Archive for the 'psychological first aid' Category

Psychosocial support in Libya: What it looks like in the first weeks of a crisis

Although barely a few weeks old, the crisis in Libya has already set the NGO world’s psychosocial intervention machine in motion. Appeals and updates from UNICEF, the International Federation of the Red Cross and Red Crescent Societies (IFRC), and Handicap International from last week have put psychosocial support up front and center (along with clean water, food, and shelter) in operations in Tunisia and Egypt and even in western (i.e., opposition-controlled) Libya designed to aid people fleeing the fighting. So just what does this psychosocial support entail?

Well, at this point there isn’t much in the way of specificity given surrounding psychosocial support. The UNICEF appeal lumps them together with “family tracing and reunification,” a critical service aimed at connecting family members who have been lost in the flight from danger. The appeal adds that “UNICEF will provide booklets for psychosocial support” and “recreation kits.” The IFRC notes that in addition to the target population, staff and volunteers will be provided with psychosocial support as well — this sounds good, but tells us little beyond the (important) fact that the IFRC is aware that burnout is a threat to people who work with displaced populations.

Another IFRC update (from March 4th, 2011), this one detailing the Libyan Red Crescent’s work, is more specific:

Volunteers are providing psychosocial support to help people overcome the difficult and desperate situation they have suddenly found themselves in. They have enabled people to make phone calls to their families and loved ones, and assisted them with travel arrangements within and outside Libya, including transport to the Libyan border, the transfer of belongings, and the facilitation of travel procedures with the authorities.

So here we have the elements of “psychosocial,” at least in the first stages of a refugee crisis: maintaining family networks and facilitating orderly travel so that the events that led to displacement do not lead to the disintegration of the supportive social structures that allow human beings to cope effectively with their situations. This emphasis on the social bonds, the social networks that are so easily damaged during wartime, is the essence of psychosocial.

PS: UNICEF makes special mention of relying on regional teams, noting that the country offices in Egypt and Tunisia “have solid expertise around child protection and psycho-social support.” Kudos for UNICEF for being explicit about going local.

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Stressors, more stressors, and blaming the victim in wartime

Those people who dedicate their lives to addressing stressors among displaced populations are frequently faced with an uncomfortable truth: people under a lot of stress sometimes create more problems for themselves. This is a well-observed phenomenon across populations, and is generally known as “stress generation.” As regards trauma work, there is good research to show that the best predictor of future trauma is past trauma. For those of you not well-versed in stress generation, see Constance Hammen’s reflection on her career researching stress generation among depressed individuals in the Journal of Clinical Psychology.

The uncomfortable part of all this is that it can move quickly into “blaming the victim” (particularly as it pertains to trauma). If a combat veteran presents with PTSD and marital conflict due to the irritability and anger that is a part of the PTSD diagnosis, it can be very difficult not to get really frustrated with that vet’s anger and sink into “it’s your own damn fault” despite our initial sympathy. An automobile accident survivor has a higher likelihood of getting into another automobile accident than someone who hasn’t been in an automobile accident because the survivors tend to be extra cautious following their first accident, drive more slowly at the wrong times, get distracted by other drivers, etc.; if these things cause an accident, who is responsible?

When it comes to refugees, blaming the victim may result in less critical aid from the international community and stigma upon resettlement. And yet it’s clear to anyone who’s worked in refugee camps that a stressed population is a difficult population is difficult to work with. Indeed, one of the impetuses behind bringing psychosocial interventions into humanitarian aid is the danger that stressed refugees can pose to aid workers. There are numerous reports of refugees striking out against aid workers for small irregularities in aid distribution or changes in policies. (I should add that their are also striking reports of other refugees coming to the aid of aid workers.)

So how do we reconcile stress generation with our discomfort? Well, first by reminding ourselves that the first order of health provision is not morality. (I’ve harped on that before, and you probably don’t need to read it again here.)

Second, by looking further into stress generation research so we know what we’re talking about. In this literature, folks like Hammen make the distinction between “dependent, interpersonal” stressors and “independent, fateful” stressors. It turns out that research with people with mental health diagnoses have (on average) more stress-dependent events than people without mental health diagnoses, but have the same number of independent events. Dependent events are almost uniformly interpersonal in nature — and therefore plausibly related to how one would act towards others if really stressed. Independent events may be interpersonal, but their core feature is their fateful nature — they are not affected by how someone is acting.

How does the dependent-independent dichotomy map on to the typology of conflict-related stressors proposed in the last entry in this blog? Well, it’s pretty clear that mental health problems aren’t to blame for people being attacked or cause them to end up in unstable resettlement contexts — this is the “direct war exposure potentially traumatic events (PTEs)” category. For “collateral” and “other PTEs” (which, as I think through them may not be as distinguishable as they first seemed), the picture is less clear, and that some of these stressors are related to “being stressed” means that education campaigns surrounding the affects of stress (at the very least) are important. “Social ecological stressors” are clearly set off by displacement, but the breakdown of community institutions may be exacerbated by interpersonal problems. This is why the “social” in “psychosocial intervention” has always struck me as the more important of the two traditions. “Daily hassles” are likewise split between those problems that are outside of the control of the individual (e.g., a military checkpoint) and those that are exacerbated (unemotional reactions to hearing of abuse of loved ones). So perhaps the dependent-independent dichotomy is a second axis that runs through the typology proposed a few days ago. (Again, comments encouraged here.)

Important to remember through all of this is that all of these stressors are precipitated by an initial event — the event that was the cause of displacement. It would be difficult to argue that displacement events were dependent stressors. And yet many subsequent stressors, be they mild or traumatic, are dependent to some degree. In order to address these, humanitarian aid workers must remember the latter, and the former; they are equally important.

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.


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