Psychosocial recovery following community disasters: An international collaboration

Ample evidence demonstrates that disasters of both natural (e.g. floods, bushfires, earthquakes) and human origin (e.g. interpersonal violence, terrorism, major life-threatening accidents) can result in adverse mental health outcomes among those directly or indirectly exposed (North and Pfefferbaum, 2013). While the majority of those affected recover over the first few months, disasters often mark the start of a complex series of secondary stressors (such as the need to relocate or rebuild, fear of a recurrence and legal, financial and compensation issues). Evidence from Australian and international disaster research demonstrates that, although some will experience no problems and others only minor difficulties that resolve with time and naturally occurring support, a substantial minority will go on to develop clinical or sub-threshold psychiatric conditions which, for some people, will persist for many years (North and Pfefferbaum, 2013). These conditions, which may include depression, anxiety, posttraumatic stress disorder (PTSD) and substance use disorders, not only cause great personal suffering and distress but also interfere with family, social and occupational functioning. The cost to the community in both human and financial terms is enormous and is recognised by global agencies as one of the most urgent public health issues (Deloitte Access Economics, 2016).

Public sector health and mental health services, as well as charitiesand non-government organisations, routinely respond rapidly following disaster with a view to (1) preventing disorder where possible, (2) intervening early for those who develop initial symptoms and (3) facilitating access to treatment for those with diagnosable conditions. Multiple challenges arise in attempting to deliver this type of response in the context of a complex and chaotic post-disaster setting, and several practice guidelines, such as those produced by the Inter-Agency Standing Committee and the Royal College of Psychiatrists, are available to guide such intervention programmes. It is now internationally accepted best practice to provide three levels of intervention matched to those three aims (Forbes et al., 2012). Early universal strategies are targeted at the whole population. Currently, ‘psychological first aid’ (or Level 1 intervention) is the universal prevention strategy of choice and is designed to enhance individual and community resilience and to foster cohesion and mutual support (although it is recognised that there is little empirical data to support psychological first aid). At the other end of the spectrum, substantial research now exists to guide evidence-based pharmacological and psychological interventions for diagnosable psychiatric conditions following disaster and trauma (Level 3). The middle level (Level 2) aims to assist the substantial number of people who develop ongoing disabling and distressing adjustment problems or sub-clinical psychiatric disorders. Unfortunately Level 2 interventions have been largely neglected until recently. This is a problem not only because psychological dysfunction at this level causes significant distress, economic loss and functional impairment but also because these adjustment problems pose a risk for escalation into serious psychiatric disorders if not effectively addressed. Moreover, in the aftermath of disaster, there can be substantial numbers of people who suffer these adjustmentor sub-clinical psychiatric problems, which overwhelms the resources of many health systems.

Some attempts have been made to develop and implement these Level 2 interventions targeted at survivors with adjustment problems and sub-clinical disorders. The goal is to assist adjustment to their disaster experience, to help them manage the ongoing stress routinely involved in the post-disaster environment and to minimise the chances of a deterioration into serious psychiatric disorders. Interventions are usually delivered by locally based health and welfare practitioners from a diverse range of backgrounds who may, themselves, have been affected by the disaster. Since the capacity for learning new information may be limited as a result, programmes should be designed to enhance existing skills (rather than focussing on new material) where possible. One such programme is Skills for Psychological Recovery (SPR) (Berkowitz et al., 2010) developed by the US and Australian mental health professionals in the wake of Hurricane Katrina. SPR comprises a highly structured set of skills-building modules targeting high prevalence problems in post-disaster settings. It was designed to be delivered by paraprofessionals, as well as generalist health professionals, and has now been implemented following several disasters in Australia and overseas. A second Level-2 intervention, developed under the auspice of the World Health Organization, is Problem Management Plus (PM+) (Dawson et al., 2015). PM+ was designed to be as simple as possible to train and implement, and aims to target common mental health disorders following adversity in low and middle income countries. Both these programmes have the capacity to be delivered in group formats if appropriate.

Although both these interventions are ‘evidence-informed’, both have limitations in terms of clinical utility and/or empirical validation in the developed world. SPR is a complex intervention: the six modules present multiple challenges in providing effective training for providers, especially those with minimal clinical skills. SPR requires those responsible for delivery to make decisions about what to include and what to omit in each individual case. This requires a level of clinical judgement that is not easy to train in a short time and also makes evaluation of the efficacy of SPR difficult. This may speak to why, as yet, there are no published trials of the efficacy of SPR, and it has not become a widely disseminated programme. Although PM+ is a standardised intervention and has been developed to target common mental disorders following adversity, it does not have a specific trauma focus. This may be a limitation for disaster-affected populations because trauma-focused psychological strategies, especially those involving emotional processing of the traumatic experience, have been shown to be highly efficacious. Finally, disaster work can take a substantial personal toll on the practitioners and at least some attention to self-care should be included.

Given these serious limitations, there is an urgent need to developan internationally agreed protocolthat is consistent with the best available evidence and that is structured in a way that allows for rigorous, multi-site evaluations of efficacy. Accordingly,a new initiative has commenced, ledby Australian researchers, to develop an innovative Level-2 interventionto address adjustment problemsafter trauma and disaster. The purpose of this initiative, therefore, was to develop an internationally agreed protocol for implementation followingdisaster and to develop an evaluation trial design that could be implemented across countries. Data from such trials will form an accumulating and consistent evidence base from which toguide advice to government anddisaster recovery agencies regarding service delivery and implementation decisions.

The roundtable meeting

Together with the Prince’s Charities Australia, and with the personal engagement and attendance of HRH Prince of Wales, Phoenix Australia convened a meeting of national and international experts in Sydney to arrive at a consensus regarding the optimum disaster recovery programme and a methodology to trial its effectiveness. In attendance were 21 international leaders in the field from the United States, United Kingdom, Canada and Australia; representation from the Asia Disaster Preparedness Network; and key Australian NGO partners (Australian Red Cross and the Foundation for Regional and Rural Renewal).

The roundtable meeting agreed on the following broad parameters for the recovery programme:

• The target population for the recovery programme are people who have been exposed to a disaster of natural or human origin. The programme will also be applicable, however, to individual survivors of trauma, emergency services workers and military personnel;

• Although primarily intended for delivery in the early to medium-term following a disaster (e.g. between 2 and 12 months), the programme will also be effective and beneficial well beyond this timeframe, particularly, if a person demonstrates persisting or delayed symptoms;

• The programme is intended for people with ongoing adjustment problems that arise, or are exacerbated, following a disaster. It is not primarily intended for those who report no problems nor for those with severe diagnosable conditions. As such, it is designed to be part of a stepped-care approach;

• The goals of the programme are to reduce distress and psychological symptoms as well as to improve quality of life and increase social and occupational functioning;

• The programme must be appropriate for delivery by primary health care and welfare practitioners at a local level, as well as by carefully selected and trained volunteers. Where appropriate, the programme would be delivered in collaboration with, or under the auspice of, the primary health networks;

• The programme will consist of a brief, highly structured and manualised intervention, which will be available in hard copy and online. This step-by-step manual will be supported by five, 1-hour sessions with a ‘coach’;

• The programme needs to recognise the need for brief training and supervision protocols that can be simultaneously effective and affordable. This is a priority because of the need to potentially train large numbers of practitioners in the aftermath of large-scale disasters.

In determining the content, considerable time was devoted to reviewing the research evidence, examining existing models and drawing on the disaster recovery experiences of the group members. The final protocol, (provisionally titled International Program for Promoting Adjustment and Resilience [interPAR]) is simple to train and implement and contains those elements that have the strongest empirical support. The key components to be included are the following: (1) promoting healthy living, (2) arousal and affect management, (3) emotional processing, (4) value-based behavioural activation, (5) maintaining healthy relationships and (6) rumination and worry control. Rather than distinct, ‘stand alone’ modules, however (as in, e.g. SPR), the proposed model will combine several components within each session, ensuring a high degree of seamless integration across the key elements. This will facilitate a coherent amalgamation of constructs, with each supporting and enhancing the other elements.For example, healthy relationships will be emphasised when teaching each of the other components; similarly, arousal/affect management strategies will not only be provided in their own rightbut will also be a feature of (for example) healthy living and behavioural activation.

A detailed research protocol to evaluate the recovery programme was also developed to ensure consistency across the international trials. A randomised trial design was chosen, using a ‘treatment as usual’ control group with standardised assessments scheduled at several time points. The evaluation measures to be used were determined, as well as the processes for collating and combining the data.

The next steps

The Australian Government Department of Health has recently provided funding support to build on the outcomes of the international roundtable and to support the development and pilot evaluation of this post-disaster mental health recovery programme. This will pave the way for a randomised controlled trial to be conducted in Australia, as well as overseas by our international partners. A website will be developed that will form the hub of a ‘learning community’ for people and organisations around Australia and internationally to access resources, share learnings and explore differential outcomes. By discovering what works, and for whom, we will be able to confidently make recommendations for brief interventions worldwide following disasters. The active involvement of our international colleagues in the roundtable and beyond will ensure quality, consistency and international acceptance of this innovative model of post-disaster care.

This exciting initiative will fill an important gap in our current knowledge regarding how best to provide psychosocial support following disaster to those with adjustment problems and sub-clinical psychiatric disorders. The potential benefits in both economic terms and in ameliorating human suffering are considerable.