January 14, 2005,
The Therapy Reflex
Psych aid shouldn’t be the first on a trauma scene.
To many mental-health workers the tsunami is a time for action. So much trauma, so little time, is the mindset. They should talk to someone themselves a Sri Lankan psychiatrist called Ganesan. He is the only psychiatrist for the country's entire eastern population of 1.3 million. Since the giant waves hit, Ganesan (who goes only by one name as is customary in his country) has been coordinating foreign aid, distributing medicine to children, and transporting corpses in his pick-up truck.
What he doesn't do is therapy.
"To talk about psychological needs when you've got thousands of people using one toilet in a refugee camp it's absurd," Dr. Ganesan, 41, told a Washington Post reporter. He is right. The main issue at this stage is to ensure the physical safety, locate missing friends and family members, and disseminate accurate information. Schools opened on January 10, the end of the country's annual holiday. More than any therapy this will promote effective coping by maintaining routines for children and keeping them busy.
In short, the prescription is this: Minimize disorder and plan for the future and for the vast majority, coping will follow naturally.
This kind of approach is anathema to a swath of contemporary mental-health workers. Dubbed "trauma tourists" by some mischievous colleagues of mine, they are quick to impose Western-style therapies without regard to victims' needs, their natural healing systems, or their very conception of what "mental illness" might be. "This is not what a doctor should do," says Ganesan who has tried to talk agencies out of sending grief counselors.
The Post article itself was a minor revelation. So many other tsunami stories played up the psychological fragility of tsunami victims: "Psychiatrists Worry Tsunami Will Cause Stress in Some Survivors for Years" (Associated Press).
To Ganesan, the agony of the tsunami was existential in essence, not psychiatric. He has come to understand, wrote Post reporter Neely Tucker, "that to suffer is to survive.... To bear it with grace and courage is to live." This reflected the first teaching of Buddhism, the principal religion of Sri Lanka, that life is suffering and that this cannot be avoided.
It is a sensibility not unique to the East. After World War II the renowned psychiatrist and Holocaust survivor Viktor Frankl pointed out, "Suffering is not always a pathological phenomenon...suffering may well be a human achievement." In other words, suffering can be ennobling. And even when calamity does not strengthen its casualties, a possibility that Frankl certainly acknowledged, it is unclear that clinical intervention will diminish the anguish.
Timing is everything when working with trauma survivors. Crying, trouble sleeping, problems concentrating, a profound sense of dislocation are not pathological within the first few weeks after a catastrophe. Mental-health expertise should be reserved for people who remain disabled by these symptoms after three months or so, the time they typically start to fade.
The immediate crisis is a time when victims need civic order to support the bedrock institutions and relationships families, communities, churches, indigenous healers that have always served them in times of uncertainty and immense sorrow. In this case, providing toilets, food and protection against disease, and giving people a semblance of normal life, should be the major form of treatment.
Frequently, humanitarian psychological aid is seen by non-Western recipients as a kind gesture but a bad fit. To downplay the need for professional psychotherapy in no way diminishes the sea of misery that surrounds Ganesan. But psychological first aid has little to do with clinicians.
Dr. Sally Satel is a psychiatrist and a scholar at the American Enterprise Institute. She is co-author of One Nation Under Therapy (with Christina Hoff Sommers) to be published in April by St. Martin's.