精神経誌（2010）112 巻 2 号

144

第回日本精神神経学会総会

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Psycho‑Social Interventions in Disasters: A Narrative Review
with a Focus on Bam Earthquake, Iran, 2003
Azadeh M alekian, M D（Behavioral Sciences Research Center, Isfahan University of M edical Sciences, Iran）

A deadly earthquake destroyed the city of

host and environment are examined to eluci-

Bam in Iran in 2003. The author, as a seniordate the “
causal pathway” to psycho‑social

resident of psychiatry at that time,participatedamong other impacts of the disaster.

in the psychosocial interventions carried out forthe survivors closely afterward.

With this

2. Haddon matrix model: In his matrix
model, Haddon considers the above mentioned

background and through an extensive review ininterrelations within each phase of the disasterdisaster psychiatry literature,this paper aimed（i.e.: pre‑event, event and post‑event phases）.

to brieﬂy introduce the principals of Psycho‑

Haddon also adds the forth factor（called vehi-

Social Interventions（PSI）in disasters, historycle）to the classical triad. His model has beenof PSI in disasters in Iran and to describe theused as a useful guide for mapping prevention

Bam earthquake and PSI carried out in Bam

and management strategies.

after the earthquake.

3. Disaster ecology model: This is a comprehensive model in which agent, host andDisasters and psycho‑social impacts

environment factors are reframed in terms of

In a vast amount of disaster literature,“forces of harm”, “
aﬀected population” andpsychosocial impacts have been recognized to“the ecological context of the disaster”. The

be among the most debilitating long‑term disas-

environment factors are special foci of atten-

ter consequences. Diﬀerent models have beention in this model. They are considered as aused to portray the causal pathway toward

continuum including three levels of ecologicalthose impacts. Also, many diﬀerent variables

context, namely individual family, community

have been studied regarding their associations

and societal structural factors. Risk and pro-with disaster psycho‑social impacts as a whole,tective factors for and against disaster negative

as well as with some speciﬁc common mental

impacts can be comprehensively described indisorders in disaster survivors.

this context.

Models to illustrate psycho‑social

Variables inﬂuencing psycho‑social

impacts of a disaster

impacts of a disaster1. Epidemiological triad model: In this

These factors can be best explained withinmodel,the classical interactions between agent,

the disaster ecology model. The variables canシンポジウム：Disaster and M ental Health145

be categorized to factors related to the disasterof controversy and contradictory ﬁndings in

itself（forces of harm）and ecological context

diﬀerent studies.

factors. The detailed discussions about thevulnerability of female gender has been

relationships of these factors with theattributed to other variables like level of educa-

psychosocial impacts of disasters are far be-tion, social support and economical status inyond the capacity of this paper. So hereunder

several studies. Many other mentioned factors

these factors are just introduced as a list :have also overlaps and interrelationships.

1）Forces of harm factors including :a）Disaster type:For example, the higher

The way in which some of these factors
may aﬀect the psychosocial impacts seems

・natural disasters

clear. Just as a very relevant example about・human‑generated disasters

the role of physical environment,one can noticeb）Disaster magnitude:
Including the concepts of relative andabsolute magnitude

that : The cities of Kobe in Japan and Bam in
Iran were shaken by earthquakes of comparable magnitude in 1995 and 2003, respectivelyc）Time dimension（This is why the Bam has been called as one ofd）Place dimension

the Kobeʼs sisters）. Most buildings in Kobe

2）Ecological context factors （proximal tocould withstand the earthquake, while those indistal layers）:

Bam collapsed almost completely. Absolutea）Individual family factors including :numbers of death and morbidity rates were・Gender

substantially higher in Bam. Health infras-・Racetructures in Bam were also destroyed complete-・Ethnicity …

ly and the time period for reconstruction of theb）Community level factors including :Bam city was much lengthier followed by more・Social support

prolonged community suﬀering. The tale of・Community socioeconomic status

these two cities regarding the diﬀerence of・Social environment

psycho‑social impacts is a real human tragedy.

c）Societal structural factors including :・Geography

PSIs in disasters; general principles

・Physical environment
・Cultural context

and common practices
PSIs for disasters are generally program-・Political structure and governance

med in three diﬀerent levels in which the target

・Health and socialservices infrastructure

population who would receive and the execu-

Some of these factors have been a focus oftors who would do the interventions areattention in several studies. For example,it isdiﬀerent.

of a wide consensus that human‑generated

The ﬁrst level or the so‑called promotion

disasters, especially those in which harm isactivities are the basic PSIs beginning from theintentionally produced, are associated withearly phase of the disaster. Activities in thismore negative psychosocial impacts than natu-

level are done by community members andral disasters.

para‑professionals and the receivers are theSome other factors have been the subject

whole aﬀected population.

精神経誌（2010）112 巻 2 号

146

The second level or prevention activities
begin later, are executed by trained counselors

aﬀected people as helpless victims10）Empowerment : PSIs should help people toand other mental health professionals andﬁnd solutions and solve their own problems

aimed toward those who manifest signs of11）Normalization and avoiding medical mod-ongoing adjustment problems.
The third level of PSIs are done bypsychiatrists and clinical psychologists and are aimed
for those people with full‑blown psychiatricdisorders like generalized anxiety, major depressive and or posttraumatic stress disorders
which have been either presented or exacerbated after the disaster.
Though PSIs may vary in practice accord-el: People should learn that their problems
are natural transient reactions to such hugestressors12）Utilizing family capacities even when they
are limited13）Advocating basic needs and information
dissemination
14）Focusing on stress and adaptation, nottraumatization

ing to diﬀerent disaster types and manycontex-15）Focusing on resilience, not vulnerability

tual factors,there are some generally‑accepted16）Paying attention to speciﬁc issue with cul-core principals in this regard. These principles

tural considerations（e.g. burial of deadare conclusions derived from several studies inbodies, rituals and grief）

disaster mental health and should be consideredin any PSI activity and program. Hereunder

PSIs in disasters: Common practices

some of these core principals are brieﬂy

The speciﬁc activities which are practiced

introduced :as PSI in disasters vary according the event

1）First of all “
Do no harm”: interventions

phase. Some activities should have begun be-should be evidence‑based and avoid activi-

fore the disaster occurs. This phase is called

ties which may interfere with the normal

mitigation or preparedness phase.

recovery

activities in this phase include:2）Respecting for the views of the target
people3）No discrimination including attention tovulnerable disadvantaged groups4）Conﬁdentiality
5）Honesty and objectivity
6）Responsibility: providing information about each intervention as well as ensuring
informed and voluntary participation
7）Avoiding further exposure to violence（e.g.
malpractice in psychological debrieﬁng sessions）

Common1）Development of a coordination system,
speciﬁcation of focal authorities responsible
for each relevant agency, with plans forcollaboration with other governmental andnon‑governmental resources2）Designing detailed plans to prepare for a
psycho‑social response3）Training relevant human resources and personnel
4）Need assessment
When a disaster strikes, the choice of PSI
again varies with the phase of the event. As a8）Specialization and referral

broad classiﬁcation two main phases are consid-

9 ）Community participation : PSIs can doered hereafter. The ﬁrst phase is called acuteharm in the case of dealing with the

emergency phase or disaster phase. This is theシンポジウム：Disaster and M ental Healthperiod during which the mortality rate is sub-147

purposeful, common interest activities

stantially elevated because of deprivation of・Wide dissemination of understandable, reas-

basic needs due to the disaster. In psycho‑suring, emphatic information on normalsocial program this phase is compatible withstress reactions to the community at large

the promotion level activities. This period iswith a focus on normal reactions

followed by a re‑consolidation phase when・Establishing people contact with mental

basic needs are again substantially met. This

health care in the local area and managing

phase is matched with the prevention and treat-urgent psychiatric complaints as far as possi-

ment levels of psychosocial program.

ble without medication following the principles of ʻ
psychological ﬁrst aidʼ

Valuable PSIs in the disaster phase・Organizing outreach and non‑intrusive emo-

・Disseminating reliable important information

tional support in the communitybyproviding,on the event itself,relief eﬀorts and the loca-

when necessary, ʻpsychological ﬁrst aidʼtion of relatives
・Organizing family tracing

Commonly suggested PSIs in・Brief ﬁeld assessment in the areas whereother basic supports are presented
・Organizing shelters in a way to promote
family re‑union

re‑consolidation phase・Continuing the alreadystarted relevant social
interventions
・Organizing outreach and psycho‑education to・Consulting the community regarding deci-

educate the public on availability or choices

sions of location and essential supplies in theof mental health care. Commencing no ear-camps. Providing religious,recreational andlier than four weeks after the acute phase,

cultural spaces in the design of camps

the public should be carefullyeducated on the・If realistic, discouraging unceremonious bur-diﬀerence between psychopathology and nor-ial of dead bodies. Contrary to myth, deadmal psychological distress, avoiding sugges-

bodies carry no or extremely limited risk fortions of wide‑scale presence of psychology

communicable diseases. Death certiﬁcatesalso need to be organized・Re‑establishment of normal cultural and religious events
・Facilitating the inclusion of vulnerable individuals into social networks

and avoiding stigmatization
・Encouraging people to apply their pre‑existing positive ways of coping. Encouraging
economic development initiatives
・Educating other relief workers as well as
community leaders（e.g.,village heads,teach-・Organization of normal recreational activi-

ers, etc）in core psychological care skills

ties for children ; being careful not to hand・Ensuring continuation of medication of psy-out recreation materials considered to bechiatric patients who may have had access toluxury items in the local context before themedication during the acute phase of thedisasterdisaster・Starting schooling for children, even if partially・Involving adults and adolescents in concrete,・Training and supervising community workers （i.e., support workers, counselors） toassist health workers with heavy case loads

精神経誌（2010）112 巻 2 号

148

・Collaborating with traditional healers when
feasible・Facilitating creation of community‑based

disasters had a very eﬀective and organizedactivity for the survivors of Bam earthquake
which will be introduced brieﬂy.

self‑help support groups
PSIs in the Bam earthquake
History of disaster mental health care in Iran

The Bam earthquake has been one of the

Iran ranks among the top ten disaster‑

most devastating natural disasters in the world.

prone countries of the world, ﬁfth in Asia fol-

Earthquake struck on a very cold winter morn-lowing China, India, Bangladesh and Pakistan.

ing, Friday, December 25 , 2003, at 05:27 a.m.

The most common natural disasters regardingwith the strength of 6.8 on the Richter scale.

the number of occurrence are: earthquake,Over 30,000 people were injured and 85,000

ﬂood, drought, extreme cold and ﬁre.

people became homeless（85 percent of houses

The ﬁrst organized disaster mental healthwere completely destroyed）. City was virtuallyactivities in Iran began in 1991 with developing

ruined and all social and economic services

a National Committee for Disaster Reduction.

were totally destroyed. Fifty percent of the

One of the subcommittees of this national com-

health staﬀ and school teachers were killed.

mittee was designed for health,to be headed byArge（Citadel）Bam, a major historical world

the minister of health. Mental health oﬃce intreasure was almost completely destroyed（itthe M inistry of Health（MOH）in collaboration

was the largest mud‑brick structure in thewith experts from Shahid Beheshti Medical

world which had guarded the Silk Road for

University planned a proposal on mental healthover 2,500 years）.

service delivery to survivors of natural disas-

Regarding the large scale disaster,the hugeters.The activity began with a review of inter-

number of mortality and morbidity, and thenational ﬁndings on disaster mental health as

extreme exposure of survivors to loss,grief andwell as a comprehensive need assessment

catastrophic change, their need to support toresulted in designing a national plan. Execu-

overcome the psycho‑social consequences wastive, educational and research strategies werea clear fact.

developed. A series of manuals were prepared

PSI was directed by the mental healthfor the public,relief workers,professionals andoﬃce in MOH and stared from the ﬁrst day.

executive oﬃcers. Relevant human resources

UNICEF supported the PSI program and later

began to be developed. Several training of

WHO launched a long‑term program for rebuil-trainers（TOT）workshops were hold for theding the mental health services network in the

Red Crescent trainers, who in turn trained theregion.

relief workers on basic skills for social support.

Only a concise review of the interventions

UNICEF also supported a series of profession-

would be possible to be presented here: The

alsʼtraining.

psycho‑social interventions after Bam earth-

The national program did its ﬁrst real

quake divided into two stages.（The communi-

activity in June 2002 after the Abgarm earth-ty preparedness before the earthquake phasequake in Iran. One year later the national

was almost none.）

program for mental health risk reduction inシンポジウム：Disaster and M ental Health

Immediate PSIs（0‑2 weeks）

149

complished for all screened survivors.

In this stage MOH rapidly erected a

The content of group trauma counselingpsychosocial post,directed a rapid psychosocial

sessions diﬀered according the age and theassessment and coordinated information dis-

problem subject of intervention but generally

semination and tracing activities. Injured survi-

included psychological debrieﬁng

vors who were transferred to other cities con-training sessions for self‑management of symp-

nected to their families via messages throughtoms like re‑experience of the trauma, hyper‑

emails, radios and billboards.

arousal, anger, irritability, and maladaptive

sessions,

M ental health workers and trained clergy

avoidance from reminders of trauma. Special-

men helped people in holding funeral andized children groups were also formed andmourning ceremonies.

parallel education groups for parents or others

M OH coordinated inter‑sectoral mental
health activity especially with Red Crescent
and welfare organization.

in charge for children care were held.
The other valuable activities which were
held by MOH with UNICEF collaboration and

The other major activity of M OH was

support were school and community interven-mobilization of man‑power both local and fromtions,training activities and regular evaluation

other country parts. Orphan support and trac-

and monitoring of the above‑mentioned activi-

ing activities were done in collaboration with

ties as well as relevant research and studies on

the state welfare organization.

psycho‑social post‑disaster issues.

M id term interventions（3 weeks‑6 months）
In this stage, the outreach activities andtent visits were carried out by psychologists,

Personal observations as a psychiatricresident participating in
PSI after the Bam earthquake

psychiatrists and psychiatric residents. Survi-

As a resident of psychiatry at that time, I

vors were gathered together in groups, andwas trained to perform psychological ﬁrst aid

initial psychosocial support （psychologicaland screening activities in the ﬁeld as well asﬁrst‑aid）was done. People with adjustment

directing and facilitating group counseling ses-

problems were screened. These screened peo-sions with diﬀerent groups of people. I worked

ple were again gathered together inin Bam in the mid term intervention phase（3homogenous groups（regarding sex and age）

months after the earthquake）and stayed there

and then professional group intervention wasfor one month.

started for them. These interventions were

In a close contact with many people, espe-

based on a modiﬁed national package based on

cially in psychological debrieﬁng sessions, I

the package originally developed in the United

learned a lot about their experience and theirKingdom and Norway. Traumatized people

sorrows. Hereunder, I would like to communi-

attended four sessions of group intervention

cate some of my observations to the readers ofwith weekly intervals and did homework inthis manuscript and to narrate some otherbetween.

aspects of Bam earthquake just as a personal

The program approached a total

coverage within the ﬁrst year after disaster andobservation.

professional group trauma counseling was ac-1）Bam is an ancient citywith a rich tradition-

精神経誌（2010）112 巻 2 号

150

al culture.Strong familyrelationships were

punishment by God. This belief was foll-apparent. Re‑uniﬁcation of families had

owed by diﬀerent attitudes toward thehelped them to overcome some of the prob-

earthquake. Some people had a sense oflems with each othersʼhelp. Most of thoseguilt, and others had anger toward thosechildren in Bam who had lost their either

who had implicated that “
you have beenor both parents in the earthquake,had beenpunished by God”
. They frequently em-

protected by other family members. The

phasized that they did not deserve such amost traumatized individuals beneﬁted

bad catastrophe. On the other hand, somefrom other family membersʼand relativesʼ

suspiciousness about the nature of theattention and support. This social embed-

disaster had been aroused. We frequently

dings seemed to be a resiliency factor.

heard that people say“this has not been an2）Bam people had been living under a rela-earthquake. It has not been the Godʼs act.

tively hard life situation even before theIt has been a kind of bombing. God is notearthquake. The weather in Bam is ex-

so cruel toward us. It has been a massive

tremely hot in summer and extremely cold

man‑made disaster.” This was a disturb-

in winter. The people were generally poor

ing sense of mistrust toward the news

even before the earthquake. Living in hardwhich would interfere with the peopleʼ
ssituations may have contributed to thepsycho‑social rehabilitation.

hardiness of the society, as a resiliency

issue was being discussed in the tents,they

factor against trauma. In debrieﬁng ses-

could better accept the reality and theysions, people frequently compared them-were somehow relieved. Clergy men andselves with the date trees in Bam who were

all other relief workers had been trained tostill alive and stable.

put example verses from the Holy Koran

When the3）Partly due to psycho‑social intervention

which assumes a disaster as “
a new life

activities, but mostly due to the peoplesʼ

chance for the survivors”rather than “aown bounding to their traditions,the tradi-punishment from God”.

tional ceremonies were resumed very soon5）The low speed in which reconstruction ofafter the earthquake. On the third month

the citywas going on,could somehow inter-

after the earthquake, people made them-fere with the peoplesʼpsycho‑social adap-

selves ready for the new year. They didtation. Schools had been held in tents andtheir best to keep their traditions alive.

many other social valuable ceremonies and（New Yearʼ
They held the “
norooz”
s ﬁrstactivities had been established while peopleday）ceremonies in the huge cemetery ofwere still encountering problems with re-the city in which their loved onesʼhad been

sponding their basic needs.

buried in groups. Even the new couplesʼ

term, one can say that psychosocial inter-marriage ceremonies were held in a tradi-

ventions were somehow ahead of othertional from in the tents although with so

supports.

many tears in peoplesʼeyes.

In another6）Numerous secondary stressors, including4）As a common belief, many people in Bam

insecurity feelings and the problem withassumed that the earthquake can be a

insects, spiders and scorpions around theシンポジウム：Disaster and M ental Health151

tents were visible. In the ﬁrst days after

casting ﬁlms in the public which showed

the disaster, robberies and abducts had

terrible scenes of the disaster and sellingbeen occurred by some opportunist thieves

such video‑CDs to people.

coming to the city. The trace of fear and11）Many people didnʼ
t trust the governmental

hatred toward this happening was seen in

authorities about the honest‑delivery of allchildrenʼs drawings（for example, the 8national and international donations.

year boyʼs drawing which showed a thief12）Another source of mistrust was about thebusy disconnecting and picking up a ring

information dissemination.People believedgold around a dead womanʼs wrist）.

that the national media including local and7）People believed that the catastrophe could

widly circulated newspapers spread news

be less devastating if the minor earth-in a way to minimize the disaster severity

quakes which had been shaking the cityand impacts and to exaggerate about the

before the major disaster had been taken

progress of reconstruction activities.

serious by the government. They wished13）Most people warmly welcomed the groupthey had been evacuated （Many people

counseling sessions and regarded these ses-stated that after many other minor earth-sions as one of the most useful helps andquakes, they had experienced a terrifying

supports they had received.

ground‑shake the night before the disaster,14）Some people argued that their dignity has

which made them to rush outside of the

been neglected by the way they hadbuildings,but they returned home and slept

received some of the basic supports.

there after a short while, because they15）As a whole, people believed that seeing so

could not tolerate the very cold weather ofmany people rushing toward them for help,that winter night）.

both from inside and outside country was8）Despite many eﬀorts by the PSI workers

the greatest source of hope for them,induc-and as a result of the huge mortality rate,

ing a sense of responsibility to re‑organize

many dead bodies had been buried in atheir life.

non‑ceremonious manner and this had
apparent negative impacts on many survivors.

Acknowledgement
I would like to extend my sincere thanks toward all9 ）Children and adults had spent a non‑evita-

JSPN and JYPO authorities and members for providing

ble diﬃcult time besides the dead bodies ofme such a great experience to take part in their annual

their loved ones（even the mutilated andgrotesque ones） before they could ﬁnd avehicle to carry them to the place of bury-

congress in Japan and to communicate with my colleagues from other Asian countries. I also give my
special thanks to Professor Akiyama and Dr M ariko
Setsuie for all their help and kindness, to Professor

ing. This was a catastrophic experience

Ahmad Jalili, the head of Iranian Psychiatric Associa-

for many people, especially children.

tion, for his helpful contribution, and to Dr Yuriko

10）Some highly sensationalistic social activi-

Suzuki and Professor Shinfuku for their perfect man-ties were held by some of the local people（and this is discouraged in disaster mental
health literature）. The example is broad-agement of Disaster Psychiatry symposium.

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精神経誌（2010）112 巻 2 号

152

References
1）Amaratunga, C.A., Oʼ
Sullivan, T.L.: In thePath of Disasters: Psychosocial Issues for Preparedness,Response,and Recovery.Prehospital and Disaster
Medicine, May‑June 2006

Crisis Counseling Programs for the Rural Community:
Disaster Crisis Counseling Services for Rural Areas,
www.mentalhealth.samhsa.gov, 2005
7）Sadeghi, N., Ahmadi, M .H.: Earthquakes andM ental Health（draft）.International Institute of Earth-

2）Ehrenreich, J. H.: Coping with Disasters: A

quake Engineering and Seismology（IIEES）,Risk M an-

Guiodebook to Psychosocial Intervention. John H.

agement Research Center, Socio‑Cultural and Econom-

Ehrenreich, 2001

ic Department, Tehran, Iran, 2006

3）Hobfoll, S.E., Watson, P., Bell, C., et al.: Five

8）Shultz,J.M .,Espinel,Z.,Galea,S.,et al.: Disas-

Essential Elements of Immediate and M id‑Term M ass

ter ecology: implications for disaster psychiatry.Text-

Trauma Intervention : Empirical Evidence, Focus 7.,

book of Disaster Psychiatry. Cambridge University

American Psychiatric Association,Washington,D.C.,p.

Press, Cambridge, 2007

221‑242, 20094）Kirschenbaum, A.: Chaos Organization andDisaster Management.M arcel Dekker,Inc.,New York,

9）Wiles. P., Sida, L., M oossavi, N.: Unicef Iran
Bam Emergency Programme 2003‑2006. Independent
Evaluation, Final Report. 200710）Yasamy,M.T.,Farajpour,M .,Gudarzi,S.S.,et20045）Lopez, J., Christodoulou, J.: Disasters andal.: Disaster mental health care in iran : Responses

Mental Health. John Willey and Sons, West Sussex,

based on needs. Advances in Disaster Mental Health2005

and Psychological Support. Voluntary Health Associa6）National Mental Health Information Center.:tion of India Press, New Delhi, 2006