Planning for Mental Health Needs in
Large-Scale Natural Disasters

The tsunamis generated by the December 26, 2004 Indian Ocean earthquake created one of the largest and deadliest natural disasters in modern history. Although exact figures are difficult to determine, more that 295,000 people perished, half a million were injured, and as many as 5 million were displaced.  Many survivors lost not only loved ones, homes, and possessions, but many of the psychological, social, cultural, and spiritual support systems that would normally provide sustenance in times of distress.

For survivors, the emotional pain generated by such cataclysmic events is overwhelming, and the need for appropriate and immediate mental health care is critical. The sheer magnitude of the Indian Ocean tsunami disaster has reminded many in the disaster community of the great need for timely and effective mental health support for survivors.  Responding to the mental health needs of survivors should be an integrated part of disaster consequence management; it is important for planners to understand the emotional needs of survivors to ensure that mental health support matches the evolving needs of the recipients. 

In general terms, survivors’ needs correspond to three phases of the post-event environment. The emergency phase is the period immediately after the disaster strikes; the early post-impact phase occurs any time from the day after the onset of the disaster until approximately the eighth to twelfth week; the restoration phase, involving the development of long term recovery programs, generally begins between the eighth to twelfth week after the onset of the disaster. This article will present a brief overview of the mental health needs of disaster survivors, and describe some of the principles that have demonstrated utility in helping individuals and communities return to pre-disaster functioning. These comments represent the consensus of best practices from a number of governmental and non-governmental organizations around the world.

Emergency Phase

Especially in very large disasters, the biggest problems in the emergency phase often have to do with logistics and coordination. Because of the wide range of activities and agencies involved, it is especially important that mental health providers coordinate with local command authorities to ensure efficient delivery of service.
In the immediate post-disaster environment, mental health services focus on two primary tasks: reducing the immediate impact of the trauma, and taking steps to protect survivors from further harm.  Workers should actively direct survivors away from areas of danger and from traumatic stimuli such as deceased or severely injured persons. Once out of immediate danger, health workers help survivors satisfy basic physical needs including security, water, food, clothing, and shelter as quickly as possible. This provides not only physical comfort, but decreases the risk for longer term consequences by instilling hope and providing resources with which survivors can begin to normalize their environment. Social/psychological support personnel should liaise with disaster response headquarters to establish collaborative relationships with local health agencies and services. If possible, they should also facilitate family tracing and assist survivors in accessing information on location of deceased loved ones.

As the re-establishment of basic needs evolves, providers begin the highly focused, short-term process of crisis counseling. In addition to empathic listening and emotional support, the provider explains the survivor’s current situation and available options in clear and simple terms. Crisis counseling introduces an element of order and clarity into a chaotic environment; it also enhances the survivors’ sense of efficacy and ability to make decisions commensurate with existing resources.  The process is not considered treatment in a clinical sense, but is often regarded as part of “psychological first aid” for persons experiencing a very painful, but normal response to an overwhelmingly abnormal event.

Professional mental health practitioners should seek to expand the cadre of potential care givers early in the post-event phase by providing brief training on the techniques of crisis counseling and psychological first aid to existing allied health and social service providers and local community leaders. In addition to expanding the number of helpers, such training reinforces development and support of local assets.

In the Early Post-Impact Phase

In the words of psychologist Katherine Shear, “Grief is an inevitable companion to love and attachment.”  In the early post-impact phase, the most critical mental health task is often the management of acute grief. In a massive disaster like the Indian Ocean tsunami, survivors may have lost virtually everything by which they define their lives, to include friends and family members, home, material goods, personal records, mementos, and economic resources.  
Although the response to acute grief is unique to each person, there are common themes that emerge in the early post-impact phase. For a vast majority of survivors, the grieving process includes preoccupation with the deceased, accompanied by feelings of sadness, loneliness, fear, powerlessness, anger, anxiety, and despair. Physical complaints, including sleep disturbances, body pains, restlessness, and neglect of one’s own health are also common. 

It is critical that the bereaved obtain timely support to properly mourn their losses. Unresolved losses are a major factor in the development of more serious psychological problems, including depression and post traumatic stress disorder (PTSD). Despite the intensity of the experience, some of the bereaved may initially fail to seek help because they are overwhelmed or immobilized by the shock and magnitude of their loss; they may appear dazed, numb, or disengaged from reality. Other survivors may actually decline help in an effort to preserve their sense of autonomy, competence, or dignity. It is important for mental health programs to accommodate such reticence by ensuring mental health services are outreach-based, and that services are offered in culturally competent ways.  Social customs, religious practices, and traditional rituals exert a large influence on the mourning process, so mental health care should be provided by as many local providers and organizations as possible. Because culture is so deeply embedded in the grieving process, mental health services should be integrated into other support and recovery activities. The most helpful bereavement services focus on survivors’ immediate physical and emotional needs in ways that are culturally confluent. If indicated, service providers are well advised to seek collaborative relationships with local traditional healers.

One of the most practical mental health priorities in the post-impact phase is to ensure the re-opening of schools. Schools normalize life for children and provide opportunities for them to share with others in a familiar environment. For adults, schools provide a secure environment for their children, which permits other family members to attend to personal and family needs. Schools also provide a culturally relevant, low-profile platform for dissemination of mental health and social services information in an environment that preserves self-esteem. Children in school are also much less likely to become victims of child exploitation, a particularly dismaying but tragically common occurrence following large-scale disasters.

Research on large-scale natural disasters reveals that historically, about 10% of disaster survivors develop severe mental health problems, but the scale of destruction of the Indian Ocean Tsunami is expected to move the percentage much higher.  However, providers caring for those in acute distress during the post-impact phase should be cautious not to assume the presence of a pathological stress response unless such a diagnosis can clearly be established. With proper support, most survivors will recover.

Restoration Phase

In the restoration phase, survivors face a lengthy period of adjustment to the losses created by the disaster. Especially in response to very large-scale events, the enormity of the losses often predicts a rise in the most serious mental health problems, including post traumatic stress disorder, depression, and suicidal thoughts.  To meet the long-term needs of survivors, mental health services must be well organized, sustained, and integrated into the local community.
The National Center for PTSD (U.S.) recommends that following disasters, long term tasks for mental health providers should include education, screening, and where indicated, referral and treatment.  Education activities may include programs on enhancing self-care and coping techniques, and information about social, financial, legal, and medical services. These activities help survivors to normalize their reactions to trauma and develop healthy forms of coping. Screening seeks to identify those at enhanced risk for negative psychological outcomes. Those survivors with a prior history of psychiatric illness, psychological trauma, or substance use disorders are particularly vulnerable, as are members of historically marginalized or disenfranchised groups. Survivors typically have a brief interview with a mental health provider and complete a risk assessment questionnaire. Where appropriate, the screening process may rely on informal sources, including aid workers, friends, or family members.  Based on screening assessments, survivors can be referred to counseling for specific problems, such as alcohol abuse or complicated bereavement, or to more medically or psychiatrically based treatments.

One of the principal mental health challenges of the restoration phase concerns the establishment or re-invigoration of sustainable economic, social, and psychological support programs to respond to the long-term consequences of the disaster’s impact. Especially for survivors whose pre-disaster livelihood depended on subsistence work, the ability to generate income is a critical link to emotional recovery.

In disasters involving a multinational response, the success of these programs requires a high degree of collaboration among public and private efforts from both the host nation and donor countries.  Because of the sensitivities that invariably attend to humanitarian aid, it is important to ensure the host government is able to exercise maximum administrative influence over the community’s return to
pre-disaster functioning.

Disaster Mental Health Lessons for Planners and Providers

Each disaster presents unique mental health challenges for survivors and providers. Following is a list of general operating principles that are helpful in development and delivery of successful disaster mental health services.

Disaster response planners are well advised to establish links between mental health assets and the rest of the disaster response community as an integrated part of pre-disaster mitigation planning. 
The overarching mental health goal is to help survivors to reestablish the routines of normal life including school for children, domestic and social activities, and to the degree possible, economic productivity. 
Interest in mental health issues is often highest during the emergency and early post-impact phases.  However, experience shows that as the need for emergency services declines, the need for mental health services increases. The most helpful programs, therefore, orient to medium- and long-term needs.

Western diagnostic schemes do not always generalize well to non-western cultures. The best mental health providers have a high degree of cultural competence, especially as related to knowledge of local customs and the spiritual aspects of wellness.

Ongoing public education is critical in all phases of disaster response. The World Health Organization recommends “widest dissemination of uncomplicated, reassuring, empathic information on normal stress/trauma reactions” to the affected community.

In the long term, the most effective mental health care usually comes from the local community. One of the principal tasks of both local and external mental health experts is to train community resources in the provision of continuing services.  

Specifically identified “mental health” programs tend to be less well utilized than equivalent services that are integrated into existing primary health care and social programs.

Mental health interventions should actively link individuals and families to existing support groups and community organizations. Program planners and administrators should therefore include both stationary and outreach approaches and ensure that members of the local community staff programs.

Program administrators must be careful to avoid the appearance of favoritism or other forms of perceived resource inequity; this is especially critical in areas with historic civil or political strife.

Traditional healers, including clergy persons, tribal, village, or community leaders, and other spiritual authorities are critical to the success of mental health services in all phases of the response.

The role of the media is very large and complex; exposure can be bad, (persistent negative images) or good (public information with a focus on success and improvements).  To the degree possible, try to work with media personnel who have a track record of community-conscious reporting.   

Care providers must work in concert with local authorities to prevent child trafficking and other forms of exploitation.

In the aftermath of a major disaster, external aid is often necessary and good, but issues of sovereignty demand that the recovery process be appropriately transferred to host governments and local organizations as quickly as possible.

For Further Information:
Marsella, A. & Christopher, M. (2004, September). Ethnocultural considerations in disasters: An overview of research, issues, and directions. Psychiatric Clinics of North America, 27 (3).

National Center for PTSD. (n.d.). Mental Health Intervention for Disasters. A National Center for PTSD Fact Sheet. Retrieved February 23, 2005 from http://www.ncptsd.org/facts/
disasters/fs_treatment_disaster.html.

National Institute of Mental Health. (2001). Helping children and adolescents cope with violence and disasters. Retrieved January 24, 2005 from http://www.nimh.nih.gov/publicat/violence.cfm.

Norris, F. (n.d.). Psychosocial consequences of natural disasters in developing countries: What does past research tell us about the potential effects of the 2004 Tsunami? National Center for Post Traumatic Stress Disorder. Retrieved January 18, 2005 from: http://ncptsd.org/facts/disasters/
fs_tsunami_research.html.

Ommeren, M., Saxena, S., & Saraceno, B. (2005, January). Mental and social health during and after acute emergencies: emerging consensus? Bulletin of the World Health Organization, 83 (1).

World Health Organization. (n.d.). Mental Health in Emergencies. Retrieved January, 2005 from: http://www.who.int/mental_health/
prevention/mnhemergencies/en/.

World Health Organization. (n.d.). Tsunami, mental health brief. Retrieved January 13, 2005 from: http://www.who.int/mental_health/
resources/tsunami/en/print.html.