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Tsunami raises questions about disaster mental health, Science reports

American Association for the Advancement of Science

Nearly eight months after a ferocious earthquake and tsunami left hundreds of thousands of people dead and millions homeless on the rim of the Indian Ocean, the disaster continues to claim a more quiet toll among those suffering psychological aftershocks, according to a news story in the 12 August issue of Science.

For two weeks in July, journal Staff Writer Greg Miller toured the destruction zone in Sri Lanka and India. While experts have predicted that hundreds of thousands of survivors will suffer from depression, post-traumatic stress disorder and other long-term mental health problems, Miller discovered that many people in the region also have shown remarkable resilience. He also found that the massive international effort to provide "psychosocial aid" has had its share of problems.

In an interview, he describes travels among the survivors and teams of mental health workers-and the human repercussions of the disaster.

Miller discovered that many people in Sri Lanka and on the East Coast of India are doing better than might be expected. Many apparently are bolstered by the strong family and community ties common in Asian cultures; some may have been inured to a life of severe hardship even before the deadly 26 December earthquake off the coast of Indonesia.

But people in South Asia almost never speak of sadness or mental anguish, many psychiatrists working in the area told him. Instead, they complain of aches, pains and discomforts that have no apparent physical cause. Even if the symptoms are masked, one therapist said, many people living in the camps are suffering from mental problems-and many could benefit from counseling or medication.

Yet Western-style therapy is a foreign concept in many of the hardest hit areas, and the massive international effort to provide "psychosocial" aid has had its share of problems. The situation highlights the need for more research on what interventions are most important for psychological relief after a disaster, Miller writes.

Miller's news story, "The Tsunami's Psychological Aftermath," will appear in the 12 August issue of Science. AAAS Senior Writer Edward W. Lempinen interviewed him by email this week.

Let's start with some scene-setting: When you first arrived in the Sri Lankan tsunami zone, what did things look like? What was your impression of the prevailing mood? Did you feel like the emotional or psychological trauma dating to the earthquake and tsunami was something palpable on the street, in your interactions with people?

My first morning in Kalmunai, I walked down to the beach. Kalmunai is a town on the east coast of Sri Lanka that was badly affected by the tsunami. The zone near the beach was once heavily populated, but now it's devastated. There's nothing left but toppled palms and piles of rubble. But on the main road through town, just a few hundred meters away, there was a chaotic buzz of activity like you'd see in any other Sri Lankan town, a swarm of autorickshaws, bicycles, overloaded buses, stray goats, you name it. Women were selling fruit and fish on the side of the road, children were running by in their school uniforms. At least superficially, life seemed to be getting back to normal.

How did this story first come together for you? What provoked your interest? What kind of preparations did you have to undertake in advance?

I have a fellowship from the Carter Center this year to do some reporting on mental health issues in developing countries. When the tsunami happened, there was a great deal of attention paid in the media to what the psychological impact would be, and I knew this was something I wanted to investigate.

In general, how would you describe your findings? How much of a lingering psychological impact has the tsunami had, and how is that making itself manifest now?

It's impossible to know at this point just what the impact has been and what it will be in the long run. In part that's because many people have felt that it wouldn't be ethical to do a thorough scientific study in the immediate aftermath of the disaster. Some groups, including NGOs and university researchers, have done quick and dirty assessments to help gauge the needs for psychosocial support, and those suggest that many people have symptoms of depression and anxiety disorders.

Can you describe some of the people you met who were evidently suffering some degree of post-disaster mental-health trauma?

One woman I met in a village near Chennai, India, lost her teenage daughter in the tsunami. She said that when she hears certain sounds she has the very vivid sense that her daughter is just outside, playing with the neighbor's children. Then of course she realizes that it can't be, which is very upsetting. Many people have intrusive thoughts like this, or flashbacks of the day of the tsunami or nightmares. Other people seem to have symptoms of depression-they can't sleep, lose their appetite and their interest in things they usually enjoy. In a village near Cuddalore, India, I went around with psychiatric social workers from an NGO based in Chennai. We visited several people who have become very withdrawn since the tsunami and won't leave their houses or take part in their normal activities. This is another common situation.

Is there enough mental health service available in the tsunami zones right now? Or enough of the right kind of service?

Mental health service in most of these areas is woefully inadequate. Sri Lanka had about 40 psychiatrists for 20 million people, and the World Health Organization estimates that 384,000 Sri Lankans have serious, debilitating mental disorders like major depression and schizophrenia, and as many as 2 million have less serious disorders that could still benefit from treatment. Forty psychiatrists is clearly not enough to take care of them all, and there are very few psychologists, psychiatric nurses or other people trained to handle mental health problems. Many experts I talked to are hopeful that the attention to mental health that has been raised by the tsunami will provide political leverage to push for much-needed improvements in the mental health care systems in the affected countries.

One of the most interesting surprises in your story was the suggestion that while millions of people will suffer some degree of psychological impact from disaster, many people in the tsunami zones that you visited were doing reasonably well, psychologically, given the magnitude of what happened. What factors-social, cultural, spiritual, even economic-might be behind that resilience?

Family and community ties are hugely important in many Asian cultures, and they tend to put less emphasis on individual self-reliance than we do in the West. Many people I talked to, both locals and Westerners, felt that this collectivist spirit and the strong social ties it fosters were helping people cope.

Others suggested that some tsunami survivors are coping better because they're used to adversity and see the tsunami as just the latest obstacle life has thrown their way rather than as a cataclysmic event. Many of the areas affected by the tsunami are very poor by Western standards and some-notably Sri Lanka and Aceh, Indonesia-have seen a lot of violence in the recent past. Several people I interviewed thought that people in these war-torn areas were doing surprisingly well considering all they've been through and attributed that to coping mechanisms they've built up through years of hardship. I think this is a bit speculative because it's based on the impressions of people working in the field, not on any scientific research, but it's an interesting consideration. It certainly runs counter to the common notion that people who have been under stress are more likely to snap when something disastrous happens.

In the U.S., in event of a natural disaster like a hurricane or an earthquake, there's usually an assumption that the official response will have to include some sort of mental health therapy. And yet, another of one the surprising elements of your story is the suggestion that after a natural disaster that inflicts broad trauma, a blanket offer of Western-style mental health therapy may not always be appropriate in other cultures. Was it appropriate in the areas you visited? Why or why not? Was it effective?

A big part of the problem is that there's not a lot of good research on what is, in fact, the best response for disaster survivors in terms of mental health. That is especially true in developing countries. A lot of the psychosocial response to the tsunami has been based on good intentions rather than solid research. Many of the NGOs have been doing very good work, but there have been problems in the psychosocial relief effort.

For example, some foreign groups arrived to counsel tsunami survivors, or train local people to do counseling, but they didn't speak the local language. In Sri Lanka, I talked to a psychiatrist who complained that some foreign groups had prevented people from carrying out local customs-particularly with regard to burying the dead-that normally help people grieve and recover. In his view, these customs are important for coping, and should have been strengthened, not pushed aside. The World Health Organization and others also complained that many NGOs were too focused on post-traumatic stress disorder and certain types of trauma counseling that haven't been shown to be effective. There seems to be an emerging consensus that PTSD is just one of many ways people react to disasters. People with symptoms of depression or anxiety disorders other than PTSD get overlooked when the aid effort is too focused on PTSD.

At the same time, there were some groups who did very good, culturally appropriate work. The Danish Red Cross delivered hundreds of sewing machines to Muslim women in eastern Sri Lanka who'd lost their husbands in the tsunami. It's not exactly a clinical intervention, but it probably had a big effect on the women's mental health. These women were expected to stay inside their houses for a grieving period of four months. But since many of them lost other family members, too, they had no one to look after them. The sewing machines gave them something constructive to do with their time as well as a way to earn an income. The Red Cross checks in on them periodically to see how they're doing.

If this sort of therapy isn't relatively common in these cultures, how do tsunami survivors and other people who live in the zone respond when it's offered to them?

In the fishing village near Cuddalore I visited, I asked one of the women we visited what she thought of all of the psychosocial programs. One of the psychiatric social workers interpreted. She said sometimes she didn't know what to make of it. She'd gone to a group counseling session recently where everyone was talking about their experience in the tsunami and the troubles they've had since. "With all these people talking about their problems, how can it help?" she asked. The social worker explained that it was meant to help her realize that there were other people going through what she was, that she wasn't alone. She smiled and shrugged kind of non-committally. But she said she really appreciated that people were always coming by to check on her and ask how she was doing. I think that's probably indicative of how people are responding, at least in the areas I visited. They're not always sure what the psychosocial aid is all about, but they're grateful that people seem to care about their well-being and are trying to help.

Based on your reporting, what are the chief lessons to come out response to the tsunami by local and international mental health groups? How should the response be different next time?

Although my article is a critique of the psychosocial response to the disaster, I think to be fair, you have to keep in mind that it was a very chaotic situation. It's unlikely that everything will go perfectly in any disaster response. A better system-or any system-for registering and keeping track of the psychosocial NGOs would help to ensure that different groups aren't duplicating efforts and would help minimize some of the friction between NGOs that has happened this time. The NGOs themselves should perhaps give more consideration to how the services they have to offer can best be adapted to the local culture and to how their presence will benefit the local people in the long run.

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