"After the first disaster, the so-called natural disaster, a second disaster to take its toll on the victims is the psychological one"

Thirty three-year-old Colombian, Germán Casas Nieto, is a psychiatrist specializing in victims of natural disasters. Following the earthquake that hit El Salvador on January 13 2001, MSF started an emergency project to provide assistance to the affected population. MSF was already present in the El Salvador when the earthquake hit. Together with health care and water and sanitation activities, MSF organized a mental health team made up by five psychologists and one psychiatrist, Casas, to assist the earthquake victims. Casas, who previously worked in similar situations - Cauca (1995); Armenia (1998); earthquakes in Colombia; aftermath of volcano eruptions in Guaguapichincha (2000); and Tumburagua (2000) in Ecuador; and during Hurricane Mitch in Guatemala (1998) - assures that "after the first disaster, the so-called natural disaster, a second disaster to take its toll on the victims is the psychological one".

Why are you so interested in the psychological consequences caused by natural disasters? Casas 

After Nevado del Ruiz erupted in Colombia in 1985, its psychological consequences took their toll on the population. Many assessments have taken place about the kind of effects caused by that disaster. The case has been studied along the years in a systematic way (after one year, after five, after ten ...). Because of this, in Colombia it is widely known that natural disasters have serious effects on the mental health of the affected populations.

How can the impact of a disaster on a population be measured?

Casas -There is a theory known as the "psychological reaction to disasters" that establishes five stages: warning stage (this stage cannot be seen in earthquakes, but only in hurricanes or volcano eruptions), impact stage, inventory stage, short term recovery stage and long term recovery stage. The effects of an earthquake start on the impact stage because this disaster cannot be foreseen. Instead, a hurricane or a volcano eruption can be foreseen, as it is possible to know when a hurricane is approaching or a volcano has become active. An earthquake bears different features from other disasters and its consequences on the victims' mental health are more serious. These characteristics are: universality (it affects everybody in a geographical area), spontaneity (it cannot be foreseen) and irreversibility. After the impact stage, we find the inventory stage in which the individual becomes aware of what has really happened and how it has affected him/her. For instance, in the consultations we had in El Salvador, during the first four to five days patients asked us what had happened. Now they explain how they have been affected. When there is an earthquake, the final stages or recovery stages take longer to arrive. In fact, the psychological recovery is as slow as the physical recovery (reconstruction of infrastructures).

Why is recovery so slow?

Casas-Because those who have lost everything have nowhere to go back to. Besides, the geography of the places where they used to live has also changed. The victims of an earthquake have lost all their physical references and, consequently, this puts off the recovery of psychological references. A home means protection, shelter, security, family cohesion. When you lose your home, all this is lost with it. On the other hand, the so-called "shelter syndrome" is an earthquake's general feature. When a disaster is foreseeable, the victims usually know they will be evacuated. On the contrary, when an earthquake takes place, the victims must adapt to a new physical reality which generates a psychological imbalance. A general feature found in displaced people living in shelters or asylums.

Do all the victims present the same psychological imbalances?

Casas - All the victims of an earthquake, whether they have lost their home or not, their families, relatives and other acquaintances or not, have a psychological response. Most of them have a normal response, a response needing certain attention and information. Other cases present a more severe response which is different in each case, depending on the person and what he/she has had to endure. -

What are the psychological consequences caused by an earthquake?

Casas - Initially people are shocked. They do not believe what has happened. They experience fear. Some have sleeping problems. Even nightmares occur. Others are constantly pre-occupied with what has happened. They may have flash-backs and sometimes do not release the event is over. To balance their continuous preoccupation, some people try to avoid everything that is related to the event. They do not want to speak about it, they avoid smells and sounds; sometimes they even avoid people who make them think of the event. We also frequently see that people suffer from all types of physical complaints whereas the doctors do not find anything after physical examination. Children change their behaviour, become restless, irritable, aggressive, silent. They also need to be constantly with their parents, suffer from insomnia, regression to a previous stage of life (sucking their thumbs, enuresis...). The most extreme cases present school phobias causing learning and development problems. These type of reactions are normal reactions to abnormal circumstances people and most people recover within a month. Despite the normalcy, people still feel upset. Some have the feeling they have become crazy. 

Are there cases that present severe reactions?

Yes, but I have to say that only a small group of people have severe reactions to their adversity. They may develop an acute traumatic stress disorder, a psychosis or depression. The most severely affected cannot and will not take care of themselves anymore. They simply lose the will to live (actively or passively). As our Colombian study shows, the prolonged effects of psychological are much bigger. These effects became commonly known as Post Traumatic Stress Disorder (PTSD). The symptoms of this disorder do not differ too much from the acute (and then normal) signs. However it has become a disorder because people are fixed or entrenched in their preoccupation or avoidance. The fixation is not only harmful to the persons themselves. Families are affected. And when, like in this earthquake, whole communities are affected, long term effects can be visible on the community level. Of course the incidence of PTSD increases but most visible is the dysfunction of the community system: substance abuse increases, conflicts (marital, family) arguments, violence and aggression rises etc.. In short, it may be that the social fabric of the community disappears. But these are more prolonged effects. The MSF intervention at this moment focuses on the immediate psychological responses.

 In what way?

Casas - Our aim is to alleviate these symptoms which make the population suffer, singling out the most complicated cases, carrying out actions to inform and psycho-educate. Here in El Salvador, we work in different areas. For those suffering from acute disorders like shock, psychosis etc., we provide direct care through psychological and psychiatric consultations. The large group suffering from evident, normal signs still need attention. After all in time they may develop PTSD or psychosocial problems. This group we try to inform and reassure through psycho-education (What is happening to you? What can you do?). For those who are really upset it is very useful to share their experiences, to get it off their chest. In this situation, it is important to coordinate our activities with the authorities, community leaders and other (local) NGO's. We encourage them to create their own community services and mental health referral network. The advocacy for attention to mental health also in these circumstances is very important because MSF will not replace the Ministry of Health. We will not take over but aim at the reinforcement of existing (self) help mechanisms. In El Salvador there are a number of good psychologists they can take over.

Which therapies do you apply?

Casas - It is important to realize that therapies are for those who are sick. In that sense we give drug therapy and acute psychological treatment. We help the people to structure what has happened, we give them psycho-education, prepare them on what may happen the next days and organize support from their social network (family, neighbours)

. But as I have said before, the majority of people are upset, sometimes feel terrible but are not suffering from a disorder. The reaction they have is normal. In a strict theoretical sense, these people do not need therapy but they do need support because they are at risk.

Therefore we inform them on what an earthquake is, we let them express their grief, vent their emotions and we give them practical information. When the people want to reconstruct their experiences in detail, we can help them. But we do not force them to relive the experience and we do not dig into their emotions. It is important that the survivor is in charge of their own healing process. We also carry out community and psychosocial activities aiming to support self-help mechanisms.

Community leaders are trained and we encourage families to support each other and to support those who are alone. In a later stage, the media can also be helpful in raising of awareness. I think it is important that MSF does not only address the material needs and physical suffering. The emotional pain, the psychological distress and the shattered basics beliefs of our beneficiaries also need attention. -

In the Cafetalon, the camp which shelters 10,000 displaced people, together with NGOs, some sects believe the earthquake to be a punishment by God. How does the mental health team deal with this situation?

Casas - When a psychological space is lost, the individual becomes very vulnerable. Sects take advantage of this vulnerability to gain adepts and riches. If the patient believes the disaster to be a punishment by God because of his or her religion, this must be respected. But if the patient is under the influence of these groups, something must be done about it. -

Can the volunteers working in this kind of disasters also be affected?

Casas - They may suffer the so-called 'exhaustion syndrome'. This is why they should not work more than six days in a row. If they do not rest, and only devote all their time and energy to their relief work, they may start suffering from irritability and automatic behaviours.