シンポジウム：Disaster and M ental Health

第153

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Recovery and Beyond : Working with
Young Tsunami Victims in Thailand
Nuttorn Pityaratstian, MD , Panom Ketumarn, MD , Vinadda Piyasilpa, M D ,Nanthawat Sidthiraksa, MD , Sirirat Ularntinon, MD1）Department of Psychiatry, Faculty of M edicine, Chulalongkorn University, Bangkok
2）Department of Psychiatry, Siriraj Hospital, M ahidol University, Bangkok
3）Queen Sirikit National Institute of Child Health, Bangkok

The tsunami struck Asia on December 26,

Immediately after the tsunami,the Depart-2004 and left a devastating impact. Hundred

ment of Mental Health of Thailand and several

thousands of people lost their lives across theprofessional bodies tried to organize mental

region.

In Thailand 6 provinces along thehealth services to the aﬀected area. Hundreds

Andaman coastline in the south was severelyof mental health personnel with good intention

hit. The oﬃcial death toll for Thailand wasrushed to the south in the ﬁrst weeks after the

5,376, but the real ﬁgure was thought to be

attack. The problem was that Thailand hadmuch larger. Four hundred and ninety ﬁshingnever experienced such a large scale disaster.

villages with an estimated population of 100,000

Therefore, some people ended up going theirwere aﬀected ; 3,689 houses were partially or

not knowing what to do. It was a common

totally damaged ; 2,435 ﬁshing boats were des-experience for psychiatrists or mental healthtroyed. The estimated ﬁnancial damage wasworkers to walk around the wrecked area

more than 200 million US$ . Of all 6 prov-

asking questions and trying to interview vic-

inces,Phang Nga was the most stronglystruck.

tims in order to oﬀer psychological help, but

One of the area in Phang Nga called Khao Laksoon found out that people were too distressedwhich was one of the best known place forand no one was in the mood to talk to them.

beaches and holiday resorts in the world with

Some of the volunteers then gave up the mental

excellent location‑the beach in the front andhealth work and found themselves more useful

the hill at the back, with the hotel rooms incollecting bodies from the beach. Some almost

between‑was almost completely destroyed.

went from helper role to victim role. There

The cruel fact was that the tsunami happened

was a story of a group of 3 psychiatrists whoduring the highest point of tourism season‑justwent to one island and while theywere trying to

one day after Christmas. Thus, the casualties

soothe people down from their distress, thenwere not only Thais, but holiday‑makers fromcame a panic shout that “Tsunami is coming

all over the world.

again !!”
,so they alarmingly ran up the hill and154

精神経誌（2010）112 巻 2 号

got separated from each other for many hours,

to Phang Nga is quite far―788 km. The visit tosurrounded by lots of terriﬁed people, before

the area has been spacing out from 5 times athey could reunion with the team.

year in the ﬁrst 2 years to 2 times a year from

Disaster recovery can be classiﬁed into 6

year 3. So far there have been 15 visits. The

stages: 1）Heroic; 2）Tunnel vision ; 3）Hon-

program is expected to be run for 5 years, as

eymoon ; 4） Disillusionment ; 5） Reconstruc-

opposed to 2 years as we ﬁrst planned since wetion Recovery; and 6） Enhancement Post ‑reckon the importance of continuing work.

traumatic growth . During the early phase of

The team has got the funding from the insti-

recovery, the tsunami victims in Thailand

tutes that the members of the team work in,received outpouring of support from people andand also from Thai Health Promotion Founda-

organizations both in‑and outside the country.

tion in the ﬁrst 2 years. In the later years it has

Governmental oﬃcers, NGOs workers, andbeen more diﬃcult to get funding ; anothervolunteers ﬂocked the area. Though out ofclassic example of the disillusionment phase wegood intention, their activities were sometimes

have discovered ourselves. Fortunately,donat-

not well‑coordinated and therefore the victims

ed money from a gentleman who really wants

did not get the optimal help they needed.

to help the children in the aﬀected area has

Poorly organized distribution of donatedkept the project going. The team is very grate-

clothes and food led to redundancy in some

ful to him, and therefore always makes sureareas, shortage in another.

that the money is very well‑spent.

Then we entered the disillusionment phase

The mission of the team was not quite

when the resources dried up, the volunteers

clear in the ﬁrst place, but after months anddecreased in number because they had some-years of learning we have come up with thisthing else to do. One or two years later, welist. First of all we want to screen mental

found no time to visit them any longer, al-health problems that children in the area mightthough this was probably the time they needed

have as a result of the tsunami. In doing so we

us the most because of the emergence of manyneed valid instruments,but we had very few,so

psychiatric disorders, for example, PTSD, de-we need to develop new ones. And when we canpression, and substance abuse, in the later

identify the cases who need help we hope tophase of trauma. It is clear that the work needs

provide the right intervention for them. The

to be extended well into the recovery phase. In

intervention also has to be developed since wethis article, we will review the work of a team

had no experience ever in treating children

in Phang Nga, with its project now movingfrom such a large scale disaster. We also plan

beyond the recovery well into the enhancement

to train teachers and health personnel so theyphase.

can form a network to take care of the children

The team consists of volunteered psychia-with us. And in the end we hope that what wetrists from diﬀerent institutes in Bangkok. We

learn could give us insight into trauma workchoose to base our work in schools, unsurpris-through the research.

inglyas the majorityof the team is child psychi-

As Phang Nga was severely hit by theatrists who are familiar with school mental

tsunami and there is no way we could go tohealth. The traveling distance from Bangkok

every child, the screening procedure is crucial.

シンポジウム：Disaster and M ental Health155

We initially try to identify at‑risk children by

ess makes it easier for many children to ex-monitoring the children who lost family mem-press themselves as they can learn though see-ber, had direct exposure to the tsunami, sus-

ing other children talk. This can also be atained injury, and had previous history of psy-

self‑help group when they learn to support andchiatric disorders. The Pediatric Symptoms

advise each other various kinds of techniques

Checklist（PSC） is among the ﬁrst question-that can help them cope with traumatic memo-

naire we use for screening,but after a while weries. The CBT techniques can also be taught inﬁnd it not veryspeciﬁc to psychiatric conditions

a group format . The easiest one we teachmost associated with trauma‑PTSD and de-every traumatized children to help them copepression‑so we later give up. The Thai version

with hyper‑arousal symptoms such as startleof Children Depression Inventory（CDI） has

response or increased autonomic activity,is the

been already available at that time so we in-breathing exercise. In Buddhist country likeclude it for depression screening. Problem is

Thailand it is not verydiﬃcult to understand as

how we can screen PTSD as there is no instru-

children can compare this concept to medita-

ment at that point. Luckily,with internationaltion. We also teach them the muscle relaxa-

contact we ﬁnd the Children Revised Impact oftion. The techniques need to be modiﬁed to a

Event Scale（CRIES） which proves to be ashorter and more fun version to facilitate theuseful instrument in many traumatic events

childrenʼs understanding,for example,to stiﬀen

such as war, sinking ship, and road traﬃcyour body like a robot and let it loose like a

accident , and after the systematic, culturally

ﬂoppy doll to learn about the feeling of tension

sensitive translation into Thai, we start using

and relaxation.

CRIES in order to screen PTSD.

The children who have the abstraction to

All of the cases that we could identify thenunderstand the concept of thinking would also

go through psychosocial intervention, mainly

be taught to deal with the intrusive thought

supportive psychotherapy, group therapy, andwhich could be very negative, for example,

cognitive behavioral therapy（CBT）. There issome might think all the time that tsunami isa problem with some cases that the team thinks

going to happen again soon. We need to teachit would be more eﬀective if the child receives

them the very basic concept of cognitive ther-

medication. The prescription process is ex-

apy which is THOUGHT leads to EMOTION.

tremely diﬃcult because the project is school‑

You have a negative thought so you feel bad.

based and the parents are not around to give

But if you can modify your thought and see it

consent. It is also hard to monitor the eﬃcacy

from a diﬀerent viewpoint,preferablyin a more

and the side eﬀects. Therefore, we decide topositive way, you can feel better. For exam-

keep medication treatment to a minimum.

ple:

The children who are screened and→“Tsunami is going to happen again soon”

diagnosed as PTSD has a chance to ventilate

feeling scared

their distress and then are supported by psychi-

How about if we change the thought to :atrist in the team. Later, they have group“
Tsunami can happen,maybe,but now mytherapy. This is very useful as children canschool is not near the beach, and we have theshare their traumatic stories. The group proc-

alarm system on a high pole with loud speaker,

精神経誌（2010）112 巻 2 号

156

and we have practiced the evacuation. And itʼstaking a dip and, ﬁnally, swimming. The chil-likelyfrom scientistsʼopinion that tsunami may

dren can imagine doing it ﬁrst before doing innever happen again for a hundred years”

vivo exposure. During the exposure task we

How do you feel when you replace the oldthought with this coping thought ?

encourage the children to use the breathing andrelaxation skills, together with the cognitive

One of the most disturbing features ofskills we have thought. There is one thing we

PTSD is the intrusive images or ﬂashbacks.

observe when we bring them to the beach to do

We then teach imagery technique to the chil-the in vivo exposure task, in that it is very

dren to help them cope. We ask them to projectcommon for Thai children to pray to someone

the image onto the screen and think it is justthey respect （Lord Buddha, previous kings,

like a TV screen showing pictures from a DVD

prominent historic ﬁgures,spirit house,etc.）toplayer. Then we teach them to act like theydraw strength before going into exposure. This

have remote control to manipulate the image:

makes a lot of cultural sense to our work

to move it forward and backward, to freeze it

because although we teach them various kinds

with PAUSE button,or to make it disappear byof strategies to cope with fear, the mostpressing STOP button. The key thing is now

eﬀective is the way we do not teach, that is,they know that they can control the image,notpraying to the superpower. We later consider

the image controlling them. Another techniqueadding the spiritual aspect to our CBT.

to deal with the intrusive images is dual tap-

Until this stage we quite know how toping. The children are asked to bring up distur

screen the children in need of help and we knowbing image in their mind whiledoing hand cross‑

how to help them. But they cannot get better

tapping on shoulders or knees. This proves tojust by our ﬂying from Bangkok to visit thembe very eﬀective as children report that disturb-

every 3‑6 months. We have learnt that one ofing image would become blurred or faded away.

the most crucial things to succeed is to empow-

When the children have all the skills, we

er the community. With that when we arethen encourage them to do the exposure task.

away the teachers and the parents can cope,

It is a basic concept for all fears that the only

and consequently the children can learn theway to overcome the fear is to face it. We

coping model from the adults. Therefore, weteach them to rate the fear using the analogyof

do the training. So far there have been more

thermometer when zero is no fear, and 100 isthan 10 trainings for the teachers and healththe maximum fear.

personnel.

And we introduce theApart from the knowledge andconcept of fear hierarchy,compared it to climb-

attitude that theygain,now the network of help

ing the ladder. You start from the lower level,and support has been set. We also allow resi-

before moving up, and up. In the case of tsu-

dents to join the trip. To date more than 60

nami, the children are afraid of the sea andresidents in child psychiatry, general psychia-

would consequently avoid going there. The top

try,and pediatrics have rotated to the area andof the ladder is going to swim in the sea, butlearnt a lot from what they see. In terms of

you need to probably start from walking hun-clinical experience, this should be the best set-dred meters away from the sea, then walking

ting to gain insight about PSTD as hundreds ofon the beach, then walking in the water, thencases are identiﬁed. What the residents canシンポジウム：Disaster and M ental Health157

only read from textbook and think it is quiteders after the tsunami, the development

rare is now very common in front of their own

of screening test ,and preliminary study of theeyes. And with supervision from the staﬀs inintervention with CBT . We are also collecting

the team they can practice some very useful

and analyzing the data regarding the applicabil-skills to help traumatized children such as

ity of cognitive model of PTSD in children andsupportive psychotherapy, CBT, and groupthe randomized controlled trial of CBT for

therapy. The residents can also learn how inchildren who have this disorder, as well as thethe real life we can make sense of the concept

study concerning resiliency as a protective fac-of community and school mental health. The

tor for PTSD.

fact that school mental health is not just the

Now we are proud to say we have moved

extended OPD leads us to understand the im-beyond the recovery into the enhancement

portance of setting up and reaching out to thephase. It is amazing to see new school buildings

network. The concept of prevention‑secondary

much better than before the tsunami. We now

and tertiary in this case‑is now not diﬃcult tohave psychological‑minded teachers and school

grasp as we learn from such a concrete exam-

psychologists. The latter ones could be seen asple like this.

luxurious because most of the schools in

Now with screening and treatment plan weThailand still do not aﬀord it. We have better

have at least 5 psychiatrists going back andprepared mental health system to cope withforth from Bangkok to take care of children in

future disasters. We do not want any more

the area every 3‑6months. We have teachers

disasters, deﬁnitely,but if it is going to happen

who are trained to detect and help the young

again we believe we are now in the better

victims of tsunami.

position to cope.

The network with thehospitals and health personnel in the area has

There is one lovelylittle storyfrom the trip

also been set. But it seems the continuityof ourto the area in the later years. During the group

work is still a bit lacking. What do we needdiscussion we ask group members to sharemore? What is the missing link ? Our answer

what helps them recover. One girl who onceis the people who will do the same work as us

had PTSD and is now free of the symptoms

when we are away. With donated money wesays she is feeling much better these days. The

decide to hire 6 psychologists and 2 nurses tocritical incidence is when she saw the news of

work full‑time in the area. They can help

the cyclone Nargis in Burma and thought thosemonitoring some cases that need more atten-

people suﬀered much more than her and theytion.

received much less help from outside. So she

Before the tsunami, we knew virtually

decided to donate her belongings（some of themnothing how to handle the psychological conse-

she received from the donation after the tsu-

quences of the large scale disaster. We havenami）to help out with the cyclone victims andlearnt a great deal afterwards and with that we

felt tremendously fantastic.

want to organize our knowledge we have

One touching picture drawn by one of thegained through the research. So far we havechild victims can sum it all up nicely. It shows

published scientiﬁc articles on the prevalencea spiral ﬁgure starting from outside at number

and symptoms description of psychiatric disor-

1 which reads “Happy day”
. Then came thePowered by TCPDF (www.tcpdf.org)

精神経誌（2010）112 巻 2 号

158

tsunami at number 4 with diﬃcult time follows.

（1）; 36‑41, 2007

Help comes in from all sorts in later numbers.

6）Piyasil,V.,Ketuman,P.,Plubrukarn,R.,et al.:At number 13“The sea is clean”and 14“Happi-

Post traumatic stress disorder in children after tsunami

ness returns”. The best of all is number 15
which reads “Tsunami makes us stronger”,andat the center depicting the map of Thailand

disaster in Thailand : 2 years follow‑up. J M ed Assoc
Thai, 90（11）; 2370‑2376, 20077）Piyasil, V., Ketumarn, P., Prubrukarn, R., etal.: Psychiatric disorders in children at one year afterwith bold letters “We can live together by

the tsunami disaster in Thailand.J M ed Assoc Thai,91

giving and sharing”.

（Suppl. 3）; S15‑20, 20088）Piyasil,V.,Ketumarn,P.,Ularntinon,S.,et al.:References

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