With more than 150,000 dead and countless more injured, severely traumatized, and homeless, December’s tsunami disaster is shaping up to be the greatest natural catastrophe in living memory. Even those familiar with the worst wartime destruction say that they have never seen anything comparable to the coastal cities and towns utterly flattened by the massive waves.
But as great as the human toll has been, Richard Mollica warns against seeing the survivors as victims.
“The victim mentality doesn’t work,” he said. “It doesn’t help anybody. Even the poorest person in Indonesia who’s had terrible losses doesn’t want to be seen as a victim.”
For more information on the Harvard Program in Refugee Trauma
For information on Project 1 Billion, and to download the Mental Health Action Plan and ‘Book of Best Practices
The UN Chronicle’s premeeting review of Project 1 Billion
Mollica, a psychiatrist at Harvard Medical School, is director of the Harvard Program in Refugee Trauma, an organization that has been working for the past quarter-century to study the mental health impact of war and violence and to develop methods of treatment. Purely fortuitously, that work has attained a new level of acceptance just in time for the Southeast Asian disaster.
On Dec. 3 and 4, a group of 35 ministers of health from countries struggling to recover from the effects of mass violence met in Rome to endorse a science-based, culturally effective, and sustainable mental health action plan for postconflict recovery. The historic meeting was organized by Project 1 Billion: International Congress of Ministers of Health for Mental Health and Post-Conflict Recovery. Among the countries represented were Indonesia and Sri Lanka, the two hardest hit by the tsunami.
Mollica served as president of the conference, and he and his colleagues are currently involved with health ministers from tsunami-affected countries. They believe the results of the December conference may have a long-term impact on how mental health issues arising from the disaster will be dealt with.
Project 1 Billion, named for the more than 1 billion people worldwide who have been affected by mass violence, is sponsored by the Harvard Program in Refugee Trauma, Caritas Roma, Istituto Superiore di Sanità (Italian National Institute of Health), Fulbright New Century Scholars Program, and the World Bank, with the support of the Italian Ministries of Health and Foreign Affairs, as well as the World Health Organization (WHO). In addition, it has the patronage of the Lazio region, the province and mayor of Rome, and the president of the Italian Republic.
Making its debut at the conference was the “Project 1 Billion Book of Best Practices: Trauma and the Role of Mental Health in Post-Conflict Recovery,” produced by leading international authorities in health, economic development, human rights, and anthropology to serve as a guideline for governments, policy-makers and donors in postconflict societies. The 380-page book was presented at the meeting and will be disseminated globally.
The success of Project 1 Billion in working toward a global mental health action plan represents a significant breakthrough, considering that until fairly recently, the role of mental health in postconflict or postdisaster recovery was not even recognized. Most aid organizations subscribed to the “rubber band” model of mental health, which holds that once food, water, shelter, and essential services are provided, individuals will snap back and resume their normal lives. Research conducted by Mollica and his group in places such as Cambodia; Bosnia; Kobe, Japan; and New York City after the 9/11 attacks have shown that the rubber band model is invalid.
Without treatment, those who have been subjected to violence, torture, displacement, and loss of family members are likely to suffer the long-term effects of post-traumatic stress disorder (PTSD) and severe depression, psychological conditions that are not only agonizing for the individuals who experience them, but, when widespread, can seriously hinder the ability of the society to get back on its feet.
What is to be done? Obviously, individual psychotherapy and antidepressant medication can’t be the answer for poor societies where trauma is widespread and infrastructure has been largely destroyed. But research by Mollica and his colleagues has demonstrated that alternative methods can be highly effective in dealing with such situations.
“You need to put a lot of resources into local healers and indigenous healing systems so that they have the capacity to meet the need over the long term. The local healing system is still there, no matter how damaged it may be, so you’ve got to focus on building the ability of these people to meet demand,” Mollica said.
Local healers may include doctors, nurses, clergy, even shamans and other traditional practitioners, whomever people have been accustomed to going to in times of need. Often such people can be far more effective in helping those who have been traumatized by violence and loss than can doctors or therapists from outside.
Local healers can help immeasurably in the long term, after outside relief organizations have moved on to the next crisis. They can also help administer what Mollica calls “psychological first aid” to people experiencing the initial shock of terrible loss. This may be nothing more than sitting with a person, listening, and providing support. But it does not mean probing or being intrusive, Mollica said.
“The ‘debriefing’ method only seems to make people worse. Generally the more intrusive the approach, the more negative the outcome.”
Another important principle that Mollica and his group have discovered is that psychological healing comes about much more rapidly when people are able to return to their normal activities and to help with the rebuilding of their societies.
“The worst thing you can do is force people into long-term dependency, to place them in refugee camps or orphanages where they can’t do anything to help themselves. There’s less chance of sinking into a deep depression if you’re occupied.”
Accordingly, Mollica recommends putting people back to work and children back in school as early as possible, even while the crisis is still going on.
“After a traumatic event, there’s shock, but then soon afterward there’s enormous energy for recovery. If that is suppressed, then people are likely to slip into despondency.”
Mollica and his group have also discovered that people undergoing traumatic events have a great capacity to help others. In fact, the altruistic impulses that flourish in the wake of trauma can offer unprecedented opportunity for warring groups to achieve reconciliation. In other instances, those who have experienced loss or violence can help others to deal with similar problems.
“Often a trauma survivor can be a great teacher,” Mollica said.
Spirituality is another vital factor in restoring mental health, even though in some cases violence between religious groups may have brought about the problem in the first place. Nevertheless, rebuilding houses of worship and reorganizing religious services can be extremely important in helping people to re-establish meaning in their lives, Mollica said.
A team from the Program in Refugee Trauma has been invited to visit Indonesia the week of March 14-18 to meet with Ministry of Health officials and assist them in creating a long-term plan for mental health recovery. The group includes Mollica; James Lavelle, the program’s director of international programs and community organizing; and research assistant Robina Bhasin. They will be joined by other Project 1 Billion colleagues and will also have meetings with WHO and other UN agencies working there, as well as local Indonesian NGOs on the ground.
“We’re being cautious,” Mollica said. “We don’t want to be in the way. But by making information available we feel we’ve already had an impact on policy-makers. They won’t have to reinvent the wheel. Now, for the first time, there’s an action plan for dealing with the psychological impact of a disaster.”