Archive for the 'natural disasters' Category

The HESPER: WHO’s measurement answer to the problem of identifying needs within displaced populations

The World Health Organization recently released the Humanitarian Emergency Settings Perceived Needs Scale (HESPER), a measure that they hope will operationalize the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings and encourage rapid assessment of perceived needs in disaster settings. Longtime disaster mental health and psychosocial researcher Mark van Ommeren was the lead on the project, which means that it was developed with the highest level of rigor given the needs, which include some flexibility. A large advisory group that reads (with a few exceptions) like a who’s who of international disaster mental health and psychosocial intervention provided regular input, and the HESPER was tested in sites as various as Sudan, the UK, Jordan, the Palestinian Territories, Haiti and Nepal. Overall the psychometrics reported look good, particularly given the diversity of locations. There are sections on individual needs and community-level needs on a surprising number of domains, a welcome relief from the unidimensional individual-level norms.

What may be the best thing about the HESPER guide is the presentation. Van Ommeren and company have provided not only the measure and the methods used for development of the measure, but also sections on training local administrators, appropriate sampling, a mock interview transcript that reads true, and even a section on how to present HESPER findings to organizations. Too often I have seen an disaster relief NGO get a measure that may be valid or may not, administer it haphazardly, and then be unsure of how to meaningfully present findings. In addition, there’s an “Other things to consider” section which includes the things that you don’t usually think about but are blatantly obvious on the ground — the dilemma of raised expectations that often come about just by asking about problems, for instance.

And then there’s this:


The HESPER Scale may be used by anybody in its current form for non-commercial purposes. Should you wish to make any modifications to the scale, or translate the scale into another language, you will need to get permission from WHO Press (for contact details, see inside cover page). Currently the HESPER Scale (i.e. Appendix 1 only) is available in English, French, Spanish, Arabic, Nepali, and French / Haitian Creole. Word files of the different HESPER Scale language versions are available upon request.

The WHO provides their measures for free and welcomes further development of these types of rapid assessments.


New York Times portrait of mental health in Haiti

Front page New York Times, March 20: In Haiti, Mental Health System in Collapse. This journalistic portrait of an already destitute psychiatric hospital now in complete collapse also includes a few column inches demonstrating the challenges of trying to provide mental health care in a disaster zone — even at the rather quotidian level of a bad interpretation:

There were some cultural and linguistic barriers. After Dr. Samuel said of Mr. Francillon, “The truth is what he’s talking about is not serious. It’s a reality that goes along with being Haitian,” Dr. Hughes tried another approach. He explained the theory of the bodily fire alarm and told Mr. Francillon, “You’re not mad,” which the Creole interpreter delivered as, “You’re not angry.”

The article features veteran disaster mental health specialist Lynne Jones, psychiatrist with the International Medical Corps. Dr. Jones has worked in Bosnia and Chad (with Darfur refugees) among other places, and has developed in her practice what several of us who do research on conflict zones have developed in theory: a multi-modal mental health approach that focuses on psychiatric first aid for most and specialist caretaking for those with pre-existing psychiatric conditions — all with an emphasis on educating local practitioners.

Many with less severe issues are seeking help at the medical clinics in the big tent cities, like the one in Pétionville, where Dr. Jones and a psychiatric colleague, Peter Hughes, ran a mental health clinic one day last week while simultaneously training a Haitian internist.

“Remember, these are not our patients, these are your patients,” Dr. Jones said to Dr. Charles Samuel, the internist. “We are going to teach you so that you can carry on.”

With only 13 psychiatrists in Haiti prior to the earthquake, clearly education and development need to be priorities now.

Fritz Francois of NYU Medical Center, head of NYU’s Haitian Effort and Relief Team (HEART), has similar tales from Haiti, but from the surgical perspective. Dr. Francois’ blog, well worth a read from start to finish, is here.

NPR puts mental health after buildings in Haiti; now we’re getting it

This morning, bleary eyed and half asleep, I turned on National Public Radio’s Morning Edition, as I do pretty much every morning of the week. Following a feature on structural instability of buildings in Port Au Prince, Haiti, Alix Spiegel reported on the field of disaster mental health. Usually popular depictions of my field make me cringe — stories of mass trauma, generations of psychological damage, and heroic psychologists healing the unthinkable are everywhere these days — but today I was delightfully surprised.

They came after the Oklahoma City bombing, and flooded Sri Lanka in the wake of the South Asian tsunami. They came in droves to New York after 9/11. And according to Richard Mollica, a professor at Harvard who’s spent his life researching mental health responses to natural and man-made disasters, mental health professionals will soon come to Haiti as well.

“There’s going to be many, many, many, many hundreds of organization—– big, little and small—– doing mental health work in Haiti, “ Mollica says. “ And they will all have their own agenda, and their own donors, and their own goals.”

All will come with the best of intentions, says Mollica, but the work of a mental health professional in the aftermath of a major disaster like Haiti’s isn’t always clear. The science of how to treat psychological trauma is still very much evolving.

“Mental health has had a hard time figuring out how to fit in with the medical response,” says Mollica. Apparently while mending a broken leg is a straight forward process, mending a broken heart is much more fraught.

Okay, so “broken heart” is not what psychologists treat (usually), but other than that, the story’s pretty good. Why? First, as you can read above, the primary issue is coordination of services, as outlined by Richard Mollica (Harvard luminary in disaster mental health). Second, the piece provides a healthy dose of criticism of how our field’s embrace of PTSD as the main trauma-related problem led us to limit our thinking for what we should do (from Sandro Galea, PTSD research wunderkind). Third (and related to the second), there’s a good discussion of critical incident stress debriefing (mistakenly referred to as simply “debriefing”), which may have resulted in more people developing PTSD than would have if they had simply been left alone. Finally, as Dr. Mollica points out, psychological first aid is really more like social work 101:

The funny thing about “psychological first aid” though, is that there’s very little that’s particularly “psychological” about it. Mollica says it’s mostly very practical, basic social work.

“You can’t find your son? Well, this is who you need to talk to at the Red Cross to find your son. You don’t have enough water for tonight? This is who you need to talk to to get water for yourself.”

A couple weeks ago, I wrote in these blog pages that we really haven’t gotten much further than this. This is still true, but there is, according to Charles Marmar in an NYU Psychiatry Grand Rounds a few weeks ago, work afoot to test a behavioral treatment for the acute phase of trauma reactions (disclosure: Dr. Marmar is one of my bosses, and I like the guy). Based on  cognitive behavioral treatment for panic attacks, this treatment would involve anxiety reduction through brief education about reactions to trauma, breathing control, muscle relaxation, and thought stopping (a basic CBT technique). It would not involve reviewing or processing the trauma expereince, contraindicated in the acute posttrauma phase (the problem with critical incident stress debriefing).

In his talk, Marmar emphasized what Mollica alluded to this morning: “Mental health intervention the absence of basic needs is generally not effective.” So let’s make extra sure that mental health relief provided to Haiti follows material relief (as it did on NPR this morning).

Psychological first aid following the Haitian earthquake: Community support and education, not therapy

There has been a lot of talk among mental health professionals about the psychological consequences of the devastating earthquake that struck Port Au Prince, Haiti, two weeks ago, and just what should be done right now. The answer, it turns out, is not what you might expect.

Check out the National Center for PTSD’s “psychological first aid” suggestions. Their list is comprised of primarily educational measures. Notably, nowhere on the list of things to do in the first weeks following a disaster is psychotherapy as we traditionally think of it. Indeed, nowhere on the list is anything that needs to be done by mental health professionals. The suggestions are pretty much good common sense: seek emotional support from friends, family, religious and other community groups; maintain as predictable a routine as possible for your kids; and although you should stay informed, stay away from sensationalized media coverage. If people are acting anxious, that’s because they are distressed — and that’s normal following a disaster. For most people this distress will decrease when basic needs are satisfied and some measure of stability is reestablished.

This is not to say that mental health professionals should not volunteer their time to help in this crisis. They might work in Haitian communities to educate people about normal reactions, or even organize events to help raise money to rebuild hospitals and schools. An effective mental health professional’s expertise in immediate post-disaster contexts is limited to education. Sending American psychologists to Haiti to do mental health work is not worth the money, given that (1) this type of education can be done by people already there and (2) the resources they would take up in terms of their housing and sanitation would be a net draw on relief efforts.

Why can’t mental health professionals come up with something better than reassuring us to follow our common support mechanisms in immediate post-trauma contexts? Well, two answers: (1) We actually do have the beginnings of what to do in the immediate aftermath of trauma in recent pharmacotherapy research (e.g., previous blog entry), but it’s still pretty uncharted territory. In Haiti applying this research would be impractical in any case as hospitals were destroyed, let alone medications not being available. (2) Attempts to do “emergency psychotherapy” — like critical incident debriefing, which was big in the 1990s and used following 9/11 — have shown to actually over-sensitize people to trauma, resulting in higher rates of trauma-related problems later on. So, as we know that most people exposed to a trauma recover, and indeed, natural disasters result in some of lowest rates of PTSD relative to other types of trauma, our best bet at this point is to educate, and leave people to marshall their own psychological and community resources.

So, support relief efforts in Haiti — but let’s not send the shrinks just yet. They will be needed later on, when it becomes clear who is in the minority that suffers long-term distress. And let’s hope that the urge on the part of mental health professionals to do something hasn’t passed by then, as that’s exactly when it will be needed.

December 2018
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