“We must embrace pain and burn it as fuel for our journey.” -Kenji Miyazawa
It is painful enough simply to watch television pictures of Japan’s tsunami and its aftermath. What is currently going through the minds of those people who actually endured it is unfathomable. If the physical task of rebuilding lost communities is gargantuan, the process of helping survivors deal with the emotional consequences of their ordeal will take much longer.
Around a quarter of a million people are being cared for in emergency evacuation centres. They are still mourning more than 10,000 friends and relatives who lost their lives in the earthquake and tsunami and they harbour hopes for the 16,000 who are still missing. How on earth do you help these people? Where do you start?
Treating the long term psychological well-being of a survivor starts in the immediate aftermath, the ‘acute phase’ which can last for a few days after the disaster itself.
“The first thing to look for are the basic needs of the people: food, water, shelter, medical aid, protection and security and that would be the first step before thinking about psychological support,” says Barbara Laumont, Mental Health Advisor for Médecins Sans Frontières. “And then there is a big need for information.”
Information is of particular importance after a natural disaster, as survivors are often left with feelings of powerlessness and the notion they have an absolute lack of control faced with nature. Telling survivors what has happened, forewarning them about what may happen next (in the case of earthquakes, for example, that there are likely to be strong aftershocks) and informing them of what relief efforts are being carried out reduces unnecessary anxiety. The knowledge that humans are mobilising and dealing with the situation helps to restore some sense of control.
Mark Van Ommeren, a mental health expert at the World Health Organisation (WHO) wrote in a 2005 article that “Access to valid information is a basic right and is essential to reduce public anxiety and distress. Information should be uncomplicated, so as to be comprehensible at the cognitive level of local 12-year-olds.”
Disseminating reliable information was a particular problem in Japan due to the radiation concerns at the Fukushima nuclear plant. The messages coming from the authorities were mixed and unclear. People were being told they were safe, whilst at the same time being evacuated from the area and tested for radiation. The confusion was a perfect breeding ground for rumours, which can erode survivors’ confidence and sense of control.
Birgitte Yigen, a technical advisor at the Psychosocial Support Centre of the International Federation of the Red Cross and Red Crescent Societies (IFRC), told me of the particular cause for concern posed by Fukushima. She says that “one of the types of disaster that is among the worst for the psychosocial well-being of people is nuclear, radiological disasters because the threat is invisible. The fact you can’t delimit yourself from the danger does stress people out in extreme ways.”
Other important actions in the acute phase of the disaster aftermath include a dignified treatment of the dead. Again this has proven problematic in Japan, where the deceased would traditionally be cremated. The sheer number of corpses has made this impossible and the dead are, for now, being buried in mass graves. Their remains will be cremated in due time, when circumstances permit.
Support for survivors needs also to be adapted to the local culture. There have been concerns in the past that a Western, clinical approach to mental health is ineffective if imposed on a population that is not accustomed to it. Derek Summerfield, a senior lecturer at the Institute of Psychiatry, King’s College London observed in the Palestinian territories that counselling programmes imported by outsiders were not appreciated by the local population.
“Western mental health discourse introduces core components of Western culture, including a theory of human nature, a definition of personhood, a sense of time and memory and a secular source of moral authority. None of this is universal,” he wrote for the WHO.
One technique used in the past and known as ‘critical incident stress debriefing’ has been particularly controversial. It involves gathering people together soon after a disaster and encouraging them to express their emotions. Counsellors may even tell survivors what emotions they will feel, saying for example ‘you will possibly have trouble sleeping’ or ‘you are likely to have flashbacks.’ The worry is that by predicting these symptoms, they are more likely to happen. For Sheri Jacobson, Clinical Director of London’s Harley Therapy, debriefing can do more harm than good. She told me “The idea is that we have natural coping mechanisms and natural ways of dealing with an event. If we intervene in that natural process there’s a risk that we tinker with it and it doesn’t come to a normal resolution. So there’s a possibility that some trauma, rather than be defused, actually gets stuck or, even worse, heightened.”
NGOs like MSF and the IFRC are keen therefore to stress that their intervention is ‘non-intrusive’ and that carers are there to listen if and when the survivor wishes to talk.
The emphasis on mental health treatment in disaster-stricken zones seeks to be community-based, creating what’s known as psychosocial support. It is not a case of NGOs riding in like the cavalry to save the day and disappear into the sunset once all is well. Rather the objective is to get the community into a position where it can rebuild its own fabric. Where it can become as close as possible to its normal, pre-disaster state.
“It’s extremely important after a disaster hits that you try to re-establish normality as soon as possible. For example schooling, even if it’s informal. It’s very important for children that they have activities that they had pre-disaster and for adults to have some sort of income-generating activity,” says Birgitte Yigen of the IFRC.
MSF sets out a similar objective: to “create an environment that facilitates the reintegration of individuals or groups of traumatised individuals by strengthening the coping process and reinforcement of protective factors of the community.”
The World Bank also subscribes to this belief, stating in a 2005 document:
“At the outset providing survivors with income earning opportunities tied to physical work often seems to help as much as grief counselling. In disasters that cause significant damage to housing, taking the time to ensure that all usable building materials are recovered and recycled is one way to ensure that the poor will be able to afford to rebuild. Once work opportunities associated with rubble clearance and materials recycling diminish, cash assistance targeted to affected families (especially) as they wait for more permanent shelter is very important – more important than providing food, blankets and clothing.”
In the case of many NGOs like the IFRC, they are not present in disaster zones to provide specialised clinical support. Rather, they train members of the local population in community-based psychosocial support. This involves ‘psychological first aid’: being on hand to listen to survivors and remind them that theirs is a normal reaction to an abnormal situation. It also sets up child-friendly spaces and encourages activities such as drawing, painting or sports. Children, being less likely or less able to express their emotions verbally may express them more easily through these activities. It is often noted that children are more resilient than many adults in such circumstances; adults are more aware of the practical difficulties and the scale of the job that lies before them. Help offered to parents is indirectly helping children. As the MSF’s Barabara Laumont puts it: “A child maybe doesn’t understand exactly what is going on but he can feel the anxiety or fear of his parents so we would work on reassuring the parents so they can reassure the child. With children it’s important to reinforce their confidence in the adults who take care of them.”
The time after the acute phase, the ‘assimilation phase’, marks a shift from dealing with the initial shock to looking towards the future. Again, a supply of reliable information is vital. So too is making sure that the reconstruction process is fair and not helping some more than others. Rituals, cultural and religious ceremonies are also encouraged to help a community come to terms with what it has lost and also recognise what it still possesses.
Japan, while not ready to resist the force of the tsunami, was at least well prepared for the earthquake given its geographical vulnerability to seismic events. After the 1995 Kobe earthquake around 1.2 million volunteers joined the recovery effort and a similar mobilisation is under way now. Much has been made of Japanese social cohesion, something the IFRC’s Birgitte Yigen observed:
“Countries, people, cultures, individuals do react differently to disasters but it’s impossible to say ‘the Japanese react better’ because you have to look at the pre-disaster situation. Japan is more prepared than any other other country. Many of the people from outside Japan who are now working there say it’s a very easy country to work in for relief work because the Japanese are extremely disciplined. Is that because of culture or are they just extremely prepared?”
A certain number of survivors, inevitably, will suffer chronic psychological problems such as Post Traumatic Stress Disorder (PTSD) despite ongoing treatment and counselling. But little by little, as the debris gets cleared, hundreds of thousands of people will move from emergency evacuation centres into pre-fabricated accommodation and eventually newly-built homes. They will go back to their schools, shops and businesses. Statues and memorials will serve as physical reminders of those who lost their lives on March 11. Those who survived are being helped to channel their pain and forge their own future.
By Mark Davis