By Steven Gregor, InPsych production editor

The long-term psychological effects of the Boxing Day tsunami may well prove to be more devastating than the physical effects, with survivors experiencing grief, guilt and fear. Psychologist, Father Paul Satkunanayagam, speaking of the psychological trauma experienced by many survivors in eastern Sri Lanka, reported in The Australian soon after the disaster: “It is the worst trauma I have seen in my 30 years of experience. They (the survivors) are in despair; they have lost everything and can see no future; they are losing the will to live.”

In an official statement released soon after the disaster, the APS acknowledged that many people, both at home and in the affected regions, will need to seek counselling in the long-term. However, based on experience from a variety of disaster situations, such as bushfires, floods and the Bali bombing, Australian experts know that what people need now (after the initial, immediate needs such as food, water and shelter have been met) is basic comforting and an outlet to talk about what has happened if they want it. Psychological evidence shows that it may not be especially helpful to rush in and insist that people talk or “debrief” when they are struggling with basic survival. However, many people will require help later – survivor guilt is common, while others will feel abandoned, angry and perhaps suffer flashbacks.

Father Satkunanayagam’s reported first hand observations of the Sri Lankan experience concur. “They (the survivors) are suffering from nightmares and flashbacks of the wave. They have the guilt of surviving when others did not.”

Associate Professor Harry Minas, Director of the Centre for International Mental Health at the University of Melbourne, believes the psychological impact of the tsunami disaster will be immense for many survivors. He identifies several main reasons for this, namely the “loss of family members and friends, loss of homes and material possessions, loss of means for earning a livelihood, dislocation and temporary resettlement in refugee camps, and the profound uncertainty and loss of a predictable and secure future.

“For many there will be guilt, anger and bewilderment. In the chaotic situation that has resulted from the disaster, criminal and violent behaviour can flourish and there will be serious concerns about personal safety. Violence within families and risk-taking behaviour, particularly among adolescents, including unsafe sexual behaviours and substance abuse, may also be expected to increase,” he said.

As people and communities affected by the tsunami assess the devastation, try to come to terms with the loss, and begin to rebuild their lives, attention must turn to the future and the inevitable question: how can people and communities recover after such a disaster?

Guidelines assessing disaster resilience and vulnerability produced for Emergency Management Australia (EMA) (Buckle, Marsh & Smale, 2001) suggest the magnitude and duration of any psychological effects experienced post-disaster should be prepared for by identifying potential disasters, examining their potential impact, and by identifying vulnerability and potential level of resilience among people and communities. “Resilience and vulnerability assessment is a necessary component of effective emergency management planning. However, it is unlikely that any assessment, or community audit, will capture every potential need or identify every person who, in some circumstance, may be exposed to a risk or to the possibility of some loss.”

Impact assessment

How can communities expect, and prepare for, the unexpected? The EMA guidelines (Buckle et al, 2001) suggest: “Individual disasters (and indeed individual characteristics) impact on a person’s or community’s vulnerability and subsequent ability to exhibit resilience. The type of disaster, and indeed its magnitude, will dictate the loss and psychological trauma inflicted, thereby highlighting the ability of the affected community to support itself, to manage its own recovery, or indeed the level of international assistance required. Professional judgment is required at the time of the disaster to assess what types of assistance and support measures may be required.

“Impact assessment tries as soon as possible after an event to obtain a snapshot of needs and capabilities. This snapshot should be repeated, updated and monitored as regularly as possible. Following from a description and evaluation of damage there will be a requirement to identify and prioritise the needs of individuals, families, groups, communities and service providers. These needs will include day-to-day and continuing service, support and welfare requirements.”

According to Associate Professor Minas, with regard to the recent tsunami disaster: “During the early emergency phase, when the urgent needs are for clean water, food, safety and shelter, the elements of the response that are most important for psychological wellbeing and resilience are general social interventions, including provision of accurate and timely information, reuniting family members who have been separated, the earliest possible identification of those who have died, return of bodies to families for dignified burial and performance of important religious rituals, and the re-establishment as soon as possible of normal activities, including schooling for children and a meaningful occupation for adults – focused initially on reconstruction and restoration of productive economic activities.”

The psychological impact: magnitude and duration

In a review of 20 years of quantitative research into the psychological effects of disasters, Norris (2001) concluded that of the 50,000 people who had experienced 80 different disasters (62 per cent of which were natural disasters):

  • 74 per cent displayed specific psychological problems;
  • 65 per cent displayed symptoms of PTSD;
  • 37 per cent displayed depression or major depressive disorder; and
  • 19 per cent displayed anxiety or generalised anxiety disorder.

Of considerable concern, particularly with regard to the recent tsunami tragedy, survivors of disasters in developing countries were identified by Norris (2001) as being at greatest risk of experiencing psychological trauma; “severe” effects were identified in 79 per cent of people from developing countries (compared with 27 per cent in US people and 46 per cent in other developed countries).

The review also identified three trends with regard to the recovery and resilience of people affected by disaster. The findings, collated from 27 panel studies (studies in which effected individuals were interviewed on multiple occasions), found that:

  • In the vast majority of studies, people improved psychologically over time;
  • Symptoms in the early phases of recovery were often accurate predictors of resilience in later phases; and
  • Symptoms usually peaked within the first 12 months post disaster – a minority of individuals within effected communities remained “substantially impaired” after this period.

Alarmingly, with regard to the recent tsunami disaster, Associate Professor Minas believes: “Based on experience following other major disasters, many, perhaps most, people with significant psychological problems or psychiatric disorders will remain undetected and untreated. Potentially preventable chronicity will, for most people, not be averted. Unless people can be returned quickly to reconstructed villages and towns, and community development programs are unusually effective, the most pervasive long-term psychological impact will come from the effect of living in dysfunctional and even more impoverished communities.”

Identifying vulnerability and potential level of resilience

The research review conducted by Norris (2001) found that, at least in lower magnitude disasters, prior experience with the specific type of event may reduce anxiety. People who had experienced disasters previously showed higher levels of “hazard preparedness”.

Norris identified the following to predict adverse outcomes among survivors who experienced:

  • Bereavement;
  • Injury to self or another family member;
  • Life threat;
  • A feeling of panic or horror during the disaster;
  • Separation from family (especially among children and adolescents); and
  • Loss of property, displacement and/or relocation.

Generally, the review concluded that injury and life threat were the strongest predictors of long-term adverse consequences.

According to Associate Professor Minas: “It is very important to identify those who are most psychologically vulnerable, including those who have lost family members, those who have sustained serious injuries, and people who have a pre-existing mental disorder whose treatment has been interrupted and who will often require specific psychological intervention from mental health specialists. Appropriate mental health training of primary health care workers and those who will be involved in community development work should begin as soon as is practicable after the immediate emergency response has brought the most urgent public health problems under control.”

Especially relevant to the Australian perspective, the EMA guidelines (Buckle et al, 2001) identify certain groups of people as having special needs after an event like the recent tsunami; among them are tourists and travellers. “Tourists and travellers, in terms of being absent from their own communities and resources and being in an unfamiliar environment, possibly with little knowledge of how to access resources and services, are a group easily identifiably as being at risk.”

Associate Professor Minas adds: “The psychological impact on tourists will of course depend on whether they were personally caught up in the disaster and suffered direct losses. If they have lost family or friends then all of the issues to do with such loss come into play. Those who have been able to leave soon after the disaster may well feel guilty about the fact that they had the ability, and took the option, to leave while locals have suffered and will continue to suffer so greatly.”

Thinking cross-culturally to aid resilience

According to Red Cross Disaster Mental Health Lead Co-ordinator George Doherty (2000), “how different cultural groups handle stress and deal with stressors, their abilities, needs and desires for certain types of assistance, their motivations, their senses of honor and pride, their religious orientations and beliefs, their political systems and leadership, and their ways of handling and dealing with grief and loss are just some of the variables which are affected by cultural differences.”

Associate Professor Minas continues: “It goes without saying that for those from the international community who are offering assistance of various kinds, cross-cultural awareness and skill will be a very important determinant of whether the efforts will be successful or not. People will be dealing with culturally determined expressions of grief and all of the other powerful emotions. Since the major part of the task will be community re-building, the re-establishment of social structures and institutions, patterns of relationships and forms of communication that are deeply embedded in a cultural matrix, it will not be possible to do such re-building effectively without the necessary cultural awareness and skill. People who are open to learning and are not too committed to their own cultural perspectives can learn such skills very quickly on the job.”

Promoting resilience now and in the future

Associate Professor Minas believes: “Widespread grief, helplessness, fear, anxiety, guilt and anger will be dominant emotions in the weeks and months to come. In such circumstances there is a need for a comprehensive population mental health response. Such a response should be co-ordinated, carefully planned, integrated into the activities of international agencies and local and international NGOs, culturally appropriate, and fully evaluated.” He believes that psychological awareness of the impact of disasters “must translate into concrete action. Governments affected and donor countries and the international agencies and NGOs that are responding to disasters must begin planning now” (Minas, 2005).

The mental health division of Indonesia’s Health Ministry is currently developing guidelines for the treatment of tsunami survivors. The guidelines, part of a program funded by the World Health Organisation and costing approximately $A184,000, employ the services of local mental health professionals who have previous experience in social crises (Quinn, 2005).

References

Buckle, P., Marsh, G., Smale, S. (2001, May). Assessing Resilience & Vulnerability: principles, strategies & actions. Guidelines prepared for Emergency Management Australia, Canberra, ACT, Australia.

Doherty, G. (2000). Cross-cultural counseling in disaster settings. The Australasian Journal of Disaster Studies, 1999-2.

McMahon, N. (2005, January 13). Problems ahead for the ‘tsunami generation’. The Age, p.9.

Minas, H. (2005, January 5). Broken psyches are as important as broken bodies. The Age, p.15.

Norris, F. (2001). 50,000 disaster victims speak: An empirical review of the empirical literature, 1981-2001. Prepared for The National Center for PTSD and The Center for Mental Health Services. .

Philip, C. (2005, January 6). Bereaved survivors now left to cope with tide of despair. The Australian, p.5.

Quinn, A. (2005, January 13). Indonesia tackles mental health crisis. The Age, p.8.

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