Hong Kong J Psychiatry 2009;19:123-5
REFLECTIONS
The earthquake which devastated Sichuan on 12 May 2008 changed my life, and I have yet to understand its full impact on me. Reflecting on a year of providing psychological rehabilitation for disaster victims has given rise to new thoughts about my life and career.
I arrived in Sichuan on 23 May and went straight to work in the psychological rehabilitation unit in the West China Hospital. Although I was trained in both medicine and psychiatry, nothing prepared me for what I saw in the temporary settlement area. The countless victims, numerous urgent problems, and ‘the need to confront one’s own fear of death’ were all beyond my experience. As a group, we volunteers had to find ways to bear the pressure and deal with our own uncertainties while exploring how to get the work started. I came prepared. I read international and domestic literature and consulted my supervisor. But to be frank, I had no confidence in my ability to persevere. Nevertheless, I have worked for almost a year providing psychological rehabilitation at the temporary settlement coordinated by West China Hospital.
Encountering the First Victim
Even though I was armed with 5 years of supervised training and self-development, doubts filled me when I met the first victim, a man who had experienced tremendous suffering. After introducing myself, I asked the villager, “If you don’t mind, can we talk?” He went on to give a vivid description of what had happened during the earthquake, and his feelings of despair, hopelessness, fear, and regret. All I could do was to listen and provide comfort, support and feedback when appropriate. When talking about seeing the smashed and disfigured faces of his niece and other children, their bodies strewn about the playground, I patted his shoulder gently to show support, and this brought a torrent of tears. It was a poignant moment. I realised that I was there to accompany and sometimes to cry with the villagers. Every day we met villagers at the temporary settlement who were willing to talk, but most were just sitting quietly in their rooms, in deep thought. We decided to stay and continue our voluntary work at the temporary settlement.
Respect and the Therapeutic Relationship
The place was bustling with activities during the daytime, as visitors came and went. Enthusiastic volunteers and professionals from all parts of the country and the world offered their help. During my first week 2 to 3 groups of volunteers arrived every day, all of them eager to help. Villagers had to answer similar questions from different people and had to recount their painful experiences over and over. “Will this help?” I could not help but wonder. A natural disaster or massive life trauma tears us from our homes and acquaintances and forces us to try to adapt to a new environment, new society and even new culture. If we are asked to build new relationships only to be separated again and again, how can we still trust and rely on such interpersonal relationships and this way of living? Repeated episodes of separation would surely cause anxiety and cumulative trauma, changing our view and presumptions about life and the world and bringing about secondary trauma. Sometimes I overheard villagers saying, “I have already talked about it this morning, why do I have to repeat myself?” I came to realise that it is more important to provide continuous support and help, and instill a sense of stability to heal their spirits. My 2 years’ training in psychology taught me that client-centred consultation achieves more, and sometimes the gains can even be unexpected. I learned to listen quietly to the disaster victims’ stories, taking hours at times. Psychological rehabilitation is neither a communication between the strong and the weak, nor is it a process involving one rescuing another. It is a dialogue between two people meeting at a point in life, one facing a temporary problem and the other offering solace, company and sometimes practical help. In all humility, I saw the victims as people encountering some temporary difficulties and believed that they could overcome their obstacles one day, at the right time and under the right circumstances. What do they need? Research? A never-ending media circus? Tourists with their cameras? Do we really make an effort to feel their pain?
The Meaning of Life
The earthquake brought about losses, not only to the victims but also to those of us who heard and saw the tragic scenes that shook the world. How does it affect the way we think about life? What is the meaning of life? What do we seek? What does it mean being human? Despair, loneliness, uncontrollable emotions, the lack of meaning...these were my foremost impressions during my time there. When we are dealing with the limitations and uncertainty of life, the loneliness, inevitable separations, illnesses and a strong sense of futility, what can we do in the face of death and such misery? A villager gave me my answer. He used to be the equivalent of a millionaire in the village. After the earthquake, he owned nothing. Six weeks after our first conversation, I saw him setting up a new shop with his family. He was taciturn but greeted me cordially and shook my hand. He had lost loved ones in the earthquake. He told me he was already over 60, but said that such is reality and one has to move on. He used to be penny-pinching and harsh with himself but now nothing was more important to him than being with his family. He showed that one can rise above the suffering and pain and accept the apparent futility of the situation, and, in the process, find a new meaning in life and living. Having witnessed his transformation I truly hope that others can learn from his example, see beyond the trauma and be liberated from their pain.
We are Together
While providing psychological rehabilitation we faced a shortage of professional skills and team stability. In the beginning, there were 10 teams, a total of 400 eager volunteers.Most had some form of training, but some lacked basic interviewing and clinical skills. Over-involvement, lack of self-awareness, and excessive personal emotions are all qualities that render volunteer counsellors at risk of reactive stress. Psychological professionalism, standardised training and qualifications needed to be addressed.Volunteer numbers dropped from 400 to around 50 within 2 months. The earthquake forced us to reflect and united people from all over the world. However, providing a psychological service is an enduring commitment and a taxing task. My team consisted of psychiatrists, psychologists, and experienced social workers. We believed that maintaining a stable and systematic psychological rehabilitation service was essential. We recognised the need to base our work on their culture and needs and to frame it in a locally acceptable context. At times we needed to stretch the limits of our professional training as therapists in order to reach the inner feelings of the disaster victims, their struggles, their suffering, sense of helplessness, panic and despair. There are various schools of therapy, but in the disaster area, it is the rapport between the therapist and the client that is the core of psychological rehabilitation. It takes time to build up a good relationship. The therapist-client relationship needs to be built gradually to allow time for the patient to open up and be receptive to treatment.We provided weekly psychological services. There were two memorable incidents. When we first set up a psychiatric outpatient clinic, few people came. We then changed the name of the clinic to ‘insomnia clinic’ and ‘headache clinic’ and attendance shot up. We needed to find a way to enhance their acceptance of our work in keeping with local culture. Our aim remained the same, but the use of different methods achieved a different outcome. The other story took place at the insomnia clinic. An old lady in her 70s came and I asked, “How is your sleep?” “Not very good”, she replied. “How long has this been going on for?” “At least 30 years.” She went on to tell me that she was unable to sleep at all and kept tossing and turning in bed all night, sometimes remaining awake until the cock crowed. She heard that the West China Hospital was offering insomnia treatment and came to have her problem checked out. She was not the only villager like this, highlighting the importance of mental health education in the area. Another villager had lost his house, his spouse and one of his children in a flood more than 10 years ago. He had been unable to sleep well since. He had a sense of impending doom and experienced flashbacks of the flood. After the earthquake, the flashbacks intensified. In the wake of the disaster the pressing need to raise public awareness of mental health issues and to promote mental health education and services became readily apparent.
Learning and Innovation
Chinese people tend to bottle up their emotions. They tend to give the facts of their experience, such as what happened at the time and how they escaped, with minimal reference to their inner feelings. Many of the survivors had somatic symptoms related to their grief and emotionally painful experiences, especially those who had lost loved ones. Complaints about chest pain, stomach discomfort, and low back pain were common expressions of their inner feelings. To deal with these somatic symptoms, we used community-oriented activities. We held weekly community activities targeting somatic symptoms, separate from specific clinical psychological techniques, and pointed out the implications of their symptoms. We also used various activities like massage, traditional Chinese medicine, physical games, to enable emotional release and expression in a relaxed communal atmosphere. Providing a community psychological rehabilitation service is very different from my previous practice conducting therapy in an office. It could take hours of trekking in the mountains to get to a hut to do a consultation.
Rebuilding Culture
We often asked ourselves, “Were houses the only thing damaged in the earthquake?” Apart from the pain, it also shook everyone’s internal equilibrium, the assumptions made about life, our understanding of life, our faith in the land and much more. In the disaster, many were supplanted and had to rebuild their community and culture. There was no telling how long it would take to rebuild a home, to reintegrate traditional culture and restore one’s relationship with nature, culture, society and with oneself. In this, the aim of psychological treatment is not to change an individual, a group or even a community, but to create an optimal nurturing environment in which the seeds left after this disaster could bear fruit in the future, bringing new hope and culture. While the collapsed houses could be rebuilt in 1 or 2 years, it would take much more work to restore the people’s belief in their homeland and hopes for the future.
Unfinished Endeavours
The stories of disaster victims were deeply touching. How does one cope with the pain of endeavours not completed, words left unsaid and unbearable tragedy laid bare? Mr. A was in mourning for his wife and son, whom he lost along with his mountain home. “One can never ever forget,” he said, with helplessness and despair. At first, Mr. A was convinced that his 18-year-old son and his wife would return. Six months later, he still went up the mountains to wait. He told me, “There is nothing I can do. There isn’t even a place for me to cry. I don’t have a photo of them and didn’t have a chance to say goodbye. I fear I’ll forget their faces one day. I worry about this every day.” How can we help?
Normalisation
After a disaster of this magnitude, it is important to provide victims with a normal living environment as soon as possible. During our psychological rehabilitation work, we observed that many people who were relocated to a temporary settlement had nothing to do, as their land, houses, and workplaces had all been destroyed. They sat weeping or staring into space. Most of them were farmers. Before the earthquake, they spent their time working on the farms and had little time for other activities. The lack of a normal routine delayed their recovery from pain. We tried to help by introducing activities related to their local culture and inviting them to participate in the development of new activities. By learning new techniques and engaging in new projects that retained their link with their native culture, we hoped to facilitate their recovery even if farming was no longer an option. My concerns about the daily influx of volunteers, donations and materials from around the world, are best illustrated by the words of a mother who said, “There are too many activities for the students now. So many people are arriving and students are engaged in activities. Sometimes they have to welcome visitors. Sometimes they need to deal with the donated materials. How can they have time for studies?” Schools should be places for teaching and learning, not centres for activities and receptions for visitors. Students need a normal learning environment for stable mental development.
My Personal Reflections
Many people have asked me which technique or method I used or which school of psychotherapy I followed when providing psychological treatment in the area. My answer is “a ‘heart’ approach”. There was no specific technique or method, other than centring on the clients and their needs. Many volunteer counsellors used various techniques such as cognitive behavioural therapy, art therapy, hypnotherapy. I do not disagree with the validity of these methods, which have demonstrable benefits. We were providing large-scale psychological treatment for victims in rural areas. Many victims, especially those living deep in the mountains, had low levels of education. There was a popular saying in the area: “Fire prevention, epidemic prevention and prevention of psychological intervention”. This is a population not only traumatised, and therefore naturally suspicious of outside intervention, but also psychologically naive. Any intervention had to be on their terms if it was to be effective. For us, the volunteers, this was a learning curve. It was of utmost importance that the victims had a stable environment in which to rebuild their community and resume their lives. The government plays an important role in leading, organising, guiding, and investing in the development of a psychological rehabilitation programme. Having an effective management structure and clear objectives, job allocation and coordination are crucial. There should be a support system involving regular case sharing and brainstorming. Volunteers need to learn how to manage their stress levels and emotions. All these require a macroscopic plan, clear goals and good collaboration, with efforts from volunteers, non-government organisations and the government.
Thank you for bearing with me as I shared my reflections on this past year.
Acknowledgements
I would like to thank Ms Lucita Chan, Ms Sarah Chia, Dr Candy Wong, and Dr Victoria Tang for their assistance in preparing the English translation of this manuscript.
ZJ Ren
E-mail: renzhengjia@hotmail.com
Mental Health Center
West China Hospital
SiChuan University
PR China