Friday, September 17, 2010

Psychiatric Treatment after the Haiti Earthquake

I just read an article on "Haiti Earthquake Psychiatric Relief" in this month's American Journal of Psychiatry, written by Kent Ravenscroft, a good friend ever since our residency training days.

Kent tells about his intervention with a medical student who had been buried in rubble for 4 days. The treatment is a brilliant model of "battlefield" mental health treatment. It conveys what a privilege it is to be able to work with fellow human beings in circumstances of crisis. The intervention embodies what it means to treat people with respect, to listen to them carefully, and to build on their strengths. Kent's spontaneous comment to the medical student/patient brought tears to my eyes.

Here is the clinical story Kent tells:
At one clinic a young woman walked in complaining of insomnia, palpitations, visions, and voices. I encouraged the Haitian doctor to get every detail. The voices and faces were fellow medical and nursing students who had been trapped with her as their building collapsed in Port-au-Prince. Trapped in pitch blackness, pinned under rubble, she could hear the voices, the screams and cries, of those injured and dying around her. Over 4 grueling days she heard her friends' voices becoming weaker and finally dying out, leaving her alone with only one friend's voice, somewhere way above her. This faithful friend knew she was down there and told the rescuers. Then the friend's voice, too, became weaker and died out, leaving the woman utterly alone.

Our patient could hear a rescuer calling her name. Finally she found enough strength to call just once, loud enough to be heard. Her throat was parched, and her loneliness deafening, but she did not give up. She felt she had to survive. She was the last of all her friends. Then, finally, someone got to her feet. She had been suspended upside down the whole time. As she talked with us, encouraged to open up about her darkest hours, her voice grew stronger, calmer, and more certain. I finally blurted out that I was so proud to have someone like her as a member of our profession.

She broke out into a radiant smile and told us she was hoping to go back to medical school when and if classes started. She would be finding out the next day when that might be. She already knew that two-thirds of her class of 45 had died, and she confessed that she was petrified about going back. She was having palpitations and hyperventilation, with panic-like attacks when she thought of getting near the collapsed school building again. She dreaded finding out who else had died, including teachers. We gave her some diazepam for her insomnia and her anxiety, in addition to three desensitization and behavioral techniques to give her ways to systematically move toward mastering her fears, thoughts of impending disaster, and phobic avoidance of school and her future.

She had told us she was a student leader, so we suggested she could help others share painful experiences and learn these treatment techniques, allowing her to re-find her community and overcome her fears and mourning. We asked her to bring a journal of her homework accomplishments to an appointment at our next clinic, a week hence. We clarified issues around survivor guilt, emphasizing that she was living for herself and that her self-exploration and healing would allow her to be a better, more compassionate doctor sometime quite soon.

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