Tending to Japan’s Psychological Scars: What Hurts, What Helps

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Even seen on tiny screens from thousands of miles away, the images of destruction in Japan are devastating. The emotional aftermath seems unimaginable, and yet once the immediate crisis is over, the survivors will certainly be faced with it.

Experience with past disasters suggest that some types of psychological first aid may help those who have lived through them, but others can actually cause harm. Scott Lilienfeld, a professor of psychology at Emory University, has written and spoken about “critical incident stress debriefing,” a technique often used by counselors who travel to disaster sites, such as Ground Zero and New Orleans. Research finds that some versions of this technique may double the chances that a trauma victim will suffer post-traumatic stress disorder (PTSD).

I spoke with Lilienfeld, who is an expert on the research evidence on the risks and benefits of the most commonly employed post-disaster counseling techniques.

So, how could the counseling of survivors immediately after the tsunami and earthquake possibly backfire?

No one knows for sure why it’s not a good idea, but given what the research shows, [some kinds of debriefing can be harmful]. It usually involves putting people in groups very shortly after the traumatic event and strongly encouraging them to “Get their feelings out” and “Talk about it” and so on. In classic debriefing, they almost prescribe symptoms, saying things like “Don’t be surprised if you start feeling X, Y or Z” or “There’s a good chance you’ll have nightmares or flashbacks.” There’s some speculation that that [in itself] might bring some of the symptoms on, so I’m not sure that’s a great idea.

What does the research find?

The research shows that [this type of debriefing is] probably at best ineffective and may actually be harmful in some cases. [It’s not clear why]. Some of what happens is that you have to respect individual coping mechanisms. Some people are ready to talk and some prefer not to talk. One problem with classic debriefing is that it often strongly encourages or urges people to talk about emotional memories that they may not really want to talk about. It’s best to kind of leave it alone.

[Another] thing we know is that if you want to deal with anxiety, you have to allow anxiety to peak first and then pass, and give people enough opportunity to fully process it. [These techniques] may bring up some anxiety and increase it, maybe even bring up new anxieties and not really resolve them or make them worse.

But one recent paper claimed that the evidence of harm [from debriefing] was overstated, so there is still some controversy over whether it’s useless or actively harmful — but even these authors admit that when used sloppily, [debriefing] probably is harmful.

I’ve heard that another problem arises from the fact that the counselors are strangers. They come into a situation from outside and are not known to the survivors.

It could be that there would be problems with strangers, but I think that a bigger concern is that [interventions] have to respect people’s culture. There are certainly cultural similarities between the U.S. and Japan but there are also other cultural differences that have to be respected.

Japan tends to be, in a broad generalization, somewhat more of a collectivist culture. There’s often more respect for community and group harmony, group cohesion. There’s a danger in people coming in who are not sufficiently culturally sensitive to those kinds of issues. They need to be very careful that interventions they use are culturally attuned.

How important is social support to recovery from trauma?

One of the few particularly bright spots here is that collective cultures offer strong social support. If I were trying to help, I wouldn’t worry too much about PTSD; I would focus instead on practical things that are most likely to help. I’d try to harness community togetherness to the extent that they can, work to put people in touch with each other, give them the chance to talk with their neighbors.

There are lots of studies, a very consistent literature, showing that in the face of stress or trauma, social support is a powerful predictor of positive outcomes. It could be that social support is somehow causing positive outcomes, or it could be that the kind of people who obtain social support are more resilient to begin with, but it’s fairly likely that social support itself can be helpful. It certainly can dampen stress.

We’re a very social species. It’s amazing what we can cope with when we’re around other people coping with the same thing.

How likely are people in Japan who’ve survived these disasters to suffer from PTSD?

It is no doubt utterly horrifying beyond anything I can fathom, but there is also no doubt that many people — probably most — will get through it without [developing PTSD]. Most studies show that even after a horrific disaster — and this is especially apocalyptic — about 70% are resilient and don’t show significant symptoms of PTSD.

But many people show some symptoms; you’d have to be abnormal not to be upset or have trouble sleeping — if you aren’t anxious at all, you’re probably psychopathic! So some mild PTSD symptoms like nightmares and jumpiness will be common early on, but 30% is typically the upper limit for significant ongoing PTSD. And that is good news, or at least comforting news.

Is it harmful to assume that most people will be traumatized?

What sometimes happens after these kinds of events is that we see interviews with psychologists who start predicting epidemics of PTSD, saying everyone’s going to develop PTSD. Psychologists should be careful about making those kind of predictions; in fact, there’s speculation that that [could actually produce] a self-fulfilling prophecy. People may think they are supposed to be weak and won’t fight it when they start developing symptoms — they think they may as well give up. I’m not sure how often that happens, but I suspect that it may happen.

So what can psychologists or even friends and relatives do to help?

There is preliminary research on psychological first aid and there are some procedures that have shown some promise. Most are not like debriefing; they’re not forcing or pushing people to talk about their emotions. It’s more about being there, having people available to talk if people want to talk, bringing together community resources, putting in touch people who are trying to reach each other. There’s some evidence that may be effective. Having someone there to talk to can be enormously helpful — just knowing you’re not alone.

Also, we’ve all probably discovered that when we’re stressed out, many people find that getting back into life and distracting yourself and throwing yourself into what you’re doing is healthier than wallowing.

Psychology seems to have a bias against distraction. Obviously, some ways of distracting yourself can be harmful — you shouldn’t shoot heroin, to take an obvious example — but some aren’t. You could go for a run or even just watch TV…

Yeah, some kinds of distractions are probably not helpful, but some forms of distraction are getting back to living again. Getting back to friendships, going back to [work if you can], making dinner if you can. Those are healthy because they harness natural coping mechanisms.

So you should be there for survivors of trauma, but you shouldn’t try to force them to talk about it?

If they don’t want to talk, respect that. I don’t know enough about popular psychology in Japan, so that may be a more distinctively American notion. But if a friend does want to talk, be a good listener.

You have to respect the person’s own preferred coping mechanism. Some people like to talk and some don’t. I know of a case of a man who was on the front lines in the Korean war. A bomb blew one of his closest friends into pieces, but he walked away with a few scratches. He saw it and he made clear that he had no intention of ever talking about it. He doesn’t have PTSD. I’m not saying everyone should deal with it that way. He was always a sort of “man’s man” — that was his style. But some pop psychology would say, “It must be eating away at you, like a toxin. You have to get it out.” I think that’s dangerous.

[Consequently] flooding these parts of Japan with counselors is probably not going to be the most helpful thing you can do. But having people on hand to listen is not a bad idea [so long as they don’t push and] stay out of the way. These people have been through enough. You don’t want to increase the risk of PTSD, which may happen, if this is not done properly.

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