PREFACE
The
mental health consequences of disasters have been the subject of a
rapidly growing research literature in the last few decades. Moreover, they
have aroused an increasing public interest, due to the dramatic impact and
the wide media coverage of many recent disastrous events—from earthquakes
to hurricanes, from technological disasters to terrorist attacks and
war bombings.
The World Psychiatric Association has had for a long time a great interest
and commitment in this area, especially through the work of the Section on
Military and Disaster Psychiatry and the Program on Disasters and Mental
Health. Several sessions on this topic have taken place in past World
Congresses of Psychiatry, and other scientific meetings organized by the
Association have dealt exclusively with disaster psychiatry.
Several research and practical issues remain open in this area. Among
them, those of the boundary between "normal" and "pathological" responses
to disasters; of the early predictors of subsequent significant mental
disorders; of the range of psychological and psychosocial problems that
mental health services should be prepared to address; of the efficacy of the
psychological interventions which are currently available; of the nature and
weight of risk and protective factors in the general population; of the
feasibility, effectiveness and cost-effectiveness of the preventive programs
which have been proposed at the international and national level. Moreover,
wherever disasters strike, policy and service organization issues that
plague the mental health field worldwide receive even more prominence:
the detection and management of mental health problems are assigned less
priority than care for physical problems; trained personnel is lacking;
community resources for mental health care are poor; a vast proportion of
people in need hesitate to ask for or accept mental health care.
However, it is clear that the field is progressing rapidly from the scientific
viewpoint (with a refinement of early diagnostic concepts and treatment
strategies, and a deeper understanding of resilience factors at the individual
and community level) and that in a (slowly) growing number of countries
concrete steps have been taken concerning training of personnel, education
of the population, and the development of a network of services prepared to
deal with psychological emergencies.
This volume aims to portray this evolutionary phase, by providing an
overview of current knowledge and controversies about the mental health
consequences of disasters and their management, and by offering a selection
of first-hand accounts of experiences in several regions of the world.
We were impressed by the liveliness of some of the reports, and particularly
touched by some of the chapters dealing with the mental health consequences
of armed conflicts, especially on children and adolescents. The
authors of these chapters have accepted our advice to be as objective as
possible in their descriptions. However, despite the intentions of the
authors and the editors, some traces of their unavoidable emotional
involvement may have been left in their chapters.
Neither the research overview nor the selection of experiences presented
in this volume should be seen as being comprehensive. We hope, however,
that the book will throw more light on the issue of mental health consequences
of disasters, stimulate acquisition of more knowledge through
research, enhance our sensitivity, and contribute to a more effective
prevention and management of the behavioural effects of disasters.
Disasters have been happening since time immemorial and will continue
to happen. We must be prepared to face them and deal with their consequences.
Juan Jose Lopez-Ibor
George Christodoulou
Mario Maj
Norman Sartorius
Ahmed Okasha
CHAPTER 6
Organization of Mental Health Services for Disaster Victims
Louis Crocq, Marc-Antoine Crocq, Alain Chiapello and Carole Damiani
Necker Hospital, Paris, France
Rouffach Hospital, Rouffach, France
French Red Cross Society, Paris, France
INAVEM (Institut National d’Aide aux Victimes), Paris, France
INTRODUCTION
In the past, the care of disaster victims was limited to rescuing them,
tending their wounds, offering shelter and material assistance, helping
them to relocate and resume their previous occupation. In the last three
decades, increasing attention has also been given to the victims’
psychological suffering, and to the psychosocial and moral burden of the
individual and the community. Thus, programs for medical, psychological,
and psychosocial intervention have been devised in various countries. They
are implemented at different stages of the disaster and its aftermath. The
guiding principles are: (a) to take into account psychological distress; (b) to
manage the psychosocial impact on the individual and society; and (c) to
prevent the development of late sequelae that would handicap individual
or group functioning. Various initiatives have been proposed by governments,
non-governmental organizations (NGOs), international associations,
and private groups. Some of these initiatives have been quite successful.
However, there is a need to integrate these various initiatives into a
coherent whole. At a certain level, rescue and rehabilitation need to be
coordinated by government authorities.
THE IMPACT OF DISASTERS ON INDIVIDUAL AND
COLLECTIVE MENTAL HEALTH
In 1988, the World Health Organization estimated that natural disasters had
afflicted 26 million persons between 1900 and 1988. In that number, 10
million had been made homeless. A 1992 report by the International
Federation of the Red Cross and Red Crescent Societies identified 7,766
disasters that had occurred in the world between 1967 and 1991, killing 7
million and affecting 3 trillion individuals [1]. Natural disasters predominantly
afflict poor populations – 68 out of 109 natural disasters that
occurred in the world between 1960 and 1987 concerned developing countries,
and only 41 affluent countries. Furthermore, the casualty rate is higher
when disasters happen in poor countries, as compared with richer
countries, because of factors such as overcrowding in areas that are prone
to natural (e.g., floodland) or industrial disasters (e.g., chemical plants).
Regardless of the degree of material destruction, disasters are first and
foremost characterized by the intensity of human trauma. The psychosocial
aspect of disasters is underlined in our definition of a disaster by a
combination of five criteria: (a) the occurrence of a negative event that
brings distress to the people and the community (a revolution that frees a
country from a tyrant is not considered a disaster, even when it causes
thousands of casualties); (b) the causation of material destruction that
significantly alters human environment (an avalanche in an uninhabited
mountain valley is not a disaster, contrary to an avalanche in a populated
valley); (c) a great number of victims, dead, injured, homeless, who suffer
significant somatic injuries and psychological suffering; (d) the overwhelming
disruption of local means of rescue and protection; and (e) the
interruption of services that are normally offered by society (i.e.,
sheltering; producing, distributing, and consuming energy, water, food;
health services; transportation; communication; public order; and even . . .
burying the dead). It should be remembered that victims have been
threatened not only in their individual ego, but also in their collective ego,
or sense of belonging to a community. Their individual misfortune is also
a collective misfortune. Gerrity and Steinglass [2] developed similar
hypotheses about the familial group, on the basis of Reiss’s ‘‘family
paradigm’’ [3]. The family elaborates a set of beliefs about the
environment. Its response to a disaster will be determined by its cognitive
and emotional perception of the traumatic event and its relationship with
the family’s history.
The term ‘‘victim’’ is somewhat unclear. In the broadest meaning of the
term, a victim is anyone who has been affected by the disaster in his/her
physical or mental health, properties, or social life. Victims are usually
classified into five groups on the basis of their distance to the disaster [4]:
(a) primary victims (dead, wounded, uninjured survivors), who have been
directly exposed to the disaster; (b) secondary victims, who have not been
directly affected, but who mourn a close relative who is part of the
primary victims; (c) third-level victims, such as rescuers, health personnel,
who intervened on the scene and have often witnessed traumatizing
events; (d) fourth-level victims, such as government or media workers,
who may have suffered emotionally when taking decisions or witnessing
scenes; (e) fifth-level victims, in the general public, who were not
physically present at the scene but suffered by proxy when exposed to
the media coverage.
MENTAL CONDITION AND HEALTH CARE NEEDS OF
DISASTER VICTIMS
The mental state of victims should be considered at the three different
stages of disaster and aftermath: (a) the immediate reaction (usually, from a
few hours to less than a day); (b) the post-immediate phase, that begins on
the second day and lasts from a couple of days to a couple of months; (c) the
delayed and long-lasting sequelae, that may be transitory (from 2 to 6
months) or become chronic (longer than 6 months).
Immediate Phase
About 75% of victims show no mental disorder, but only short-lived neurovegetative
and psychological symptoms that are transitory (a few hours)
and are part of the normal adaptive stress reaction. A short period of
physical and psychological exhaustion may follow, because stress depletes
energy. From a psychological viewpoint, this adaptive stress reaction is
characterized by an adaptive focusing of attention on the danger situation,
by the recruitment of mental capacities, and by the facilitation of action.
Adaptive stress leads to decision-taking, acting on a decision, and adaptive
fight-or-flight reactions. However, adaptive stress is an exceptional
response that has a high cost in energy and discomfort. Therefore,
individuals who exhibited this adaptive response may still need psychological
help afterwards.
A smaller proportion (25%) of victims may present with abnormal and
maladaptive stress reactions, which may follow one of four patterns [5,6]:
stupor, agitation, panic flight, automatic reaction. These maladaptive stress
reactions always comprise elements of peri-traumatic dissociation [7],
including confusion, derealization, fright, impression of absence of relief,
and abulia. In ICD-10, such reactions are termed ‘‘acute stress reaction’’.
DSM-IV proposes no diagnosis for this acute stress reaction, since the
criteria of ‘‘acute stress disorder’’ require that the disturbance lasts for a
minimum of 2 days, which exceeds the duration of the immediate stress
reaction. Individuals who responded with maladaptive stress should be
viewed as ‘‘psychological casualties’’; they have lost their capacity for
autonomy and should be given psychological help.
Post-immediate Period
Either the mental state returns to normal in a few days (neuro-vegetative
and psychological symptoms subside, the individual is no longer entirely
preoccupied by the event and can resume his previous activities), or a
psychotraumatic syndrome appears, characterized by the re-experience of
the event, avoidance of stimuli reminiscent of the trauma, hyperreactivity,
and constant preoccupation with the trauma. Psychotraumatic symptoms
may appear only after weeks, or months. This is the so-called ‘‘latency
period’’, which had been identified in traumatic neurosis by Charcot and
Janet, and called period of incubation, contemplation, meditation or
rumination. The duration of this period is variable: each individual needs
a different amount of time to organize new defense mechanisms.
Furthermore, if the individual is still hospitalized, he may wait till he
recovers his autonomy to start coping with the trauma. ICD-10 and DSM-IV
propose the diagnostic term ‘‘post-traumatic stress disorder’’ (PTSD) (acute
type, since the duration is short) for this syndrome. In addition, DSM-IV
offers the category ‘‘acute stress disorder’’ for the cases with dissociative
symptoms (appearing in the immediate phase) and psychotraumatic
symptoms such as re-experiencing (appearing within 4 weeks of the
trauma). Individuals who presented with a maladaptive acute stress
reaction are more at risk to present with acute PTSD afterwards. However,
this course is not unavoidable, and there are cases of maladaptive stress
reaction that recover without consequences, whereas individuals who
initially responded adaptively to the trauma may later develop severe
PTSD.
Delayed and Chronic Period
Cases of acute stress and post-traumatic stress that occur during the postimmediate
phase may resolve – spontaneously, or with treatment – fairly
rapidly (in less than 3 months). However, they may also persist, and even
become chronic. The typical clinical picture of PTSD may then become
manifest during the delayed and chronic period, with its key features of:
(a) exposition to a traumatic event, evoking a response of intense fear or
helplessness; (b) persistent re-experience of the traumatic event (in intrusive
recollections, dreams, flashback episodes, etc.); (c) avoidance of stimuli
associated with the trauma and numbing of general responsiveness; and
(d) symptoms of increased arousal.
It is worth noting that the above criteria (c) and (d) together reproduce
the personality changes that were described in the former European
diagnostic category termed ‘‘traumatic neurosis’’. According to Fenichel,
this personality change was characterized by the blocking of such
functions of the ego as: (a) filtering of the environment; (b) presence;
(c) relationship with others. Briefly, the victim no longer has the same
relationship with others and the world since the traumatic event. He has
developed a new way of perceiving, thinking, loving, wanting, and acting.
In addition to PTSD, ICD-10 provides another diagnostic category entitled
‘‘enduring personality change after catastrophic experience’’ (F62.0),
defined by criteria such as a mistrustful attitude toward the world,
social withdrawal, feelings of emptiness or of being threatened, and
estrangement.
Traumatic neurosis, as it was described in Europe, associated several
non-specific symptoms, such as physical, psychological, and sexual
asthenia; anxiety; hysterical, phobic, or obsessive overlay symptoms;
somatic complaints (notably in children); psychosomatic complaints;
conduct disorders, addiction, suicide attempts. Many patients still present
with these symptoms, which are considered ‘‘comorbid’’ in DSM-IV and
ICD-10, like the pseudo-depression that is linked to psychological
numbing. These non-specific symptoms may be prominent in the clinical
picture, and lead to errors in diagnosis and treatment. In clinical practice,
many patients do not meet all the DSM criteria for PTSD, or the ICD
criteria for ‘‘enduring personality change after catastrophic experience’’.
There are many atypical cases of varying onset, duration and severity,
with a diverse degree of handicap. All disaster victims who still present
with symptoms at this stage should be offered psychological or psychiatric
care until recovery.
Numerous surveys have shown that a substantial proportion of disaster
victims still present with PTSD symptoms several years after the traumatic
event. Green and Lindy [8] observed a PTSD prevalence of 44% two years
after the 1972 Buffalo Creek flood disaster, and of 14% after 14 years.
Bromet and Dew [9] mention a 22% rate of psychological sequelae
(including 11% PTSD) after a hurricane in Honduras. In a survey of 43
terrorist attack victims, Bouthillon-Heitzmann et al. [10] reported a 79%
PTSD rate 3 years after the event; one-third of subjects showed clear
psychosomatic disorders.
MENTAL STATE OF THE AFFLICTED COMMUNITY
A disaster strikes a whole community, causing types of collective behavior
which cannot be reduced to the mere sum of instances of individual
behavior. Collective behavior is influenced by a community’s psychology,
by the crowd’s state of mind, and is characterized by its own specific
features. After a disaster, collective behavior may be either adaptive or
maladaptive.
Adaptive collective behavior is often rehearsed and expected. Instances
of adaptive collective behavior during the immediate phase are remaining
at one’s post, orderly evacuation, helping others. Adaptive collective
behavior is characterized by three features: (a) group structure is
preserved; (b) leadership is maintained or reestablished; (c) mutual help
is organized. During the post-immediate and long-term phases, adaptive
collective behavior is manifested by normal mourning, regaining
autonomy, reconstruction and resuming normal professional and social
activities.
Maladaptive collective behavior during the immediate phase may show
as: (a) collective stupor (the population remains reactionless or evacuates
the impact zone in a long centrifugal exodus); (b) collective panic (headlong
flight, scrambling for safety); or (c) exodus. These three types of collective
behavior are characterized by: (a) the loosening of group structure; (b) the
collapse of leadership; and (c) the lack of solidarity. Additionally, it is
possible to observe, during the post-immediate period, the spread of
rumors, and violence outbursts (riots, hooliganism, and search for
scapegoats). The delayed and chronic phase may give rise to a paranoid
collective mentality (hostility toward the world and demanding redress),
and a dependent mentality, with feelings of being entitled to assistance, and
the inability to recover autonomy.
The leaders who are responsible for organizing rescue operations must be
aware of these behavior patterns, and their predisposing factors. Raphael et
al. [11] identified some pathogenic factors in the social context of disaster:
(a) the extent of material destruction, (b) the disturbance of the normal
channels of psychosocial support, (c) a history of previous collective
trauma, (d) the pre-existing state of the community (e.g., migration), and (e)
the separation of families. Additional negative factors are the composition
of the population (proportion of elderly, children, women), its lack of
structure and preparedness, its mental state on the eve of the disaster (the
"expectant attention", described by Le Bon, facilitates panic), rumors
fostering feelings of panic or abandonment, and the presence of specific
individuals who overtly spread alarmist views and will "contaminate"
others. After a disaster, individual interventions should be complemented
by collective measures aimed at restoring collective psychological health.
