特別講 演

第 116 回日本精神神経学会学術総会

The Rewards and Challenges of Disaster Psychiatry
Craig L. KATZ
Icahn School of Medicine at Mount Sinai

Disaster psychiatry is an area of practice that seeks to apply mental health knowledge andexpertise to the setting of disasters. Ministering to the psychological needs of a disaster‒stricken
community in the acute aftermath of a disaster is distinctly different from what it is required indealing with the long‒term aftermath months or years later. The context of service delivery, therelevance of psychiatric diagnosis, the clinical interventions, and the personal challenges for thepsychiatrist are all vastly different from the rest of psychiatric practice. In order to help psychiatrists judge whether to engage in acute disaster psychiatry or prime them for how to engage in it,
this paper reviews both the rewards and challenges of engaging in this work. Ultimately, the challenges outnumber the rewards, but the disaster psychiatrist sees rewards even in the challenges.

Keywords

disaster, trauma, mental health, psychiatrist, psychological first aid

fellowships in the U. S. except for one at the Uniform Ser-

Introduction

vices University in Bethesda, Maryland in the U. S.
（https://www.usuhs.edu/psy/fellowships）. Training in thisDisasters are traumatic events that overwhelm a com-highly specialized area must be sought out via conferences

munity. Disaster psychiatry is the professional application

or reading. There are thankfully many excellent textbooksof mental health knowledge and expertise to the unique set-or manuals on disaster psychiatry19,22）.

ting of disasters10）. In the United States, disaster psychiatry

Indeed, it can also be said that for most psychiatrists

is generally thought to have been first recognized as a（and other mental health professionals）it is an“accidental”

unique area of practice following Erich Lindemann’s publi-

area of practice, as their involvement often occurs based on

cation on grief following the fire that that occurred at thethe happenstance of a disaster striking a community where

Cocoanut Grove nightclub in Boston in 1942 and claimed

they live, or they have a pre‒existing personal or profes-

492 lives, making it one of the deadliest fires in U. S. histo-

sional connection. Therefore, many psychiatrists learn

13）ry . However, decades later, disaster psychiatry remains

disaster psychiatry“on the fly”from the experience of being

an“extra‒curricular”field as there are no known academ-

thrown into a disaster and being called upon to apply theiric departments or divisions of psychiatry in the U. S.,prior psychiatric training and expertise to a disaster‒although such a department does exist at Tohoku Universi-

affected community. To the extent that they are able to seekty in Sendai, Japan. There are also no formalized trainingout training or reading on the subject, it is“just in time”

666

精神経誌（2021）第 123 巻 第 10 号

Table 1

The rewards of disaster
psychiatry

Invigoration
Community mindedness
Proactivity
Humanitarianism
Opportunities for prevention
Collaboration

but compared with the rhythm of daily life and as long as
one has not sustained personal loss, it sparks a rush ofadrenalin. With the possible exception of emergency
department‒based psychiatry, psychiatric practice rarely
occurs in such an action‒oriented environment. The flashing lights, perpetual motion of responders, and pop‒uppress conferences are a world apart from the psychiatrist’s
consultation room. Although it is difficult to find any psychiatrist who has put this in print, this departure from theirlargely staid professional lives is alluring. This was hinted

learning.
This paper describes the broad themes in disaster psy-

at when a close colleague wrote the following about drop-

chiatry in order to efficiently orient the many psychiatrists

ping everything and rushing with the author and other team

who seek to rise to the challenge of a disaster without themembers to post‒earthquake El Salvador in 2001：“Thebenefit of prior training or experience. It may also be help-

priorities of a continued research program with its ups andful to anyone contemplating embarking on disaster psychi-

downs seemed mundane in comparison to the life‒and‒atry as part of their career. The focus will be on the acutedeath struggles of such a disadvantaged population of peo-

aftermath of a disaster, as this is the period that most trulyple.”6）

distinguishes disaster psychiatry from more conventional

The invigoration of disaster response is mentioned as a

psychiatric practice. This is usually the period in the imme-

rewarding aspect of disaster psychiatry, but it should also

diate aftermath of the disaster, from days to weeks, where-

be mentioned that it can pose a risk for some. If psychia-

as the post‒acute period encompasses weeks to months totrists wanted such professional stimulation, they likely

12）even years . It is when the“dust”has begun to settle. The

would or should have chosen a different field of medicine

themes are drawn from the author’s experiences as a part‒or even a different field from medicine. Thus, not all psy-time disaster psychiatrist over the last twenty years, includ-chiatrists thrive or even function adequately amid the hub-ing as part of the founding leadership of an organization

bub of a disaster response, nor do they enjoy it.

known as Disaster Psychiatry Outreach, supplemented by
the scientific literature whenever possible. They span the

2．Community—Mindedness

experience, techniques, ethos, and aspirations of practicing

Psychiatrist‒clinicians largely work with patients, usu-

disaster psychiatry and will begin with an enumeration ofally individually and sometimes in groups. Psychiatrist‒

the rewarding aspects of practicing disaster psychiatry, fol-

researchers largely work with research subjects or test

lowed by a discussion of its professional and personal chal-tubes. Although American medical education has become

lenges.

more and more focused on teaching the social determinantsof health, a major curricular transformation has yet to

Ⅰ．Rewards

occur.7）Thus, physicians in general are trained to focus on
individuals rather than communities or systems. It is there-

Disaster psychiatry boasts a number of rewards, as
listed in Table 1 and described below.

fore not surprising that American psychiatrists who areinterested in communities have taken to carving out theirown professional niche via a professional organization, the1．Invigoration

It should be stated at the outset that responding to a

American Association of Community Psychiatry（www.
communitypsychiatry.org）.

disaster is energizing, a truth that can feel like a confes-

However, with the emerging emphasis on social deter-sion. Disaster conjures many feelings, many distressing,minants of health, it can be argued that the field of psychia-

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667

try ought to focus more on these determinants and on the

denly homeless family crying amid those ruins）. Emotions

communities in which psychiatrists practice. Acute disasterare raw in the immediate aftermath of disasters and disaster

psychiatry, with its emphasis on working outside of ourpsychiatrists therefore can expect an uncommon welcome

usual offices and organizations, offers such an opportunity.

from affected communities. We often spend our time invit-

Physically being out in the community can offer disaster

ing, even imploring, our patients to feel and identify their

psychiatrists both the opportunity to learn more about theiremotions, but with disasters, the emotions are upfront andcommunities and also the chance to experience those com-

our presence in the community make us a timely resource.

munities other than through the eyes of our patients.
Responding to a disaster is a unique chance to connect in a

4．Humanitarianism

very direct way with what in prior versions of the Ameri-

Disaster psychiatry affords the chance to marry thecan Psychiatric Association’s Diagnostic and Statisticalrewards of traditional psychiatric practice with the rewards

Manual of Mental Disorders was called“Axis IV”, psycho-of humanitarian work. Humanitarianism involves respond-2）

ing to human suffering and realizing human fulfillment bysocial and environmental stressors .

acting in a virtuous manner based on compassion, empathy,
or altruism1）. Bound up in the modern understanding of

3．Proactivity

Bringing ourselves and our services to people is out-

humanitarianism are its voluntary nature, focus on emer-

5）

gency aid, and belief in ministering to all human sufferingreach . One dictionary defines outreach as“the extending
15）of services beyond current or usual limits” . Indeed,without prejudice23）. As acute disaster psychiatry inevita-

disaster psychiatry offers the chance to bring psychiatry to

bly, and properly, entails voluntary action under dire cir-people rather than the much more customary stance of

cumstances, it is very much founded in a humanitarian

waiting for people to come to us. Under usual circumstanc-ethos. To the extent that its“patient”is a community rath-es, there are any number of barriers in the way of access toer than an individual, disaster psychiatry in its truest sense

our services, especially the stigma around doing so. How-

must be egalitarian―anyone is a potential beneficiary of

ever, outreach, although not necessarily a direct response to

the disaster psychiatrist’s services simply because they live

stigma, is at least a way to circumvent or mitigate its

in or are helping out in the disaster‒stricken community.

effects.
Indeed, if there is a heightened need for mental health

5．Opportunities for prevention

support after a disaster, there are also many more than thePsychiatric care typically involves tertiary prevention

usual barriers for seeking care. Survivors’ lives are turned

because psychiatrists diagnose and manage psychiatric dis-

upside down by death, injury, illness, displacement, andorders. It is not a field oriented towards primary preven-

unemployment, and with so many concrete needs, thinking

tion, i.e., intervening before mental illness occurs or even

about one ’ s emotional life may get de‒prioritized evensecondary prevention, i.e., screening to identify emerging

more than usual. Sitting back in one’s office waiting for

illness early before it worsens. This unfortunately puts thedisaster survivors is a lonely business.

field at some distance from concerns about public health.

The outreach of disaster psychiatrists is especially

However, disaster psychiatry is different because it is pre-likely to be successful and necessary not simply because

mised on the belief that not only is reaching out to a strick-they have located themselves within the disaster affected

en community the compassionate thing to do, but it is also

community, but also because it is occurring at a time whenpotentially preventative. Although studies must yet gauge

attention to mental health is more acceptable. Consider thatthe reality of this aspiration, it is a reasonable belief that

although depictions of disaster in the media often involve

early and thoughtful intervention by psychiatrists and otherscenes of destruction（i.e., houses flattened by a tornado）,

mental health professionals in a potentially traumatic situa-

they at least as often show survivors in distress（i.e., a sud-tion can only serve to mitigate suffering and thereby reduce668

精神経誌（2021）第 123 巻 第 10 号

the chances that expectable human suffering evolves into

ical faculty at medical schools across Europe and Asia said

the three most common post‒traumatic psychiatric disor-

they felt psychiatrists were not good role models for medi-

ders‒‒major depressive disorder（MDD）, post‒traumatic

cal students21）. Psychiatrists getting into the“trenches”ofstress disorder（PTSD）, and alcohol use disorders（AUD）.

disaster‒stricken communities with other physicians andDisaster psychiatry ought to be an exhilarating chance toresponders can project a powerful image of compassion

prevent traumatized individuals from showing up at ourand activism.

clinics in the future, as disasters are the most public of

Ⅱ．Challenges

traumas.
Disasters are also opportunities to treat people whoshould have shown up at our clinics before the disaster.

There are many challenges posed by disaster psychiat-

Prior psychiatric problems, and especially under‒ or

ric practice and they far outnumber the rewards, as reflect-untreated ones, are a well‒validated risk factor for develop-

ed in Table 2. Indeed, some are the mirror image of theing post‒disaster mental health problems, as are having

rewards, perhaps none more so than the challenge of prior-pre‒event problems of living（i.e., relationship or work-

itizing mental health. Disaster may be a unique opportunity

place problems）12）. The highly emotional post‒disasterto be proactive, but as important as it is for the psychiatrist

environment where having psychiatric issues is much more

to get out into the disaster affected community, the wel-

acceptable and the easier access to psychiatric care due tocome may be uneven. Disaster response agencies will beon sight disaster psychiatrists may enable pre‒existing

greatly reassured by their presence, which can have themental health problems to be captured and addressed.

effect of erecting an invisible but palpable“trauma tent”
over the scene, a psychological space where the heightened

6．Collaboration

Although perhaps the least of the rewards of disasteremotions of the moment are safely felt, expressed, andshared11）.

psychiatry, the chance to collaborate with fellow respond-

However, the survivors of a disaster have much to con-ers offers an opportunity to get to know an entirely differ-tend with beyond their mental health, an invisible dimen-

ent professional world. In the U. S., the vast number of fed-

sion of life that too often and too easily gets overlooked

eral, state, and local agencies that respond to a disaster areeven in the best of times. The disruption and destruction ofoften referred to as the“alphabet soup”of responders

disasters usually thrusts countless new and unexpected tan-because of all of the acronyms they go by（i.e.,“ARC”＝gible needs into the laps of governments, communities,

American Red Cross or“FEMA”＝Federal Emergency

organizations, families, and individuals, and tangible needs

Management Agency）. If the psychiatrist normally works

should come first. This is the fundamental idea of Maslow’s

in an organizational setting, such as a hospital or a clinic,so‒called hierarchy of needs, which describes how humans

then working in disaster response thrusts them into an

are fundamentally motivated to address the most basic ofentirely different team where they may well be the only

needs, such as safety and physiological needs, before turn-mental health professional or even health professional. If

ing to higher order needs such as those of belonging andthe psychiatrist works in a private practice, then they tradeself‒ confidence14）. Although a time of unavoidably height-

their usually more solitary practice for team‒based efforts.

ened emotions may create a window for psychiatrists to

Although a recent meta‒analysis revealed consider-make an impact, unlike at any other time, it is also a time

ably more acceptance and de‒stigmatization of psychiatryof simply heightened needs, many of which can, and often

and psychiatrists by the public during 2000‒2015, theshould, divert attention from explicitly addressing mental

investigators also suggested that the public sees psychia-

health.

trists as more suited to prescribing medication than listen-

Indeed, it is fair to say that no psychiatrist should

ing and talking3）. Another study revealed that 90％ of med-

involve themselves in responding to a disaster who does

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Table 2

The professional and personal challenges of disaster psychiatry

Prioritizing mental health
Pre—diagnostic framework
Adjusting to PFA

Psychological benefit may be derived
from non—psychological interventions
Practical／ethical challenges of conducting
research

Adjusting to a humanitarian role
Lack of evidence for acute interventions

Improving the community’s pre—event
mental health may be as impactful as
addressing post—event issues

Defining role and impact
Working in unfamiliar settings
Identifying psychiatric need
Challenging work／living conditions
Who becomes a patient?
Direct exposure to trauma
Ensuring long—term follow—up
Promise and peril of the media
Sustainability of effort

not recognize the primacy of basic needs like safety, shel-ond, and psychiatrists third.

ter, and nourishment, and who is not prepared to address

For the psychiatrist to function as such in the third rolethem. It can even be said that an appreciation of this prima-

in the acute disaster setting, identifying individuals withcy constitutes a necessary ingredient for being a good psy-

psychiatric needs will also pose a challenge because they

chiatrist in everyday practice. However, although theare not typically announcing themselves as such. The pro-everyday psychiatrist can usually leave it to others toactivity that can be a rewarding part of disaster psychiatry

address basic needs while they ply their specific psychiat-

means that“case finding”is usually needed. Although every

ric skills, the disaster psychiatrist has no such luxury. They

disaster setting is different, if there is an array of services

must face the challenge of adjusting to a humanitarian

set up for survivors and community members, disaster psy-role. If as we said earlier humanitarianism involves

chiatrists will need to integrate into them. This may involve

responding to all human suffering without prejudice, thissetting up a“booth”and circulating among other service

not only means assisting all people, but also attending to allagencies to let them know, often repeatedly through“dailyof their needs. For example, while the team was on the ear-rounding”, of the availability of psychiatric services. Thelier mentioned disaster psychiatry mission to earthquake‒latter is especially important as other responders and agen-stricken El Salvador in 2001 and another earthquake struckcies can serve as“referral sources”, especially the ubiqui-

while they were en route to a psychiatric hospital, they

tous medical first aid station. Individuals in need may pres-diverted and went to the town at the epicenter of the second

ent to the booth through them or on their own, but casequake. When they arrived at the town ’ s hospital, theyfinding will likely be essential. And, throughout, the disas-adjusted their efforts. It was no time for anti‒depressants or

ter psychiatrist should be sure to wear an identification

psychotherapy as pre‒existing patients were being evacuat-

badge that clearly identifies them as a psychiatrist so as not

ed into a sunbaked plaza to make room for the newly

to“ambush”anyone. The outreach can run the gamut frominjured. They instead went around offering water toasking someone how they are feeling while the psychiatrist

patients who were able to drink or even placing I. V. lines

hands out blankets（acting in the role of a fellow communi-

for those who could not. The best disaster psychiatrists arety member）or checks blood pressure（acting in the role ofthose who consider themselves people first, physicians sec-a physician）or while casually joining them over coffee or670

精神経誌（2021）第 123 巻 第 10 号

a meal at the food service areas that are usually set up in

accustomed to in order to achieve psychological ends whiledisaster assistance centers. All of these non‒psychiatricaccomplishing practical ones.

encounters present opportunities to perform informal men-

As considerable psychological benefit may be derived

tal health screening, but such outreach can be challenging

from non‒psychological interventions in the post‒disasterand may not fit every psychiatrist’s comfort level.

setting, the disaster psychiatrist may need to lay down their

Inherent in this shift of professional identity is a shift

psychological tools or at least put them at the bottom ofin technique. In the acute aftermath of a disaster,“treat-

their toolbox and focus on practical interventions. This canment”is not the order of the day. Instead, disaster psychia-

be highly challenging for some psychiatrists, and for thosetrists, and anyone wishing to work in a psychologically

who seek to work through this possible struggle, PFA

minded manner, should operate within the evidence‒

reminds us that even if we are not utilizing our usual psy-

informed framework known as psychological first aid

chological tools as we normally would, this does not mean

4,16）

（PFA）

. Adjusting to working within PFA presents

we forgo our psychological mindset.

another challenge to psychiatrists because it focuses on

Before technique comes assessment, and here thepromoting coping and adaptation to traumatic circumstanc-challenge for psychiatrists lies in working in what is large-

es and ideally is the vehicle for the earlier mentioned

ly a pre‒diagnostic framework. In the acute aftermath of achance to prevent the very mental health conditions thatdisaster, reactions to the event are hopefully far more adap-

psychiatrists have much more experience and comfort withtive than otherwise, as much of the distress survivors andtreating after their onset. The following are the elements ofother members of the disaster affected community experi-

PFA according to the U. S. National Institutes of Mental

ence will likely be expectable and healthy. To the extent

16）

Health ：that some of this distress is excessive and dysfunctional, it

1．Provide for basic needs

is most likely to come in the form of symptoms rather than

2．Protect from further harm

diagnoses. Not only are many if not most people resilient,

3．Reduce agitation & arousal

but there is also simply not enough time for symptoms to

4．Support those in most distressmeet the duration criteria of our diagnostic criteria, at least

5．Keep families together and provide social support

for new onset disorders（and unlike recurrent disorders,

6．Provide information, foster communication & edu-

which can manifest in this time frame）. These can come incationthe form of emotional, cognitive, physical, and behavioral

7．Orient to available services

reactions12）. Indeed, as much as psychiatrists are trained to

8．Use effective risk communication techniques

base their ministrations around diagnoses, coming into the

These very much reflect Maslow’s theory on the hier-disaster scene primed to diagnose survivors not only

archy of human motivation and needs, but many PFA ele-

ensures needless and even harmful pathologizing, but also

ments do not reflect standard psychiatric practice. Less

constitutes terrible public relations for the field of psychia-

important than the specifics of psychological first aid is its

try.

ethos, which is distinctly practical, calling for us to roll up

There is unfortunately no perfect answer to how to

our sleeves and not necessarily get out our prescription

work pre‒diagnostically. One interesting but yet‒to‒bepads. Non‒mental health professionals can be oriented toadopted method is to consider acute, clinically significant

PFA in order to help them think about the psychologicalpost‒traumatic distress a“stress injury”, for which theimpact of the many non‒psychological activities theycausative stressor is identified as either trauma, fatigue, or

undertake（i.e., handing out blankets to shivering tsunami

grief 8）. This approach addresses the clinical significance ofsurvivors）, in a sense, helping them to think of what theydisaster‒related distress without pathologizing it, muchdo at higher level. On the other hand, PFA often requires

like a broken bone resulting from an earthquake‒induced

psychiatrists to operate at a“lower level”than they arecollapse of a home needs a doctor but is not considered

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671

pathology. On the other hand, a more conventional

Center established by the city to address the range of New

approach to diagnosis may be to use the diagnosis ofYorkers’ needs, we gave out short‒term supplies of zale-

Adjustment Disorder from the DSM‒Ⅴ, which involves

plon to 250 individuals and of lorazepam to 199 individu-

the“development of emotional or behavioral symptoms inals. The average number of pills dispensed was five.

response to an identifiable stressor（s）occurring within

Although we were unable to systematically follow‒up with2）

three months of the onset of the stressor（s）.” A third andthe recipients to evaluate our impact, our clinical impres-probably best option at this time is to simply avoid diagno-

sions were that these medications were overwhelmingly

sis and labelling, and to name the symptoms requiring clin-

beneficial and well‒tolerate and helped people to“get overical attention.

the hump”and tamp down their distress. Indeed, the mostFor clinically significant distress that falls short ofevidence‒informed recommendation that can be made isdiagnostic criteria for the common post‒traumatic disor-

that prescribing short‒term medications for anxiety orders or any other major psychiatric disorder identified in a

insomnia, at least for adults, can have an important impact,

disaster survivor, we should turn to Psychological Firstand that one should rely on clinical judgment and compas-

Aid. In all likelihood, the individuals most likely to comesion when prescribing.

to the attention of a disaster psychiatrist and who are in

As for psychotherapy, there is more evidence, and it

most need of doing so are those in greatest distress. The

supports short‒term interventions based around cognitive‒

psychiatrist trying to apply the PFA techniques of reducing

behavioral or exposure psychotherapy delivered overagitation and arousal, and attending to those in most dis-

approximately 4 weeks within 1‒2 months of the event intress will naturally consider using their traditional psychi-

most studies18）. These can both offer secondary prevention

atric tools, psychotropic medications and psychotherapy.

that helps reduce the incidence of PTSD or shorten its

However, there exists a lack of evidence for acute interven-

duration. However, offering such psychotherapies poses

tions for acutely traumatized individuals, whether from alogistical challenges, as they require ongoing contact withdisaster or otherwise. This is especially the case with acutethe disaster‒affected individual and involve psychotherapy

psychopharmacotherapy, where a recent review of medica-

modalities that many psychiatrists may not be trained in.

tions for preventing PTSD plainly stated,“We conclude that

A related issue is what to call the people whom disas-

there are no pharmacological preventive interventions thatter psychiatrists assist, as most are not seeking us out as

9）

are ready for routine clinical practice.” On the other hand,announced“patients.”It would be a misnomer to call some-there is no evidence to support the oft‒cited clinical wis-

one whom a disaster psychiatrist engaged in a conversation

dom that giving medication to someone who has just beenover coffee a patient. Thus far in this paper, we explicitly

traumatized will interfere with natural healing.

avoided mentioning“patients”wherever possible andAs there is neither good evidence for or against pre-instead referred to“individuals”,“individuals in need”,

scribing, experience can potentially guide the acute use of“survivors”, and“affected community members”. When do

medications. In our psychiatric outreach to individuals

they become a patient? This happens once the psychiatrist

affected by the 9/11 terrorist attacks in New York City, we

decides that a more formal evaluation is needed and, ofrelied on donations of the anxiolytic, lorazepam, and thecourse, the individual consents to this transition. It is the17）

hypnotic medication, zaleplon . Choice of the former wastime when the psychiatrist decides they need to put down

based on experience of lorazepam being a medication that

their coffee and pick up their figurative pen. This can be

is flexibly used for both anxiety and insomnia and having

captured in the rough rule that someone should become a

the added advantage of minimal drug‒drug interactions.

patient when the psychiatrist decides that the usual ano-

Zaleplon became available as a chance donation from anymity of what we might call the“brief encounter”no lon-

pharmaceutical company. In the approximately 2 1/ 2

ger suffices and they need to know their name as part of amonths where we were working at the Family Assistance“formal encounter.”672

精神経誌（2021）第 123 巻 第 10 号

As some individuals may indeed need a formal

to have been 40,000‒80,000 responders at the WTC site）.

encounter and turn out to have a mental health condition,

In the mental health treatment program that serves thosethey will require follow‒up. Ensuring long‒term follow‒up

responders who“screen in”, in a recent month there wereis a necessity and a challenge even as the focus is on theover 50 new intakes, nearly 750 psychotherapy visits, andimmediate recovery from the disaster. Thought must be

almost 250 medication management visits（unpublishedgiven to this because acute disaster psychiatry is inevitably

data courtesy of Sandra Lowe, M. D.）. This program cer-a voluntary activity, and it usually takes place under tran-

tainly underscores the potential need for long‒term mental

sient and rapidly shifting circumstances and in temporary

health follow‒up and represents something of a“gold‒stan-locations. In our experience, disaster psychiatrists usually

dard”approach for how to do it, including pairing up men-have one or perhaps two contacts with recent disaster‒tal health services alongside medical services in order toaffected individuals and do not engage in this work withimprove access and reduce stigma. However, this long‒the intention of providing long‒term services. Thus, there

term mental health program was born of generous philan-

are two choices：A system can be set up wherein disaster

thropic funding and maintained on what is now long‒term

psychiatrists are able to take on these cases in their usual

federal funding that arose out of enormous advocacy

practices or clinics. However, this brings up the issue ofefforts by labor unions, elected officials, and others.

reimbursement, which can be complicated depending upon

Whether through formal encounters immediately

the country and healthcare system. In a fee‒for‒service

post‒disaster or through long‒term screening programs,

system, there is also the challenge of not appearing likesuch as what is offered at the World Trade Center Health“ambulance chasers”who seek to diagnose disaster survi-

Program, the mental health problems that are identified arevors in order to build their practice. On the other hand, pro-unlikely to be due entirely to the disaster. They may beviding long‒term care on a voluntary basis may simply notrecurrences of prior mental health problems brought on by

be sustainable despite its idealism. A second choice,the stress or trauma or ongoing problems that went undiag-although not necessarily to the exclusion of the first, is to

nosed or untreated but come to attention in the aftermath of

establish linkages with existing mental health agencies indisaster due to worsening from the stress or trauma or sim-

the community. We have seen examples of the voluntaryply due to better access to mental health services. Especial-model and the latter linkage model.

ly in the acute period, there may also be people who need

Ultimately, this raises the issue of the sustainability ofcontinued medication such as among displaced residents

the disaster psychiatry effort. This is both an individual

following Hurricane Harvey in Texas20）. As mentioned ear-issue and a systems issue. How long does the individuallier, pre‒existing mental health problems are among thedisaster psychiatrist wish to be involved, and can andmany risk factors for having new or recurrent post‒disastershould a system be set up with the view to the long‒term?

mental health problems, as are pre‒disaster problems in

Answers to these questions are specific to the person andliving. As such, and as important as psychiatrists’ involve-

the community. To lend some perspective, the program wement in disaster response is, there is therefore much reason

established in early 2002 to respond to the medical andto believe that if psychiatrists and the entire community ofmental health needs of 9/11 responders in New York City,

mental health professionals were positioned to steer more

now known as the World Trade Center Health Program,efforts towards improving population mental health before

continues to this day, nearly 20 years after 9/11. As of ear-any disaster occurs, the need for disaster psychiatry would

ly 2021, nearly 25,000 World Trade Center disasterbe reduced12）. Helping our communities to be mentally

responders have undergone at least one annual monitoring

healthier will improve life on a day‒to‒day basis and in thevisit, which includes screening for 9/11‒associated medi-rare chance of a disaster. Improving a community’s pre‒cal and mental health problems, and approximately 1,000

disaster mental health may be as impactful as addressing

responders are screened every month（there are estimatedpost‒event issues. Even if this is not necessarily as exciting

特別講演

673

as disaster psychiatry, it is a practical and possibly even a

include suddenly finding oneself working in an unfamiliar

moral challenge for psychiatrists and planners to thinksetting, including both the physical environment and inter-

about whether and how to put their resources more towards

personal milieu. The atmosphere is far removed the charac-

everyday mental health rather than disaster mental health.

teristic tranquility and orderliness of the psychiatrist ’ s

How much more investment in pre‒disaster mental

office. As discussed earlier, the teamwork and collabora-

health will impact disaster mental health is a question thattion of being part of a disaster response can be invigorat-

only research can answer, but there are considerable practi-

ing, but not necessarily for everyone―for some it can becal and ethical challenges to conducting research in disas-

overwhelming or frustrating.

ter psychiatry. In a potential disaster psychiatry research

Disaster zones are by their very nature marked byagenda, no area needs more study than acute post‒disaster/

physical deprivations and emotional intensity, making fortrauma interventions, especially the use of medications foruniquely challenging working and living conditions.

primary prevention of post‒traumatic sequelae such as

Extreme temperatures, inconsistent cell phone connectivi-

PTSD. Considering the relative rarity and unpredictability

ty, scarce food, and, if the disaster psychiatrist is respond-of disasters, it has thus far been a nearly insurmountableing far from their own community, spartan sleeping accom-

challenge to have research protocols ready to be deployedmodations may be too personally distressing to allow thein their immediate aftermath, especially for intervention

psychiatrist to be effective at managing others’ distress.

studies. This requires that the protocols be sufficiently flex-

The emotional intensity of the setting can also constituteible for the many faces of disaster, that funding anddirect trauma for the psychiatrist. With the possible excep-

resources are at the ready, and that the all‒essential part-tion of emergency psychiatrists, psychiatrists are normallynerships with emergency response agencies, which areaccustomed to seeing trauma survivors at a time far

already difficult to establish for purposes of service deliv-

removed from the incident. All psychiatrists minister toery, can also accommodate a research agenda that has nosurvivors at a physical distance from the scene of a trauma.

direct benefit for the members of a disaster affected com-

There is always the risk of vicarious trauma in general psy-munity. In addition, there lies the dubious ethics of con-chiatric practice, but this is unlike the risk of the direct

ducting intervention research with the rigor of double‒

trauma of being at the scene of the incident, let alone soblind, placebo‒controlled studies in such a vulnerable pop-

soon afterwards.

ulation as recent survivors of a disaster. For example, when

Lastly, the disaster psychiatrist will encounter the

someone has lost their home and most of their earthly pos-promise and peril of the media. A major disaster invites

sessions in a flood, how free would they be to decline par-major media coverage. This can be an exciting chance toticipation in research that provides compensation and, on

step out of the relatively reclusive world of psychiatricthe other hand, how likely would such individuals be topractice into the spotlight and an opportunity to be ansign unto un‒compensated research when they are focused

ambassador for psychiatry and help many at once withon the basic survival of their family? Much more imagina-

carefully chosen words, but under the bright heat of klieg

tion and foresight will be required if we are ever to gather

lights, psychiatrists can step into a minefield of misstate-empirical evidence for disaster psychiatric interventions

ments. For example, the press and the public inevitablythat is the equal of the good will of disaster psychiatrists.

hunger for personal stories of survivors, and the psychiatrist may jeopardize the confidentiality of their encounters

Ⅲ．Personal Challenges
Thus far we have enumerated the many professionalwith survivors in trying to feed this appetite.

Conclusion

challenges of practicing disaster psychiatry. Before closing,some personal challenges are also worth mentioning. These674

The challenges of disaster psychiatry far outnumber
精神経誌（2021）第 123 巻 第 10 号

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the rewards, but for many psychiatrists, the depth of the
rewards more than compensate for this disparity. A potential reward（s）lies in every single challenge. A good way toforecast whether disaster work suits a psychiatrist’s style orexperience may be the following：As one reads throughthe list of challenges, do they feel excited or defeated?
Ultimately, we do not need all psychiatrists to engage indisaster psychiatry, and most need to“maintain their posts”
and keep addressing the vast mental health needs that exist
in our every‒day world apart from disasters. Everyone running towards a disaster is almost as bad as everyone running from it.

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