History Of Mental Health Interventions After Disasters

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The detection and treatment of mental disorders caused by disasters began in the USA, thanks to the advent of the PTSD diagnostic category in the aftermath of the Vietnam War, and the subsequent application of this diagnosis to civilian situations. A literature survey [12] revealed that a great variety of treatment methods have been proposed at different times. Treatment has been offered to victims [13,14], relatives and other community members [15,16], or rescuers [17,18]. The usefulness of treatment was accepted only gradually in the community, and Lindy [19] mentions that the main difficulty was gaining access to victims.

As early as 1983, Mitchell [20] defined debriefing procedures, on the basis of cognitive techniques. His method aimed at treating police officers or firemen who had been exposed to a critical event. Mitchell's method can be applied during the post-immediate period (first week); it follows a seven-step procedure (introduction; facts; thoughts; reactions; symptoms; education; conclusion). Mitchell's approach is mainly cognitive (it helps the patients to gain an exact knowledge of the event); it aims at prevention (lack of knowledge might lead to PTSD) and restoring operational capability. It is not meant to treat and to be applied to victims. Mitchell's debriefing techniques were modified by several authors: some established a distinction between didactic, psychological, and therapeutic debriefing; others placed debriefing in a ''continuum of care'', and emphasized the importance of coping mechanisms and cognitive structuring. After the San Francisco earthquake in 1989, Armstrong et al. [21] developed a ''multiple stressor debriefing model'', taking into account all stressors and comprising four steps: disclosure of the event and all stressors; feelings and reactions; coping strategies; and conclusion and return to the familial group. In 1992, Dyregrov [22] developed a collective debriefing method, which made use of the group's capacity to provide mutual help. In France and Belgium, debriefing has been based on the verbal expression of the experience, both cognitive and emotional, and considered to be an early therapeutic intervention, which could be followed by longer-term management.

It is only in the 1990s that American authors started proposing more comprehensive management programs [23] that included reducing symptoms (intrusive re-experience and avoidance), restoring emotional control, incorporating the personal significance of the event, and social reinsertion. Similar initiatives happened in Europe at the same time. In the United Kingdom, the police used to take care of the initial psychological needs of the victims, before medical and social services intervened. In 1995, Turner et al. [24] surveyed, 7 years after the event, the mental health of the survivors of King's Cross underground station fire in London (18 November 1987), which killed 31 people. The authors remarked that physical wounds were adequately treated, whereas psychological wounds and long-term consequences were neglected. After the Herald of Free Enterprise car ferry capsized (1987), a special group - the Herald Assistance Unit - was created by the Kent Social Services to coordinate social and psychological help over a 15-month period. The group produced a newsletter and operated a 24-hour telephone hotline; further treatment was given in London. Similar initiatives were launched in Belgium, the Netherlands, Germany, Sweden, Finland, and Norway.

In Norway, the military is in charge of first aid, including psychological and psychiatric assistance (it intervened as early as 1985 at a factory fire, and at an avalanche site). In Sweden, psychologists and psychiatrists practicing in civilian hospitals will also evaluate and treat victims, as was the case, for instance, after the rail collision at Lerum, on the Stockholm to Goteborg line, which caused 9 dead and 100 wounded, on 16 November

In France, initiatives to treat disaster victims were taken as early as 1987. A specialized consultation was created at Saint Antoine Hospital in Paris in

1988 by Crocq, Alby and Puech, first for victims of terrorist acts, and later for victims of different kinds of psychological traumata. Special interventions were made to assist survivors of the collapse of a spectator stand at a soccer game in Bastia, Corsica, on 5 May 1992; relatives of passengers of the DC-10 of the French airline UTA destroyed by a midair explosion over the Tenere desert of Niger in 1989; and passengers of an airliner hijacked between Algiers and Paris on 24 December 1994.

However, it was a terrorist attack in the Paris subway that triggered a decision by the President of the Republic to create a network of cells for medical and psychological emergencies (Cellules d'Urgence Medico-Psychologiques - CUMP). The CUMP network is present with a cell in each one of the French d├ępartements (i.e., counties); each cell comprises psychiatrists, psychologists, and nurses, who are trained in disaster psychiatry. The CUMP is guided by a proactive philosophy, which is to assist disaster victims as early as possible, anticipating the subject's request [26].

In Israel, Shalev et al. [27] intervene early, as soon as the victims of terrorist attacks are admitted into the hospital. They described how the mental state can vary, according to external factors and time (first hours, first week, etc.). They favored a flexible therapeutic approach, taking into account the victim's needs and the course.

The example of the severe earthquake in the Sea of Marmara region in Turkey on August 17, 1999 shows how the notion of mental help after disasters has become accepted by national and international organizations. The earthquake, reaching 7.4 on the Richter scale, damaged several villages in an area of 20 million inhabitants; 18,000 died, 50,000 were wounded, and thousands were left homeless. The Turkish government and the international community reacted immediately. Gokalp [28] described a 6-month post-immediate period, when survivors expressed confusion, grief, regressive demands, and lack of initiative. In the area of Adazpar, where 39% had lost a relative, 60% of the sample were diagnosed with PTSD after 12 months, with comorbidity in 40%. In the areas of Yenikoy, Otosan, and Mehmetcik [29], 47% of subjects had PTSD and 33% depression. Gokalp stressed the importance of preparing for disaster.

The recent earthquake that damaged the whole region east of Algiers (May 2003) exemplifies how mental health has become a priority. On the first day of the disaster, the psychiatrists and psychologists of the region were called to assist victims; later, they were relieved in 10-day shifts by their colleagues from neighboring areas. In addition, 30 psychologists intervened in refugee camps. Three months after the earthquake, these personnel were debriefed to prevent burnout; they expressed a wish for additional training on trauma.

In Latin America, the Pan American Health Organization (PAHO) has been actively engaged for the last 20 years in efforts to assist disaster victims, in particular after hurricanes in the Caribbean [30]. The first strategy consisted in sending teams to the afflicted community. However, sending teams from outside did not help the countries to prepare for future disasters. Thus, a new strategy was adopted to elaborate national rescue plans in several stages: (a) creation of an agency to evaluate needs and priorities; (b) training of first-level personnel (first-aid teams, social workers, cadres) to identify serious casualties; (c) training of medical and psychiatric services; (d) creation of teams that can train first- and second-level rescuers; (e) systems to educate the population. Such plans can be successful only if they are supported by competent teams at the ministry of health.

In Asian countries, the recent earthquake in Kobe, Japan, on 17 January 1995, showed that installing a mental health service in a disaster area is fraught with difficulties. The Hanshin-Awaji earthquake left 5,500 dead and 350,000 homeless in that conurbation of 1.5 million. Local authorities were overwhelmed and could not respond immediately in an adapted manner. One and a half million volunteers came from all over Japan, mostly students and relatives of victims. They helped victims salvage their belongings and find shelter, water, and food. Often, they listened to the victims' stories. However, this spontaneous rescue action was not coordinated; rescuers were too few in some isolated areas, and too numerous in more accessible centers. A few psychiatrists organized mental health rescue centers; however, survivors were more interested in salvaging their belongings and satisfying material needs. Psychiatrists prepared booklets containing guidelines for volunteer rescuers. Shinfuku [31] reported that mental symptoms followed three successive stages: (a) a first immediate phase of stupor and derealization; (b) a second phase, during a few weeks, of anxiety, fear of a recurrence, and psychosomatic symptoms (hypertension, gastric ulcer); (c) a third phase, after a few weeks, characterized by depression and mourning of human and material losses. After a year, problems were more of a social nature than purely mental (loss of drive, alcohol abuse, etc.). The prevalence of PTSD was not reported. However, the publicity around PTSD in the media helped reduce the social stigma attached to mental problems. Kobe University inaugurated a Research Center for Urban Health, with a department of disaster medicine. Five years after the earthquake, the population of Kobe was reduced by 100,000, but it seemed to have returned back to its usual life.

Recently, McFarlane [32] gave more indications about the management of psychiatric morbidity in disasters. It is important to reduce the impression of chaos and to inventory needs by rapidly drawing a map of the situation, assessing the number of casualties, and the extent of destructions. Public health plans, prepared beforehand, should be enacted. However, types of disaster are so varied that it necessary to show flexibility rather than strict adherence to plans. Often, disaster victims will initially cope with the situation, and present with symptoms only weeks or months later. The attack on the World Trade Center on September 11, 2001 showed that rescuers can, in turn, become primary victims. The popularity of mental help intervention in the public led to an increase in requests for assistance, but also to an influx of poorly trained volunteers who have little experience in psychological help and team work. Such volunteers may embark on the treatment of a victim, whom they will abandon after a short while when they realize the task's difficulty. The intervention of outside experts, even if they are highly competent, may thwart the efforts of the local services. Often, victims prefer to be taken care of by their own local teams, with whom they can relate better.

In 2002, Raquel Cohen wrote a survey of mental health intervention with disaster victims [4]. She stressed that mental health intervention should be integrated within the larger frame of the public organization of rescue operations, and establish links with other partners. She suggested that the psychological intervention plan should be refined in several modules according to the type of victims (primary, secondary) and the stage of the disaster (immediate, aftermath). One of the key tasks is to give emotional support to the survivors, to help them understand the stress they experienced, and to help them put their thoughts in order. The operational concept is based on the "individual-situation-configuration" model. Postcrisis intervention aims at giving back to the individual the capacity to adjust to the new stressful situations. The three objectives are: (a) helping victims to recover their capacities; (b) helping them organize their new environment; (c) assist victims in their interactions with the bureaucracy in charge of rehabilitation. The methods to achieve these objectives are a function of the different schools of thought, but flexibility and creativity must always complement a classical clinical approach. It will be necessary to take care of mourning families, in particular after they have been called to identify the corpses of deceased relatives. Population groups housed in camps and temporary shelters have to endure poverty and promiscuity and may be prompt to react with depression, anger, violence, alcohol or other drugs. It will be necessary to assist these refugees, help them organize their new life and recover their ability to take care of themselves, and also to help them express their emotions. Treatment can rely on a wide variety of methods: medications, cognitive therapies, individual or group psychotherapy, family therapy. It will also be necessary to consider prevention, as well as social and professional rehabilitation, for instance the children's schooling. Finally, it will be necessary to identify patients who evolve towards chronicity and need particular treatment. It may be useful to include collaborators from the private sector, from allied health professions (nurses, etc.), and also members of the clergy if they are trained and correspond to the cultural and religious needs of the victims. The relationship with the media is of crucial importance. The media are fond of interviews with psychiatrists, and it is important to use them to convey information to the population about mental health services.

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