Spotlight: Mental Health, Trauma Counseling, and Physical Therapy Needs

Tues, Feb 9 -

Many news outlets yesterday carried an Associated Press story by Frank Bajak about the growing and urgent need for bereavement and trauma counseling and broad mental health services for the tens of thousands of Haitians who survived the earthquake and their families. This is especially true for those who are surviving amputations, for whom physical therapy is also an essential service.

In Haiti last week, I met with doctors at several hospitals to find out if mental health teams had been recruited there to assist with TRAINING in bereavement and trauma counseling, etc. Most had no specialists in mental health or trauma specialists, and urgently sought these professionals to join their emergency teams. They also agreed that TRAINING Haitians is a critical next step to address what will be a huge need for post-traumatic care and counseling in the years to come for the quake survivors and the country.

As the AP article noted, PAHO's Dr. Jorge Castillo, and a consultant Irish psychiatrist are hoping to establish some organized system for providing mental health services, integrating outside professionals,and most importantly, training in trauma support, and education for communities in the area of coping with trauma and psychologically recovering from disaster.

The same need for Training holds for physical therapy - it's urgently needed on the emergency and longer-term TO GET list for Haiti.

I do know many medical groups who have expressed an interest in sending field-experienced psych support professionals and teams, so let's hope that the PAHO-Irish duo can quickly provide a contact coordinator for these needed volunteers, as Intl Red Cross tried to do for other specialty medic teams.

Meantime, my own advice for Haitian nurses, pastors and others that I met or visited were caring for many patients and post-op case last week was to help them start PEER DISCUSSION and SUPPORT GROUPS - ideally led by one person with an ability to begin facilitating discussion. This is not in lieu of having trained trauma counselors, but because it was clear people were needing to talk and share, and they need to have a channel to do this - some forum.

I was pleased to see that in two centers I visited days later, this was getting started, and the early reports were, not surprisingly,that survivors were happy for the groups, and they deeply need to share about what has happened. This suggestion has been shared with medical groups like Partners in Health, GHESKIO, etc... though people are so overwhelmed, it's hard for them to add new mental health services without additional staff or lay volunteers to do this, and this requires some coordinator to take it up for these front-line agencies or medical teams....

Learning from Rwanda...and Francophone Africa....

From my past years of field work in Rwanda (2004-ongoing) with genocidal rape survivors, our group found that SURVIVORS are often those who are poised to become trauma counselors or volunteer to lead support groups - they can draw from their own experiences. There, as is true in many countries, there are too few trained trauma counselors who have been through the 2- or 3-year course work given the enormous needs of a population that experienced genocide. Instead, Rwanda has focused on trying to provide some level of skill- a step above 'l'ecoute - just listening - that is what is usually done by nurses or social workers. There are a variety of shorter-course trauma counseling workshops and trauma materials developed for the Francophone African context.

Note: I'll begin posting these here in the coming days.

The program I co-founded in Kigali, WE-ACTx (the Women's Equity in Access to Care and Treatment, www.we-actx.org) benefited from a holistic care approach that included short-course TRAUMA and MENTAL HEALTH training designed for use in no to low-resource settings and aimed at training local women /men, social workers, community 'animateurs' or advocates - many recruited from the clinic patients of our program. These individuals in turn trained others in a Training of Trainers (TOT) model, and led group discussions and one-on-one trauma counseling in their organizations, communities, etc.

WE-ACTx has had trained psychiatrists , including Mary Fabri, a trauma specialist with the Marjorie Kovler Center for Survivors of Torture in Chicago and others who worked closely with Rwanda's few psychiatrists and community partners there to translate and adapt tools and materials initially developed for use in high-resource settings and 'Western' contexts. These materials have now been field tested and are proving very useful in Rwanda, and have since been adapted for use in other countries, including the Democratic Republic of Congo, where years of civil war and sexual violence have left millions needing trauma services too.

I believe this will hold true in Haiti, and that community education and training materials developed by and for use in low-resource Rwanda and elsewhere could immediately benefit Haiti.


Hesperian Foundation Education Materials

Note that HESPERIAN foundation materials also continue to be excellent, field-tested tools for community and village-level education and training. Their popular books, such as Where There is No Doctor, are now available in Kreyol (Creole) and have some information that touches upon mental health, so check them out. They offer FREE downloads of the Kreyol book as a PDF.

Here's the When There is No Doctor link:http://www.hesperian.info/assets/Where_There_is_no_Doctor_Creole.pdf

And the For Women When There Is No Doctor: http://www.hesperian.info/assets/hesperian_wwhnd_haitian%20creole_2000.pdf

Note that pages 412-422 broadly address Mental Health issues for women - and some of this is useful though it is not specifically a trauma protocol or training guide.

See also a few Hesperian links to community-level education materials in English for helping children who have survived trauma, and amputees. Their Disabled Village Children book has excellent information on helping children, but also how to create or produce crutches and other equipment needed by disabled children (and adults) due to amputation. Good reading for anyone wondering how to help Haitians now, while waiting for professionals and prosthetics and other equipment that may arrive later.

From their Disabled Village Children handbook, chapters included:

Amputation chapter: http://www.hesperian.info/assets/DVC/DVC_Ch27.pdf

Using Crutches chapter: http://www.hesperian.info/assets/DVC/DVC_Ch43.pdf

Working with the community:

http://www.hesperian.info/assets/DVC/DVC_Ch44.pdf

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BASICS OF POST-TRAUMATIC STRESS DISORDER - HOW TO IDENTITY AND TIPS TO COPE (From American Psychiatric Association website):

Posttraumatic Stress Disorder


Posttraumatic stress disorder (PTSD) is a psychiatric disorder that can occur in people who have experienced or witnessed life-threatening events such as natural disasters, serious accidents, terrorist incidents, war, or violent personal assaults like rape. People who suffer from PTSD often relive the experience through flashbacks or nightmares, have difficulty sleeping, and feel detached or estranged.

PTSD has often been misunderstood or misdiagnosed, even though the disorder has very specific symptoms. Although it was once thought to be mostly a disorder of war veterans who had been involved in heavy combat, researchers now know that PTSD also affects both female and male civilians, and that it strikes more females than males. In some cases the symptoms of PTSD disappear with time, whereas in others they persist for many years.

PTSD often occurs with—or may contribute to—other related disorders, such as depression, substance abuse, problems with memory, and other problems of physical and mental health. Everyone who experiences trauma does not require treatment; some recover with the help of family, friends, or clergy. But many do need professional treatment to recover from the psychological damage that can result from experiencing, witnessing, or participating in an overwhelmingly traumatic event.

PTSD usually appears within three months of the trauma, but sometimes the disorder appears later. Symptoms for PTSD fall into three categories:

Intrusion
In people with PTSD, memories of the trauma reoccur unexpectedly, and episodes called "flashbacks" intrude into their current lives. This happens when sudden, vivid memories, accompanied by painful emotions, take over the person’s attention. Flashbacks may be so strong that individuals feel like they are actually re-living the traumatic experience or seeing it unfold before their eyes and in nightmares.

Avoidance
Avoidance symptoms affect relationships with others: The person often avoids close emotional ties with family, colleagues, and friends. At first, the person may feel numb, have diminished emotions, and may only complete routine, mechanical activities. Later, when re-living the traumatic event, the individual may alternate between a flood of emotions caused by the flashback and an inability to feel or express emotions at all. A person with PTSD avoids situations or activities that are reminders of the original traumatic event.

The inability of a person with PTSD to work out grief, anger or fear from the traumatic event means the trauma can continue to affect the person’s behavior without them being aware of it. Depression is a common product of this inability to resolve painful feelings. Some people also feel guilty because they survived a disaster if others—particularly friends or family—did not.

Hyperarousal
PTSD can cause individuals to act as if they are constantly threatened by the trauma that caused their illness. They can become suddenly irritable or explosive, even when unprovoked. They may have trouble concentrating or remembering current information, and, because of terrifying nightmares, may develop insomnia. This constant feeling that danger is near causes exaggerated startle reactions.

Finally, many people with PTSD also attempt to rid themselves of painful flashbacks, loneliness, and anxiety by abusing alcohol or other drugs to "self-medicate" or help them to dull or forget the pain and trauma temporarily. A person with PTSD may show poor control over his or her impulses and may be at risk for suicide.

Treatment

Today, psychiatrists and other mental health professionals have good success in treating the very real and painful effects of PTSD. They use a variety of treatment methods to help people with PTSD to work through their trauma and pain.

Cognitive Behavior Therapy focuses on correcting the painful and intrusive patterns of behavior and thought by teaching people with PTSD relaxation techniques and examining (and challenging) the mental processes that are causing the problem.

Exposure therapy uses careful, repeated, detailed imagining of the trauma (exposure) or progressive exposures to symptom “triggers” in a safe, controlled context to help the survivor face and gain control of the fear and distress that was overwhelming during the trauma. In some cases, trauma memories can be confronted all at once (flooding). For others, it is preferable to work up to the most severe trauma gradually or by taking the trauma one piece at a time (desensitization).

Psychodynamic psychotherapy focuses on helping the individual examine personal values and how behavior and experience during the traumatic event affected them.

Family therapy may also be recommended because the behavior of spouse and children may result from and affect the individual with PTSD.

Discussion groups or peer-counseling groups encourage survivors of similar traumatic events to share their experiences and reactions to them. Group members help one another realize that many people would have done the same thing and felt the same emotions.

Medication can help to control the symptoms of PTSD. The symptom relief that medication provides allows many patients to participate more effectively in psychotherapy when their condition may otherwise prohibit it. Antidepressant medications may be particularly helpful in treating the core symptoms of PTSD either alone or in combination with psychotherapy.


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AP ARTICLE:

Healing Haiti's battered psyche
Survivors have not had a chance to grieve - and their relatives have been buried in mass graves
Feb 8, 2010 10:48 PM | By AP

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The battered bodies may be mending, but the minds still struggle.

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As many as one in five Haiti earthquake victims have suffered trauma so great that they won't be able to cope without professional help, doctors say.

In a country where mental health services barely existed before the quake, building the required support is a huge challenge. The symptoms can't be diagnosed by stethoscopes, blood tests and X-rays, and can take time to surface after the initial shock of the disaster.

"It's not about immediate psychological counselling,'' said Dr Lynne Jones, a senior medical adviser for the International Medical Corps. "It's about assisting mourning. People cannot recover if their social needs are not met.''

Jones, a veteran of natural disasters and wars, is teaching front-line doctors how to identify "disabling fear" and, quite literally, hold people's hands and listen.

Port-au-Prince's only psychiatric hospital is barely functioning. All but 11 of its more than 100 pre-quake patients were removed by relatives who feared the building would collapse in another quake, said Dr Peter Hughes, an Irish psychiatrist who arrived late last week and is studying what to do.

"There's no electricity and no running water. Some patients are in a barred room. There is a need for mattresses and toilets.''

It is not known how many mental health workers are available to help in Haiti. Pan American Health Organisation officials who are co-ordinating medical care among more than 200 aid groups have only just begun to create a database of hospitals, patients, doctors and medical resources.

Haiti will have to train more of its own personnel to work on the front lines with people suffering from psychological trauma.

"The most urgent need is for psychiatrists," said Pierre Bru-nache Jnr, an official with the Citizens Network for Foreign Affairs.

Dr Jorge Castilla, lead co-ordinator of the aid groups in Haiti, put out an urgent request on Sunday for mental health professionals.

"They have to be able to adapt to the culture and language," he said.

One of the most traumatic experiences for tens of thousands of Haitians is knowing that their relatives have been buried in mass graves, deprived of funerals while their survivors are denied the chance to grieve. Walk into any one of the five public hospitals and 14-odd field hospitals in Port-au-Prince and you see the psychological scars of survivors who have not been able to bury their dead.

Many sit quietly in corners, staring blankly into space. Others wait in line for tranquilisers.

Palpitatations - rapid, fluttering or pounding heartbeats - are rampant among them, doctors say.

At Port-au-Prince's general hospital, Louna Jean-Baptiste waits in line to be seen.

"My heart is racing all the time," said the 34-year-old mother of four. "Sometimes I feel like my heart is in my throat. Other times I can't breathe and feel like I'm going to die.''