieving process.
Post Traumatic Stress
Having acknowledged the resiliency that most people will show after such mass trauma, many people will have at least some symptoms of post traumatic stress disorder ( PTSD). They will have recurrent and intrusive distressing recollections of the events that they have seen and been through. This can include nightmares and daytime flashbacks. At times people will act or feel as if the traumatic event were recurring. There may even be hallucinations or misperceptions where real things are misperceived as something related to the recent traumatic events. For example, the noise or vibrations of a passing plane or truck might immediately bring back a flood of the feelings that occurred during the earthquake. This can include rapid heart beat, fast breathing and other physical symptoms. When there are even mild after-shocks following a major earthquake some people are overwhelmed with emotion.
In the aftermath of such an event, people suffering post traumatic stress symptoms can make efforts to avoid conversations or thoughts associated with the trauma. They may avoid certain locations or even people who will remind them of the recent trauma. Some will feel detached and estranged from other people and may not be able to have any loving feelings for a long time. There can be difficulty in falling or staying asleep, increased outbursts of anger, difficulty concentrating and hypervigilence. Quite characteristically people who are having symptoms of post traumatic stress will have an exaggerated startle response in which they can typically appear to “jump out of their skin” after a loud or unexpected noise.
While at least 50 % of people exposed to the horrendous experience of a major earthquake can have one or more of these symptoms, perhaps only 10-15% will have significant symptoms lasting for more than one month in a pattern, which mental health professionals will diagnose as PTSD. Depending on the criteria used, some research has suggested higher numbers than I have stated above..
Treatment For Psychological Problems after a Traumatic Event
We have learned a great deal from past experiences, how to offer psychological help in the aftermath of a disaster. As previously mentioned, it is most important to assist with food shelter and help people find out about what happened to loved ones. In the past survivors were commonly offered a group technique called “critical incident stress debriefing (CISD)” where people were encouraged to relive their emotional experience in a supportive group environment. This technique has come under scrutiny as to whether it is the best technique or not and when and if it should be used. Experience has taught disaster experts that while some group meetings maybe helpful, it is usually best to use them to provide survivors with needed information about coping with real issues as well some general information about the emotional reactions which they may be having, perhaps cautioning about the tendency in such a situation for some people to turn to alcohol and drugs. At the same time such meetings will allow mental health professionals to observe and identify the participants who may be doing poorly and require more specific individual or group therap. This treatment may be a specialized cognitive behavior type of treatment or more traditional psychotherapy
There has been some interesting research, which suggests that certain medications given during the early stage of disaster may prevent or minimize the development of posttraumatic stress symptoms. However at the present time medications of choice that are given are usually mild tranquilizers or sleep medication. Obviously people with severe symptoms or preexisting major mental disorders may require specific medications.
The Secondary Victims of Disaster
The psychological effects of a disaster not only potentially impact the people who live in Haiti or were there when the earthquake struck, but can also effect the emergency personnel who flowed into Haiti to provide services and who can become secondary victims. This includes all the fire, police, rescue teams and military personnel as well as the many doctors, nurses, including mental health professionals. Even though many of these workers are used to seeing people who are traumatized, injured and dying or dead, the magnitude of this tragedy may be beyond anything that they have seen or experienced.
The Media Are Often Neglected as Potential Victims of PTSD
The other night I saw Anderson Cooper, CNN anchor, reporting from Haiti. He was telling about the dead bodies of children being pulled out of the rubble and other very difficult scenes. He was clearly emotionally affected. It is the job of the working press to view the worst of all the destruction, talk to victims, as well as the families of those who have perished. They often work around the clock without much rest. I have had experience working with media people who have been through disasters and I have seen the emotional toll that can be taken on them. ()
It will not be easy for the Haitian people to get through this tragedy without emotional scarring. I know that among the many volunteers assisting them and their helpers will be psychiatrists and other mental health professionals who will play an important role in the recovery from this ordeal.
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