Psychosocial effects of the earthquakes
A year ago today, the prime minister's chief science adviser, Sir PETER GLUCKMAN, gave the Government a briefing paper on the likely psychosocial effects of the earthquakes. Today, we publish edited extracts of that paper so that people can judge whether his advice was followed.
Many people directly experiencing a major natural disaster such as an earthquake experience psychosocial effects - both individual psychological effects impacting on how people feel and social effects impacting on how they relate to each other.
Indeed, such effects are inevitable and a normal part of human psychology.
However, there is considerable variation in individual and social responses. Nevertheless, it is fair to state that the potential exists for the emotional effects of disaster to cause as great a degree of suffering as do the physical effects such as injury, destruction of infrastructure and loss of income.
In fact, they are often interrelated. Indeed, it is clear that recovery is primarily judged in terms of people feeling that they are coping with their lives and livelihood, not just in physical terms.
The problem is that every disaster is somewhat different. The Christchurch series of earthquakes is more complex than [say] a hurricane in that there is an inherent threat in the continuing aftershocks that can last for many months, exposing people to recurrent acute stress, while at the same time chronic stress is imposed by the ongoing human, economic and social costs.
A distinct feature of this event is that the initial M7.1 earthquake caused sufficient damage to induce significant traumatic stress in its own right and then, rather late in the recovery cycle, the M6.3 earthquake returned many people back to the beginning of the cycle.
These aftershocks may well extend the recovery process. Some of the population may experience ongoing feelings of insecurity, uncertainty, loss of trust in scientific information, continued hypervigilance and disturbed sleep. As we know, this disaster is also characterised by considerable numbers of people leaving the area. This population will also show psychosocial consequences of dislocation that may need to be addressed.
Classically, four phases are described after a disaster, although separating them out as distinct phases with sharp transitions is somewhat artificial: An initial heroic phase, in which people help and don't count the "costs".
A honeymoon phase in which people see some help arriving and feel that the situation will improve.
A third phase which is somewhat awkwardly and unhelpfully termed the "disillusionment phase" in which people realise how long recovery will take and become angry and frustrated. I would prefer to call it the long-term recovery and rehabilitation phase.
Finally people return to a new equilibrium, but we must understand that this is a long-term process with no clear endpoint in that things can never return to exactly what they were before the disaster, although people will find a "new normal".
While many people will be relatively resilient, many others may demonstrate the emotions of numbness, depression, despair and anger. These are normal responses to exceptional circumstances and such people should not be seen as unwell. Despite the fact that for most people these emotions will slowly diminish, in a minority they can be exhibited for months if not years.
Accumulated experience warns us to expect peaks in distress on anniversary dates.
The key issue is a psychological sense of empowerment. The earthquake was a disempowering event - an event that individuals had no control over and that leaves them essentially with no control over how they live.
The need to regain some sense of some control over one's life is central to the recovery process. Disempowerment essentially reinforces the initial trauma.
Women (especially mothers of young children), children and people with a prior history of mental illness or poor social adjustment appear to be more vulnerable than other groups. Vulnerable groups evolve over the recovery period and this needs monitoring from those working in the field.
Effective ways of including these groups may include non-clinical intervention services facilitated through schools and other organisations working with families, and "check-ins" of people already known to mental health services.
Young children (ages 1-5) may exhibit fear of separation, strangers, "monsters" or animals, withdrawal, or sleep disturbances. Older children (ages 6-11 or so) may engage in repetitious storytelling or play that re-enacts parts of the disaster.
Sleep disturbances, fear of the dark, irritability, aggressive behaviour, angry outbursts, separation anxiety, school avoidance, and general changes in behaviour, mood and personality may appear. Children of all ages are strongly affected by the responses of their parents and other caregivers. "Protecting" children by sending them away from the scene of the disaster, thus separating them from their loved ones for extended periods, can add to the trauma.
Adolescent behaviour becomes increasingly similar to adult responses and may include greater levels of aggression, defiance, substance abuse and risk- taking behaviours. Support from teachers and peers and exposure to positive news stories are protective. Adolescents are particularly unlikely to seek out counselling.
Addressing tensions and conflicts
In every disaster there is an inevitable tension between the desire for an immediate response and the need for planning and risk reduction. This tension aggravates the situation and creates opportunities for externally driven exacerbation of symptoms. Anger and frustration are inevitable and endogenous. It is wrong to respond to this anger in a defensive way.
It would appear that key to minimising this phase is the promotion of local empowerment and engagement by working closely in a collaborative way with the affected population in co-ordinating and co- leading the response effort.
If the population do not sense this is happening, then the phase may well be longer and the symptoms of anger and frustration more intense.
A feeling of self-efficacy and community efficacy assists the population in reactivating their coping mechanisms. Local governance, empowerment and ownership have been shown to facilitate recovery.
Then inevitable tensions and conflicts in achieving this are obvious (long-term versus short-term, public versus private, local versus national interests) and cannot be avoided - rather, they have to be openly handled with sensitivity.
It follows that, from the psychosocial perspective, those involved in directing the recovery should create governance structures that understand and actively include community participation and enhance individual and community resilience. Such approaches will be most likely to be effective in re-establishing coping and functioning communities.
It appears important to try to give people back some sense of control and agency over their lives. Key to recovery is firstly "normalisation" - that is, getting people in some way back to business, social life, schools, church and a sense of community, even if in temporary housing or locations.
Secondly, there also needs to be normalisation of the responses to people's varied psychological reactions - that is, for there to be a wide understanding that "most emotional reactions are usual reactions to abnormal or difficult situations" and are not reflections of being mentally unwell or weak.
This requires education and orientation on the expected reactions and provision of access to available resources.
For withdrawn and depressed individuals, multiple strategies are needed (such as John Kirwan-style TV slots, alert neighbourhood visitors or community-led events). It is important that such messages are about functional changes and how lives progress rather than the symptoms per se.
Surveillance and monitoring by local organisations and GPs is an important preventative step, provided that these monitors are appropriately briefed.
Non-clinical psychological intervention at this stage can help by:
- Avoiding the labelling of normal people as "patients", thereby reaching a wider range of people;
- Providing information on the normal range of psychological effects people can expect themselves and their families to experience;
- Providing information on when further psychological assistance may be helpful and how to access it;
- Helping to restore the social connectedness and community life necessary for long-term recovery.
The expected emotional reactions to the earthquake are such that they can prevent people from taking on new information as they are preoccupied by trying to manage their responses to the threat.
Thus, many people will need repeated exposure to information and resources - often this is not recognised as a need. Open and honest information dissemination is key; mythology and rumours are the enemies of resilience.
Perhaps 5 to 10 per cent of the population in the most affected areas will need more specialised professional help at some stage. Formal psychological debriefing techniques should not be used as evidence shows that they can reinforce the problem.
And it is critical that the public messages are supportive, not threatening.
The most important ameliorating factors for the recovery phase appear to be:
- Recognising that the situation is distressing and not easy for the affected population;
- Being explicit about how governance arrangements will facilitate local engagement and empowerment;
- Recognition by the community of the conflict that is inherent between the desire for a rapid physical recovery and the difficulties that planners face. This conflict is inevitable and real - the key is to involve the community openly in resolving it;
- Providing information on expected post-disaster emotions;
- Providing community monitoring and good information on access to support services;
- Providing clarity over reconstruction and rehabilitation plans.
Issues in the 'new normal' phase
Most people make a good recovery from the psychological and social effects of significant disasters.
Giving early psychological support to the population can avoid some acute stress reactions becoming chronic and allow some extreme reactions to be picked up and referred earlier.
Around 5 to 10 per cent of the population are likely to consider that their long-term psychological health has deteriorated following a disaster of this size and may seek or require further intervention. This population will show a varied pathology: depression, high-anxiety states, as well as some post- traumatic stress syndrome states.
Unresolved post-traumatic stress syndrome and similar conditions can lead to epigenetic intergenerational effects. Factors can be identified that may increase the risk of long-term psychological symptoms and there should be monitoring within the context of the Christchurch community so that trends are identified early.
Known risk groups include families that have suffered bereavement or a personal crisis (which may be unrelated to the disaster), individuals with pre-existing mental health conditions, and children whose parents have unresolved mental health issues.
Stigmatisation of mental health issues can lead people to suppress symptoms and make healing more difficult.
Managing the psychosocial response is complex and cannot be separated from managing the rebuild of Christchurch.
Tensions between different agendas are inevitable in any major disaster and are likely to be greater here given various factors such as the continuing high public and media focus, the fact that the disaster is in a large urban area, the electoral cycle, the economic costs of a disordered Christchurch business community, and the ongoing reminders in the form of aftershocks.
There is a need for ongoing human and organisational resources, perhaps even those of a conflict resolution team, as well as a long-term commitment to ongoing psychosocial support.
Key to success will be to convince people that the focus on the physical rebuild is not an end in itself but is designed to allow people to rebuild their lives and livelihood.