Psycological Assistance in Psycological Assistance in Disasters:Disasters:

Paradoxes and ChallengesParadoxes and Challenges

Prof. Dr. (Moty) BenyakarProf. Dr. (Moty) BenyakarProf. Dr. Carlos CollazoProf. Dr. Carlos Collazo

Dr. Raquel CohenDr. Raquel Cohen

Inner World

External World

DISASTERS AND DISASTERS AND CATASTROPHESCATASTROPHES

• A challenge to psyichiatry due to the A challenge to psyichiatry due to the

external world impactexternal world impact

–CharacteristicsCharacteristics–ConditionsConditions–RequirementsRequirements

I Paradox The pathogenic character of a

disruptive situation lies in the situation

itself

DISRUPTIVE SITUATIONDISRUPTIVE SITUATION

It concerns the pathogenic It concerns the pathogenic quality of a factual event quality of a factual event imploding into the psycheimploding into the psyche

DISRUPTIONDISRUPTION

Destroy, ruin, interrupt, disorganize, burst Destroy, ruin, interrupt, disorganize, burst

(of rage, of pain), which(of rage, of pain), which

tends to interrupt continuity tends to interrupt continuity

From the latin “disrumpo”:From the latin “disrumpo”:

DISRUPTIONDISRUPTION - 1979 Benyakar: Disruption in Mental Health.- 1979 Benyakar: Disruption in Mental Health.

- 2001 Benyakar: Anxiety by Disruption. WPA - 2001 Benyakar: Anxiety by Disruption. WPA Madrid. Madrid.

- 2001 Benyakar – Collazo: Anxiety by Disruption.- 2001 Benyakar – Collazo: Anxiety by Disruption.

- 2002 Anxiety by Disruption: International - 2002 Anxiety by Disruption: International Research Team. Research Team.

- 2003 Benyakar: Disruption: Individual and - 2003 Benyakar: Disruption: Individual and Collective Collective Threats. The book.Threats. The book.

Characteristics of the event Characteristics of the event and the psychic experienceand the psychic experience

• Disruptive EventDisruptive Event

• Different types of psychic experienceDifferent types of psychic experience

Disasters and CatastrophesDisasters and Catastrophes

• ForeseenForeseen or Unforeseen.or Unforeseen.

• SuddenSudden or or Preannounced.Preannounced.

• Only onceOnly once or Recurrent.or Recurrent.

Events which cause Physical and/or Psychic Events which cause Physical and/or Psychic damage to a large number of people.damage to a large number of people.

Causes of DisastersCauses of Disasters

• Natural: earthquakes, Natural: earthquakes, floods, etc.floods, etc.

• Human: wars, terrorism, Human: wars, terrorism, etc.etc.

• Combined.Combined.

Internal World

Dr. Mordechai (Moty) Benyakar

II Paradox

Assisting and assisted persons are

under the same threats

Characteristics of threatsCharacteristics of threats

• AgressionsAgressions: : The threat is open, The threat is open, visible and traceable.visible and traceable.

- Wars, natural disasters, conflicts.- Wars, natural disasters, conflicts.

• ViolenceViolence: : The threat is hidden, conceiled The threat is hidden, conceiled and untraceable.and untraceable.

- Terrorism, rape.- Terrorism, rape.

.

AIM OF TERRORISMAIM OF TERRORISM

• To use surprise as a constant, diffuse and untraceable threat.

• To cause psychic damage.

• To turn the daily environment into a threatening surrounding.

• To use all of these as political pressures.

CHARACTERISTICS OF CHARACTERISTICS OF THE THREATTHE THREATIN VIOLENCEIN VIOLENCE

(terrorism, market or politics, etc.)(terrorism, market or politics, etc.)

• DifusseDifusse

• Impersonal threatsImpersonal threats

• Permanent confusion Permanent confusion

between internal between internal or or

external threatexternal threat

• Of human originOf human origin• Difficult to detect as a Difficult to detect as a

signal signal • Cannot be approached Cannot be approached

in a defensive wayin a defensive way

III Paradox

People undergoing a disruptive event can be damaged persons but

not necessarily patients

IV Paradox

From “damaged” to victim:

a) The one causing the damage, damages.

b) “Victims” are a product done by harmed groups or collectives who need them to guarantee the memory of the harming event.

Victim Damaged

The subjectivity of the person depends on the society.

Person who has suffered a damage.

His subjectivity is in danger and our function is to assist to recover the integration ability and functioning inside his familiar and social environment.

The subjectivity is despised and it is not recognized

He feels the demand to adapt to the domineering image and keep in a stereotyped roll, that is useful to the society

Some ways to characterize Some ways to characterize human suffering due to the human suffering due to the

environmentenvironment

• Survivor’s syndromeSurvivor’s syndrome• Stockholm Syndrome Stockholm Syndrome • Reactive Disaster Syndrome (Toxic Oil Reactive Disaster Syndrome (Toxic Oil

Syndrome) (López Ibor)Syndrome) (López Ibor)• Gaza Syndrome Gaza Syndrome • PTSDPTSD

Psychic Consequences of Psychic Consequences of ViolenceViolence

New expressions of psychic human New expressions of psychic human

suffering in this historical and social suffering in this historical and social

context lead us to reconsider the context lead us to reconsider the

classification of the diseases as we classification of the diseases as we

have accepted it until todayhave accepted it until today

V Paradox

PTSD as a single diagnose fails to

acknowledge the variety of psychic impacts due

to disasters

ABOUT PTSDABOUT PTSD

• Establishes the impact of the factual event. Establishes the impact of the factual event. • Vague and unspecific concept.Vague and unspecific concept.• It does not differentiate between Stress and Trauma.It does not differentiate between Stress and Trauma.• Comorbidity: 88.3% in menComorbidity: 88.3% in men 79.0% in women79.0% in women (Shalev)(Shalev)• Patients do not have good responses to Patients do not have good responses to

pharmacological and psychotherapeutic treatments.pharmacological and psychotherapeutic treatments.

DriveAction

Relation

Experiencing(Process)

Affect

Representation

Traumatic Experience (Disarticulation)

Experience(Articulated)

Dr. Mordechai (Moty) Benyakarby PHP Solutions

GENERAL RESPONSES GENERAL RESPONSES FACING THE THREATFACING THE THREAT

• Personal uncertainty increased by Personal uncertainty increased by collective uncertainty.collective uncertainty.

• Feeling that beliefs, certainties, safeties, Feeling that beliefs, certainties, safeties, protection and the rules of the game protection and the rules of the game collapse.collapse.

• Loss of belief in an organized world Loss of belief in an organized world based on morals and ethics.based on morals and ethics.

FACING THE THREATFACING THE THREAT

• The diffuse threat unables the development of The diffuse threat unables the development of

adequate coping defenses. adequate coping defenses.

• Anxiety is not produced by psychic incapacity.Anxiety is not produced by psychic incapacity.

• The vague threat requires a constant alertness The vague threat requires a constant alertness process.process.

Anxiety by DisruptionAnxiety by Disruption

In this historical and social context we can In this historical and social context we can

observe the appearance of new ways of observe the appearance of new ways of

psychical suffering. This leads us to psychical suffering. This leads us to

reconsidering nosology as we know it reconsidering nosology as we know it

until todayuntil today

ANXIETY BY ANXIETY BY DISRUPTIONDISRUPTION

AbDAbD

The radical distortion of the human The radical distortion of the human environment implode into the human environment implode into the human

psyche, confronting us with a new psyche, confronting us with a new nosological entity nosological entity

We have labelled it: We have labelled it: A b DA b D

ANXIETY by DISRUPTIONANXIETY by DISRUPTIONAbDAbD

Psychical malfunction produced by the Psychical malfunction produced by the disruption of the environmentdisruption of the environment

Its main feature is that there is no psychical Its main feature is that there is no psychical deficit in advancedeficit in advance

It is a response not sharp nor spectacularIt is a response not sharp nor spectacular

- Traumatic Experience

- Stress Experience

- Anxiety by Disruption Dr. Mordechai (Moty) Benyakarpor PHP Solutions

- Traumatic Experiencing

- Stress Experiencing

VI ParadoxThe ratio between personnel to assist physically injured

individuals and psychologically damaged people during disasters is

20 to 1

The Paradox of Mental Health The Paradox of Mental Health Assistance in Disasters since Assistance in Disasters since

II War to the present timeII War to the present time

• 1 Physically Injured 1 Physically Injured == 4 Psychically Damaged.4 Psychically Damaged.

• 1 Physically Injured 1 Physically Injured == 20 Psychically Damaged.20 Psychically Damaged.

• 1 Physically Injured 1 Physically Injured == 200 Psychically Damaged.200 Psychically Damaged.

==

1 Mental Health 1 Mental Health Professional. Professional.

• 20 Physically 20 Physically Assistance Assistance ProfessionalsProfessionals

VII ParadoxThe disorganizing effects of

disasters also encompass those who assist.

Professionals usually isolate in small groups who can even rival one with the

other.

10 W ‘s10 W ‘s

10 key concepts 10 key concepts on which to base on which to base

psychological assistance psychological assistance methods during disastersmethods during disasters

Prof. Dr. Mordechai (Moty) Benyakar Prof. Dr. Mordechai (Moty) Benyakar

10 principles in the course of 10 principles in the course of actionaction

• Warding OffWarding Off

• WhyWhy

• WhatWhat

• WhoWho

• WhomWhom

• Whose

• When

• Where

• Ways

• Wholeness

WARDING OFFWarding off the psychological stability

• Be prepared for the unpredictable, such as tornado, hurricanes, etc.

• Mental Immunity:

1-  Recognize the menace and its characteristics.

2- Use psychological capacities to cope with threatening situations.

3-Take preventive and objective measures in case threaten becomes a fact.

WHY Why are mental health professionals

necessary during a disaster?

• To reduce the potential disasters have to cause traumatic experiences or other pathologies.

• To serve as a bridge between the disruptive external world and the inner world of each person.

• To diminish pain and avoid pathology by allowing elaboration through contention and holding.

• To screen main pathological reactions.• To decide what kind of interventions should be

carried out, adequating them to actual needs, time and places.

WHAT What is our objective while assisting

during disasters?

• Endangered or actually harmed psychological abilities for processing are the core of our interventions

• Two concepts to be stressed:a) The recovery of the individual’s

subjectivity.b) Maintenance of the ability to elaborate the

inner-outer world relation.

WHO Who must intervene to ensure the people’s psychological stability?

• Being the ratio between available practitioners and people in need of mental health care so inadequate, the population as a whole must become a resource.

• Mental health professionals should recognize people’s abilities to assume responsibilities among the members of the community.

• Build a network including people as health agents and coordinating it.

• People integrating the net need to receive the necessary holding and supervision

WHOM

Whom are we going to assist?

• Mental health care is usually given to those showing their needs spectacularly.

• But, we need to be sensitive in order to take notice of those who remain silent, apart or make-believe that “nothing happened to them” .

• Notice groups that are special targets: children, the elderly, pregnant women, disabled people, etc.

WHOSE Whose responsibility is at stake?

This question concerns individuals and social institutions in two different aspects

a) Mere presence makes human beings feel subjectively responsible.

b) Necessity and Chance. c) Communities must have institutions accountable social

and legally for disasters. A group of political authorities, institutions and effecters as “legitimating recognizers” to assume the assistance is essential.

WHEN When do we have to intervene?

Four different stages during disaster intervention

• Pre-impact phase• Impact phase • Immediately after the occurrence of

the event • Assistance in the long-term

WHEREWhere do we have to intervene?

• Health professionals will need to be flexible, creating adequate therapeutic milieus even in completely inadequate environments

• Any place can become a suitable place for therapy if it is signified as such

• “From the couch to the stones”

WAYS In which ways are we going to

intervene?

• Assistance can resort to individual, family group or institutional intervention.

• Professionals must stick to the core of their theoretical frameworks while adapting techniques to the circumstances.

• “Intervention by presence” vs.“Intervention by demand”.

• “Functional leadership” vs. “Structural leadership”.

WHOLENESS An integrative approach based on the

previous 9 W’s • The complexity of disasters requires to intervene in

an integrative way.• It needs as well knowledge about social, political,

economic and cultural processes. • We must be flexible with the contributions of other

disciplines.• This does not mean that we will take care of all

aspects of the problem.• We must restrain the interventions to our specific

role.

The specificity of mental health The specificity of mental health intervention in disastersintervention in disasters

1) Assisting normal people in an 1) Assisting normal people in an abnormal situationabnormal situation

2) Coping with a complex 2) Coping with a complex situationsituation

3) Reducing its complexity3) Reducing its complexity

4) Disruptive situation with high 4) Disruptive situation with high pathogenic potentialpathogenic potential

Minimal Professional Minimal Professional RequirementsRequirements

1.1. Clear conceptions about the situation dealt Clear conceptions about the situation dealt with.with.

2.2. Trained teams to intervene in each area and Trained teams to intervene in each area and phase of the event.phase of the event.

3.3. Adequate assistance approach techniques. Adequate assistance approach techniques.

4.4. Warmth, flexibility, capacity to cope with the Warmth, flexibility, capacity to cope with the unpredictable.unpredictable.

Training Programs to face Training Programs to face Disruptive SituationsDisruptive Situations

• General populationGeneral population

• Social agentsSocial agents

• Community leadersCommunity leaders

• Health professionals in generalHealth professionals in general

• Mental health professionalsMental health professionals

Specific and adecuate Specific and adecuate approach of mental health in approach of mental health in

disastersdisasters

- Reduce human pain provoked by natural impacts

- Reduce human pain provoked by man

- Reduce the iatrogenic potential of the professional interventions.