Michel L.A. Dückers On the relativity of the mental health consequences of disasters On the relativity of the mental health consequences of disasters This book is a publication of Arq Psychotrauma Expert Group and is part of the Arq book series. © 2019, M.L.A. Dückers All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior written permission from the author. Cover: Stephan Csikós Cover image: Paul Klee betrofferer Ort, 1922, 109 Affected Place, 1922, 109 pen, pencil and watercolour on paper on cardboard 30,7 x 23,1 cm Zentrum Paul Klee, Bern Printing/binding: Gildeprint, Enschede ISBN: 978-94-632-3544-0 On the relativity of the mental health consequences of disasters Michel L.A. Dückers Foreword To love at all is to be vulnerable. Love anything and your heart will be wrung and possibly broken. If you want to make sure of keeping it intact you must give it to no one, not even an animal. Wrap it carefully round with hobbies and little luxuries; avoid all entanglements. Lock it up safe in the casket or coffin of your selfishness. But in that casket, safe, dark, motionless, airless, it will change. It will not be broken; it will become unbreakable, impenetrable, irredeemable. To love is to be vulnerable. C.S. Lewis – The Four Loves (1960) C.S. Lewis reminds us of how our vulnerability is linked to what matters most dearly to us. He beautifully describes the risk of adopting a counterproductive strategy to protect ourselves from losing what we love. It is true that those things we care about most, can affect us deeply when we are at risk of losing them. They are closely connected to human vulnerability, which is a central theme in this book, written by Michel Dückers, emphasizing the causes and human consequences of disaster vulnerability on mental health and service delivery. It is an essential body of work that fits within the research tradition of psychotraumatology, the study of psychological trauma. Psychotraumatology is a discipline which covers treatment, prevention and research of traumatic situations and people’s reaction to them (Everly & Lating 1995). At the same time, the chapters in the book match the aim of health services research as defined by Bowling, to “produce reliable and valid research data on which to base appropriate, effective, cost-effective, efficient and acceptable health services” (1997). Dückers has focused on typical trauma-related mental health reactions such as post-traumatic stress disorder, mood and anxiety disorders and suicide. These reactions have been studied in relation to different types of exposure, and risk and protective factors at the level of individuals, communities and societies. From different angles he has explored what principles we should apply to the provision of post-disaster psychosocial services and the extent to which these norms are actually applied in practice. Dückers has even gone a step further and has attempted to assess and predict associations between the structure, process, outcome and the cultural and socio-economic context of service delivery across countries. This is where he has discovered the counter- intuitive finding that mostly determines the tone of this book. Contrary to patterns at the individual level, low vulnerability (which is linked to high levels of wealth) at the country level is a risk factor for the development of mental health problems and is not protective. It is a saddening thought that populations in more wealthy societies have a higher risk of poor mental health. Could it be that we lost our armour to be prepared for misfortunes on the path of modernization, where our basic human needs such as safety, shelter and nutrition are guaranteed for many in an unprecedented way? Controversial findings like the vulnerability paradox definitely are appealing and deserve more research. They contribute to discussions within the fields of psychotraumatology and health services research. Indeed, we need to understand its underlying mechanisms and implications for everyday services. From a health services research perspective it encourages us to be extra critical in our attempts to decipher what appropriate, effective, cost-effective, efficient and acceptable health services are in the face of trauma, especially in the context of disasters and other events with a major impact on societies. We all know, reminded by history, that such events can happen and occasionally do happen. We can all imagine how they can confront people with life-threatening situations and heavy personal losses, taking them brutally away from the safety and certainties of normality. This book contributes to the ongoing efforts of international research communities to better understand the impact and risks linked to disasters, together with potential areas where governments, professionals and community members can intervene. Things can go badly wrong and we need to be prepared. It is impossible to do this without knowledge based on earlier events and current risks. Furthermore, we need to position the knowledge effectively in networks where it is needed the most and invest in maintaining these networks. In this assignment, Arq and Nivel find each other as logical partners with complementary specialities and focal areas. We are very much aware that we can only build the necessary knowledge hubs and bridges in cooperation with our vital local, national and international partners, including the National Institute for Public Health and the Environment (RIVM) and the Institute for Safety (IFV). To use a Dutch saying, Lewis hit the nail on the head in his colourful reflection on what makes us vulnerable. Our vulnerability is entwined with the things we care about the most and cannot afford to lose. This insight is a strong driver to continue our interdisciplinary work, echoing the words of the legendary Sigmund Freud: “Out of your vulnerabilities will come your strength.” Jan-Wilke Reerds, MBA, Msc Chairman of the Executive Board of Arq Psychotrauma Expert Group Prof. Cordula Wagner, PhD Executive director of Nivel Foreword Historically, trauma research in the context of disasters has focused on individualistic concepts of psychopathology. The concept of resilience has gained importance in recent decades. However, resilience and its counterpart vulnerability have been utilized as individualistic (and contrasting) phenomena as well. More innovative approaches depict resilience and vulnerability as interdependent and multidimensional constructs. Michel Dückers’ book On the relativity of the mental health consequences of disasters is an example of such an innovative approach to disaster research. Contrary to most studies in this area, which emphasize on individual psychopathology, Michel Dückers adds a community and society perspective and places accents on cultural and socio-economic factors. As such, justice is done to the idea that trauma-related mental health problems, including the concept of post-traumatic stress disorder, are embedded into a societal and cultural context, which is given and evolves as well. Furthermore, he redefines the multi- faceted concept of vulnerability and shows that what is seen as vulnerability in one context can be a resilience factor in another context. Michel Dückers´ ideas about trauma and mental health contain important new insights that will influence future research in this field. I am very happy to have been part of the habilitation process. Prof. Barbara Juen, PhD Professor of Psychotraumatology and Clinical Psychology Faculty of Psychology and Sports Science, University of Innsbruck The longer the journey between here and the world beyond is, the more perceptible the tragic tension becomes. Paul Klee – Affected Place [betroffener Ort] (1922) Table of contents Chapter 1 Introduction 15 Part I. Cross-national patterns in disaster vulnerability 25 Chapter 2 Exposure, culture and country vulnerability 27 Chapter 3 Exposure, country vulnerability and mental health: PTSD 53 Chapter 4 Exposure, country vulnerability and mental health: any disorder 67 Chapter 5 Country vulnerability, gender and mental health: PTSD 77 Chapter 6 Country vulnerability, gender and mental health: suicide 87 Chapter 7 Country vulnerability and psychosocial service delivery 103 Part II. The quality of psychosocial services in crisis 121 Chapter 8 Consensus on psychosocial service norms and degree of 123 implementation Chapter 9 Conceptualizing the quality of psychosocial support programmes 143 Chapter 10 Evaluating the quality of psychosocial support programmes 157 Chapter 11 Crisis leadership guided by psychosocial support principles 181 Part III. Synthesis 199 Chapter 12 A multi-layered psychosocial resilience framework 201 Chapter 13 General discussion 213 Summary 236 References 238 Acknowledgements 266 Funding 269 Chapter 1 Introduction Chapter 1 1.1. Human consequences of disaster In the field of mental health research it is not uncommon to start a book with a case description of a woman or man with particular problems requiring therapy. Opening with a personal, real-life case can set the right tone for readers as it is a technique which captures the practical relevance of the topic they are about to explore. Media in the 21st century means that the news coverage of any ensuing disaster typically includes the personal situation of at least one or more of the 16 affected. For example, after Hurricane Katrina in 2005, a desperate man walking the streets with his two young boys explained to a reporter how he and his family had been taken unawares by the rising water, how their house had flooded, and how he had lost his wife in the havoc. The man, in shock, was saying: “She’s gone. I held her head tight. She told me ‘you can’t hold me’ and she said ‘take care of the kids and the grandkids’. (…) We have nowhere… I don’t know where I am going. I am lost. That’s all I had.