Recovery
Most people will recover from traumatic events like emergencies and disasters without professional intervention. However, some are likely to need additional support to help them cope. A small minority of people (10-20%) are at risk of developing significant mental health conditions and will require specialised mental health care. Decisions regarding the level and timing of this care require careful clinical judgment, with the recognition that formal intervention may not be appropriate until sometime after the event. In the interim, appropriate support and advice, along with careful monitoring, is usually indicated.
It is important to consider the different levels of psychosocial support that can be offered to people affected by disasters, depending on their different needs.
It is vital that psychosocial support is coordinated and integrated with other recovery efforts. It is also important to recognise the impact that disasters can have on the social cohesion of communities. It is not unusual to see strong rifts occurring within previously close-knit communities, as powerful emotions (notably anger) generated by the disaster are directed at friends and neighbours. Health providers need to understand these systemic issues and support the community in helping itself through the recovery process.
Population level support for common distress responses
Following a disaster, many people may experience concerns about various outcomes. These people are not experiencing mental health problems, but may be worried about practical issues, or require simple guidance on topics like talking with children about the disaster, or supporting friends and family members who have been affected by the disaster. Others may have quite significant distress which will respond to support, reassurance and problem solving.
Effective means of providing this care exist as part of most state and territory responses, such as the provision of psychological first aid (PFA), the Red Cross personal support program and the Victorian Bushfire Case Management Service (VBCMS).
Common responses after disasters
People who are involved in an emergency or disaster can have a range of emotional, cognitive (thinking), physical (health) and behavioural reactions to the events.
- Emotional reactions may include shock, distress, grief, anger, anxiety and depression
- Cognitive reactions may include unpleasant memories, poor concentration and difficulty making decisions
- Physical reactions may include feeling tense and on edge, as well sleep disturbance, stomach upsets, and general aches and pains
- Behavioural reactions may include irritability, loss of interest in activities, and wanting to be alone.
For most people, these reactions are relatively mild and reduce over the initial days and weeks with the support of family and friends.
Self-help resources
There are several things that people can do to look after themselves and promote recovery from a traumatic event or situation. People can watch how they are responding and increase the coping strategies that have worked for them in other stressful situations. There are many self-help resources available online.
Community recovery
Disasters have a community-wide significance and, depending on the extent of the disaster, the whole community may go through a protracted process of recovery.
A key task in recovery is to re-establish a social infrastructure within which assistance can be provided. Often this will take the form of dispelling myths and rumours, and encouraging effective communication (for example, through newsletters, local media, public meetings etc.). It will also take the form of encouraging activities that will bring the community together in a positive and collaborative way (for example, sporting events, BBQs, markets and fetes). These activities will help to stop the community splitting as a result of their individual disaster experiences.
Support groups
For some people, groups are good places to get some support with dealing with the psychosocial impact of a disaster. Following disasters, groups are often established around specific issues like bereavement, or for particular target groups such as youths or men. These peer support groups bring together people in similar situations and are a way of people being able to share knowledge, experience, and/or emotional, social or practical help with each other.
Helping children who have been affected by disasters
After a traumatic event, children need comfort, reassurance and support. Children are not always able to express complex feelings in the same direct way that adults do and therefore often do not show the same reactions to stress as adults. It is important to look out for changes in children's behaviour that suggest they are unsettled or distressed.
Peer support in disaster recovery
After a disaster, many organizations who work in emergency response will use peer support programs to support staff during periods of high stress. These programs are becoming increasingly popular.
Moderate distress
A significant proportion of people will experience worry, distress, sadness, insomnia, anger or other psychological well-being issues after a disaster. This level of distress will be more common than formal diagnosable mental disorders. This level of need can be addressed by providing basic strategies aimed at assisting people to manage the common reactions following disaster.
Supportive counselling can be useful for people who are dealing with distressing symptoms, or problems like relationship difficulties, family functioning, coping strategies, grief and loss. People are more likely to access formal services when they are linked to informal, flexible, community-based, outreach-oriented initiatives and activities.
Counselling is available through a variety of public and private organisations and practitioners.
Skills for Psychological Recovery
An evidence-informed model called Skills for Psychological Recovery (SPR) has been developed to facilitate the recovery of people affected by recent disasters. Rather than a formal mental health treatment, SPR is an intermediate, secondary prevention model designed to teach people basic skills. For many people it will be enough. If SPR doesn't help to alleviate distress as effectively as is needed, it is appropriate to refer for more intensive mental health intervention. Additionally, if serious issues are revealed in the initial assessment, immediate referral is required.
Core components of SPR
- Gathering information and prioritising assistance
Identify clients' most pressing needs and concerns, and instances when referral is necessary. - Building problem-solving skills
Teach clients to break down problems into more manageable chunks, consider a range of ways of responding and choose the best actions to take. - Promoting positive activities
Encourage people to plan and participate in positive, meaningful activities to help improve mood and regain a sense of control and normalcy. - Managing reactions
Teach calming skills, ways to put thoughts and feelings into words, and techniques to manage reactions to triggers or reminders of the disaster. - Promoting helpful thinking
Help people understand how thoughts influence their emotions, and how to replace their unhelpful thoughts with more helpful thoughts. - Rebuilding healthy social connections
Help people identify supportive individuals and groups in their network, then create a social support plan to access and/or offer support.
Mental health and primary care resources
These guidelines were designed to assist general practitioners and health professionals working in primary care after the disaster of the 2009 Victorian bushfires. They are relevant to other natural disasters where people are exposed to life-threatening stressors and losses.
These guidelines were produced by the National Mental Health Disaster Response Committee and Taskforce, Disaster Medicine, University of Western Sydney, and the Australian Child and Adolescent Trauma, Loss and Grief Network.
Community health services
Intake services offer counselling plus a range of allied health services. Community health services are aware of the local services available and the role each local government and non-government organisation plays, making it an ideal first point of contact for counselling. Intake officers are trained in assessing the need to refer on to specialist mental health services where appropriate.
Crisis help lines
Parentline: 13 22 89
www.parentline.com.au
Griefline: 03 9935 7400 (noon to 3am)
http://griefline.org.au
Lifeline: 13 11 14
www.lifeline.org.au
SuicideLine: 1300 651 251 (Victoria only)
www.suicideline.org.au
Mensline: 1300 789978
www.menslineaus.org.au
Rural Support Line: 1300 655 969
beyondblue: 1300 22 4636
www.beyondblue.org.au
Kids Help Line: 1800 551 800
www.kidshelp.com.au
Crisis Assessment and Treatment (CAT): Contact details of CAT teams providing intensive treatment of mental illness are accessible by phoning the nearest local hospital.
Grief and loss counselling
For a variety of reasons, some grieving people may feel the need to seek professional help in the form of counselling. People who are grieving may need to talk about their story over and over again and may not want to rely just on family and friends to provide the support. Counselling can provide a supportive, safe and accepting environment that can help a person to grieve and receive support.
Stepped care for children who have been affected by disasters
For the majority of children, distress and social and emotional reactions will start to reduce. For some, however, general distress, fears and anxiety, grief, feelings of loss of control and increased uncertainty, and heightened emotional arousal can persist. Whilst these distressing reactions may not be clinically significant problems like PTSD or depression, these children may benefit from additional support to manage and reduce this distress. Stepped care is an approach of providing different forms of assistance that are sequenced and start at more basic community, school and large group-focused levels, and move progressively to those that are more intensive and family and individually focused.
Post-disaster school resources
Teachers are in a unique position to identify children who are experiencing difficulties following a natural disaster because of their role, expertise, and extended contact with children. Teachers need to be able to identify emotional and behavioural difficulties in their students following a traumatic event, as well as be well informed about what they can do to prevent the likelihood of children developing long-term adverse reactions.
Find a general practitioner
General practitioners are a common starting place for people seeking consultation with a counsellor or allied health professional. GPs have information about local allied health professionals.
Significant mental health problems
A significant minority of survivors will develop a diagnosable mental disorder, most commonly posttraumatic stress disorder, depression, complicated grief, anxiety or substance abuse. Proper clinical assessment is required before treatment.
Major mental health problems that can develop following trauma
The most common mental health problems that can emerge after a traumatic experience are:
- posttraumatic stress disorder (PTSD)
- major depression
- complicated grief
- panic disorder
- anxiety disorders
- substance use disorders
- psychosomatic complaints.
Other problems include the exacerbation of pre-existing mental health problems and increased vulnerability to the development of other mental health problems.
Referral to specialist mental health professional
Specialist help from a psychologist, psychiatrist or other mental health professional may be needed if a person experiences significant distress that does not settle, if the symptoms interfere with his/her ability to relate to loved ones, or if the symptoms interfere with his/her ability to carry out his/her normal role. Specific things to look for are if someone:
- still feels upset or fearful most of the time
- exhibits changed behaviour compared to before the trauma
- has difficulty with normal activities
- has worsening relationship issues
- displays substance overuse
- feels jumpy or has disturbed sleep
- keeps dwelling on the event
- seems unable to enjoy life and appears numb or withdrawn.
Public mental health services
Every state and territory has public mental health services for children, adolescents, adults and older people. Services are provided through community mental health units, hospitals and community health centres.
Useful interventions for mental health problems after disaster
The treatment approaches for common disorders should be based on the available scientific evidence, as well as the individual practitioner's experience in managing these conditions following disaster and trauma. Interventions typically include psychoeducation, arousal management and distress tolerance, exposure therapy, cognitive therapy, and scheduling activities. Evidence-based clinical practice guidelines are available for most of the common disorders.
Psychological trauma in children and youth
Although resilience is the norm, and most children and adolescents do not experience mental health problems in response to a traumatic event, a significant minority will develop a diagnosable mental disorder. The most common disorders are PTSD and other anxiety disorders, depression, and complicated grief. These disorders may have chronic courses if untreated and increase risk for the development of other psychiatric disorders. Fortunately, there is a reasonable evidence base for treating these disorders in children and adolescents (although much more research is needed).
