Before the Tsunami devastated many of the countries that the Aid corporations are now clamoring to get into, corporations had kept them poor. So poor that one could ask which was the cause of the trauma spoken about in the following article. Eye movement therapy is not going to be of much use to them, I think. Nor are hugs and teddy bears from abroad. -- Sheila Steele
As the colossal scale of the Indian Ocean disaster unfolds, the emotional impact on the survivors and those who have lost relatives and how they can best be supported are becoming critical issues.
Fifty-one Britons are confirmed dead, and a further 352 are highly likely to have been killed, according to the Foreign Office. A further 582 are believed to have been in the immediate area and remain unaccounted for.
In an attempt to make sure that the survivors, the bereaved and those desperate for news about a missing relative receive early emotional and psychological support, the Department of Health plans to write to all GPs within the next seven days. The letter is expected to give detailed, practical advice on how to make sure that those who have been caught up in the tsunami disaster receive the most appropriate support.
The advice will include referral options for vulnerable patients needing bereavement or psychological counselling as well as early warning signs of acute stress reactions, and psychological techniques that can help.
Many survivors will relive the horror in their minds. Feelings of guilt that they have survived may be overwhelming. How was it, they may ask, that they were able to cling on to a palm tree or find a place of safety, only to see a child or friend swept to their death?
Many of the bereaved also face the emotional anxiety of not knowing when, or if, they will be able to bury their dead. Although DNA science is now extraordinarily sophisticated - thanks, partly, to advances made as a result of attempts to identify fragments of body tissue in the aftermath of September 11 - it could take months, if not years, to identify everyone. "To have your loved one missing, probably dead, is an incredible emotional challenge when added to dealing with your grief," says Pamela Dix, co-founder and vice-chairman of Disaster Action, a charity which campaigns for changes to disaster response. Her brother died in the Lockerbie explosion. "Emotional and psychological issues are pushed to one side as the practical issues are addressed, but they will soon emerge as very important."
They may also be experienced by friends and relatives undertaking the search of mortuaries and examination of photographs of those feared dead. Research following Lockerbie, Dunblane, Hillsborough and September 11 shows that, when given prompt social and psychological help, people are far less likely to develop chronic depression, long-term anxiety attacks or post traumatic stress disorder.
"A study, 30 years on, shows, sadly, that 30 per cent of the children who survived the Aberfan disaster still had serious stress reactions," says William Yule, professor of child psychology and an expert in childhood trauma at the Institute of Psychiatry in London. He has been advising the Department of Health on the letter to be sent to GPs. "The idea that children are so resilient that we do not need to bother is nonsense. The sooner we get services running to give both adults and children a sense of normality and safety, the better.
"During the first year, it is going to be sheer hell for many who have lost loved ones. You cannot speed up the bereavement process. We recommend people to see their GPs, and the GPs to keep a close eye on how patients are faring for at least four weeks. With many people, grief reactions may be exacerbated by their reaction to the trauma of a disaster.
"We know that in response to trauma of any kind, acute stress symptoms decline over six to eight weeks, but there is usually a substantial minority of people who need further help. Referral to a bereavement agency, such as Cruse Bereavement Care, might help. We will also draw the attention of GPs to two techniques - trauma-focused cognitive behavioural therapy and eye movement desensitisation therapy (see below). We now accept that these make a big difference for some people."
Prof Yule is a member of a National Institute for Clinical Excellence committee which has drawn up guidelines, to be announced in full in April, on how the NHS should treat patients after a trauma, such as the murder of a loved one, a traffic accident or a disaster. By writing to GPs now, the Department of Health is, in effect, bringing forward the guidelines.
"We must ensure that those who work with patients recognise disaster stress reactions as early as possible," says Yule.
The social, practical and emotional support for returning Britons, orchestrated by the Foreign Office, is designed to swing into action as soon as passengers leave the plane.
The ambulance service offers help at airports and, where necessary, takes people to hospital. Inside special reception centres at Heathrow, Gatwick and other major airports, police family liaison officers meet returning passengers. They are co-ordinated by the Metropolitan Police and are the key contacts for those seeking missing family or friends. They liaise with forensic teams in Thailand and elsewhere, advise on DNA sampling and stay in touch with families once they return home. There are about 260 officers deployed in this role, a number expected to rise during the coming weeks. "We do not provide emotional or psychological advice, but we can suggest who to contact," says the Met.
British Red Cross and Cruse volunteers are available at airports and, where possible, spiritual support is offered by a multi-faith chaplain. Even a locksmith was on hand at Manchester airport to help those who had lost their keys.
The Red Cross, funded by the FCO, runs the national Tsunami Support Line 12 hours a day. "Callers raise every possible question. For many, we are the first port of call to find out who survivors and relatives can contact," says Martin Annis, who heads the support line, which was first used after September 11. "Most call about tracing a missing friend or relative, and many ask about how they can speed up the process in Thailand or elsewhere. People do not want to leave anything to chance. One person called four times to ask the same question. However, although people may be distressed, they are mostly in control. We can transfer the caller to a Cruse volunteer if they want to talk about bereavement."
While counselling might help some, disaster advisers are keen not to "pathologise" the response to disaster, says Dr. Stuart Turner, a leading trauma specialist and director of the independent Trauma Clinic in London. "Most people recover well. Reactions to grief and trauma are often strong and unpleasant, but they are normal. How well people recover can be influenced by the degree of trauma, the presence of other stresses (including an existing mental disorder), and by the quality of the support given by family and friends."
Pamela Dix, whose charity fights for a more cohesive and sympathetic approach to the emotional aspects of disaster, welcomes the Department of Health's letter to GPs. "The involvement of police liaison officers has, we know, transformed the experience of victims of trauma by providing a point of contact. Early help from GPs and community health workers could mean a lot less counselling will be required later on. It may be that all the survivors need is a professional listening ear. Relatives and friends can only do so much."
For details of UK specialist trauma services, see: www.disasteraction.org.uk
Confronting trauma can ease pressure
Learning how to think differently
The memories of traumatised people are often as vivid in their minds as if they are stuck in time. The more they try to avoid the images, the more they relive the disaster. Trauma-focused cognitive behavioural treatment is a technique that aims to help people relabel what has happened and put it firmly in the past.
"You do this with their imagination," says Prof Yule. "You talk to them and, say, get them to insert into their narrative that the tsunami happened on Boxing Day, but it is not happening now. It is like date-stamping a visual memory. Once that has happened, the image is processed in a different part of the brain, where it is verbally rather than visually stored. In follow-up sessions, the memory begins to fade."
Prof Yule thinks some victims of disaster may complete this process unconsciously by confronting the memory themselves. "As they do this and realise they are not being hurt, they learn to cope with it."
Eye movement therapy
An individual is asked to create and hold in their mind a picture of the worst moment during the disaster, while following the movement of their clinical psychologist's fingers with their eyes. The psychologist instructs the patients to "let the image go freely where it wants to". Astonishingly, says Prof Yule, during up to 20 sessions, the feelings of distress gradual fade.
"We don't understand how it works. Patients do not go into a trance. Initially, there was scepticism that it was some off-the-wall technique, but studies show it works almost as well as the more structured cognitive behavioural technique. We cannot get psychologists trained quickly enough."
It can also be effective for children, though there is less research to back this up.
Leaving the door open
When patients who have witnessed a horrific disaster tell Prof Yule that they have good emotional and social support from family and friends and do not need extra help, he always agrees.
"But I leave the door open," he says. "I always ask them to come back in six months. If they are not doing so well, as happened with one young man recently, I decide how to help them. If they are doing well, I ask how they did it, because I want to let others know."
After September 11, many family members felt that a formal association gave them a sense of a community with people who understood what they had gone through. Memorials and occasional meetings provide a focus for sharing emotions. Disaster Action can help anyone who wishes to be involved in a cohesive group for survivors of the tsunami disaster and the bereaved (see: www.disasteraction.org.uk). Establishing an association is likely to be handled initially by Tessa Jowell's Department of Culture, Sport and Media, which will also arrange a national memorial service later in the year.
It is commonly assumed in this therapy-oriented world that nearly every grieving person can benefit from bereavement counseling or therapy. But both the experience of psychologists who provide bereavement services and a thorough review of the literature on the results of grief therapy suggest otherwise.
Rather, the findings suggest, a majority of people who suffer the loss of a loved one neither need nor benefit from participation in a bereavement group or from more formal grief therapy. These people experience what might be called a normal grief reaction, and the symptoms of it gradually diminish over 6 to 18 months.
"Feeling grief is the burden we face because we're capable of becoming attached and loving people," said Dr. Robert Hansson, a psychologist and student of grief at the University of Tulsa. "It's a natural process. It hurts, but most people can work through it and go on."
A major new "Report on Bereavement and Grief Research" prepared by the Center for the Advancement of Health concluded, "A growing body of evidence indicates that interventions with adults who are not experiencing complicated grief cannot be regarded as beneficial in terms of diminishing grief-related symptoms."
The report adds that there is very little evidence for the effectiveness of interventions like crisis teams that visit family members within hours of a loss, self-help groups that seek to foster friendships, efforts to show the bereaved ways to work through grief and a host of other therapeutic approaches believed to help the bereaved.
In fact, the studies indicate, grief counseling may sometimes make matters worse for those who lost people they loved, regardless of whether the death was traumatic or occurred after a long illness, according to Dr. John Jordan, director of the Family Loss Project in the Boston area. Such people may include the only man in a group of women, a young person in a group of older people, or someone recently bereaved in a group that includes a person still suffering intensely a year or more after the loved one's death.
Further, the research suggests, bereavement counseling is least needed in the immediate aftermath of a loss. Yet it is then that most grieving people are invited to take part in the offered services. A more appropriate time is 6 to 18 months later, if the person is still suffering intensely.
Even when bereavement therapy is needed, however, the benefit may depend on the approach used.
For example, most bereavement groups focus on emotional issues. These are most helpful to women.
But men tend to grieve differently, and they are more likely to benefit from an approach that focuses on their processes of thinking.
Caring friends and relatives often coax those who have just suffered the loss of a loved one to seek professional help, either by taking part in a bereavement group or through individual psychotherapy. But Dr. Robert A. Neimeyer, professor of psychology at the University of Memphis, editor of the scientific journal Death Studies and chairman of the committee that prepared the new report, said in an interview: "Not everyone requires the same thing. Dealing with grief is not a 'one size fits all' proposition."
Dr. George Bonanno, psychologist at Columbia's Teachers College, has found that the bereaved who naturally avoid emotions should not be forced to confront grief. Even three years later, such people show no traumatic consequences as a result of suppressing it, he reported.
In more than half the cases, Dr. Neimeyer explained, far more useful than therapy to the bereaved are the empathy and emotional and physical support that friends, relatives and caring people in the neighborhood and at work can provide in the first weeks and months after a death.
Only when grieving is "complicated" -- intense and protracted, associated with deep unrelieved depression and interfering with normal enjoyments, life tasks or an ability to work -- is there a clear-cut need for grief therapy, Dr. Neimeyer said.
Dr. Hansson of Tulsa observes that many people who experience complicated grief have neither faced their losses nor allowed themselves to work through the emotions that naturally ensue.
If, months down the road, a bereaved person is still grieving intensely, therapy should be sought, Dr. Neimeyer said. Among the hallmarks of complicated grief he listed are "intrusive thoughts about the deceased, recurrent images of how the person died, a continual quest to reconnect with the deceased, corrosive loneliness, feeling purposeless and empty, difficulty believing the death ever happened and feeling that the world cannot be trusted.
Treating people with these symptoms is important because their unresolved grief can have serious, even life-threatening health consequences, including high blood pressure, stroke, heart attack, substance abuse and suicide. "Such people can literally die of a broken heart," Dr. Neimeyer said.
Perhaps the most revealing study of the varying courses of bereavement was undertaken by Dr. Bonanno, Dr. Camille B. Wortman, a psychologist at the State University of New York at Stony Brook, and six co-authors.
They evaluated 1,532 people (all married, with at least one partner of each couple over age 65), then followed them for up to eight years. When a spouse died, they assessed the bereavement experiences of the widow or widower over time. This is what they found:
*Forty-six percent of the survivors were "resilient." They experienced transitory distress, but scored low in depression both before the death and at 6 and 18 months after losing their spouses.
*Eleven percent followed a common grief course, with rather severe depression at 6 months that had largely disappeared by 18 months.
*Sixteen percent, who were not initially depressed, nonetheless were devastated afterward, experiencing prolonged depression.
*Eight percent were chronically depressed beforehand, with the depression worsened by the death.
*But 10 percent who had been depressed before the death did very well afterward, perhaps because they had been in bad marriages or were relieved from the burdens of taking care of ill spouses.
*The remaining 9 percent did not fit into any category.
No Single Pathway
"Clearly," Dr. Neimeyer said, "the five stages of grief -- denial, anger, bargaining, depression and acceptance -- don't necessarily fit. There is no one pathway through grief. Depending on their grief reaction, people may require very different therapy or no therapy at all."
Also new are professional beliefs about the goals of resolving one's grief, which traditionally focused on forgetting the loss and moving on.
"We are less wedded to seeking closure, to the idea of saying goodbye to the one who died," Dr. Neimeyer said. "We now recognize the importance of finding healthy ways to sustain a relationship with a deceased loved one, to maintain continuing healthy bonds, for example, by carrying forth their projects.
"Closure is for bank accounts, not for love accounts. Love is potentially boundless. The fact that we love one person doesn't mean we have to withdraw love from another."
When one young man was killed and another severely wounded by a shooter in the hallway of a small Alberta high school last week, an army of grief counsellors was dispatched to the scene.
But the presence of such counsellors in the aftermath of tragedy may be unnecessary, and possibly even harmful.
"We have studied what people do when they're grieving," Dr. George Bonanno, a research psychologist at Catholic University in Washington, D.C., said yesterday.
"And we find that the more that people express their pain, the more they talk about it, the more they focus their attention on it . . . the worse the outcome."
The counsellors who descended on the W.R. Myers High School in Taber, Alta., were brought in from other schools in the area and had been trained to help students deal with a variety of sad occurrences, from fatal motor vehicle accidents to suicides.
Upon their arrival, they began the process of "critical-incident-stress debriefing" as prescribed in the manual governing such events.
Students were not permitted to leave the school before the grief experts had given a preliminary round of therapy.
Those who thought they needed additional help were urged to seek it on an individual basis, and some were phoned later at home to ensure they were coping adequately.
News reports said 200 students availed themselves of the service.
A similar process would have been followed anywhere else in the country, said Dr. Paul Hasselback, the medical officer of health for the Chinook Health Region.
Intervention "is well known to prevent unusual behavioural reactions such as has been occurring in other jurisdictions . . . as a result of the collection of events which have occurred," he said.
The "collection" includes the Taber shooting as well as the massacre of 13 people in a high school in Littleton, Colo., which occurred the week before.
Dr. Hasselback said young people in Calgary and parts of Manitoba have reacted to the violence in frightening ways -- with weapons and bomb threats.
"We know that sort of thing is likely to happen after an event of this nature and that's part of what the counselling process is all about," he said.
"We also know that individuals faced with a severe, violent, traumatic death of someone nearby, particularly if they (observed the violence) or if it was somebody that they knew closely, have a much greater difficult time grieving and coping with the reality of those events."
But Dr. Bonanno said there is no evidence to support the belief that grief counselling is helpful. Nor is there evidence that supressed grief will surface at a later time, he said.
"This whole thing of going in and treating everybody after a particular event … if people are going to be doing that, there should be some evidence that it's effective.
"In the absence of evidence, I wouldn't advise doing that, because it could be harmful."
The standard grief-counselling procedure is based on a notion by Sigmund Freud that people should work through the memories and emotions associated with those they have lost until they can let go of the bond.
"My research suggests that the people who can minimize the amount of emotion that they express -- the people who can shift their attention, who can distract themselves, people who can laugh -- are people who are doing better," said Dr. Bonanno.
In other words, it does not pay to wallow in one's misery.
It would be wrong to dismiss all grief counselling as inappropriate, he said.
"But people cope in differently ways and I don't think there's one approach that can be applied to everybody.
"The people that need to talk about it can find therapy. There's plenty of therapists out there. The people that don't cope that way should not even be asked if they want therapy. They'll find it if they want it."