Metin Basoglu's blog on war, torture, and natural disasters

Mental health consequences of disaster in Japan: How reliable are “expert” opinions in the media?

In my previous post I had pointed to ill-informed comments from mental health professionals about the mental health effects of Japan disaster. I will expand on this issue a bit further by highlighting how “expert” opinion on this issue is plagued by various common misconceptions about earthquake trauma. There are numerous examples of this in the media but I will focus on only a select few.

A New York Times article – Lessons for Japan’s Survivors: The psychology of recovery – based on expert opinions illustrates some of the most common misconceptions in the field of psychological trauma. There are several unsubstantiated assumptions in expert statements. First, that man-made disasters have more lasting psychological effects than natural disasters is not based on any evidence. There are no studies comparing long-term effects of different types of disaster.

Second, the view that man-made trauma has more cognitive effects than natural disasters – such as blame, guilt, loss of faith in people, etc. – is not supported by evidence. Our studies show that earthquake survivors do not differ from torture survivors in this respect. In fact, over 90% of earthquake survivors we have assessed in our studies blamed local or national government authorities for allowing construction of sub-standard buildings, as well as for delayed or inadequate rescue and relief efforts. Their feelings of anger, resentment, demoralization, disillusionment, distrust, loss of faith in people, and pessimism were similar to those we observed in torture survivors both in frequency and intensity.

Third, the article states:

“After purely natural disasters, about 95 percent of those directly affected typically shake off disabling feelings of sadness or grief in the first year, experts say; just eight months after Hurricane Ivan leveled Orange Beach, Ala., in 2004, about three-quarters of people thought the town was back on track, researchers found.

Although such comments may inspire hope, unfortunately, many studies show that this is not the case with earthquake survivors. Our studies with more than 4,000 survivors of the 1999 earthquakes in Turkey show that traumatic stress problems in the community persist for at least 40 months after the disaster. Indeed, over 50% of the survivors we contacted three years after the disaster needed help and requested treatment from us.

The view that most survivors will recover spontaneously implies that no interventions are necessary for most people in the early stages of the disaster. This is also not true for earthquake survivors. Earthquake survivors are desperate for help in the early stages of the disaster mainly because of pervasive and debilitating fear. Indeed, when we set up a treatment delivery project in the epicenter region, we were inundated by requests for help from so many survivors that we were compelled to develop very brief and largely self-help-based interventions for them. We treated with good results many survivors in the acute phase of the disaster – namely within the first year during which they experienced a second major earthquake and hundreds of aftershocks. This helped them gain resilience against the effects of ongoing trauma. Such early and effective intervention is critical in preventing chronic traumatic stress, depression, and other health problems.

With its focus on cognitive effects of trauma, such as blame, anger, frustration, sense of injustice, the NYT article gives the impression that the psychological effects of Japan disaster is likely to last decades. While it is true that such cognitive effects and related emotions may last a very long time, what is overlooked is the fact that such trauma effects are secondary to traumatic stress, i.e. fear, distress, and helplessness. In other words, people do not have traumatic stress because of such cognitive effects. Rather, they develop these beliefs and associated emotions because of traumatic stress. This implies that, with effective treatment of the causal process, their thinking is likely to change. There is indeed evidence to support this point. The NYT article totally misses this important point and portrays an unduly pessimistic picture about the long-term outcome of the disaster. Having said this, I should also add that this prediction could turn out to be true (for different reasons though), if the survivors do not receive appropriate treatment for traumatic stress.

It is also important to note that the problem of radiation leak in Japan is likely to make the psychological impact of the disaster worse through augmenting people’s fear and not because “many people … have begun to doubt the official versions of events” or that “…people are getting angrier because of the inaccurate information they’re getting.” If the radiation leak incident had not occurred, such distrust of authorities and anger would have been as common among Japanese survivors for other reasons. This is because people have a natural tendency to attribute blame to other people even when the disaster is not of human design.

Pointing to the risks of “one-on-one therapy and crisis counseling efforts” the article quotes a medical anthropologist and psychiatric epidemiologist at the University of California, Davis:

“We have to be careful that we don’t create a whole class of victims, that we don’t put people into some diagnostic box that makes them permanently dependent.”

This statement is no more than a cliché  shared by many in the field of psychological trauma. Although it may come across as a ‘politically correct’ view, it serves to de-emphasize the importance of individual psychological interventions in helping people recover from trauma. As I noted in my first post, such interventions are of paramaount importance in facilitating recovery from trauma, provided that the right treatment is chosen. Traumatic stress is not a “diagnostic box”; it is a real problem that affects millions of people after major disasters. What makes survivors “permanently dependent” is depriving them of effective interventions.

This brief analysis of a few but a rather representative sample of comments highlights the state of current knowledge in the field. Furthermore, most Western trauma researchers do not have sufficient experience with major devastating earthquakes. Those with such experience often do not have recourse to a sound theory in understanding how earthquake trauma impacts people. Those with experience with other disasters often believe that such experience is easily transferrable to work with earthquake survivors. This is not the case. Earthquake trauma has important features that distinguish it from other disasters. Our comparative studies show that the immediate and long-term psychological effects of earthquakes are almost indistinguishable from those of torture trauma. This is because both trauma events share the same characteristic: a strong element of unpredictability and uncontrollability. Consequently, both lead to widespread and severe helplessness responses. This is not true for most other disasters.

Earthquake-induced traumatic stress runs a chronic course in a substantial proportion of survivors. This is to be expected, considering that aftershocks continue for a long time – at times more than a year. Furthermore, fear of future earthquakes does not easily subside in a seismically active region. Further earthquakes in the region often sustain and reinforce the traumatic effects of the previous disaster.

I have already said several times in my previous posts that the focus of attention in any mental healthcare approach to earthquake trauma needs to be on fear and related traumatic stress problems. To highlight this issue, I will use a news story by Reuters. Here is an excerpt:

“Many people cannot sleep well at night as they are afraid of earthquakes. They have lost many things so they are psychologically hurt,” doctor Keiichiro Kubota told Reuters at a makeshift clinic in Kesennuma.

The difficulty of comforting survivors is compounded by the more than 350 aftershocks recorded since March 11.

“I am sleeping with my regular clothes on. I am always feeling an earthquake. Even when a car passes by, I think it’s an earthquake,” said Toshie Fukuda, 64, a survivor in Rikuzentakata, one of the cities hit hardest by the tsunami.

At the main disaster evacuee center in Rikuzentakata, a junior high school, the psychological counseling center is a curtained-off 4 square meter (36 sq ft) corner of a classroom.

“Do you suffer from headaches, stomach aches, diarrhea? Are you easily agitated and unable to sleep? Do you have no appetite, suffer nightmares about the disaster, or lack your normal energy? Are you irritated by the smallest sound, unable to stop crying and unable to relax?” reads a clinic poster.

“These feelings are not at all unusual — they are the normal reaction of people who have received a severe shock,” the poster said. “Talk to a specialist to lighten your burden.”

The problems described here represent a symptom profile that is very characteristic of earthquake trauma. Pervasive fear caused by expectations of another earthquake – reinforced by ongoing aftershocks – leads to sleeping problems, avoidance behaviors (e.g. sleeping with clothes on), and extreme alertness and startle responses (e.g. in response to vibrations caused by cars passing by). Although these symptoms are accompanied by some other PTSD symptoms (not mentioned in the Reuters article), these problems are at the core of earthquake-related PTSD. Other symptoms mentioned in the story stem from intense fear.

Survivors often avoid a wide range of situations where they are either reminded of the trauma experiences during the earthquake or where they think they might get caught up in another earthquake. We found that they avoid on average about 15 different situations (including even sexual intercourse) because of associated fear or distress. Such extensive avoidance aggravates feelings of helplessness, causes significant functional impairment in work, social, and family life, and very quickly leads to depression. Research  shows that all this can be effectively prevented in over 90% of survivors by helping them overcome their fear or distress by not avoiding feared situations and distressing trauma reminders. It is as simple as that! Such intervention increases sense of control over trauma, reduces helplessness, and leads to generalized improvement in all life domains affected by the trauma.

We have reported all these research findings in more than 20 publications in the last 10 years. Yet, unfortunately such knowledge does not seem to have sunk in. It is worth mentioning in this connection an article posted in the American Psychological Association website noting that Psychological First Aid is a vital intervention for Japanese survivors. To my knowledge, there is no evidence to show that this intervention is useful in earthquake survivors. It is not likely to be useful, because it lacks a therapy element specifically designed to tackle the causal process in earthquake-induced traumatic stress: fear. As I said in my previous post, you need antibiotics to treat an infection; aspirin will not work!

Earthquake-induced fears are often of phobic quality, irrational, beyond cognitive control, and therefore resistant to any intervention lacking such a critical element. Informing survivors about how they can avoid helplessness by confronting such fears needs to be the first intervention in the early aftermath of an earthquake before fear becomes pervasive and extensive avoidance sets in.

USA Today article says that the Japanese Red Cross has 2,400 nurses trained to provide psychosocial support after disasters. It also says

“One tool mental health workers in Japan could use is the U.S. Department of Veterans Affairs’ and the National Child Traumatic Stress Network’s Psychological First Aid: Field Operations Guide, which has been translated into Japanese and is available online. It is designed to reduce stress and help people function better immediately after a disaster and includes 17 pages of handouts covering such topics as the value of social support to relaxation tips and advice on easing kids’ fears.”

Unfortunately, none of this is likely to help survivors, given that psychosocial support alone or relaxation is not conducive to substantial recovery from traumatic stress.

The same article refers to American Psychological Association, which apparently advised the following:

the U.S. psychologists with disaster response experience should stay home unless they’ve been formally invited to help survivors of the March 11 quake and tsunami and are proficient in Japan’s language and culture.”

This is sound advice! I would however propose a minor amendment to make it even more sound: Stay home unless you have something useful to offer!

To conclude, Japan needs to undertake a mental healthcare program without further delay and start planning for long-term care services for survivors. Mental health professionals need to consider the fact that their experiences with trauma survivors may not necessarily apply to earthquake trauma and exercise more caution in their comments to the media. Ill-informed comments are likely to mislead care providers, governments, and other organizations concerned with survivor care, leading them to underestimate the gravity of the problem. Similarly, the media needs to adopt more responsible reporting by seeking comments from appropriately qualified mental health professionals.

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