Disaster Trauma from an International Perspective:

An Overview of the World Health Organization Model

(Continued from newsletter)

The international response to this disaster has sparked a renewed attention to seeking consensus on "best practice models" for various phases of mental health response to disasters. The WHO has been sharply critical of a mass intervention response that is based on largely Western principles of trauma and recovery; it has cautioned against using intervention models that are not integrated into the cultural, social and governmental infrastructure of the affected countries and populations. As a major representative of the international response to disasters, the WHO approach to disaster response and recovery emphasizes the following points: 1) integration of mental health services into the existing public health systems; 2) utilization of psychological first aid as a primary intervention model; and 3) development of social and mental health interventions, which are somewhat different than the Western concept of psychosocial interventions, and tailored to the unique economic needs of developing countries. Additionally, the WHO cautions against two perspectives that are often understood by international groups to be part of a "westernized" response to disasters:

1) the use of single-session debriefing and 2) the focus on post-traumatic stress disorder (PTSD.) A recent WHO report indicates that single-session debriefing is highly contraindicated as a mass approach to disaster response.2 Additionally, the WHO has indicated that from an international perspective, it is a misconception to assume that PTSD is the main or most important disorder resulting from disaster.3

The international approach to disasters must take into account realities that are not part of the sociopolitical context of Western countries and cultures. These realities include but are not limited to the following factors: lack of a broad-based, public health system; a limited mental health system that remains largely hospital-based in many developing countries, providing assistance to only those with the most severe mental disorders; and limited public funding for a public health and mental health response to disasters. Many of the functions and services provided by public agencies within Western countries following a disaster are provided by either non-governmental organizations (NGO’s) or faith-based groups in developing countries. For example, Buddhist monks provided significant psychosocial support in the tsunami-affected areas of Thailand, similar to what a FEMA-funded crisis counseling program would have provided here in the states, yet with a key distinction that the intervention is provided in the context of the Buddhist culture. The vital role played by these NGO’s and faith-based entities cannot be overlooked in disaster response. Affected populations in these countries will seek the services and counsel of these groups; the comfort of familiar faces and of their religion during these times is what is needed as a mental health intervention. As one Buddhist monk stated "in our culture, we are taught from birth that suffering is part of life, that loss is part of life . . what we tried to offer people was the comfort of the teachings that are familiar to them, from childhood. From the perspective of our culture, whether we offer someone a cup of water or a simple mantra, it is all the same: it is the gift of human healing that we must extend to one another." (personal communication, V.R. Thiranpothole, Ph.D., March 13, 2005). From the Western perspective, this type of response can best be understood as a form of psychological first aid. There is growing consensus for psychological first aid as the "best practice" approach for the immediate and acute phases of the disaster.4,5 Psychological first aid promotes non-intrusive emotional support, coverage of basic needs, protection from further harm, and organization of social support and networks.

The WHO takes a population perspective to disaster response, which is public-health based in its approach to service delivery. This approach identifies four groups or populations, each requiring a different response.3

1) People with mild psychological distress that resolves within a few days or weeks – the WHO estimates that roughly 20-40% of the tsunami-affected population falls into this category, and require no intervention beyond psychological first aid.

2) People with either moderate or severe psychological distress that may resolve with time or with mild distress that may remain chronic- this group is estimated to be 30-50% of the tsunami-affected population. This group would benefit from a range of social and basic psychological interventions that are designed to reduce subjective distress, enhance coping mechanisms and rely on existing social supports.

3) People with mental disorders, mild to moderate – the WHO estimates that world-wide, the 12-month prevalence rates for all mild to moderate mental disorders (depression, anxiety, including PTSD) is on average approximately 10% across countries in the world (World Mental Health Survey 2000 data). This rate is expected to rise, to possibly 20%, after exposure to a severe trauma and resource loss, such as occurs after a major disaster. Over several years, rates of mild to moderate disorder are expected to slowly decline, possibly to 15%, in severely affected areas. Thus, as a result of the disaster, population rates of psychological disorders are expected to increase by 5-10% overall. The WHO cautions against assuming that PTSD is the main or most prevalent disorder after a disaster. In many non-western cultures, rates of help-seeking for PTSD symptoms are relatively low, suggesting that PTSD may not be the focus of many trauma survivors. These population-based estimates and projections by WHO are consistent with much of what has recently been reviewed regarding PTSD in developing countries.4,6

4) Severe mental disorder – estimated to affect approximately 2-3% of the population world-wide (World Mental Health Survey data, 2000.) This rate is estimated to rise to approximately 3-4% after this population has been exposed to severe trauma and loss. Trauma and loss may exacerbate pre-existing disorders, as well as cause more severe disorders in vulnerable populations.

The ongoing controversy regarding issues such as the "legitimacy" of the PTSD concept in non-western cultures, and what constitutes "best practice" models in disaster response and recovery, prompted a study undertaken by the Department of Mental Health and Substance Abuse of the WHO.4 The authors of this study commissioned a literature review and a survey of international experts in the mental health response to trauma and disasters. The results of this study suggest that although opinions vary widely on focusing public health efforts on PTSD and trauma services, agreement on basic issues emerges. These points of consensus have been developed into eight principles used as the current "best practice" model by the WHO and it’s sponsored agencies and programs:

1) Contingency planning – to include interagency coordination, detailed plans for mental health response, and training of relevant personnel in indicated interventions that have broad support.

2) Assessment – should cover the sociocultural context and available resources. With respect to individuals, assessment should focus on daily functioning and indicators of disability and well-being.

3) Long-term perspective – even though the impetus for mental health programs is often highest immediately after a disaster, populations are best served by a focus on medium and long-range services.

4) Collaboration – ongoing collaboration with other agencies, public and private, insures the most efficient utilization of resources.

5) Integration into primary health care – mental health care should be made readily available within the primary health care system. Vertical, stand-alone trauma programs (i.e., separate services focusing solely on PTSD that are not integrated into the overall system) are discouraged.

6) Access to services for all – again separate mental health programs that focus on specialized services for only small sectors of the population are discouraged. Outreach and enhancing awareness of services is encouraged.

7) Thorough training and supervision – these programmatic aspects should be provided by qualified mental health professionals. The WHO has expressed concern that training provided by professionals from western countries does not adequately take into account the cultural context in which services will be provided, and may do more harm than good.3 In designing interventions and trainings, the WHO advocates that professionals follow the "Guidelines for International Training in Mental Health and Psychosocial Interventions" provided by the Task Force on International Trauma Training of the International Society for Traumatic Stress Studies.7

8) Monitoring indicators – activities should be monitored through key indicators over a substantial period of time to determine changes in needs and resources.

As the world converges into an increasing "global society", it is hoped and anticipated that there will be growing collaboration on what does indeed constitute a "best practice" model of disaster response and recovery. There is much to be learned and exchanged between the traditions and rituals of the "non-western" world, and he empirically-based interventions of westernized cultures.

Notes:

1World Health Organization. (April, 2005). Three months after the Indian Ocean earthquake-tsunami: Health consequences and WHO’s response. Brief report, WHO, Geneva.

2World Health Organization. (2002). Single-session psychological debriefing: Not recommended. Brief report, WHO, Geneva.

3World Health Organization. (April, 2005). Mental health assistance to the populations affected by the tsunami in Asia. Brief report, WHO, Geneva.

4van Ommeren, M., Saxena, S., Saraceno, B. (January, 2005). Mental and social health during and after acute emergencies: emerging consensus? Bulletin of the World Health Organization, 83, p. 71-77..

5Department of Mental Health and Substance Dependence, World Health Organization.

(2003.) Mental health in emergencies: Mental and social aspects of health of populations exposed to extreme stressors. Report of the World Health Organization, Geneva.

6Weiss, M.G., Saraceno, B., Saxena, S., van Ommeren, M. (September, 2003). Mental health in the aftermath of disasters: consensus and controversy. The Journal of Nervous and Mental Disease, 191, p. 611-615.

7Weine, S., Danieli, Y., Silove, D., van Ommeren, M., Fairbank, J.A., Saul, J., (2002). Guidelines for the international training in mental health and psychosocial interventions for trauma exposed populations in clinical and community settings. Psychiatry, 65(2), p. 156-164.