Fernando Muñoz Prieto (Madrid, 54 years old) coordinated the urgent psychological assistance device of the Official College of Psychologists of Madrid after the terrorist attacks of March 11, 2004. After that he intervened in accidents with multiple victims such as the Spanair accident (2008) or Alvia (2013). Today he works as a professor at the CES Cardenal Cisneros, a center dependent on the Complutense University of Madrid. He answers elDiario.es a week after a natural disaster that has caused the death of more than two hundred people. Ten days after the floods caused by a super destructive DANA, there are still missing people. The Ministry of Health has already warned that the mental health risk of this ‘tsunami’ is “very high” and is therefore preparing a specific document to evaluate it independently of other dangers.
Do you see similarities with this tragedy in the care the victims need? Or is a natural disaster moving in coordinates that have nothing to do with a terrorist attack?
Both events have similar and also different characteristics. They share that people have faced a situation with a risk to their lives and loved ones. However, a natural disaster is one thing and being intentionally victimized by third parties is another. In general, grieving in a catastrophe can potentially be less difficult than when we talk about terrorist attacks, but it must be seen in each personal situation.
In this case we have three large groups of victims. Those who have lost their belongings and may have physical injuries, but no one around them has died; those who have died and their families and friends; and those who have disappeared. There are three scenarios that must be worked on with different psychological approaches. The latter have a particularly complicated situation. There are still victims of 9/11 in the United States who never recovered the bodies of their loved ones and that greatly influences the grieving process. Special attention must be paid to the psychological situation of these profiles.
Can lessons be learned from then, from 11M, to apply them now?
In our country we have a long history of caring for traumatic events. We had the Biescas flood and terrorist attacks for decades, which has given us extensive technical knowledge. But 11M marked a before and after in the response to victims of mass traumatic events. What we learned then is knowledge that is being perfected and will now be transferred to this situation.
Why was it a before and after?
We had to attend to an extraordinarily large volume in our context and urgent psychological assistance devices had not been developed for the population on such a massive scale. We incorporate care in a multitude of scenarios: in funeral homes, in the corpse recognition lineups at Ifema, in hospitals, in hotels, in the Police, in 112… Then we saw that it was important to provide assistance in a support center, but also on a telephone hotline that has accessibility in the response.
We also learned to be proactive in responding. By this I mean that if a child has died in a school or there are students who have lost loved ones, we must go there and provide resources so that adaptation is the best.
Do not wait for the victim to reach the psychologists, but go for them.
Indeed. It is a very interesting issue and one that generates debate. In macro situations, like this catastrophe, the most optimal approach is the dual one. On the one hand, the reactive one, because we are going to have to serve many people who can overwhelm the services that are already usually quite limited. These services have to respond to everyday life and everything that comes up with good coordination with Primary Care, 061, by telephone, on-site assistance centers… And furthermore, we have to approach certain groups or populations . It is not about pathologizing, but rather about making a rapid detection and providing strategies so that the psychological consequences are as few as possible. Don’t act as if nothing happened.
Grieving in a catastrophe can potentially be less difficult than when we talk about terrorist attacks, but it must be seen in each situation.
Are there always consequences?
Not necessarily, although it is highly likely to happen. In all cases, yes, there will be a trace. It differs from the sequel in the level of affectation of the person. In life, everything negative that happens generates a greater or lesser impact.
What impressed you most in 2004?
It was a truly difficult situation. If I have to remember something it was the excellent work of the emergency services and the absolute collaboration of the civilian population. I remember the thousands of people who lined up to donate blood.
How do you console someone who has lost someone they love in circumstances like this?
The first thing I would like to convey is peace. We have resources to help, we know how to do it and we are going to do it. What is expected is that victims go through various phases of grief and not all of them are the same. That is, we have to look at the specific circumstances in which each person has come to this. This is closely associated with one key thing: whether they have been able to view the body or whether they have not found it or have not been able to see it. Most people are probably in the first phase, which is shock. It can last hours, days or weeks. The second is the recognition of the loss: that means facing returning home – in whatever state that house is –, returning to everyday life without your loved one, what to do with your belongings… In this phase you can be months.
Healing is the place to reach, where people once again have a minimum social life associated with their vital functioning. It is a phase of stabilization and global acceptance in which it takes time to land.
After this, which is probably delayed due to the specific circumstances of this catastrophe, there is usually a stage of isolation that has very intense pain associated with it because the joy of others is difficult to accommodate when you are going through this. Healing is the place to reach, where people once again have a minimum social life associated with their vital functioning. It is a phase of stabilization and global acceptance in which it takes time to land. It does not usually occur before the first year. In any case, they are not linear stages, you can go and return to them depending on different events; progress is not always made.
On the other hand, it is very important for people to say goodbye; we must help generate a ritual that allows the process to take place. Grief is a situation that we are all going to face, but these people have faced it abruptly and it is a risk for pathological grief.
And to the relatives or friends of the disappeared?
They have a very high level of psychological vulnerability. The situation they find themselves in must be evaluated daily in what we call psychological triage. What the guidelines say is that we must give them regular and updated information about what the emergency services are doing, so that they know what they are working on. They also need sleep. This type of situation generates enormous psychological stress and it is common for sleep disturbances to occur because they become permanently awake. It is also common for people to ask us how they can tell other loved ones, a young daughter, for example.
How do you manage that in one area of the province everything is devastated while 20 kilometers away life continues as if nothing had happened?
The result will depend a lot on the level of social cohesion. It is as relevant that an area is desolate as it is that the population feels protected by the administrations and that is where the focus must be placed.
That is exactly what many victims have reproached the institutions: that they did not protect them.
When we feel helpless it is extraordinarily complex. We cannot avoid these catastrophic situations, but we can minimize the feeling of helplessness in the face of them. And here comes the psychological part but also the social or economic part. There are people who may never return home. That is why it is important to streamline all processes, that is the way.
There is a first part after a catastrophe that is physical survival: having food, water and a safe place; and then other needs appear. That’s where the psychological comes in.
The Spanish Society of Emergency Medicine (Semes) has shared this week a document that recommends limiting viewing a lot of news and being permanently connected to networks. How do you see it?
Too much information is not going to help you have better psychological adaptation. The role of the media is extraordinarily important and organizing information is positive for victims. However, overexposing yourself is not the most ideal. Psychological work is based on what we do now; and now; and now. That is, once something has happened, what can be done to help manage coping and reduce dysfunction.
Can we expect the most serious psychological consequences to appear over time in catastrophes like these? Is there a lot to process?
It is possible that yes, but it will depend a lot on the level of response that occurs in all spheres, the quality of that response, and how we can help them longitudinally. It is not the same to recover your home in two weeks than in six months. It is not the same if you have lost a loved one or more than one.
There is a first part that is physical survival: having food, water and a safe place; and then other needs appear. That’s where the psychological comes in. The sooner we are able to expedite psychosocial recovery processes, the sooner we will help this entire generation. There is a huge amount of work to be done and we must start doing it immediately. It will last months and maybe years.
What types of disorders can be common after experiencing something like this?
It is difficult to specify it, but I would talk about three main aspects: adaptation disorders because we have exposed people to a situation in which their abilities are insufficient; to acute or post-traumatic stress disorder; and, finally, pathological grief. Without underestimating anxiety and depression disorders. Furthermore, people who have not experienced a risk to their life, but who are close in distance to the area, for example, can develop these symptoms. If it starts to rain heavily and there are red alerts, they may have similar symptoms of generalized anxiety. Expectant anxiety is the term.
Isn’t this expectant anxiety inevitable in a world that suffers the consequences of climate change? Does this mark a before and after in the management of that uncertainty?
This catastrophe reminds us that the world is vulnerable and that certain things can happen to us. From here, from psychology we will have to continue working and researching to respond to the new social situations we experience, such as climate uncertainty. Profile and improve information systems for the population, so that people are familiar with how we are going to convey an emergency situation to them. That we know what risks we are exposed to so that the population develops better housing is one of the lessons learned. There is much left to do.
Can the fact that there are so many people who have gone through a similar experience help in recovery?
Sharing trauma can help because the higher the level of social cohesion, the more psychological adaptability.
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