Mental Health & Psychosocial Problems After Disaster and

The Intervention Program in Primary Health Services

(for under resourced countries)

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 You are a health personnel send to
disaster affected community

You found there are many people with huge

mental health and psychosocial problems

What will you do?

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 How do you provide mental health
service?

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Is there any (mental) health facilities
in the primary health service?

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 Is the mental (health) services not
devastated due to disaster?

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 Is (mental) health personnel not
traumatized?

How can the traumatized mental health

personnel deal with traumatized
survivor?

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 Is there any
established (mental) health system?

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Are you sure that you are strong enough
to face such heavy problems?

Won’t it cause you traumatized?

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Learning Objective:

• To understand mental health (MH) and

psychosocial problems of disaster
affected community

• To understand MH & psychosocial

intervention program of primary health
center for disaster affected community
in under resourced countries

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Introduction:

• representatives of disaster’s affected

community:
– Refugee
– Internally Displaced People
– Survivors of disasters
– War or conflict or genocide or outbreak
affected population
🡪Those population have high risk for MH & psychosocial
problems
• Disaster can be natural or man made disaster
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MH & psychosocial problems after disaster

Occur in person/people who:

– experienced,
– witnessed,
– confronted to an event(s) that
involved
• actual or threatened death, or
• serious injury, or
• a threat to the physical integrity of
self or others

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MH & psycho ……..(cont’d):
Phases:
• Critical phase:
- Acute stress disorder
< 1 month following extreme stressor
• After critical phase:
- Posttraumatic Stress Disorders (PTSD)
> 1 month (can be decades) following extreme stressor
- Occur immediately to those who has had traumatic
experiences previously
• Prolonged stressors:
- Enduring personality change after prolonged catastrophic
experience (> 2 years)

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Symptom & Sign:
• Persistent re-experienced:
• Recurrent & intrusive distressing recollections of
the event: images, thoughts, or perceptions
• Recurrent distressing dreams
• Flashback
• Intense psychological distress at exposure to
internal or external cues that symbolize or or
resemble an aspect of the traumatic event
• Psychological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect
of the traumatic event

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Symptom & Sign (cont’d):
• Persistent avoidance:
• Avoid thoughts, feelings, or conversation associated
with the trauma
• Avoid activities, places or people that arouse
recollections of the trauma
• Inability to recall an important aspect of the trauma
• Marked diminished interests or participation in certain
activities
• Feeling of detachment or estrangement from others
• Restricted range of affect (e.g. unable to have loving
feelings)
• Sense of foreshortened future
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Symptom & Sign (cont’d):
• Persistent symptoms of increased
arousal:
- difficulty falling or staying asleep
- irritability or outburst of anger
- difficulty concentrating
- hypervigilence
- exaggerated startle response

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 Major routes to develop psychological
morbidities after disaster
Impac
t
Event
Devastated of health
Fear facilities
Loss Disruption life,
Threat
(love peoples, social network,
properties)

MHS MHS MHS

Strategies Strategies Strategies
PTSD
Depression
Panic Relapse of
Psychosoma Gambling
Anxiety Substance abuse chronic mental
tic
Behavior disorders
Suicide
problems
psychological

spiritual Doubt of meaning of life/God, justice Loss of faith/ hope

Self blame:
curse or punishment?

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*Modified from Hiroshi Kato, 1997, Finlay-Jones
for Disaster&Affected
Brown, 1981
Community
Progression:
• Disasters besides cause mental disorders as a direct
result usually also causes:
– Loss (love peoples, properties): 🡪
• Depression
• Psychosomatic
• Suicide
– Disruption life, social network 🡪
• Gambling
• Substance abuse
• Behavior problems
– Devastated of health facilities 🡪
• Relapse of chronic mental disorders
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 Progression (cont’d):

• Mental disorders as a direct result of

exposure to life threatening may:
– Fully recover (natural reaction to extraordinary
events)
– Persisted for years (even decades)

• Due to poor solution of psychosocial problems

after disaster 🡪 usually MH problems will
persisted for years

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Psychosocial problems due to disasters:

• Affects huge population

• Traumatized individual🡪 Traumatized
community
– Decreasing productivity
– High burden for other people, family,
community & country
– Risk for suicide
• Damaged infrastructure 🡪
– Influence daily activity 🡪 additional / new
problem 🡪 For how long?
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Psychosocial problems due to disasters
(cont’d):
• Loss of parents 🡪 orphans 🡪 problem of care:
• Law
• Culture
• Identification etc
• Loss of belongings & jobs 🡪 most important
problems of non Western people is daily life
problems, not trauma it self.
• Risk groups: children, woman, handicapped, &
minorities
• Live in refugee camps 🡪 New traumatic events
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Psychosocial problems due to disasters
(cont’d):

• (Mental) health facilities & system?

– How to access?
– Referral system?
– How to rebuild/reestablish?

• Lack of (mental) health and other

professionals human resources?
– Recruitment ?
– Training for mental health provider?

• Traumatized professional provider

🡪 traumatized services
🡪 traumatized future-generation
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General principal of intervention:
1. Pre emergency preparation:
• Planning in detail
• Establish coordination system with local
resources
• Training
2. Assessment of local condition:
• Cultural aspect, local wisdom
• History & problems
• Perception toward disaster & illness
• Way out / solution,
• Available internal resources,
• Priority setting,
• External resources, etc
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General principal of intervention (cont’d):

3. Collaboration:
– With (non) governmental organization = (N)GO
– Maintain sustainability of the program
– Coordination
– For staff & management’s staff: local people
should be involved

4. Integrate to primary health center’s program

5. Health service for all (not just specific for

disaster affected community)

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General principal of intervention (cont’d):

6. (Mental) health training for primary

health providers & community leaders

7. Long period perspective

– Community base
– Social intervention
( Social intervention has secondary psychological effect &
Psychological intervention has social secondary effect)

8. Monitoring & Evaluation, learnt from

previous experiences

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Phases of post disaster time:
1. Acute emergency phase:
Increasing of crude death rate due to the lack of
basic needs:
• Food
• Shelter
• Safety
• Water
• Sanitation
• Access to primary health services
• Communicable diseases control
2. Reconsolidation phase:
Basic needs already balanced with pre emergency
phase

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Intervention:
1. Acute emergency phase:

A. Immediate social intervention:

Fulfillment of urgent basic needs (food
etc) including:
• Information flow:
– Emergency status
– Effort for physical safety
– Information to decrease suffering
– Location of relatives, effort to
reunification
– Information should be simple & clear
• Tracing of family member
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Intervention (cont’d):
1. Acute emergency phase (cont’d):
A. Immediately social intervention (cont’d):
• Information about location of the
official (for medical aid, food
distribution etc)
• Build shelters for maintain the cohesion
of the family & community
• Public facilities (school, mosque, church,
water supplier)
• Dead body management
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 Intervention (cont’d):
B. Psychological intervention during acute phase:

a. Meet local primary health center or

emergency services professionals:
• Manage emergency psychiatric symptoms
(major depression, agitation etc)
• Ensure the availability of psychopharmaca
• Continue the administration of
psychopharmaca for mentally ill people who
have taken medication previously

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Intervention (cont’d):
B. Psychological intervention during acute phase
(cont’d):

b. “Psychological first aids”:

• Active listening
• Empathy
• Access the basic needs
• Don’t push to speak
• Avoid from secondary stressors
• No medication

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 Intervention (cont’d):
B. Psychological intervention during acute phase (con’t):

c. Cultural & religious activities

d. Involves & facilitates widow, widower, orphans, & who
lost the relative in to social networking
e. Refreshing activities
f. Go to school again
g. Involve youth & adult to the programs.
h. If acute phase prolonged give training to the whole
community.

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Intervention (cont’d):

C. Education for the community:

a. Emphasizing to the natural recovery

expectation.

b. Too early giving information about

psychopathology will worse the condition.

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Intervention (cont’d):
2. Reconsolidation phase:
– Continue social intervention similar with social
intervention in acute emergency phase:
– Outreach & psycho education starts at least 4
weeks after the condition stabile:
• Positive coping
• In case the main issue is economic, conduct
economical development by income generating (e.g.
micro loan etc)

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Intervention (cont’d):
2. Reconsolidation phase (cont’d):
– Psychological intervention:
• Training for volunteer for humanitarian aids
with main psychological services
• Training & supervise primary health center
officer with basic mental health service
• Training & supervise community leader with:
– case finding of MH & psychosocial
problems, and
– basic counseling & referral system

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Intervention (cont’d):
2. Reconsolidation phase (cont’d):
– Psychological intervention:
• Collaboration with local healers
• Facilitate supportive groups to self help
(community base)
• Strengthen MH service in the community
• Establish public health service with MH
service as one of main cores
• Prevention from secondary disaster

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Review: Disasters due prolonged conflict & tsunami
(prolonged) conflict
peac
e
! .

____________________________________________________________________________
Acute Stress PTSD Enduring personality change after
Disorder * * catastrophic experience
+ acute exacerbation + acute exacerbation etc

Tsunami
(new
stressor)
loss & traumatic
experience / other new prolonged stressor
Conflict between the
descendant in refugee camps & afterwards
of the conflict groups

loss of family
members,
job, belongings
etc

Necessary for +
reconciliation treat
& reconstruction recovery
basic need ment
fulfillment

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References:

1. Crisis & Recovery Center Faculty of Psychology, Gadjah Mada University Yogyakarta – Indonesia, June 2006 Recovery and development of mental
health and psychosocial status of the 27th May 2006 earthquake disaster in Yogyakarta & Central Java Prov.
2. Depkes RI, WHO, UNICEF. Rekomendasi yang Boleh dan Tidak Boleh dalam Intervensi Psikososial
3. Ehrenreich, J.H. 2001. Coping With Disasters. A Guidebook to Psychosocial Intervention (Revised Edition)
4. Finlay-Jones & Brown, 1981. Major routes to develop psychological morbidities after disaster
5. Geertz, C. 1960. The Religion of Java. The Free Press, Glencoe,Illinois.
6. Hidayat,2006. Model 3 Faktor untuk Analisis Kebutuhan & Kerangka Penangan Dampak Psikologis Bencana Gempa Bumi 27 Juni 2006 di
Yogyakarta dan Sekitarnya
7. Hiroshi Kato, 1997, Major routes to develop psychological morbidities after disaster
8. Hospitals Cumulative Data in Yogyakarta & Surroundings
9. Meetings at Dinas Kesehatan provinsi Daerah istimewa Yogyakarta, June 3, 10, 17, & 24, 2006
10. Patel, V. 2001. Where There Is No Psychiatrist. The Royal College of Psychiatrist
11. Personal communication with a couple of survivors
12. Personal experiences in dealing with disaster’s affected community
13. UNOCHA, sarkolak DIY June,17.18.00wib
14. Wessells, M. 2006 Psychosocial Support Following the Yogyakarta Earthquake
15. World Health Organization, 2003. Kesehatan Mental dalam kedaruratan. Aspek Mental dan Sosial Kesehatan Masyarakat yang Terpapar
Stressor yang Ekstrem, Geneva. (Indonesian version)

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