Editorial: Great East Japan Earthquake and Early Mental-health-care Response
Version of Record online: 17 OCT 2011
© 2011 The Author. Psychiatry and Clinical Neurosciences © 2011 Japanese Society of Psychiatry and Neurology
Psychiatry and Clinical Neurosciences
Volume 65, Issue 6, pages 539–548, October 2011
How to Cite
Kim, Y. (2011), Editorial: Great East Japan Earthquake and Early Mental-health-care Response. Psychiatry and Clinical Neurosciences, 65: 539–548. doi: 10.1111/j.1440-1819.2011.02270.x
- Issue online: 17 OCT 2011
- Version of Record online: 17 OCT 2011
ON 11 MARCH 2011, a devastating earthquake struck off the coast of Japan, causing blustering tsunami that swept over the northeast coast of the country. Many struggled to evacuate from their homes, schools and workplaces as 8–9-meter-tall tsunami rapidly reached the coast within half an hour after the earthquake (Emergency Disaster Response Headquarters). The officials reported a record-breaking magnitude of 9.0 (Mw), which made this earthquake the greatest earthquake in the country's history. It had not been long since the last massive earthquake had hit Kobe in 1995, killing 6434 people (Japan Meteorological Agency). The Japanese government immediately set up the Emergency Disaster Response Headquarters to initiate disaster relief. As many as 156 countries offered support through releasing emergency aid, and sending medical teams and relief workers (Emergency Disaster Response Headquarters). While the country was struggling with aftershocks, the impact of the earthquake and tsunami led to explosions and leaks of radioactive gas at the Fukushima Daiichi Nuclear Power Station. This nuclear crisis was categorized as being as severe as the accident in Chernobyl and has been considered as an international emergency. The Nuclear Emergency Response Headquarters has been taking measures to halt the worst nuclear crisis in the nation's history. The official death toll from the earthquake and tsunami has reached 14 998 as of 12 May 2011, and as many as 9761 people are still missing (the National Police Agency of Japan). Tens of thousands of residents within a radius of 30 km from the power station were legally enforced to evacuate from their communities, to be housed in temporary shelters (Emergency Disaster Response Headquarters).
MENTAL HEALTH COUNTERMEASURES
In contrast to the previous great earthquakes in Kobe1 and Niigata,2 where the damage was mostly restricted to one prefecture and its local government organized the mental-health-care provision, the scope of the disaster this time was much larger and included three prefectures and one ordinance-designated city, so it was necessary to set up comprehensive mental-health-care planning to cover all the affected areas beyond the prefecture boundaries. The overall headquarter role was assumed by the Ministry of Health, Labor and Welfare (MHLW) in addition to spontaneous initiative roles taken by academic and clinical organizations of psychiatric and co-medical professions.
Some academic associations and institutes also took immediate countermeasures. Within 2 days of the initial seism, the Japanese Society for Psychiatry and Neurology (JSPN) set up a disaster response committee followed shortly by a mental-health-care disaster response operation center,3 gathering a number of academic, clinical and co-medical organizations, such as the Japanese Association of Psychiatric Hospitals, Japan Municipal Hospital Association, Japanese Association of Neuropsychiatric Clinics, Japan Association of Chairpersons of Departments of Psychiatry, Japanese Society of Traumatic Stress Studies, Japanese Association for Emergency Psychiatry, and others, which sent mental health teams or professional advisors to the afflicted sites; those organizations also set up committees of their own, some of which also sent mental-health-care teams and personnel to the affected sites. JSPN also declared the general policy of post-disaster mental health countermeasures,4 followed by updated information by the disaster response operation center.5–7
On the third day, the National Center of Neurology and Psychiatry (NCNP) decided to launch an information website, to set up more than 20 guidelines or manuals that covered the overall policy of mental-health-care provision for the specific treatment of, for example, handicapped children or demented elderly patients. The site quickly came to be recognized as the most reliable and authoritative information resource by the MHLW and other organizations involved in post-disaster mental health care.
An urgent and crucial issue was to continue psychiatric service for those patients whose treatment was disrupted after the disaster due to transportation difficulty through ruined towns and villages, or the damage to mental clinics and hospitals themselves. The shortage of mental drugs was also a problem. The initial difficulty was that the supply of gas fuel was quite limited and the train network was almost stopped because the roads and railroads were ruined; also, aftershocks meant that secondary transportation accidents were a threat. For that reason, even local government staff could not easily go to the afflicted coastal areas, sometimes 200–300 km away from the local government capital. Telephone communications, including mobile phones, were also out of use. Despite tremendous efforts, these issues made it difficult to obtain exact information about the disaster sites, to supply the necessities of life and medical supplies, and, above all, the systematic rescue and care of victims.
It was also a worrying problem that the traumatic impact of the disaster would cause immediate severe distress, clinical or subclinical, resulting in the manifestation of acute delirium, panic, late post-traumatic stress disorder (PTSD), bereavement and depression.1,2 The perception of the great tremble, the impact of the tsunami, the loss of family members and friends as well as the witness of corpses would generate traumatic memories, followed by the persistent distress of living in shelters, mostly the gymnasiums of local schools, with hardly any privacy.7
Transportation of psychiatric inpatients
The transportation of inpatients from collapsed psychiatric hospitals was a matter of urgent concern. Three psychiatric hospitals in Miyagi prefecture and two in Fukushima lost their function due to the earthquake and tsunami and five psychiatric hospitals near the atomic plant in Fukushima did so a short time later for fear of suspected contamination with radioactivity. As a result, more than 1000 inpatients lost beds. On the second day after the disaster, 14 March, the MHLW surveyed the capacity of psychiatric hospitals for new admission in the non-afflicted prefectures around Tokyo and Tohoku. Within 10 days after the disaster, transportation was almost completed to other hospitals within the same prefecture or in distant areas. In Japan, the number of inpatient beds is determined by the government, but the number of beds in nearby hospitals was not sufficient, so that the admission of patients beyond the permitted number was temporarily allowed by the MHLW and some hospitals were transferred to hospitals in distant and unaffected prefectures, such as Tokyo.
The below-mentioned on-site mental-health-care teams provided a temporary outpatient service for the patients of the collapsed hospitals or clinics, or for those who could not reach mental facilities due to damaged roads.
Supply of psychiatric drugs
The supply of psychiatric drugs risked running short, as the expressways were collapsed and railroads were destroyed everywhere. In response to an appeal from the afflicted local governments, drugs were conveyed by the MHLW, Japanese Associations of Psychiatric Hospitals. JSPN also played an advisory role in the effective distribution of drugs. Some pharmacological companies also donated drugs. The concern for the shortage of psychiatric drugs was most serious in antidepressant drugs or anticonvulsants, which in turn caused the restriction of the days of the prescription of those drugs in further areas, such as Tokyo. Some anticonvulsants are usually prescribed for up to 180 days, but for some time after the disaster, this was restricted to around 30 days.
The MHLW immediately scheduled and organized the dispatch of mental care response teams composed of psychiatrists, nurses, and/or psychologists, psychosocial workers, and clerks. The teams from national psychiatric hospitals, organizations such as the Japanese Association of Psychiatric Hospitals, the Japanese Association of Neuropsychiatric Clinics, and the Japan Association of Chairpersons of Departments of Psychiatry, were registered through the MHLW to the local governments, and their visiting schedule and working place were allocated in order to meet actual needs and to avoid overlapping of resources. In some cases, not teams but medical staff of a certain profession were sent, or voluntarily went, to those hospitals that were damaged or whose staff members were affected. The exception is the Red Cross, which is allowed to send medical teams by Japanese law independently of the government's decision.
Even before the scheduling system came to work effectively, which actually took several days, some medical organizations spontaneously sent mental health teams, based upon their own information or personal communication with the directors of psychiatric departments of universities or hospitals of the afflicted sites. During the first 1 or 2 weeks, some of those teams entered the afflicted sites without notification to the local or national governments, but they soon came to be organized into the unanimous dispatching schema. Most teams came at first to the local government or the affiliated center of mental health and welfare, mandatorily founded to each prefecture, to receive an explanation of the ongoing mental health care and policy, and received mental-health-care manuals that contained the description of policy, assessment, and reporting procedures and forms, which goes in accordance with the national post-disaster mental health guideline issued in 2003. Otherwise they could download the guideline, manual and road map from the information website set up by the NCNP on 16 March. They were asked to send daily and weekly reports to the local government mental health office.
Within several days, the mental health teams dispatched via MHLW started their activity on the affected areas and the number of districts supported by those teams soon increased to be 30 in around 2 weeks, excluding the Red Cross teams and those who went there spontaneously without registration. The MHLW wished that from 1 month after the disaster, each team would hold responsibility for a certain district, but most teams voluntarily did so at an earlier phase, in that they spontaneously made routine teams to be sent successively, around every week, to provide continuous on-site mental care. They rounded among refugee shelters amidst various administrative and medical teams, and in the initial phase their major task was to continue treatment and medication for the patients who had already been treated by psychiatrists prior to the disaster. Some cases of acute stress disorder, panic attack, delirium or psychotic excitement were also reported, precipitated by the adjustment difficulty to a new refugee shelter. Such cases were even reported from the medical professionals who witnessed the ruined towns and injured dead bodies. Along with the time course, the reports of such fresh cases disappeared.
The treatment of people involved in the recovery process was also a critical issue and a focus of social concern.8–10 In most cases, such activity was composed of psycho-education, supportive counseling and temporary medication of distressing mental symptoms, on an outreach basis to the refugee camps. Subclinical distress and emotional upset were also seen, but the majority of the affected people did not show overt symptoms, although they occasionally uttered a deep sense of sorrow. This is a similar behavior to what had been observed after the Great Niigata Earthquake in 2005, which also occurred in traditional rural areas of Japan, where people are accustomed to a restrained manner of behavior and the expression of negative feelings in front of other people is strongly avoided. Such a restrained manner, however, is different from being mentally intact, and some reports from this disaster say that some people who lost their family members in the tsunami were composed during the daytime but sobbed outside the refugee camps at midnight.
As mentioned above, the NCNP launched a website for adequate information provision. It contained the Japanese Guidelines on Post-disaster Mental Health Care, its manual, road map, and leaflets. In order to provide effective mental health care, it is crucial that professional mental-health-care providers share a common understanding of both the nature of disaster-related stress reactions and the rationale of intervention. From the bitter experience of Kobe where a flood of various types of information arrived from abroad or other areas of Japan, it was necessary to avoid confusion regarding the concept of mental health care in the acute phase, by establishing a standard guideline. The JSPN also joined the process of information provision by creating a mirror site of the NCNP information site.
JSPN's disaster response operations center also mediated collaboration with international societies, such as the World Psychiatric Association (WPA), by setting an international telephone meeting or by arranging presentations at such international meetings as the WPA. It also responded to an erroneous report from abroad, written by a person who came to the disaster site immediately after the initial seism and jumped to the conclusion that Japan was ill-prepared to provide psychological care for victims, a statement that did not support but discouraged the care-givers, who would continue to live with the victims to take care of them. To make matters worse, the report emphasized that acute psychological intervention would prevent future post-traumatic symptoms, an idea no longer supported by any contemporary guidelines.
JSPN issued a statement11 to promote the ethical awareness of researches, which was also a crucial concern. The boundaries between support and research can sometimes be obscured and some researches were actually planned and carried out without adequate ethical preparation. The Japanese National Ethical Guideline for epidemiological researches says that in emergency disaster cases, the dean of medical or other universities can give permission to research planning that meets the immediate needs of the victims without holding an ethical committee. Even such a simplified ethical procedure risks being ignored and could result in an abuse of victims through interviews about their distress, which they believe to be a support, but are actually aimed at research purposes.
Policy for acute mental health care
In post-disaster mental health care, humanitarian mental support tends to be confused with the psychiatric primary and secondary prevention of mental disorders, as is stated in the NCNP brochure, ‘What is mental health care?’ on the information website. Since the time of the great Kobe earthquake, we have experienced considerable confusion caused by the imported concept of psychological debriefing or any other acute psychological intervention focused on trauma. This concept not only said that it would be effective for preventing future post-traumatic symptoms but also nearly accused the local care-givers of not doing such an intervention and of leaving the victims in the malicious process of chronic agony. It is, of course, a precious human deed to sit aside victims and listen to their sufferings so far as it is desired by the victims themselves; however, it is a totally different story to unanimously encourage or force them to talk about terrible experiences and to express deep sorrow and terror with risks of worsening their symptoms and preventing the natural recovery process, which is actually expected to occur in the majority of cases. The concept of the efficacy of early psychological intervention focused on trauma has been criticized and rebutted repeatedly; after the 9/11 terrorist attack the American Psychological Association issued a statement of warning against the technique of psychological debriefing.
Even when the psychological debriefing has been discarded as a credited early intervention, belief in the healing power of touching the trauma still prevails. An early international report12 written by a temporary visitor positively reported an intervention carried out, also by a foreign visitor, with a child, who cried after his intervention. It revealed the risk that the child was just emotionally disturbed rather than being comforted by such a trauma-focused intervention by a visiting foreigner who was not accustomed to the manner of emotional expression in the local culture and where the intervention was not followed by sustainable psychological support in the community. The report is not only incorrect in its content, but also obstructs continuous mental care efforts on site.13,14 It would be an issue of further discussion why such a rash view is generated in the aftermath of a tremendous tragedy, with a split and inaccurate view of what is all good and bad.
The Japanese Guideline on Post-disaster Mental Health Care was published in 2004,15 in which an emphasis upon resilience and natural recovery process is clearly stated, and mental health professionals are requested to refrain from trauma-focused on-site intervention in the early phase. The guideline was disseminated by the MHLW to all the local area governments and has been used as an official standard guideline in post-disaster mental health care in Japan, including the disaster this time. After the tsunami disaster in Indonesia and Thailand, the guideline was translated into English, Indonesian and Thai. The outline of the guideline is attached as an appendix.
The Guideline stated that we should respect resilience and it is important to watch and wait for the spontaneous recovery process.15 Furthermore, psycho-education should be focused on the natural course of psychological response and how to cope with this, instead of threatening victims with the gloomy picture of their psychological outcome, while it is also important to offer an outreach service to help the vulnerable. Overall, the strategy of this guideline will be introduced in the following. The guidelines from the National Institute of Clinical Excellence16 and Inter-Agency Standing Committee17 follow the same principle, however they were developed independently from Japanese experience, that watchful waiting is important, as is expressed in the NICE guideline.
Among Japanese mental health professionals, this view of psychological intervention in the acute phase has been widely prevailing, but it has not been disseminated into every corner of the activity. Some psychological professions and the media still emphasize the expression of traumatic memory as a useful way of preventive and healing intervention. The technique has been used even outside of the psychological profession: an organization tried to let affected children paint their psychological state and exhibited the paintings in order to show their power for recovery and to encourage the victims. The Association of Japanese Clinical Psychology issued a statement to warn against the popularized use of art therapy, stating that such therapy should not be done without a safe environment and that when paints are mixed they can generate horrible colors that can cause distress for children. There is a report by a clinical psychologist who witnessed such an activity in which a child became embarrassed, saying he could not understand why such an ominous color appeared in the sea that he painted.
Coherence of mental health professionals
As various organizations with different professional backgrounds, or even without professional expertise, tend to enter disaster sites to provide mental health care, it is crucial to keep a coherent purpose, the methodology of the care activity and to promote collaboration among different teams. For that purpose, sharing of information and the policy of mental-health-care provision is quite important, and medical-care teams need to reach a unanimous consensus on how to provide mental health care, in accordance with the Japanese Guideline on Post-disaster Mental Health Care, which was developed prior to the currently prevailing international guidelines, such as NICE or IASC, but shares the common basic policy for the management of psychological distress and for respecting resilience. Such sharing of information had to be renewed and maintained, receiving feedback from the onsite care activity.
The ongoing communication among different bodies was conducted by the crisis-response headquarters of the JSPN as mentioned above. The JSPN regularly held meetings inviting the representatives of the organizations that provide mental health support but also the directors of the mental health division of the afflicted prefectures and cities to update information of the effects of the disaster, the needs for mental health care and the overall situation of the people's recovery process.
Initially, activity had to be started amidst considerable confusion: due to the disruption of traffic and the inability to systematically access the afflicted coastal sites to evaluate the degree of psychological distress of the people and life burden, or the need for psychiatric services. So, the voice from the dispatched teams was a precious information resource, which was transmitted by the official documents via local governments to the national ministry, but the JSPN provided an occasion for direct and practical exchange of views, information and proposals. It provided interactive feedback from the scene of the disaster to the administrative offices regarding the principals. The meeting was held every 10–14 days, and adapted to the Skype system to communicate with the leading doctors and administrative directors in the afflicted sites, which was soon replaced by a television communication system.
The great difference from the previous disaster in Japan is that this time a number of opinion-makers in Japanese psychiatry came to be seriously concerned and devoted to the psychiatric care provided. Like most countries worldwide, psychological trauma has been an issue of only limited concern for the majority of psychiatrists in Japan, mainly because most psychiatrists have little chance to see victims of criminal offence, accidents, or disaster in their daily practice. This is partly because such incidents are rare and also because the victim would not receive psychiatric treatments for fear of insecurity of how they would actually be treated. PTSD and trauma-related mental responses were seriously discussed at the time of the Great Kobe Earthquake, but attracted professional concerns from a limited part of the country; Kobe was far from Tokyo and such a great disaster was supposed to occur only once every century. The debate over the robustness of the concept of PTSD also prevented some outstanding psychiatrists from getting involved in this field. This time, however, the site is nearer to Tokyo, and the anxiety about the pollution with radioactivity is so widely spread that no one around Tokyo can be a secure bystander.
Now the headquarters come to discuss a vision of how to renew the mental-health-care system in the affected areas. We should also remember that the suicide rates among those areas were the highest in Japan during the years before the disaster, and a number of reports on seasonal depression came from there. As some of the affected areas had been poorly equipped with mental health facilities and people's stigma against psychiatric disorders had been strong, a common phenomenon in local districts of Japan, a new system of community-based mental health care has to be established.
This report has described the outline of the initial mental-health-care responses on various levels. It has focused on the comprehensive strategies and policies that were intended to cover all the affected areas, and has not described the individual countermeasures and reactions in each prefecture and city. The psychological effects of the atomic plant accident in Fukushima has not been mentioned in detail, because the scope of the physiological effect of the accident has not been settled yet and the society is not necessarily ready to deal with the accident as a psychological matter rather than a sociopolitical one. As a number of psychiatric professionals are deeply concerned with the psychological and prolonged impact of the accident, including those who are in the Fukushima prefecture and conducting heroic efforts to care for the residents, the mental health activity in this area and the status of people's distress will be summarized elsewhere.
- 1Disaster mental health: Lessons learned from the Hanshin Awaji earthquake. World Psychiatry 2002; 1: 158–159..
- 2[Psychological care during disasters: Through the experience during the 2004 Niigata-Chuetsu Earthquake]. Seishin Shinkeigaku Zasshi 2010; 112: 521–529..
- 4The Japanese Society of Psychiatry and Neurology. Statement by the Japanese Society of Psychiatry and Neurology on Reconstruction Efforts related to the Eastern Japan Earthquake/Tsunami Disaster [Internet]. 2011. [Cited 9 September 2011.] Available from URL: http://www.jspn.or.jp/english/info/2011_03_11info/statement_geje2011_05_21.html
- 5The Japanese Society of Psychiatry and Neurology. Cover Letter. [Internet]. 2011. [Cited 9 September 2011.] Available from URL: http://www.jspn.or.jp/english/info/2011_03_11info/es_inve_cover_letter.html.
- 6The Japanese Society of Psychiatry and Neurology. The Japanese Society of Psychiatry and Neurology Great East Japan Earthquake Disaster Response Operations Center (JSPN TEDROC). [Internet]. 2011. [Cited 9 September 2011.] Available from URL: http://www.jspn.or.jp/english/info/2011_03_11info/info_jspn_tedroc.html.
- 11The Japanese Society of Psychiatry and Neurology. Emergency statement on the investigation and research practices concerning the Great East Japan Earthquake. [Internet]. 2011. [Cited 9 September 2011.] Available from URL: http://www.jspn.or.jp/english/info/2011_03_11info/es_inve_statement_kashima.html.
- 15Guideline for Local Mental Health Care Activities after a Disaster. National Institute of Mental Health, National Center of Psychiatry and Neurology, Japan, Tokyo. [Internet]. 2011. [Cited 9 September 2011.] Available from URL: http://www.ncnp.go.jp/nimh/seijin/EnglishDisasterMentalHealth.pdf., , et al.
- 16National Institute for Clinical Excellence. Post-Traumatic Stress Disorder: The Management of PTSD in Adults and Children in Primary and Secondary Care. Royal College of Psychiatrists, London, 2005.
- 17Inter-Agency Standing Committee. IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings. [Internet]. 2007. [Cited 9 September 2011.] Available from URL: http://www.who.int/mental_health/emergencies/guidelines_iasc_mental_health_psychosocial_june_2007.pdf.
Summary of Guidelines for Local Mental Health Care Activities after a Disaster
Drafting Committee (Abe Yukihiro, Araki Hitoshi, Fujita Masako, Iwai Keiji, Kato Hiroshi, Nagai Naoko, Watabiki Kazuhiro, Yamamoto Kohei)
In the wake of recent natural disasters such as the Great Hanshin Earthquake Disaster (January 17, 1995) and disasters due to human crime or accident, the public as well as specialists in mental health in Japan have become keenly aware of the need for post-disaster psychological care, and a variety of practical work has been performed. In order to widely share what has been clarified through that experience, and link it to better programs in the future, we have drawn up these ‘Guidelines for Local Mental Health Care Activities after a Disaster.’ Posttraumatic stress and various other psychological reactions occur after a disaster, and it is vital to ensure not only accurate diagnosis, but also continued comprehensive provision of mental health care.
These guidelines are designed for the integration of all types of programs, with proposals based on accomplishing what is possible amid the chaos of a disaster situation. We have included with as much specificity as possible what has been learned in actual practice up to now about first contact, the importance of natural recovery from trauma, responding to multicultural contexts, and cooperation with volunteers and the press.
We hope that these guidelines will be widely used in disaster situations, and that the further experience of many caregivers will lead to their improvement in the future.
January 17, 2003
- I. The Need for Local Mental Health Care after a Disaster 1
- 1Disaster Experiences and Local Mental Health Care Activities 1
- 2Local Mental Health Care after a Disaster 2
- 1) Policies for Local Mental Health Care after a Disaster 2
- 2) The Need for Patience 2
- II. Psychological Reactions after a Disaster 3
- 1Types of Psychological Burdens 3
- 1) Mental Trauma 3
- 2) Grief, Loss, Anger, Guilt 3
- 3) Social and Lifestyle Stress 3
- 2Types of Psychological Reactions 4
- 1) Initial Period (One month after the disaster) 4Note: The First Few Days 5
- 2) Long Term (After the first month) 6
- III. Development of Local Mental Health Care after a Disaster 7
- 1Planning for Mental Health Care at the Disaster Relief Headquarters 7
- 2Initial Response (During the first month) 7
- 1) Practical responses and mental health 8
- 2) The immediate response – First Contact 8
- 3) Screening for people who need observation 8
- 4) Psychological first aid 9
- 5) Medical screening 10
- 6) Public information 10
- 7) Counseling hotline 11
- 8) Dealing with PTSD 11
- 3Natural Recovery from Trauma 12
- 1) Conditions that encourage natural recovery 13
- 2) Factors that impede natural recovery 13
- 4Liaison with Outside Volunteers 14
- 1) Assistance policy should be set by the Disaster Relief Headquarters 14
- 2) Contact with residents should be controlled by the Disaster Relief Headquarters 14
- 3) Surveys by outside groups should be controlled by the Disaster Relief Headquarters 15
- 5Working with the Press 15
- 1) The importance of informational assistance from the press 15
- 2) Risk of triggering PTSD through newsgathering 15
- 3) Dealing with the press 15
- 6Multicultural Issues 16
- 7Mental Health of Relief Workers 16
- 1) Background 16
- 2) Stress factors for relief workers 16
- 3) Psychological reactions of relief workers 17
- 4) Countermeasures 18
- IV. Things to Start Doing Now 18
- 1) Public education about mental health care and disasters 18
- 2) Mental health care simulations during disaster drills 19
- 3) Arranging funding for mental health care 19
- 4) Making mental trauma care part of routine mental health services 19
- 5) Training for mental health care providers 19
Checklist for Necessity of Observation (Immediately after disaster event) 21
Upon arrival at the disaster scene, the first requirement in providing mental-health-care activities is to support mental health centers in the afflicted communities so they can continue to carry out their mental health routines and treatments. In the case of Tohoku earthquakes, provision of medical assistance as well as medication supply took place immediately after the disaster in response to an interruption of medication delivery. In addition to supporting the local mental health centers, there are two main types of local mental-health-care activities targeting local residents affected by the disaster. The first type includes activities within the chain of general assistance programs which are designed to improve the mental health of the entire community as a group and to reduce the stress and mental trauma of the group. This type of activity consists mainly of ordinary assistance-givers and local mental health treatment staff going to the disaster area in outreach activities, delivery of disaster-related information, and psychology education for the general public. In addition, practical assistance for disaster recovery and life support in itself helps to improve the mental health of the community.
The second type includes prevention, early detection and treatment of particular mental disorders. The second type of activity consists mainly of screening individuals with mental disorders, encouraging people to come for consultations, providing psychology education for individuals, and making referrals to specialists. For the first 1–2 weeks or longer, the first type of activity will be the main focus. The health level of the community will be enhanced as relief workers enter the scene to meet and talk with survivors and victims and respond to their actual needs. The second type of activity should then follow and be directed toward alleviating states of confusion, excitement and disorientation, rather than making diagnoses.
Types of psychological burdens
There are three major types of psychological burdens following a disaster. Mental trauma is a condition in which the sympathetic nervous system stays overstimulated in response to a threat-to-life experience and is associated with the increased retrieval of traumatic memory. It can be characterized by heightened anxiety and fear, inability to take in the entire scene in front of one's eyes, and focusing of attention on the most fear-inducing stimulus. Acute memory of the disaster scenes and fears are deeply engraved in the mind. The second type includes emotional responses such as Grief, Loss, Anger and Guilt, and they may come to the fore after the initial disorientation and excitability have settled down. A person may be beset by a sense of heavy obligation for being the one who survived (survivor's guilt), grief following deaths of loved ones, or a feeling of having been unable to do the right thing. And at the same time, resentment at the fate that has befallen survivors may lead to anger toward relief workers or other people around them. Social and Lifestyle Stress is induced by a new living environment and can be characterized by physical or mental malaise, indefinite complaints, insomnia, and irritability. When a large group of displaced people live together, issues arise concerning privacy, the living space (food, toilets, garbage, duty assignments), and care for children, the elderly and the handicapped.
Initial response (during the first month)
Still the nature of the area or the disaster could make the situation unusual, requiring special measures which match the actual circumstances. With regard to the anguish arising from actual damage, the best response is to take whatever practical measures are obviously required. Issues of survival, bodily health and living arrangements must of course be speedily resolved as the precondition for starting to deal with anxiety or other psychological reactions. But since those steps alone will not be enough to alleviate all of the terror, worry or other reactions, it is important to keep mental health issues in mind while responding to the urgent practical problems.
One of the most important immediate responses is to carry out ‘first contact.’ First contact means meeting and talking with survivors as soon as possible after the event by visiting them at the disaster scene and evacuation centers. If it is delayed, people will be left in anxiety, despair and confusion. As a rule, the early responders making first contact should be people who have served the needs of the local population on previous occasions. While carrying out first contact, when possible, the responders should try to identify individuals who are under especially strong stress and provide basic mental health information, such as the availability of psychological services.
The experience of disaster does not necessarily lead to post-traumatic stress disorder (PTSD). In disaster situations the most commonly observed causes of PTSD are personal experience of fire, flooding or house collapse, the death or injury of a loved one, or seeing corpses. Since there are many other kinds of psychological reactions that may occur after a disaster, mental health treatment is not focused on early detection and treatment of PTSD. Rather, it is important always to maintain the basic approach of readiness to identify a broad range of psychological changes, and to respond as appropriate with diagnosis, evaluation or assistance. Assistance should be provided to minimize the survivor's responsibilities for care of others, so that the survivor finds security, peace of mind, and restful sleep as soon as possible.
As a rule, in counseling soon after the event, do not ask the survivor to recount the story and emotional impact of the disaster experience. This can be harmful. It was previously thought that using this technique (psychological debriefing) at an early stage could help to prevent the future onset of PTSD. But the technique is now discredited internationally and avoidance is clearly recommended. What is important is to build a network around the survivor of understanding people who can talk together about the actual suffering in the disaster and subsequent difficulties in moving forward.
Natural recovery from trauma
For most survivors, even if there is some temporary mental instability, they will naturally return to their normal selves. As a policy for mental health care for the community as a whole, it should be assumed that natural recovery will occur in most cases, and support can be provided for that process. In supporting the process of natural recovery, it is necessary to provide conditions that encourage natural recovery and to diminish factors that impede natural recovery.
Conditions that encourage natural recovery include practical support, such as providing bodily safety, providing protection from secondary events, maintaining living conditions and continuity of daily life, offering prospects for recovering economic footing, and providing protection from day-to-day stress. General support, such as providing information on damage and assistance, and responding to requests and questions in a prompt manner, can be helpful. Informing people about expected psychological changes following a disaster is an important part of psychological care. Suggestions for counseling can be made when needed.
Factors that impede natural recovery are intrusions that cause secondary trauma or threaten the stability of daily life. Some of the most common factors include delayed assistance in rebuilding deteriorated living conditions and loss of family members. Special attention should be paid to those who belong to any of the especially vulnerable groups (infants, the elderly, the handicapped, the sick or injured, people whose first language is not Japanese, and families of any of these groups). Socially isolated persons (single persons, people with nobody outside the family to talk to) should also be considered as vulnerable. Other common factors include being interviewed by the media against a person's will and having inspections by the police, public officials, insurance companies, etc.
Regardless of purposes of stay, most foreigners are considered as especially vulnerable to disaster because of their limited comprehension of the language spoken in the afflicted area. In general they cannot fully grasp public information, and are therefore liable to suffer secondary uncertainty anxiety. In addition, depending on their native culture, foreigners are likely to have different patterns of reaction to a disaster. This may well lead to complications in the course of group activities and refugee shelter living, and mental-health-care supervisors will need some special understanding to rectify them. It would be helpful to have volunteers who can speak the native languages of the foreigners, but it is often impossible to have the right people on hand in the disaster setting. When there are multicultural needs, it may be possible to have linguists from outside the area prepare special messages for public information releases, or to request the media to prepare multilingual versions of disaster information broadcasts. Even though foreign-language versions may be less complete than the originals, the mere fact that information is provided in their native language will provide valuable reassurance to these survivors.
Mental health of relief workers
Relief workers can be fatigued from ongoing pressure of relief work. They may face limitations in performing a task in the ideal fashion. It is possible that a psychological conflict between the sense of mission and the limitations of reality will cause feelings of guilt or powerlessness. Amid the extensive damage and suffering, area residents often display emotional reactions such as anger and guilt. It is not unusual for survivors to release their anger toward relief workers who are in the vicinity. If the workers feel like the anger is personally directed toward them, they may come under considerable stress. In addition to the stress of carrying out duties, relief workers are quite likely, even more than most local residents, to be exposed to the sight of terrible damage, corpses and the like, which may result in PTSD or other trauma reactions. It should also be noted that some relief workers may be disaster victims themselves, and they are at risk of extra psychological tensions and exhaustion. Adjusting to a new place and being away from home may also cause considerable stress, especially if the assignment is for an indefinite period.
Relief workers may tend to neglect their own health issues or, even when they recognize them, have too strong a sense of mission to take breaks or seek treatment. The following are some of the countermeasures that can be helpful to relief workers. Although it may not be possible during the emergency phase just after the event, as soon as it is practical, the activity periods, relief schedules, responsibilities and job descriptions must be clarified for all mobilized relief workers. It is effective to teach relief workers that stress is nothing to be ashamed of, but instead must be recognized and adequately treated. It is important to give each relief worker a check-list of potential physical and mental irregularities, and when necessary to offer health counseling.
These principles mentioned above have been widely known to relevant authorities and organizations in Japan over the past decade and regarded as the basic principles of post-disaster mental-health-care activities. It appears that most of the mental-health-care teams have been following these basic principles in their relief efforts for the afflicted areas in Tohoku. Nowadays few believe that it is beneficial for the survivors to recount the emotional impact of the disaster experience soon after the event, but there are a few reported cases in which some relief workers of non-clinical backgrounds have used somewhat similar techniques. Further measures have to be taken to disseminate the knowledge to all relief workers regardless of their backgrounds, in order to deliver more effective post-disaster mental health care.
This study was funded by the Ministry of Health, Labor and Welfare. The original document is available at National Center of Neurology and Psychiatry.
Guidelines for Local Mental Health Care Activities after a Disaster
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