Care for Nepal

Written by Mark B. Borg, Jr., Ph.D, Grant H. Brenner, MD, and Daniel Berry, RN, MHA

The current ongoing humanitarian and natural disaster unfolding in Nepal has caught the world's eye. It is estimated that over 8 million souls have been affected. The mass exodus of people from Kathmandu, out of fear of aftershocks and back into traditional homes in the countryside is a factor which will provide greater local support, but will also place a strain on resources as well as complicate aide delivery.

So far, the number of fatalities is passing 5000, and still counting. While attending to basic needs is a key priority, especially with strained resources (and will remain an issue), the psychological and emotional impact will linger for many years to come. Interventions now combining local and outside expertise may help to mitigate the impact, identify people having more profound difficulty, and help to re-establish a sense of safety and community but there are many other repercussions that need to be addressed.

Based on an extensive review of the literature, and on-the-ground experience, Hobfall et al. (2007) have listed the following Five Essential Elements for Mass Trauma Intervention as follows. 

People need:

• A sense of safety

• Calming

• A sense of self- and community-efficacy

• Connectedness

• Hope

What do psychiatrists need to understand in order to have a basic level of preparedness in the event of disaster? Many of the skills we already know are applicable. Disaster psychiatry draws on emergency psychiatry, consultation-liaison psychiatry, an understanding of family and systems dynamics, child psychiatry, basic principles of psychotherapy and psychology, and community psychiatry, to name a few. The basic principles of self-awareness, self-reflective processing, processing with colleagues, and counter-transference come into play. We need to understand who we are, how we are prepared and unprepared, and how we are prone to react, and how we are reacting - to particular situations.

Yet, disaster work for the psychiatrist can be radically unfamiliar for many of us. Working in the field, away from the hospital, the private office, divested of medical resources we often take for granted, away from basic resources (food, water, shelter, a stable context) - the most seasoned psychiatrist can get caught up in surprising and sometimes problematic situations and emotional reactions.

The qualities of the particular disaster are critical to take into account:

Is it natural or man-made? Man-made disasters are associated with stronger feelings of injustice and activate us differently than do natural disasters. They make sense to us in different ways, and require different explanatory frameworks. Is it a tangible threat such as a conventional explosive, or an invisible threat, such as an airborne biological or chemical agent, or radiation? These qualities activate our own developmental patterns differently, depending upon who we are, and in particular also affect the way we may perceive and misperceive the degree of threat (and hence the level of anxiety and related behavioral reactions).

Is it a singular event such as an shipping accident, or are there ongoing threats, as with aftershocks in an earthquake? What is the duration of the event itself? If there is an ongoing threat, then it is challenging to establish a solid sense of safety and get on with the process of recovery.

Is the disaster far away, or local? If it is local, we ourselves are part of the disaster community - and are ourselves affected directly by the event. This changes how we engage and respond in ways which are important to be cognizant of, and periodically re-consider, to avoid potentially powerful maladaptive reactions.

What are the resources of the community affected? What cultural factors may come into play? What are the material resources and how have they been impacted? How is the infrastructure affected, and how robust was it before the event? What underlying issues were there which may be necessary to take into account, for example poverty, civil conflict, ethnic tension? How is the community responding? In what ways is the community response helpful, and unhelpful?

Disaster responders have to be acutely aware of how they enter a disaster zone, and especially be mindful of being invited rather than intruding, thoughtful, erring on the side of caution and using tact and diplomacy. More than anything else, taking care to understand, respect and truly appreciate the innate resources present in the disaster community. Crucial is to deeply value local resources - community leaders, religious leaders, local healers and healing customs - and to avoid imposing our cultural belief systems and diagnostic systems on affected populations. What is commonly referred to as "cultural imperialism".

There are of course many other factors this brief treatment cannot address. Readers may find Disaster Psychiatry: Readiness, Evaluation and Treatment (APPI, 2011) a useful and handy reference.

It is helpful to spell out some of the common hazards associated with disaster response, in order to help us be prepared for what we may encounter:

• Enacting rescuer fantasies and placing oneself and others in harm's way

• Coming to see oneself as an invulnerable hero

• Becoming too self-sacrificing and neglecting one's own basic needs

• Developing negative feelings (resentment, for example) toward colleagues or disaster-stricken individuals

• Becoming burned out or developing compassion-fatigue

• Activation of one's own unprocessed past traumas

These behaviors can be understood as counter-transferential and transferential reactions to disasters, as well as "real" feelings which arise in the course of the work. Along these lines, it is worth being aware that the choice to do disaster response work, as with any other intense and demanding job, may arise partially from childhood experiences. Know thyself is the addage of the informed disaster psychiatrist, necessary to protect oneself and others. For this reason, we always recommend that the work be done with at least 2 people working together.

On the brighter side, disasters bring out the best in human nature. In the immediate aftermath of a disaster, and in the months that follow, the majority of responders shine. The best side of human caregiving is expressed, and people make deep and intimate connections with one another and the people they help, leading to personal growth and enduring meaningful experience.

The chances of this healthy balance being struck in disaster response, is increased when the organizations sending people have it built into their operations to ensure that there are definitive boundaries put in place to prevent over-engagement. They include limiting the number of hours worked, to setting aside time each day for reflection and processing, attending to team dynamics, shortening the duration of deployments and replacing personnel with fresh volunteers. They also address giving appropriate recognition for effort and accomplishment, setting aside a safe space and room to seek consultation if things get too difficult physically and/or emotionally, and establishing a culture of tactfully transparent communication both horizontally among team members, and vertically with leadership where roles and responsibilities are clearly defined, with room for improvisation and respect for individual capacities and skills.

Nepal Earthquake Relief: Disaster Psychiatry Outreach is responding to the Nepal earthquake and needs support to implement its Mission. The current fundraising goal of $30,000 will allow three teams to implement our effective strategies of needs assessment, care, training and support on the ground. All funds are used to cover expensive and administrative costs. Our volunteers donate their time pro bono. Please visit: http://www.gofundme.com/dponepal1

DPO’s mission is to alleviate suffering in the aftermath of disaster through the expertise and good will of psychiatrists. After the initial wave of an acute response is over—DPO volunteers step in to assist with education and services of treating the invisible wounds of psychological trauma. To fulfill our mission, DPO responds to catastrophes and provides education and training in disaster mental health to a range of professionals in the healthcare, public health and emergency management sectors.

We:

• Organize volunteer psychiatrists who provide immediate mental health services in the aftermath of disasters in conjunction with government and private charitable organizations;

• Develop and implement educational programs, training, and referral mechanisms, and;

• Develop research and policy in the field of disaster mental health.

• DPO’s activities are guided by its vision to prevent the development of mental illness after disaster. Disaster Psychiatry Outreach is a registered 501(c)3 nonprofit organization in good standing. All donations are tax deductible in full or in part.

References

Hobfoll, S. E.; Watson, P.; Bell, C. C., Bryant, R. A.; Brymer, M. J.; Friedman, M. J.; Friedman, M.; Berthold, P.R. ; Gersons, J.; de Jong, T. V.; Layne, C. M.; Maguen, S.; Neria, Y.; Norwood, A. E.; Pynoos, R. S.; Reissman, D.; Ruzek, J. I.; Shalev, A. Y.; Solomon, Z.; Steinberg, A. M., & Ursano, R. J. (2007). Five Essential elements of immediate and mid–term mass trauma intervention: Empirical evidence, Psychiatry, 70, 283-315.