2010 APS Annual Oration delivered by Professor Richard Bryant FAPS
The 2010 APS Annual Oration was delivered by Professor Richard Bryant, APS Fellow, Scientia Professor in the School of Psychology, University of New South Wales, an ARC Laureate Fellow, and Director of the Traumatic Stress Unit, Westmead Hospital.
Richard is an internationally renowned disaster expert who has been involved in recovery work in most of the major disasters around the world over the last few decades. The APS is fortunate to have Richard as a member of its Disaster Preparedness and Recovery Reference Group.
His contribution to the field of disaster recovery, and to the development of the APS disaster knowledge base and resources, has been immense. Given the flurry of devastating disasters over the last year (Haiti earthquake, Pakistan floods, Christchurch earthquake, not to mention the Black Saturday bushfires in 2009) and the increasing involvement of the APS in disaster preparedness and recovery work, it was most fitting to have Richard present this year’s APS Annual Oration: The psychological cost of disasters.
What we know, what we don’t know and why
Richard, at heart, is a scientist. He has conducted numerous studies, written hundreds of articles, and uncovered considerable insights into the key biological and cognitive markers of risk of posttraumatic stress disorder (PTSD).
Richard is very matter-of-fact, honest about the limits of what we know, and quick to point out when we are working on faith rather than fact and using an intervention that has yet to be ‘proven’. Richard is also quick to point out when we are continuing to use an approach that has been proven to be unhelpful which, given the considerable time lag between research into best practice and the lay person’s understanding of best practice, can be quite often.
In the field of disaster research, there is still much we don’t know. Why? Well for a start, says Richard, an emergency or disaster situation is not a controlled environment. “It’s crazy. People are just trying to get by day by day. Any high quality postdisaster research is very difficult. It’s a very limited field.“
So how do most people around the world learn about disasters? It seems, according to Richard, that there are many ways the puzzle is pieced together, even though the end result leaves us still with many unanswered questions.
For starters, trauma research provides considerable information and insight. The existing disaster research is typically epidemiological, which helps us to understand how and why a response trajectory occurs, but not really what to do about it.
Then there is the knowledge gleaned from the numerous expert consensus meetings which take place around the world after any disaster. Here, experts gather together to discuss what’s happened, what’s been done, what’s worked and what hasn’t. People draw on their own experience in the field. There is some evaluation of postdisaster programs, but this is not randomised controlled research.
And some researchers also simply ask the survivors what they think of the programs, and whether they were helpful. “At best”, says Richard, “people are basically stumbling along working out what’s best to do, but they don’t have a great body of research to direct them”.
Over the last decade, there has been an explosion of attention to disasters. September 11 was a seminal moment for disaster research. It had an incredible impact on the American psyche (as did Hurricane Katrina), and thus also a major impact on research around the world, and on how we think we should be preparing and responding.
So we now have an increasing understanding of the trajectory of response in the short term after a disaster. We know that initially most people will be very distressed. This is not abnormal, but quite reasonable. But we know in the weeks following a disaster, without any intervention, those symptoms will go away, and after about three months, most will recover. People are resilient.
Ten years ago, said Richard, this was a pretty radical thought. Then, the popular view was that people were very vulnerable and that disasters would result in considerable psychological damage unless people received psychological care. For decades we took the approach that we had to rush in and help. Now we know better.
Of course, a sizeable minority are also vulnerable to developing significant mental health problems (around 10-15 per cent are at risk of PTSD, complicated grief, and/or depression). Whilst the proportions may seem small, the absolute numbers are enormous if millions are affected by earthquake, floods, tsunami, etc. This knowledge has led to a dramatic change in what we do following a disaster.
A commonsense, humane approach
The current approach to helping people following disasters no longer assumes pathology and thus no longer emphasises the importance of immediate debriefing as a way of preventing the development of PTSD. Indeed, we now know that debriefing is not going to prevent PTSD, and might actually be harmful by escalating the biological processes that need to be calmed down, thus enhancing the trauma.
Instead, disaster experts recommend a much more normative approach to treating victims of disasters and emergencies, using Psychological First Aid (PFA). PFA is a commonsense, minimalist approach to supporting people, which tries to reduce arousal, calm people down and enhance problem solving. It is not the sole province of counsellors or mental health practitioners, but can be delivered by a wide variety of people. It’s easy to train people in PFA except for one issue – training people in what not to do! PFA is not counselling; it is just support.
So does it work? Well, Richard, in his matter of fact way, is quick to point out that we have no evidence that it does any good. “But then, I don’t mind that”, he says. “Because if we ever ask the question of any of these interventions – Does it work? Is it any good? – this presupposes that there’s a goal, that it intends to do something. So it’s important to note that PFA is not meant to be preventative. It’s not meant to treat a disorder. It’s just meant to help people to cope. But, essentially it’s just common sense.”
Essential skills for coping
The next major development in disaster response came out of Hurricane Katrina. Thousands of people were still hurting in the weeks and months afterwards, and experiencing a whole range of problems – worrying about how to get a roof back on the house, unable to sleep, unsure how to deal with kids who were acting up, and not knowing what to do with all of these problems.
The agencies involved wanted a strategy to help these people. They saw that these problems were not necessarily mental health issues; people were simply being overwhelmed with problems emanating from the disaster. Richard Bryant and other disaster experts joined forces to come up with a skills-based program.
They began by building on the existing evidence about the major change mechanisms that are predictive of good adaptation after disaster. They decided to find the common elements, and build them into a training package to equip people with useful skills for recovery.
The program ended up being called Skills for Psychological Recovery (SPR), with the aim of accelerating recovery, nipping problems in the bud, and steering people towards better adjustment simply because they are using better strategies to deal with things.
The SPR guide was written as a modular program, so that each skill could be taught as a stand-alone strategy. Given that the modal number of counselling sessions people attended after Hurricane Katrina was one, this strategy was an important feature. Immediately following the Victorian Black Saturday bushfires, Richard joined disaster colleagues for discussions about how best to respond to people’s needs.
The APS convened a series of meetings with a cross-professional working group made up of mental health professionals, GPs, allied health, State and Federal Governments, and key post-trauma treatment centres, with the purpose of designing an approach for meeting the mental health and psychosocial needs of the thousands of people affected by the fires.
As Richard says, this was a major breakthrough in disaster recovery in Australia. For the first time ever, all the major players were at the table, working together on a coordinated approach to psychosocial recovery. The group signed off on an approach for training professionals across the state to deliver three levels of intervention.
Level 1 was Psychological First Aid targeted at the general population. Level 2 was Skills for Psychological Recovery, and Level 3 was psychological treatments for people at risk of developing significant mental health problems. These trainings rolled out across the state in the following 18 months.
Skills for psychological recovery
| Skill |
Rationale |
| Information gathering |
The first step. Simply identifying and prioritising people’s needs, and developing an action plan for tackling the probems is very helpful. |
| Problem solving |
Clearly a huge need as people will have a lot of problems and not much practice in dealing with them. |
| Activity scheduling |
It is well known in depression literature that the single best intervention is behavioural. Getting people up and doing things is likely to have the biggest effect size. |
| Managing stress reactions |
This is built on literature that arousal in the acute phase is a huge predictor of PTSD and anxiety disorders. It is very important to teach people how to reduce arousal e.g., breathing skills, self-talk. |
| Healthy thinking |
The literature shows that people’s interpretation of the event is very predictive of how they’re going to fare. It’s important to teach people to recognise unhelpful thoughts and practice more helpful ones. |
| Social support |
People who don’t fare well are often those who don’t engage with their networks. They need to be taught how to proactively engage or build social networks. |
Future challenges
Richard’s overview of the current approach internationally to helping people affected by a disaster describes a commonsense model of caring for people and groups that draws on fundamental understandings of what people need to feel safe, supported and cared for. Importantly, he explained, it makes you realise that what we do as psychologists is relatively simple.
Perhaps the next challenge is changing media and public expectations of what is needed after a disaster, and ensuring the best support is available and accessible at the most appropriate times.