Sunday, Jan. 17, 2010

Haiti: After the Devastation, the Emotional Wreckage

The scale of the earthquake devastation in Haiti is all but impossible to measure accurately now. Eventually, it will be reduced to hard numbers: so many people killed, so many buildings destroyed, so much wealth and infrastructure lost. There will, however, be invisible injuries too — to the psyches of the survivors. Emotional wounds may be the slowest to develop, but they can also be among the toughest to heal.

It may seem premature to think about now, but Haitians who survive the horrific earthquake will be at risk of developing post-traumatic stress disorder (PTSD). Americans have become increasingly familiar with PTSD in the wake of 9/11 and Hurricane Katrina, not to mention in the experiences of veterans returning from the wars in Iraq and Afghanistan — who have suffered such symptoms as depression, anxiety, emotional numbing, sleep difficulties, substance abuse and more. The Veterans Administration estimates that 7% to 8% of the U.S. population will suffer from the disorder at some point and 5.2 million Americans experience it in a given year.

The way individuals or an entire culture respond initially to a trauma is not necessarily an indicator of whether they're likely to develop PTSD — though it never hurts to get feelings out in the open early. The Russians and British are famously stoic sufferers. Americans are more candid about what they're feeling. Haitians are better still.

"We express what we feel differently," Haitian-born psychologist Marie Guerda Nicolas of the University of Miami told in a conversation shortly after the quake. "There may be a lot of crying and wailing. [Survivors] may faint, they might fall down, but it doesn't mean they're not able to cope or function."

Indeed, most people function remarkably well in the midst of a crisis. It's only when the shaking or the shooting or the flooding stops that PTSD begins to appear. "The psychological impact doesn't occur until several months later," said Nicolas. "When things get start to feel the impact and the sadness of the images you witnessed."

That post part of the post-traumatic reaction is what so often takes people by surprise. The brain, however, processes fear in a particularly lasting way and once lessons about danger are learned they're very hard to unlearn. Indeed, research that was coincidentally published in the New England Journal of Medicine the day after the quake shed some light on that idea.

In the study, Navy scientists reported that when doses of morphine are administered immediately after a traumatic event — which is often just what happens when soldiers are wounded on the battlefield — the likelihood of PTSD is halved. The researchers aren't certain what the mechanism at play is, but they speculate that the drug might be working in three ways: by blunting pain, and with it the sense memory of that suffering; by dulling recollection of the trauma itself; and by reducing the production of norepinephrine, a neurotransmitter that amplifies fear signals. The Haiti victims, of course, will get no such chemical balm.

The relief teams now pouring into Haiti from around the world do include plenty of doctors, and among them are mental health professionals. For now, however, they will be performing only psychological triage. "The victims aren't equipped for counselling now and the psychologists will be doing mostly assessment," says psychologist Raymond F. Hanbury, a trauma expert at Mount Sinai School of Medicine in Manasquan, N.J. "They first have to see what people's more basic needs are."

Ultimately, though, the PTSD will show itself. Treatment, which is readily available and very effective in the developed world, includes cognitive therapy (reframing the experience as something terrible but survivable) and behavioral therapy (gradual exposure to the memories and images the person is trying to avoid in order to strip them of their power). Antidepressants and other drugs may also help. In Haiti, where basics like paved roads and running water were in short supply even before the quake, such mental health luxuries may never be forthcoming. Instead, Nicola says, the victims may have to rely on what is known as lakou — the extended web of friends and neighborhood that forms a critical part of Haitian culture.

"In Haiti," she says, "people in your neighborhood are an integral part of your family. If you're a family of two and you live in a lakou, you have 15 family members that will be responding to you at any given time if you need it." A country that is poor in so many things, is at least rich in that. It's something Haitians will need more than ever as they face the months ahead.