As the earthquake and tsunami disaster in Japan unfolds, we cannot help but feeling helpless and overwhelmed as we learn of the increasing death and injury toll and see the tremendous destruction. Even though some of us as psychiatrists and other mental health professionals have worked in disaster situations, very few of us have witnessed the magnitude of the events taking place in Japan.
Mental Health Experts will Offer Help
I am sure that there will be mental health specialists from the United States and elsewhere offering their assistance to our colleagues in Japan as has been the case with other major catastrophes. During the Kobe earthquake in Japan in 1995, I was a member of the Committee on Disasters of the American Psychiatric Association and we arranged to translate a good part of our mental health written materials for disaster into Japanese so I am sure they will be made available again at this time. In that event and during subsequent events, American psychiatrists held conference calls with mental health professionals in impacted areas to offer the benefit of experience which we had from working in various events including plane crashes, The World Trade Center bombing, Oklahoma City, Katrina, 9/11 and other events. An organization called Disaster Psychiatry Outreach was formed by a group of young psychiatrists from New York who trained many psychiatrists who then participated in the mental health efforts in various locations throughout the world. For several years I participated with my colleagues in teaching courses at the annual meeting of the American Psychiatric Association about disaster psychiatry. I am sure there will be many mental health professionals joining other volunteers to assist the Japanese in dealing with this traumatic event.
I would like to briefly review some of the anticipated mental health issues in a disaster such as this one.
Psychological First Aid
Needless to say – the first effort is always rescue and attempt to save as many as lives as possible. All resources will be directed towards searching and finding the victims of this tragedy. First Aid to the victims should always have priority over mental health support but it should be given with Psychological First Aid. this means that food, water and shelter should be provided in a compassionate manner. An essential part of this effort is to communicate in efficiently and humanely with families and loved ones who have survived. Another part of this psychological first aid is going to be some kind of continued support to those who have suffered so many losses personal and material loses. The role of insurance, government support and foreign aid along with that of friends and family will be very meaningful and psychologically supportive.
Actual treatment might be better than a support group for some patients who have undergone severe trauma.
Not Just Grieving But Complicated Grieving
Whenever there is loss of life there is grieving by family, friends and I am sure by the entire country. Grieving is a universal process and while it is influenced by culture and religion, there are certain physical and emotional components of it that are well know by physicians, ministers, mental health professionals and anyone who has been around long enough to see such responses in themselves and others. There will be waves of emotions whenever anything reminds them of the loss, tears and depressive symptoms. While the lost person may never be forgotten, the severity of the symptoms and inability to function as before will usually improve over time with normal grieving. However a situation like this is one which falls into a different category usually named complicated grieving. Such a designation is made when there is the death of large numbers of people especially when children are killed or large numbers of children are grieving, unexpected death often of horrible and bizarre circumstances. ( This designation also applies when there is murder or suicide which doesn’t apply here ).It is more likely to occur when the body has not been located and given a ceremonial funeral. Complicated grieving usually is prolonged for at least a few years, sometimes longer. It is complicated by symptoms of severe depression and may lead to substance abuse and suicidal behavior. There is often a need of the bereaved to to find an explanation for the event or seek some type of restitution. This may lead to tremendous anger directed towards the government and public officials even in a situation where there was a natural disaster. These feelings can also get directed towards God and towards one’s religion. It becomes very meaningful for the government, and society to recognize the loss of lives. Memorial and commemorative services at anniversaries of the event as well as monuments and dedicated rebuilding becomes part of the healing process.
Acute Psychological Stress
There are acute psychological stress symptoms which will occur in huge numbers of people in the days and weeks after the event.These will consist of extreme anxiety, depression, insomnia, bad dreams, flashbacks of the horrible events which they experienced, helplessness, numbing, detachment, feelings of unreality, depersonalization dissociative amnesia where a person can’t recall important aspects of the trauma, tendency to avoid anything or any thoughts to do with the trauma and a tendency to have an increased startle reaction or tendency to jump very easily. At this stage people are susceptible to abusing alcohol and drugs. It had been very common for peer groups and mental health professionals to organize debriefing group meetings where people who recently had been through a trauma would be encouraged to review their experiences as well as their emotional responses including the personal meaning to them. It was thought that this approach could diminish the possibility of long term psychological symptoms. Subsequent research did not establish this as a valid approach and raised questions whether at times the group discussions created more anxiety in some individuals. While each situation is different and there are often limited psychological resources, the best psychological approach appears to be psychological first aid with warm supportive environment where the victims basic needs are met, valid information is supplied by caring people, efforts are made to connect with families, intermediate and long term planning is established and the victims are counseled about what type of psychological feelings they might be expected to have . People should be cautioned about tendency to abuse alcohol and drugs. During group meeting where information and other necessities are being provided, there should be screening for individuals who may need individual counseling, therapy with or without psychiatric medication. People with pre-existing mental disorders may have an exacerbation of their condition although in some cases such people faced with an external catastrophic event may actually fare fairly well as they put aside their “personal demons” and actually cope better than usual. People with underlying mental conditions may need adjustment of their medication. In addition there can be an important role for the use of administering sleep medication , anti- anxiety medication of other psychotropic medication to some people during the acute phase of a trauma.
Post Traumatic Stress
It is invariably that a certain number of people will go on to develop a post traumatic stress disorder where they can have persistent symptoms as described above. This can be quite distressing and incapacitating for some people . There are several psychological treatment techniques which may or may not include medication While the percentage is variable perhaps between 10-50% can have significant symptoms in months and years to come. We have learned that the majority of people in such situations have shown great resiliency and have a good psychological recovery over time . People closest to the areas of destruction are more likely to suffer although this is not invariably the case. Children are particularly vulnerable and should not be neglected in screening for emotional problems. Today with mass media, people watching the events can identify with their fellow countrymen and women and suffer symptoms. We now also know that there are psychological causalities among the police, fire, emergency personnel, hospital workers, morgue workers government officials and especially members of the working press who go out of their way to witness a great deal of the death and destruction.
Mental health professionals can provide assistance and consultation in all phases of a disaster. There are also mental health experts who have studied the field of risk communication which is how public officials and the media provide information about potential danger. It has been shown that it is both essential for there to be a spokesperson who is trusted to deliver honest information to the public at the same time to do it in a manner to minimize fear and panic. This has been studied and there are techniques which this can be done in the most effective manner.
Psychologcial Impact of Radiation Threat
One additional thought related to the above issue of risk communication is the situation where there is the potential of radiation fallout to the communities surrounding nuclear plants which is the situation occurring as I am writing this. There was a similar situation in the United States with the Three Mile Island incident where there was a question of the accidental release of radioactive vapor into the air. Subsequent studies have shown that while there actually was no physical danger many people suffered psychological symptoms especially women of child bearing age and mother of small children who were highly anxious about the potential danger of radiation.
There are some excellent books on psychological issues in disasters which can be easily accessed. I have pictured some of them in this blog. I welcome your thoughts on this very important current issue.