Psychological Implications of the Connecticut School Shooting

A lone gunman killed 20 children and 6 adults including himself at a Connecticut) School He used guns registered to his mother. The emergence of ASD and PTSD Acute Stress Disorder and/ Post Traumatic Stress Disorder) were identified as happening after a major incident such as this one. The symptoms that can be present in this situation were reviewed as well as some possible long term effects. The grieving process was also discussed. In the aftermath of such situations, attention is often focused on people with mental illness who might have the potential do do violence and/or commit a copycat crime even though in retrospect this is very small proportion of the population.The gun control issue and related psychological factors were also discussed.

I am writing this blog one day after the horrific massacre at a school in Newtown, Connecticut. Thus far it is known that a 24 year old man shot and killed his mother and then took three weapons including automatic assault rifle, dressed in combat gear and  appeared at the school where his mother taught. He was recognized as the son of a teacher and was buzzed in. He then killed 4 adults including the principle who had recently  instigated stricter security measures at the school and 20 students between the ages of 6 and 10 as well as himself. There was one report that he had some kind of argument at the school the day before the shooting. There are also descriptions that he was a troubled kid in school who had no friends and was very shy. He was said to be very bright in math. It was suggested that  he may have had Asperger’s Syndrome and was on the Autism Spectrum. Another report said that he spoke of demons and therefore suggesting he may have been paranoid with schizophrenia. His parents were divorced after 17 years of marriage and his mother was reported as very protective. He has a brother at college.

I have no idea of his diagnosis and would not make any attempt to speculate on on the nature of his mental condition.

Psychological Trauma 

Common wisdom and research in this area tell us  that the closer a person is to the traumatic event,  the more likely and the more severe the psychological trauma will be. This however is a complicated issue. Certainly the adults and children who witnessed the shooting (including of course anyone wounded ) would be directly effected.  This would include anyone in the school  who heard sounds and participated in the terror of hiding and escaping from danger.

The two conditions that will emerge from such an incident  are  Acute Stress Disorder (ASD) and Post Traumatic Stress Disorder(PTSD) . According to the Diagnostic Manual of the American Psychiatric Association (DSM IV), the necessary requirement for both of these conditions must include the following :

The person has been exposed to a traumatic event in which both of the following were present.

1-The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury or a threat to the physical integrity of self or others.

2- The person’s response involved intense fear, helplessness, or horror (in children, this may be expressed instead by disorganized or agitated behavior.)

In addition for us to make a diagnosis of ASD there needs to be three or more  symptoms such as  numbing, detachment, absence of emotional responsiveness or reduction in awareness of his or her surroundings (being in a daze) or derealization ( things don’t seem real) or depersonalization ( you don’t feel like yourself) , a tendency to re-experience the event by flashbacks, an avoidance phenomena related to recollection of the traumatic event, impairment of social and other areas of functioning, increased  anxiety and arousal with sleep and concentration problems and a duration of these symptoms  2 to 4 weeks.

In order for us to make diagnosis of PTSD  there needs to be similar symptoms as ASD with one or more symptoms of recurrent and intrusive recollections (manifested in young children by repetitive play), recurrent dreams, re-experiencing the traumatic event with illusions , hallucinations and flashbacks , physiological reactions, , persistent avoidance of stimuli associated with the trauma, numbing , efforts to avoid thoughts and feelings related to trauma, decreased interest or estrangement, inability to have loving feelings, insomnia, outbursts of anger , exaggerated startle response  impairment in social functions, with a t least one of these symptoms lasting more than one month.

For more detailed and exact definitions see the DSM IV (or the new DSM V which may be somewhat revised )

Trauma Not Limited to Immediate Geographic  Area

The development of these symptoms is not limited to people in the immediate vicinity.

Classmates who didn’t attend school that day can have symptoms as can people all over the world who are traumatized by accounts in the media which vividly reconstruct the events and allow others to identify with the victims. There will be very few school age children in the U.S. who will not have heard about the details of this event

I recall at the time of the Challenger disaster, we saw school children all over the country effected by seeing this spacecraft carrying the astronauts and some teachers disintegrate before their eyes on television . Similar situations have happened in other tragedies, which are covered, on TV.

Long Term Effects

It should be recognized that the acute and  long term psychological  effects of this trauma  goes beyond the two disorders described above The experience also  becomes woven in the psychological makeup of people who are impacted by it whether near or far where it happened . For some, the innocence of childhood is taken away . The sense of security is changed forever. Long after the acute symptoms are gone, the effects of this event will have changed the individuals who experienced it. In some cases it will be a determining factor in how they will mold their future lives. Perhaps they will always be a cautious person, looking for unexpected danger. In other ways, the trauma can motivate persons to become doctors, nurses, police, researchers or influence the way they view their own lives for better or worse.

The Need for Immediate Psychological Intervention;

There has immediately been an outpouring of offers of psychological help.

I am sure the school system ,local and state agencies  will bring in counselors and therapists. Local mental health professionals  will ofter their help. I know the Committee on Disasters of the American Psychiatric Association ( of which I have been a member ) has offered the local Psychiatric Society materials and information that can be useful . There has been offers from International Groups that have experience  with these situations as well as from the Red Cross and from the nearby Yale Child Study Group. There will be individual and group meeting with the teachers and counselors as well with parents and of course with the children. The teachers will be trained how to be sensitive to the reactions of the children. It is important that all involved be aware of the various symptoms that can develop after events like this (some of which were described above) Danger signals need to be picked up. I am sure a wide variety of techniques will be used for one to one therapy  as well as in groups. Talking in groups can be useful for many but for others individual sessions can be very helpful  or a combination can  be used. For some of the children, the comfort of discussions and interactions with their parents will be  most important. Some parents will know how to handle this, other parents will benefit by discussion or counseling. I don’t believe there is one method which needs to be applied. The techniques used in individual and group treatment can cover a wide range from catharsis which involves expressing  one’s experience and feelings, Cognitive Behaviors Therapy ( CBT) which uses correcting misconceptions  and directly dealing with ideas and behavior and  psychodynamic therapy  where underlying meaning is explored and interpreted. In some acute situations medication (anti-anxiety or other stronger tranquilizers  can be used and when conditions  such as major depression is identified, antidepressants may be prescribed.  Other techniques and combinations of approaches will be used especially the human support and caring offered by people near and far and by such groups as the Red Cross which will be quite useful and meaningful.

Grieving the Loss of Life.

As most of us know grieving is a very intense process. Kubler-Ross described five stages of grief ; denial,, bargaining , anger , depression and acceptance. However, when there is unexpected death, traumatic death especially by murder and death of children, the grief takes on a different pattern which has been labeled Complicated Grief. We can expect the anger and depression to be greatly intensified and the duration of the intense emotions to be much more prolonged especially when there is the loss of a young child. Ultimately various types of memorials to the lost child which can give significances to the lost out life can be helpful

Concern About Other Disturbed Individuals Including Copycat Incidents

It is only natural that there will be concern on all levels that disturbed individuals who might do anything like this incident should be identified , receive help and be safely  in a place where they can not harm anyone. This problem is accentuated at the time of such an incident and in the immediate aftermath since we know that sometimes in the mind of a severely mentally disturbed person, media reports of this event have  the possibility of precipitating a copycat pattern of behavior in another disturbed person. The presence of mental illness is usually identified by family , friends and teachers at an relative early point in life. While there has been great progress in providing mental health care in the United States since the 1960s , there are still people who do not get the care that they need because of finances and the unavailability of services. Quality health care should be available to everyone and this includes those with mental illness.

The Overwhelming Majority of People with Mental Illness are Not Dangerous

Only a very small percentage of people with mental illness are a serious danger to other people. An incident such as this school shooting invariably unfairly intensifies the stigma towards people with mental illness. This can hinder recovery and adaptation to this condition. We need continued research in identifying people who could be dangerous and we also need to understand and educate the public about mental illness.

The Gun Control Issue and The Psychological Implications.

We don’t yet know the history and the story why the Connecticut shooter’s mother   had registered guns in the house. I would guess that most probably if there were not these guns in the house ( which included automatic weapons ) that untold psychological trauma would not have occurred. The young man may have done something terrible but if guns were not available to him, the   chances are,  not as many people would have been killed.

I also wonder about the psychological effect of his growing up in a household where such guns were owned , kept and valued. I understand the argument that most gun owners may teach their children about gun safety. However when there are guns present, there may very well be the underlying message to a disturbed child, that when you are angry this is the way that you can act.

 

My Experience During 9/11

At the time of the commemoration of the 10th anniversary of 9/11 I reflected on my experiences at that time. The phenomena of “missing persons” posters which appeared throughout Manhattan shortly after the tragic events is discussed as well as some other observations about this fateful event.

Several weeks ago we commemorated the 10th anniversary of 911 and like many of you. I reflected back on what I was doing and how that event impacted on our lives. The latter question will require much more continued contemplation. However, the memories of that day and subsequent weeks were quite meaningful.

I lived in the northern suburbs of New York City at the time and the local newspapers had photographs of cars in train station parking lots that were not picked up by commuters who had perished in the World Center attack. I did not think that I knew anyone personally who died or had a close family who was killed  in the tragedy. Several months later I found out that  a chaplain with whom I worked with from time to time at the medical center had lost his son who worked at the World Trade Center. Over the ensuing years I saw many patients whose lives were impacted significantly by this event and worked in intensive therapy with several of them.

On the morning of 9/11/01 I was at Westchester Medical Center when I heard of the unfolding events. The nearest television set was on a psychiatric inpatient service near my office. I sat with staff and patients and watched the second plane hit the tower. Although many of the patients had severe acute mental illness-schizophrenia, other psychosis, suicidal behavior etc., we all responded in the same manner. There were groans and tears and statements of  “those poor people.” There was no panic and no apparent incorporation of this reality into the patient’s delusions. It has been shown that people with decompensated mental illness often show improvement at least in their short term symptoms when they are faced with emergency or tragic events.

I was reminded of an experience I had while I was in training in New York City many years previously when there was a sudden unexpected blackout with loss of power citywide for at least several hours. I also was visiting on a psychiatric inpatient service when it occurred and most people handled it quite well. I eventually published a paper how this event did interact with the psychopathology of a two patients.

By coincidence I was scheduled to give a Grand Rounds presentation on September 21 , 10 days after 9/11 at a hospital in downtown Manhattan from which you would have been able to see the World Trade Center. Ironically the topic of my talk had been about disaster psychiatry but I changed it to specifically allow a discussion on how my colleagues had responded and what they had done to address the mental health issues related to this tragedy in their backyard. A center had been set up on Pier 92 for the survivors, families and friends  of the victims. Mental health professionals from all over the Metropolitan area donated their services to work with the Red Cross in helping these people with their physical and emotional needs.

At the time of this presentation, I walked around downtown Manhattan and the area surrounding ground zero. I noted the presence of something very interesting there and also scattered throughout Manhattan.. There were posters with pictures made by family and friends of people who had been in the World Trade Center at the time of the tragic events and did not come home. The posters, as you can see, were made from the point of view that these people were “missing.” They provided a description of the person with the request that if anybody were to see them they should call a specific telephone number. There were numerous such posters. The fact is that people were not found wondering throughout the city. The relatively few injured people who were brought to the hospital were identified and families were notified. Of course, the New York City morgue had a very sophisticated system of trying to contact any family members if they had made identification of the remains of victims. So what were these posters about?

They obviously were part of the denial phase of  the acute complicated grief that the survivors were beginning to feel as on some level they realized their  loved ones were killed. Within the next two weeks people began to make alterations in these posters which showed that they recognized that these people had died.  They crossed out the words “lost” or  “missing” and would write things like “in memory of”. The posters now would be adorned with flowers. I don’t recall this phenomena ever being reported in the psychiatric literature.

While I did not participate in the work on Pier 92, I was asked to do some “debriefing” activities for some organizations. One such group was the personnel of a major TV network. (I had done some previous work identifying the psychological trauma that members of the working press often experience in the course of their work). I was the co-leader of this group with a Professor from the Columbia School of Journalism.  Prior to this time debriefing activities would have meant trying to get the participants to express their emotional reactions to their recent experience in the disaster. More recent research had suggested that this wasn’t the best approach. In fact,  it might even make things worst. So our approach was a much more general approach in which we acknowledged the type of emotional symptoms that they might experience and made suggestions how to minimize them.

The evening before I worked with this group I had spoken with a family member of mine who told me that she had a dream that the well known television anchor from this network was having a personal conversation with her about the disaster. This dream appeared to reflect the importance that such TV personalities have in reassuring people at the time of frightening events. I was able to tell my relative that I spoke with the TV producer who worked with this anchor and she was going to tell him about her dream .

There has been a great deal written about this disaster in professional journals as well as in other media.We also will dearly hold on to our personal memories of that fateful day. Feel free to relate any of your experiences or thoughts about this day in the comment section below.

Psychological Problems Expected After Japanese Disaster

Psychological problems are expected after the recent earthquake and tsunami in Japan. In the past American psychiatrists with experience in disaster psychiatry have offered assistance to colleagues in other countries who are dealing with a catastrophic event and it is expected that this will occur with the current incident. In the initial phase psychological first aid will be given to the survivors and then symptoms of acute stress will be addressed. Between 10-50% of those impacted can be expected to develop symptoms of post traumatic stress disorder. Expertise in risk communication will also be helpful in dealing with the task of informing the public. This becomes especially relevant with the threat of radiation contamination from damaged nuclear reactors.

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

Edited by M. Blumenfield & R. Ursano

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

Edited by Fred Stoddard, Jr., Craig Katz, and Joseph Merlino

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

By Robert Ursano, Carol S. Fullerton, Lars Weisaeth and Beverly Raphael

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

By V. Alex Kehayan & Joseph C. Napoli

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.

Risk Communication

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.

The Rabbit Hole-Complicated Grief

A movie review written by the author of the recent film “The Rabbit Hole” is presented. The story deals with the responses of two parents to the death of their five year old son. The film shows realistic grieving of each parent. The issue of “complicated grieving” is explained and discussed. It is suggested that this movie should be used as a teaching tool for professional students interested in understanding the grieving process.

One of things that I enjoy doing when I am not writing this blog or doing other professional work, is to watch movies. In fact, my wife and I frequently attend preview screenings and we write brief reviews in our blog named FilmRap.net

Recently we saw a new movie which is going to be released this week in Los Angeles and New York as well as across the country shortly thereafter. Aside from it being an excellent film which will probably get some Academy Award consideration, I believe that it will make an excellent teaching film for mental health professionals who are studying manifestations of grief. I will reproduce our review of it and then add a few additional comments :

The Rabbit Hole – Rating 4/5 stars

David Lindsey–Abaire as screenwriter for this film, based on his own play, really gets into the head and the emotions of two grieving parents 8 months after the death of their five year old son who died running after his beloved dog. We never meet Danny and barely see a picture of him but we come to clearly understand the relentless pain in all it’s forms which his parents Becca (Nicole Kidman) and Howie (Aaron Eckhart) are feeling. Each of them are  grieving in his and her own way which despite sharing this most personal tragedy and a good previous relationship, there seems to be  no room for empathy between them. Becca’s quest to find some way to deal with her deep dark feelings leads her to establish a relationship with Jason (Miles Teller), the 18 year old high school senior who swerved his car, which he confesses to her may have been going a mile or two over the speed limit, which led to the tragedy and  now has created a bond between them. Becca’s somewhat religious mother (Diane Wiest) whose son died at age 31 , eleven years previously, provides a counterpoint from where she is coming. Nicole Kidman who saw the original play and started the ball rolling to make it into a movie chose John Cameron Mitchell to direct it. Mitchell and Lindsey Abaire who were guests at our screening acknowledged that they complemented each other as they explored the fine points of this film. The director, who had only a 4 million dollar budget, shared with us that he let the actors steep  themselves into their emotional  roles which he appeared to nimbly direct as well as spending  a great deal of time in editing the fine points. He gave a touch of humor to   a primarily a dark movie and kept us the audience observing at a slight distance from the unimaginable tragedy. We did not shed a tear for the young boy who we did not meet or really know. As mental health professionals who have worked with many grieving patients, we had the feeling that we were empathizing with people we cared about, as we might with a patient who is   involved in their own dynamics that are unfolding before us at somewhat rapid pace. The fact that the writer, director and the actors really nailed the complicated feelings and interactions without ripping apart the guts of the audience (which they could have easily done) may be judged a shortcoming of the movie by some or the height of sophistication by others.

This movie also merits comparison with four other movies which we have seen in the past year and each of which shows attempts at dealing with grief in a different manner.

A Single Man shows Colin Firth in an Oscar nominated performance as George a college professor whose lover has died in an auto accident and in his grief he is on the verge of suicide when he meets a young student who cares about him. Robin Williams does an excellent job as an unsuccessful writer in World’s Greatest Dad grieving   a teenage son who committed  suicide. The father pretends his late son has written the story of being bullied and the result is a game changer for the community and for the dad which gives some meaning to this tragic loss.  The Lovely Bones deals with the murder of a young teenager (Saoirse Ronan) who had just begun to feel the glimmers of romance which leads the audience to feel her parent’s unresolved grief despite the youngsters ethereal existence. There is a small amount of compensation as the killer is caught through the efforts of the girl’s sister.  The film, which most closely resembles the Rabbit Hole, is The Greatest which brought together a comparable great performance by Pierce Brosman and Susan Sarandon who are the grieving parents of a teenager killed in car accident while he is with his girl friend played by Carey Mulligan. The potential for the parents to live with their grief is the unborn child being carried by the young girl friend whereas  in the film which we reviewed today,   the hope for a better future is only hinted by a subtle but important gesture at it’s conclusion. We thought these two were both excellent films The  Greatest didn’t achieve the critic’s Oscar acclaim and it appears that the Rabbit Hole may get some such bids. However overall, we rated the Rabbit Hole a notch lower. We certainly do believe that  this movie is the finest example and should be used as a teaching tool and stimulus for discussion for those who are studying the grieving process as well as a movie worth seeing for anyone interested in these all too real human emotions

Additional  Comments

To experience the death of your young child is one of the most painful, difficult and traumatic events that a human being can go through. Mental health professionals who have studied this event have recognized that the subsequent grieving has certain characteristics that go beyond and are somewhat  different than the usual emotional responses that are seen after the death of a close friend or relative. It has been labeled as  complicated  grief and this term includes other circumstances in addition to the loss of child, such as the death of an adult or child  by murder, suicide, unusual unexpected trauma such as terrorists attacks ie 9/11, etc.  While the loss of a close person is rarely forgotten, there often is a gradual resolution of the intense feelings over the course of a year with amelioration of most of the symptoms such waves of sadness, episodic crying, insomnia, intrusive thoughts, occasional hallucinations, intense anger, etc. Most people who grieve usually do not find it necessary to have counseling or any form of therapy.With complicated grief such feelings rather that resolve often intensify in the months following the loss. There may be evidence of major depression with weight loss, continued insomnia and even suicidal ideation. There can be a resort to heavy drinking or drug use. There can be intense anger, not only at self but at others , often with a demand of some type of restitution or revenge. Relationships are greatly strained and marriages often are not able to withstand this trauma. Psychotherapy is often helpful with or without medication. Sometimes a group process is used which includes other people who have gone through similar losses.   It may be useful for some type of a memorialization process to be developed where the memory of the lost person is perpetuated in some worthy fashion. The above movie certainly did not touch upon most of these issues but it did clearly show the impact on the parents of the traumatic loss of their child. The subsequent behavior and the emotional responses of each of the parents were very real and plausible in view of the loss that they had suffered. As I noted, this film would be an excellent starting off point for professional students to discuss and analyze the grieving responses in this very difficult situation. Obviously the movie gives the viewer a certain cathartic experience and you can also appreciate it as a very good creative artistic accomplishment which may be viewed by many as one of the best films of the year.

Haiti Earthquake-Psychological Care Needed

More than 150,000 people have died in the recent devastating earthquake in Haiti. There is fear, anxiety, depression and tremendous psychological pain. The uncertainty about the future will intensify these emotional reactions. Most likely the initial help by mental health professionals will be to assist the stunned people in getting food, shelter and information about the whereabouts of their loved ones. Psychiatrists may write prescriptions for general medical conditions or even assist in emergency surgery. There also is a need for the authorities to provide “risk communication” of truthful information. Death notifications need to be done skillfully. Mental health professionals can be helpful in training for these tasks. In the immediate aftermath of a disaster, people may deny the reality of what has happened. There will be grieving by survivors for the many people who perished. Grief after unexpected violent death especially when it includes children can be prolonged and complicated with additional emotional problems including alcohol and drug problems. At least half of the survivors will have some symptoms of PTSD. There are various forms of mental health interventions which may be helpful. The psychological effect of such a disaster can also impact on the secondary victims which include all rescue and medical personnel as well as members of the media. Psychiatrists and other mental health professionals will play an important role in helping the people of Haiti to recover from this ordeal.

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. HAITIThere 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).

Denial

Sometimes the people involved are actually denying the reality that has clearly occurred. DenialIn 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.

Grieving

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.

ANDERSON COOPERThe 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. (See Page 42-43 of this reference)

Conclusion

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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