Psychological support and mental health care

Due to increased understanding of need both during and after disasters, it is routine procedure for government and non-government organisations to provide and coordinate psychosocial support and mental health services for affected populations.

Following the 2009 Victorian bushfires, a best-practice framework to guide provision of mental health care and support to disaster-affected communities was developed by a wide range of government and non-government stakeholders. The framework has three levels of support, based on the level of distress experienced and the timing of the intervention post disaster.

• Level 1 refers to early response information and support.
• Level 2 refers to simple psychological strategies that are helpful for people with more persistent problems.
• Level 3 refers to formal mental health interventions for smaller numbers of people who are at risk of developing significant mental health problems.

This framework and relevant programs have been successfully applied to the planning and implementation of previous government-led natural disaster response and recovery. Training in all three levels was provided to appropriate people in disaster-affected communities. The framework is referred to in the Attorney-General’s Australian Emergency Management Handbook series (handbooks 1 and 2).

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This approach is implemented collaboratively with state and federal government departments responsible for community recovery, as well as all the other professional mental health providers and key disaster agencies. The approach maximises the possibility of creating an optimal recovery environment.

GPs are advised to familiarise themselves with these three levels and, when treating patients in disaster-affected communities, determine what level of support is required.

Level 1 refers to information and simple practical and emotional support provided to affected individuals and communities in the days or weeks following a disaster. Most people will only require this level of support. It is what GPs and practice staff often do on a daily basis with their patients who are in distress. Psychological first aid (PFA) for individuals is a well-known example of this, but it can also take the form of support groups, community meetings, and other community development activities.

Level 1 support can often be provided by community members with basic training to assist those experiencing distress and loss immediately following a disaster.

Critical incident stress debriefings and single-session psychological debriefing sessions were previously provided to individuals immediately after a disaster or traumatic event. However, the World Health Organization (WHO) Department of Mental Health and Substance Abuse has since stated that this approach is ineffective and in some cases may even be detrimental according to current evidence.¹¹

In the event of an emergency, it is recommended that PFA be employed when appropriate to help people distressed by the impact of an emergency or a disaster.

PFA is an evidence-informed approach used to support those affected by a disaster through the recovery phase. This includes in the initial hours, days and weeks post-disaster. PFA is not to be confused with counselling or debriefing.

Overall, PFA aims to minimise stress and anxiety levels, meet immediate needs, promote flexibility in coping mechanisms and encourage positive adjustment. It is a primary tool used in the immediate post-disaster period for people who require assistance after experiencing a trauma.

The fundamental basis for this intervention is that people adversely affected by disasters will naturally experience a range of emotional, behavioural, psychological and physical reactions following a disaster that may hinder their ability to cope and recover from a disaster.

Note that PFA should not be confused with mental health first aid, which is specifically about managing existing mental health problems and disorders.

PFA can be delivered by anyone with appropriate level of training and those in the practice team who wish to provide extra services to individuals and communities in disaster-affected areas are encouraged to undertake training in PFA. The Australian Red Cross has a list of training providers.

For further information about PFA refer to this section on Australian Psychological Society website.

Figure 1 outlines the five core elements of PFA.

Figure 1.

Five elements of psychological first aid

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Disaster survivors and others affected by such events will experience a broad range of reactions, and some of these reactions will cause enough distress to interfere with adaptive coping and recovery.

While most mental health problems following disaster are of mild severity, depending on the scale of the disaster, some people may experience disaster or trauma-related mental health problems requiring low-intensity assistance to assist with recovery and resilience.

Level 2 support refers to simple, brief and practical psychological strategies that can be taught to community members with more persistent mild–moderate mental health problems.

Developed in the United States in the wake of Hurricane Katrina, ‘Skills for psychological recovery’ is a skills-based approach that assists individuals to better recover from the effects of disaster. Level 2 support can be provided by practitioners with basic counselling skills working in general practice, primary care, mental health care and community-based settings. The Australian Centre for Posttraumatic Mental Health developed a reference guide to this approach.

Level 3 refers to formal evidence-based psychological and pharmacological interventions for people with more persistent and severe distress, including those with diagnosable mental health conditions such as PTSD, depression, anxiety, complicated grief and substance use disorders.

Level 1 and Level 2 interventions will in most instances be sufficient in supporting the majority of people through their recovery from an emergency. However, some more vulnerable people will be at greater risk of long-term mental health issues. A relatively small number of people affected by disaster will experience long-term effects and may require Level 3 interventions. These interventions are typically provided by mental health specialists such as psychiatrists and psychologists with expertise in treating people with mental health conditions.

It is important that GPs continue to monitor for and consider the possibility of long-term mental health effects of disasters, which may not be evident for months or years.