If in the previous article we explored the theme of emergency and how Single Session Therapy adapts to psychological first aid models, today we will focus on the consequences that a tragic event such as the Pandemic can determine on a psychological and access to mental health services.
Furthermore, through the description of a clinical case in which the TSS method was applied with a woman involved in the 2010 Haiti earthquake , we will see how TSS can be concretely used in post-disaster intervention (Guthrie, 2016) .
What will await us after the Covid-19 Pandemic?
The forecasts are undoubtedly different, some more catastrophic , others more oriented towards a scenario full of hope , however beyond the hypotheses what we can say is that following a natural or other entity disaster, both the witnesses and the survivors to disaster they experience fear , uncertainty about the future and in some cases disorders such as anxiety , depression and symptoms of Post Traumatic Stress Disorder (US Department of Veterans Affairs, 2011; Galea, Nandi, & Vlahov, 2005; Norris, Friedman, & Watson , 2002a; Norris, Friedman, Watson, Byrne, Diaz, & Kanisty, 2002; Rubonis & Bickman, 1991).
How should one prepare for health disasters?
Health services should be integrated from the moment the emergency is triggered and the medical response should also immediately intervene on mental health (North & Pfefferbaum, 2013; Pfefferbaum et al ., 2012). In the aftermath of the disaster, survivors are faced with the task of rebuilding their lives and their communities , many people have also experienced the fear of losing their lives and those of their loved ones , others have lost family members and significant people in their life.
What could happen in Italy following the Pandemic?
Surely there will be several consequences, the first will be that of a great economic and job loss . This will lead to a general impoverishment of families and of the health resources to be made available, including those for mental health . At the same time , on a social level , people will have to rebuild their lives , providing for different ways of sharing spaces and everyday life .
What types of needs might the population face?
Many people, in addition to facing economic difficulties , will also need to access mental health services for psychological support . Among the first we will find the survivors of the coronavirus and the families who have lost their loved ones , the doctors and all the health workers who have worked on the front lines, suffering the stress of the heavy workloads and psychological traumas of the assisted people .
So how can so many needs be met with fewer economic resources?
Usually, in high-income countries , coordination at the national and community level of the implementation of disaster management plans is planned . In such countries, first responders can rely on a response system that allows access to public health, including mental health, which provides follow-up and treatment services for those continuing to struggle with physical injuries, stress and mental disorders . even long after the disaster.
But when resources are scarce or are we in low-income countries?
Many low- and middle-income countries generally have limited capacity health systems even before disasters. In a 2007 report on the global state of mental health services, Saraceno et al. (2007) have identified a number of barriers affecting the sustainable development of mental health services:
- insufficient mental health funding
- resources centralized and located near major cities
- primary care health care not integrated with mental health services
- low number of health professionals trained in mental health and not supervised
How can we intervene in these contexts?
Providing a single session of psychosocial support may be the only alternative available . Many communities after a disaster may find it difficult to provide essential life services, such as the distribution of food, water and in some cases even shelter. In the case of the Pandemic , for example, the resumption of a social life could take a long time being conditioned by some limits, including social distancing . Contagion-related phobias will develop and all the consequences associated with these discomforts.
Now let’s see in practice how a SST intervention can be carried out in extreme conditions
The case reports the experience of the therapist Brian Guthrie, specialized in the treatment of trauma , together with his team of doctors during the mission carried out in Cité-Soleil (Haiti) two years after the 2010 earthquake.
What damage did the earthquake cause?
The earthquake in 2010 caused widespread damage to the already precarious water and sewage pipeline system, putting survivors at even greater risk of contamination and disease. More than 300,000 people died, and it was estimated that 250,000 residences, 30,000 commercial buildings and 80% of schools were severely damaged by the earthquake. About 1.5 million people found themselves living in 1,555 temporary camps (Disaster Emergency Committee, 2014).
What services were available?
According to data provided by the Caribbean Country Management Unit (2006) before the earthquake, about half of the population did not have access to a formal system of general health services and even less to mental health services. The clinic where the SST service was provided was located in Cité Soleil, on the outskirts of the capital Port au Prince where some 300,000 people lived in extreme poverty . The city has been called a microcosm of all ills of Haitian society in which there was endemic unemployment, illiteracy, non-existent public services, unsanitary conditions, rampant crime and gun violence (Revol, 2006).
In which cultural context was the intervention carried out?
Culturally in Haiti mental health problems are often attributed to supernatural forces, as a result of a spell or curse passed on by a jealous person. Mental illness in particular is attributed to a failure to please the spirits of the deceased including those of deceased family members. In this context, Haitians often rely on their spiritual and religious beliefs to deal with mental health problems (Nicolas, Jean-Jacques & Wheatley, 2012; WHO, 2010).
The case is anecdotal and not intended as proof of the effectiveness of TSS, but is intended to illustrate how a SST intervention can be implemented following a disaster in situations of poverty . The example also demonstrates the importance of recognizing the person’s lived experience as valid in his/her cultural context.
A 75-year-old woman was referred for counseling following a medical evaluation where she presented as frail and malnourished, with headaches, muscle pain, low weight, and trouble sleeping. The doctor reported that the symptoms, although related to malnutrition, could also be the result of depression. The lady she was accompanied by two neighbors who had helped her since she had lost her family in the earthquake. The two women reported that the symptoms had emerged shortly after the earthquake and were now concerned as they were becoming more and more evident.
The therapist explained the nature of the single session right from the start . He reported that he would focus only on the aspects that the woman considered important in her life, making sure that the intervention could be placed in the specific cultural context of the woman’s life . Given the fear of stigma and the possible consequences of being identified as having a mental illness, the therapist first addressed somatic and physiological issues, then explored emotions and stress reactions.
The woman herself related the history of her physiological symptoms, confirming the significant increase in the severity of the latter after the earthquake and since she was left alone. She recounted how the earthquake killed her entire family, she began to cry as she recounted how she held her son in her arms as he died from injuries sustained in the collapse of the family home.
She related how happy she felt in life before the earthquake, her sense of pride as a mother, and how strong and healthy she was before the earthquake.
As she continued her narration, she spoke of her children, how overwhelmed she felt by their loss, and the bouts of deep sadness during which she could not eat or sleep. She described herself as solitary, avoiding people and places in the community that reminded her of her children.
According to an initial assessment, his symptoms were attributed to a difficulty in coping with the various stages of mourning and grief, the treatment of which involved the combination of cognitive behavioral techniques with other aspects of interpersonal psychotherapy and motivational interviewing (Simon, Pollack & Fischmann , 2005). But given limited resources and the inability to access psychiatric intervention, the recommended diagnosis and treatment were not applicable.
Significant, however, was the knowledge of human pain, the different intensity experienced between different cultural groups and between individuals. The goal was to uncover the woman’s unique experience, explore potential resources within the community, and help her deal with the grief process . The therapist asked questions that allowed him to obtain his collaboration and to identify those alternative behaviors capable of promoting a return to the psychological state prior to the crisis. The session focused on his attempts at coping, his strengths and his formal and informal resources. Subsequently, she asked her what was her hope for the interview and the woman replied that her goal was to get rid of headaches, body aches and be able to sleep.
Focus of therapy.
Consistent with TSS principles, the therapist redefined problems in terms of observable behaviors specific to his experience and under his control. The two main interventions were compliments and reframing : compliments allow the therapist to point out and highlight previously unnoticed, forgotten actions or resources or possessed strengths and skills ; Rephrasing is a technique used in TSS that offers the possibility to review one’s situation in a different way . It is the ability to look at a problem from another perspective, especially from a more accurate, more comprehensive or positive perspective (Flaskas, 1992).
After praising the woman for her love for her children and for her efforts to keep their memories alive, the therapist asked how she managed to survive after suffering such an unbearable loss without also being able to access food and shelter. The woman said it was God’s will and that her neighbors had taken care of her. The therapist’s hope was to draw on her strength, restore her sense of autonomy and trust, and to find possible solutions with her to implement.
The first step was to normalize her symptoms as an adequate response to the stress generated by the earthquake and the pain of her children’s death. A standard intervention for people experiencing trauma following a disaster is to normalize the physical and psychological problems experienced as normal reactions to an abnormal event.
The next step was to help her begin a healthy grieving process . After hearing how overwhelmed the ruminations about the loss of her children felt, the therapist focused the session on how she could remember them without rethinking their loss . He asked her to tell him about her children and what she adored about each of them. He also asked her what they would like her to do and what memories they would like her to keep close to her heart.
The woman replied that her children would want her to be happy, knowing that they were safe with God. As the session was drawing to a close, she thanked the therapist, stating that it had been very helpful for her to be listened to, understood, and that it had been lifted a weight from the heart. As she prepared to leave she said that she would talk to her children through her prayers and that she would tell him what she had talked about with the therapist. The woman believed that God would give her strength.
As the session closed, the therapist provided the woman with practical stress management techniques for dealing with her insomnia and anxiety . Formulating a treatment plan was complicated by the fact that it was not possible to refer the lady to a psychiatrist or mental health therapist for treatment of the diagnosis of complicated pain reaction, nor to proceed with follow-up . The therapist concluded the meeting by reframing the lady’s presentation about the physical symptoms associated with surviving the earthquake and the loss of her children as a first step in enabling her to see her problems as more manageable. Finally she encouraged the woman to return to the medical clinics she had previously attendedor in the area where he could receive follow-up for physical problems.
In the aftermath of a disaster, survivors are faced with the task of rebuilding their lives and their communities . Often in addition to experiencing fear , pain and anguish about the future , people are faced with job loss and impoverishment . This also affects communities that often find themselves lacking the necessary resources to respond to the growing needs of the population, especially those of mental health .
In this scenario, Single Session Therapy can be a valid tool especially in those contexts where immediate access to mental health facilities cannot be guaranteed or where continuity of treatment cannot be guaranteed . Furthermore, due to its characteristics, the TSS is able to promote the psychotherapeutic skills of the professionals already present in the structures and offer the person a specific action plan from which to start again.
Team Psychotherapist of the Italian Center
for Single Session Therapy
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