Christchurch quake survivors and the long road to mental recovery
After recovering, there is the recovering from the recovering. The earthquakes have left many wondering why it has taken so long to feel normal again. But the experts know it is a roller-coaster. JOHN McCRONE reports.
When do we get to put it behind us? Christchurch psychiatrist Dr Caroline Bell says the Canterbury earthquakes feel like something that happened both a lifetime ago and yet only yesterday.
So many aftershocks, so much change to a city and the lives people were leading. Four years of disruption, and still such a long way from a return to normal.
In terms of mental health, greater Christchurch remains in the thick of it. Did you know there are four stages to a person's natural response to a disaster like the earthquakes – the final one being the recovering from all the recovering?
And right now, says Bell, many are feeling "cellular fatigue", that running on empty feeling. It's as if every cell in the body has been drained, washed out by the weekend, not refreshed on Monday morning.
"People are going to their GP saying there must be something wrong with me. I'm just so tired all the time."
So what should we be expecting of ourselves? Is it still alright to be using quakebrain as an excuse? How do we know when our reactions are out of line?
Bell, an associate professor at Christchurch's Otago School of Medicine, spoke about the latest mental health research in a recent talk, Shaky Times.
If nothing else, she says, the psycho-social impacts of the Canterbury earthquakes are being incredibly well studied. And the general finding is that Christchurch is about where we would predict for mental trauma.
Bell says it was a big event – unusual in being four dangerous shakes that spanned a year and a half. Yet deaths and injuries were light, the damage well insured.
So on the one hand, the figures for clinically diagnosable conditions are not extreme. But on the other, the length of the recovery should not be underestimated. Much of the city is still going through a process of change and the psychology of that needs to be understood.
Starting with the raw impact, Bell says the data shows that Christchurch is seeing an 8 per cent overall increase in mental health disorders – feelings of anxiety, depression and trauma that are serious enough to warrant medical treatment.
"So it's not massive, but it is a significant number." And the studies have been able to drill into some considerable detail.
Bell says Christchurch is in the unusual position of having a long-running longitudinal study which has been tracking the lives of 1000 people who were born in the city 38 years ago. For decades this group has been measured on every score from their career choices to their drug use.
Thus there is a population sample whose mental health before the quakes was recorded. And half of them also happen to have been living outside of Christchurch at the time of the earthquakes, giving the study its own ideal control.
Those living within the city were then divided into people with a high or low exposure to both the "shaking and breaking" and the consequent knock-on life stresses that followed – the loss of homes, jobs, relationships.
Bell says the results show that the rate of depression for those living outside Christchurch was about 9 per cent. And even for those with a moderate exposure to the quake, it remained around the same. But for those with high quake exposure, depression rates jumped to 19 per cent.
Then for post traumatic stress disorder (PTSD), it was a 1.7 per cent rate for those not in Christchurch, leaping to 5.2 per cent for those with the highest exposure.
The results taken overall – including anxiety disorders, nicotine dependency and suicidal thoughts – show that the highly exposed group had 1.4 times the usual risk for developing some form of clinical-level response.
This is a confirmation rather than a surprise says Bell. About what disaster recovery experts predicted. But useful calibration.
There have been some striking findings too. Bell says another study looking at PTSD, the severest direct reaction, discovered a strong association to what people actually felt at the moment of the big earthquakes.
Those most risk of being traumatised were either hyperaroused during the shaking – "convinced they were going to die" – or instead experienced dissociation.
"They lost time during the earthquakes, felt everything was going on in slow motion, or sometimes described being out of their bodies looking down on themselves."
Bell says this fits with the neuroscience – the idea that trauma is produced by becoming frozen in the moment, unable to digest and reframe an experience.
"The memories get lodged in a way that's not normal. With PTSD, the experience has been so overwhelming, there's no processing that's gone on afterwards. It's all stored in a very primitive sensory way."
A clue that processing matters comes in comparing the thought styles of those seeking PTSD treatment with others who have proved resilient to the very same levels of exposure, Bell says.
The resilient spoke about the earthquakes factually, describing the simple violence of the shaking, and talked optimistically. "They'd say, 'I'm so lucky I wasn't in that building that fell down.' "
By contrast, those needing treatment were focused on the negatives. Bell says when they thought about the Christchurch buildings that collapsed, it became "well, what if?" and "I almost was there".
She says this may explain another feature of the earthquakes – the degree to which older people turned out to be more resilient. Bell says 60 per cent of us have some kind of trauma in life – a brush with cancer, a failed marriage, deaths in the family.
It could be the older you are, the more likely it is you have already learnt the necessary coping lessons. So the earthquakes may have been hardest for those who faced them as their first big life challenge.
But again, she says, the general finding is that despite a sizeable jump in serious mental illness, it is not the majority experience. Another telling piece of data here is the prescribing rates for psychiatric medicines.
Bell says there was only a brief spike in the use of sedatives and anxiety combating drugs. These have since returned to routine pre-quake levels. Even more surprisingly, anti-depressant drug use never really took off.
Yet while the overall story is that the worst mental damage is relatively confined, at the sub-clinical level, says Bell. It is taking people far longer than they ever expected to get back to something they might describe as normal. So what accounts for that?
THE FOUR STAGES OF RECOVERY CAN TAKE 10 YEARS
Australian psychologist Dr Rob Gordon, an expert on bushfire disasters and a regular visitor to Christchurch to advise the Canterbury Earthquake Recovery Authority (Cera) on its psycho-social strategies, says much of the city may only be at its halfway mark.
Gordon says there are four stages to a full recovery and it can take seven to 10 years for people to work all the way through them.
The first reaction to a disaster is of course the emergency response – the phase driven by adrenaline. There is the initial shock followed by a surge of heroic activity and positive community energy.
Then comes the second stage of enduring – the response driven by the stress hormone of cortisol. The immediate threat to life has gone, but the grind of coping with the aftermath has now begun.
A lot of Christchurch is still in that mental space says Gordon, particularly where people are locked in their insurance battles, waiting for new homes to be built or camped in old ones needing to be repaired.
But also there is the generalised stress of living in a city with broken roads, messed-up traffic, a cloud of uncertainty hanging over the central city rebuild, the loss of many of the familiar patterns of life.
Gordon says stress narrows the focus of the brain. It is an evolutionary coping mechanism, fixing the mind on the most immediate tasks. Yet when the endurance phase starts to become stretched out into years, it develops its own consequences.
"People contract the areas of their lives that don't immediately address the stressors. But these are in fact all the things that add value to life – our recreational pursuits, relationships with family and friends, and so on."
Even without realising it, we cut down on what normally keeps us mentally healthy. So the damage is not acute, but it is chronic and cumulative.
"There is a lot of suffering going on because people lose the intimacy of their relationships. People just aren't emotionally available to each other for a couple years."
Gordon says this is very noticeable with children. The parents are absorbed in their insurance battles and other stresses. The kids miss out on a normal family life.
After the bushfires, there was a later surge in adolescent psychiatric referrals. Teachers commented on how immature and unready school starters appeared to be because their parents are psychologically absent.
It takes a few years, but the effects of being shut down begin to show quite widely.
Gordon says the Canterbury earthquakes are unusual because they created an emergency phase that went on for more than a year. A typhoon or bushfire strikes and then is gone.
And the endurance phase is also looking unusually lengthy. Being a modern city with all the complexity of life that entails, Christchurch is having to re-establish itself on all of its levels – amid matchingly high expectations.
So even while in the context of a world disaster, Christchurch's stresses might seem at the milder end of the spectrum – the daily unpredictability of the traffic, the wondering when the insurer is going to cough up some money – Gordon says their seriousness should not be underplayed.
The feelings of helplessness, of a loss of personal control, can be just as strong. If it is not the fate of your house that obsesses you, it could still be the fate of the Cathedral or the east of the city that weighs heavy.
And then there is no instant rebound once the post-quake stresses finally start to ease. This is in fact when the cellular-level fatigue really hits, Gordon says.
"When you are in a state of chronic stress, your body has an enormous need for energy, so it hijacks the energy from parts of the body of less importance. Basically it's all got to be redirected to brain and brawn.
"There is a generalised leaching. Hence our hair goes grey, our fingernails wrinkle up, our skin looks awful, our digestion doesn't work."
Then as life does begin to return to normal, Gordon says the body must repair from this borrowing.
"When the stress chemicals start settling down, all those tissues scream for their deficit to be made up. That's the cellular fatigue. Just when you thought it was all over, there's this tremendous tiredness which isn't just physical, but also emotional, moral, spiritual, social."
Gordon says everyone moves through these stages at different rates and to varying degrees, depending on their own personal make-up and the kind of difficulties they have experienced. But understanding and even expecting them is useful information. It helps to put the feelings in context.
And he warns it is hardly done even after the cellular fatigue.
Stage three proper is what he calls the identity crisis. Life has been put on hold during the endurance stage. So there is an accumulation of experiences to be digested. Then there is stage four, which is recovering from all the effort of recovering.
Gordon says while still in stress, people operate with a restricted set of emotions. "They'll feel anger, frustration, anxiety." Life is having to be improvised, the future remains up in the air.
But then comes the day when they find themselves in a new house or repaired home. Friends have moved, the city is different, time has jumped forward by a whole four or five years. They have to work out what the forced changes mean to their own sense of identity.
"They embark on this process of grieving really. Because grieving is a luxury you can afford when you don't have to be doing other things. So there is this time of sadness, reflection, nostalgia. There's an unexpected period of emotional reactivity ushered in."
It is here where people often become self-critical says Gordon. Physically, there appears no reason to have any complaints. However this ignores how much we rely on having a developed sense of place – a life with long-term goals and expectations. A disaster can wipe that slate clean.
So stage three is about coming to terms with what may be gone. Stage four is then about starting to live life in terms of some new established mindset, says Gordon.
"If the old goals no longer work because that world's gone, then people have to go back to their most fundamental values – ask what's important in their lives and how will they do it? Review their life plan, then start to live it in that light."
NEW COPING SKILLS FOR QUAKE-HIT COMMUNITIES
It would seem that an added worry for Christchurch is that the city got so bent out of shape, this may drag out individual recovery even longer. How do you construct a fresh relationship with a place that is many years from being rebuilt itself?
However, as Bell notes, the mental health of greater Christchurch is being tracked most carefully. It is benefiting from the best modern advice.
The extreme reactions are not many. And with a few nudges in the right direction – frank acknowledgement that the recovery is it's own lengthy psychological roller-coaster – Bell says the majority of people will be able to rely on their own resources to get back on track.
Bell says there are even some positives. A disaster can be just as much the setting for post-traumatic growth – the kind of life shock from which people bounce back better.
She says surveys are finding people commenting that they feel more connected to their communities, they have become less materialistic, they have learnt new coping skills.
Indeed, it is among those with the highest exposure to the worst of the earthquakes or their consequences who are reporting the greatest personal growth, says Bell.
So the main message is that recovery takes time. Even after four years, much of greater Christchurch is only halfway there. And no surprise when you realise there is even the last business of recovering from the recovering.
COULD THE AUTHORITIES DO MORE?
Could the authorities be doing more? Canterbury District Health Board consultant psychiatrist Dr Caroline Bell thinks so.
Speaking on psycho-social recovery, Bell says much of the mental health impact is down to the stress of the post-disaster stage and it is this the government should be easing.
Greater Christchurch has its obvious secondary stressors like runaway rental costs and wrangles over insurance claims. The Government has not wanted to intervene, saying these are private property issues.
However Bell says this is creating groups of people who are being left behind. The eventual toll on them is going to be that much worse.
Ivan Iafeta, deputy general manager of community wellbeing at the Canterbury Earthquake Recovery Authority (Cera), replies that the government has in fact made many big moves. But it has also learnt that it needs to fly somewhat under the radar if it wants people to accept help.
Iafeta says within days of the February 2011 earthquake, the Government came out with its "no questions" jobs support package. "For employers to apply over the phone for money that would be in their bank account the next day was unprecedented."
A city of small business was saved and so a major mental health risk – the collapse of employment – was averted.
Likewise, says Iafeta, there was swift action with the residential red zone offer. If that had been left for the market to sort out, there would have been a much greater level of insurance pain being felt.
In other areas, like the call for rent controls, the Government had less room to for manoeuvre. There was the risk of creating special policies for Christchurch that would be unfair to other parts of the country.
But Iafeta says overall, Christchurch is ahead of other comparable overseas disasters both in terms of its physical and mental recovery.
Iafeta says New Zealand has a history of being socially focused, so the Canterbury response was more people-centric from the start.
And then Christchurch has benefited from a greater modern awareness that psycho-social recovery is a journey. Policies need to be designed to deal with the general mental health issues and not just the outright trauma.
For this reason Cera set up its six monthly well-being survey to create a baseline record of how greater Christchurch is feeling. This is producing considerable detail that Cera can then use to plan its support.
Iafeta says for instance there was a period when a surge of stress was being reported in the 35 to 49 year old age bracket. "But they moved in, then out again."
Logic suggests this age group would have been juggling multiple problems for a while. "They would generally have had young children, but also older parents. They'd be working and maybe living in a damaged home."
However they would also have had the resources to cope, so recovered quickly as soon as there was less on their plate.
On the other hand, the last survey showed a rise in acute mental health issues in local teenagers. Iafeta says this fits with parents being emotionally unavailable for the past few years. As a result, a targeted public health program is going to be rolled out within a few weeks.
Iafeta says it has been a continuous job of measuring and responding, gauging where resources need to be invested. However what Cera has also come up against is a reluctance by people to take up the help made available.
He says the "she'll be right" staunch Cantabrian attitude means people prefer to deal with their problems in silence. And this is particularly a problem with those who have never needed help before. The traditionally vulnerable – the beneficiaries and lower income – are quicker to access the services.
An example is the Residential Advisory Service (RAS) set up to give free insurance help. Iafeta says it has been underused even though it has been highly rated by those who have tried it, and could have been scaled up to meet a greater demand.
Iafeta says this is one reason why Cera has become consciously less visible in its actions. Being "official" has a way of putting people off.
When Cera ran its Summer of Fun programme of barbecues and other neighbourhood activities, there were the criticisms that the money should be spent on fixing roads and homes.
So now the Government works mostly through NGOs and community groups, funding their work. Another lesson of the quakes is how people respond best to psychological support when it comes at the community level, says Iafeta.
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- Christchurch Press