Post-traumatic disorders: a socioPolitical PersPective

Survivors of the tsunami: dealing with disasterderek summerfield

Three recent, highly publicized tragedies provide an oppor-tunity to review the field sometimes called ‘emergency’ or ‘disaster’ mental health: the Beslan school seige and the Asian tsunami in 2004, and the Pakistan earthquake in 2005. We should, however, note at the outset that in much of the world there is no clear demarcation of ‘disaster’ or ‘emergency’ from ordinary times. Why are the deaths of millions of children every year from the diseases of poverty not an emergency, but ‘normal’?

The Beslan school siege, the Asian tsunami and the Pakistan earthquake

At Beslan, 48 psychiatrists, psychologists and psychotherapists assembled before the seige had even ended, and a team of psychologists was still manning a 24-hour telephone hotline 3 months later. These professionals talked of ‘profound psy-chological scars’ and of the expectation of long-term psychi-atric problems – post-traumatic stress disorder (PTSD) – for a proportion of survivors.1 After the Asian tsunami the Depart-ment of Health circulated briefing papers on acute stress reac-tions and PTSD throughout NHS trusts, and pronouncements from various experts suggested that as many as 25% of child survivors would develop PTSD requiring professional interven-tion. Many appeals for aid emphasized that ‘after the physical wounds heal, the mental scars remain’ or ‘the longterm trauma will be mental’. I have seen as yet unpublished research stud-ies reporting that more than 70% of post-tsunami children had PTSD! One expert, reporting live on BBC radio from a Sri Lankan village, expressed his astonishment at the resilience and cheerfulness of survivors, and that the children seemed keener to get back to school than to talk about the events of 26 December. He described them as being ‘clearly in denial’. There was an influx of trauma counselling teams from Western countries, most with little or no knowledge of local points of view and culture, but all apparently clear that this intervention was crucial. In Sri Lanka there are accounts of survivors being herded into almost compulsory counselling. A month after the Pakistan earthquake, and with 3 million people still homeless and facing the onset of severe winter, the Lancet reported that

Derek Summerfield MBBS MRCPsych is Consultant Psychiatrist at the

South London and Maudsley NHS Trust, an Honorary Senior Lecturer

at the Institute of Psychiatry, King’s College, London, and Teaching

Associate at the Refugee Studies Centre, University of Oxford, UK.

He has been a consultant to Oxfam and other aid agencies.

PsYcHiatrY 5:7 25

the first teams of mental health workers had arrived.2 Psychologists were quoted as saying that ‘thousands of children are plunging into depression’.3

Aberfan

It is instructive to contrast these accounts with those of a simi-larly emotive tragedy of a generation ago. In 1966, 144 school-children and teachers were engulfed when a coal waste tip slid into the Welsh village of Aberfan. Surviving children resumed school 2 weeks later so that their minds would be occupied, no counselling was provided and there were no dire predictions of long-term mental trauma and disability. Newspaper reports com-mended the villagers for getting back on their feet so admirably and with little need for outside help. A child psychologist noted some months later that the children appeared normal and well adjusted, and there is no suggestion that this has not remained true over subsequent decades.4

To coin an aphorism, we are on average as resilient as the society we live in expects us to be. Not only adults but chil-dren were once assumed to be pretty tough, and it is said that ‘childhood’ is largely a Victorian invention. However, West-ern cultural assumptions about individuals and adversity have changed, and momentously. The concept of a person now emphasizes not resilience (as it did at the time of Aberfan) but vulnerability. We witness the implacable rise of the medi-calization of distress, a focus on ‘emotion’ and the language of emotional deficit, and on candidature for a mental health intervention. In this climate there is a real risk that the horror evoked by a tragic event will too easily transform itself into dire predictions about psychological damage, which have a capacity for self-fulfilling prophecy.5

Globalization of Western cultural trends in psychiatry

The profile given over the last 15 years to the idiom of ‘trauma’ and the lexicon of therapeutics in humanitarian operations worldwide reflects a globalization of these Western cultural trends. I have critiqued this work in detail elsewhere, arguing that for the vast majority of survivors, post-traumatic stress is a pseudocondition, a reframing of understandable suffering and misery as a technical problem to which short-term tech-nical solutions such as counselling are supposedly applicable.6 Moreover, most of the published studies of the mental health of the largely non-Western survivors of war or natural disas-ters are invalidated by what Arthur Kleinman, a doyen of cross- cultural psychiatry, called a category fallacy: the assumption that if mental state phenomena can be elicited in various settings, they mean the same thing everywhere. Even research using the best back-translation methodologies cannot entirely solve this problem, which is one not of translation between languages but of translation between worlds. We need to remember that the Western mental health discourse introduces core components of Western culture, including a theory of human nature, a defini-tion of personhood, a sense of time and memory, and a source of moral authority. None of this is universal. Western counsel-ling, which is being exported as if a universal panacea, cannot make much sense to peoples who do not share a Western ethno-psychology that defines ‘emotion’ as internal, often biological,

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Post-traumatic disorders: a socioPolitical PersPective

unintentioned, distinct from cognition, a cause of pathology, and subject to detached introspection; above all, a feature of indi-viduals rather than situations.7

We should beware of the mechanistic view of mind inher-ent in the Western medicotherapeutic gaze. ‘Recovery’ is not a discrete process: it happens in people’s lives rather than in their psychologies. It is practical and unspectacular, grounded in the resumption of the ordinary rhythms of life – economic, familial, sociocultural – that make the world survivable and intelligible.

Reports from tsunami-affected areas question this fashionable emphasis on an intervention that ignores the very social context whose destruction defines what survivors think has happened to them. In Sri Lanka the caseloads of traditional healers have reportedly swelled since the tsunami, but people have not sought counselling, instead pointing to their shattered homes and liveli-hoods. The children have been observed as sad, and a few with night terrors, but are well functioning and keen to have their schools rebuilt.8 Surveys from the war-affected parts of the coun-try indicate that even people who turned up at mental health centres were actually primarily concerned with issues such as employment.9 The focus is not on what has been lost, but on what has to be done next. This mirrors my own experience over many years with war-affected people in non-Western settings, or as asylum-seekers in Western countries. In the post-tsunami mêlée we see again how little the voices of recipients of humani-tarian aid count.

There is little evidence for the efficacy of trauma counselling programmes even in Western settings (e.g. in New York after 11 September 2001), and there is a consensus that one-off trauma debriefing is ineffective or harmful for some. The recent WHO consensus statement on post-emergency mental and social health endorses social assistance as having the primary role, and ques-tions the public health value of trauma programmes, particularly in non-Western, low-income countries.10 It has long been under-stood that most people are not paralysed by panic or horror after a disaster, and indeed the social bonds of solidarity and coop-eration may be strengthened. In the absence of evidence of psy-chological fall-out distinctive in nature or degree and requiring professional attention in its own right, ‘disaster mental health’ is perhaps an oxymoron. ◆

PsYcHiatrY 5:7 25

RefeRenceS

1 Parfitt t. How Beslan’s children are learning to cope. Lancet 2004;

364: 2009–10.

2 lancet editorial. a forecast of disaster for Pakistan. Lancet 2005;

366: 1674.

3 Walsh d. thousands of child victims bear physical and mental scars

of a lost generation. The Guardian 1 November 2006, p. 23.

4 Furedi F. Therapy culture: cultivating vulnerability in an uncertain

age. london: routledge, 2004.

5 summerfield d. cross-cultural perspectives on the medicalisation

of human suffering. in: rosen G, ed. Posttraumatic stress disorder:

issues and controversies. chichester: Wiley, 2004.

6 summerfield d. a critique of seven assumptions behind

psychological trauma programmes in war-affected areas.

Soc Sci Med 1999; 48: 1449–62.

7 lutz c. depression and the translation of emotional worlds. in:

Kleinman a, Good B, eds. Culture and depression. Studies in the

anthropology and cross-cultural psychiatry of affect and disorder.

Berkeley, ca: university of california Press, 1985.

8 Jones l. Personal communication, 2005.

9 miller G. the tsunami’s psychological aftermath. Science 2005; 309:

1030–3.

10 van ommeren m, saxena s, saraceno B. mental and social health

during and after acute emergencies: emerging consensus?

Bull WHO 2005; 83: 71–6.

Practice points

• distress or suffering is not psychopathology

• there is no evidence of a significant psychological fall-

out of a disaster that would justify interventions such as

counselling

• Western psychiatric constructs like post-traumatic stress

disorder or depression do not have universal validity

• survivors of the tsunami and other disasters did not ask for

counselling

• ‘recovery’ is not a discrete psychological process or event

• the social world is central to personal and collective

recovery

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