January 23, 2001
An Interview with Germán Casas Nieto, an MSF Psychiatrist in El Salvador

Thirty-three-year-old psychiatrist Germán Casas Nieto is a Colombian volunteer who specializes in working with people who have experienced natural disasters.

"After the first disaster, the so-called natural disaster, the second disaster to take its toll on the victims is the psychological one." — Germán Casas Nieto © Gerard Gomez/MSF

In response to the earthquake that struck El Salvador on January 13, 2001, MSF, which was already carrying out a variety of projects in the country, started an emergency program to assist the affected population. Together with its health-care and water-and-sanitation activities, MSF organized a mental health team made up of five psychologists and one psychiatrist, Germán Casas, to assist the earthquake victims. Dr. Casas had previously worked in similar situations: the Cauca (1995) and Armenia (1998) earthquakes in Colombia; the volcanic eruptions in Guaguapichincha (2000) and Tumburagua (2000), Ecuador; and Hurricane Mitch in Guatemala (1998). He says that, “after the first disaster, the so-called natural disaster, the second disaster to take its toll on the victims is the psychological one.”

What interests you about the psychological consequences of natural disasters?

The eruption of Nevado del Ruiz in Colombia, in 1985, had serious psychological consequences on the population. Many assessments have taken place about the effects of that disaster. The case has been studied over the years in a systematic way (after one year, after 5, after 10…). Therefore, in Colombia, it is widely known that natural disasters have serious effects on the mental health of the affected populations.

How can the impact of a disaster on a population be measured?

There is a theory known as “Psychological Reaction to Disasters” that establishes five stages: the warning stage (which is not seen in the case of earthquakes, but is observed in the case of hurricanes or volcanic eruptions), impact stage, inventory stage, short-term recovery stage, and long-term recovery stage.

The effects of an earthquake start at the impact stage, because the disaster cannot be foreseen. A hurricane or volcanic eruption, by contrast, can be foreseen, since we know when a hurricane is approaching or a volcano has become active. An earthquake bears different features from other disasters, and its consequences on the victims’ mental health are more serious. These characteristics are: universality (it affects everybody, without distinction, from a certain geographical area), spontaneity (it cannot be foreseen), and irreversibility.

After the impact stage, we get to the inventory stage, in which the individual becomes aware of what has really happened and how it has affected him or her. For instance, in the consultations we had in El Salvador four or five days after the earthquake, patients asked us what had happened. Now, instead, they explain how they have been affected.

In the case of an earthquake, the final, or recovery, stages take longer to arrive. In fact, the psychological recovery is as slow as the recovery of physical infrastructures.

Why is recovery so slow?

Because those who have lost everything have nowhere to return to. Besides, the geography of the places where they used to live has also changed. The victims of an earthquake have lost all their physical references and, consequently, this delays the recovery of psychological references. A home means protection, shelter, security, family cohesion… When one loses one’s home, all this is lost with it.

Moreover, so-called “shelter syndrome” is a common characteristic of earthquake victims. When a disaster is foreseeable, the victims usually know they will be evacuated. On the contrary, when an earthquake takes place, the victims must adapt to a new physical reality, which generates a psychological imbalance. This is a general feature found in displaced people living in shelters or asylums.

Do all the victims present the same psychological imbalances?

All the victims of an earthquake—whether or not they have lost their homes, their families, relatives, or other acquaintances—have a psychological response. Most of them have a normal response, a response requiring a certain type of attention and information. Other people may present with a more severe response, which is different in each case, depending on the person and what he or she has had to endure.

Which are the psychological consequences of an earthquake?

Initially people are shocked; they do not believe what has happened. They experience fear, some have sleeping problems, nightmares even occur. Others are constantly preoccupied with what has happened. They may have flashbacks and sometimes do not realize the event is over. To balance their continuous preoccupation some people try to avoid everything that is related to the event. They do not want to speak about it; they avoid smells and sounds; sometimes they even avoid people who remind them of the event. We also frequently see people complaining of all types of physical ailments, which the doctors are unable to diagnose through a physical examination. Children have behavioral changes; they become restless, irritable, aggressive, silent, and they also need to be with their parents constantly. They suffer from insomnia, regression to a previous stage of life (for example, sucking their thumbs or wetting the bed). The most extreme cases develop school phobia causing learning and developmental problems. These types of reactions are normal responses to abnormal circumstances, and most people recover within a month. Despite the normalcy, people still feel upset. Some feel like they’ve gone crazy.

Are there cases with severe reactions?

Yes, but I have to say that only a small group of people have severe reactions to their adversity. They may develop an acute traumatic stress disorder, a psychosis, or depression. The most severely affected cannot and will not take care of themselves anymore. They simply give up on life (actively or passively).

As our Colombian study shows, the prolonged effects of psychological stress are much more widespread. These effects have become commonly known as Post-Traumatic Stress Disorder (PTSD). The symptoms of this disorder do not differ too much from the acute (and, at the time, normal) signs. However, it becomes a disorder when people are fixed or entrenched in their preoccupation or avoidance. The fixation is not only harmful to the person him- or herself. Families are affected. And when, as in this earthquake, whole communities are affected, long-term effects can be visible on the community level. Of course the incidence of PTSD among individuals increases, but most visible is the dysfunction of the community system: substance abuse increases, marital and family conflicts rise, violence and aggression grow, and so on. In short, the social fabric of the community may disappear. But these are more prolonged effects. The MSF intervention at this moment focuses on the immediate psychological responses.

How does MSF intervene?

Our aim is to alleviate the symptoms that make people suffer, singling out the most complicated cases, and helping others through information and “psycho-education.” Here in El Salvador, we work in a variety of ways: for those suffering from acute disorders like shock, psychosis, and so on, we provide direct care through psychological and psychiatric consultations. But the larger group suffering from apparent, normal signs still needs attention. After all, in time they may develop PTSD or psychosocial problems. For this group we try to inform and reassure through psycho-education (“What is happening with you? What can you do?”). For those who are really upset, it is very useful to share their experiences—to get it off their chests.

In situations like this, it is important to coordinate our activities with the authorities, community leaders, and local NGOs. We encourage them to create their own community services and mental health referral network. Advocating for ongoing attention to mental health in these circumstances is also very important, because MSF will not replace the Ministry of Health. We will not take over, but we do aim to reinforce existing self-help mechanisms. In El Salvador, there are a number of good psychologists who can take over.

Which therapies do you apply?

It is very important to understand that therapies are for those who are sick. In such cases, we provide medicines and acute psychological treatment. We help people to restructure what has happened, we give them psycho-education, we prepare them for what may happen in the coming days, and we organize support from their social network (family, neighbors).

But as I said before, the majority of people are upset; they sometimes feel terrible but are not suffering from a disorder. Their reaction is normal. In the strict theoretical sense, these people do not need therapy but rather support, because they are at risk. Therefore we inform them about what an earthquake is; we let them express their grief and ventilate their emotions; and we give them practical information. When people want to reconstruct their experiences in detail, we can help them. But we do not force them to relive the experience and we don’t dig into their emotions. It is important that the survivor is in charge of his or her own healing process.

We also carry out community and psychosocial activities aimed at supporting self-help mechanisms. Community leaders are trained, and we encourage families to support each other and to support those who are alone. At a later stage the media can also be helpful in raising awareness. I think it is important that MSF does not only address the material needs and physical suffering. The emotional pain, the psychological distress, and the shattered basic beliefs of our beneficiaries also need attention.

In the Cafetalon camp, which shelters 10,000 displaced people, some sects who believe the earthquake was a punishment by God arrived along with the NGOs. How does the mental health team deal with this situation?

When one’s psychological space is lost, the individual becomes very vulnerable. Sects take advantage of this vulnerability to gain adherents and riches. If the patient believes the disaster to be a punishment by God because of his or her religion, this must be respected. But if the patient is under the influence of these groups, something must be done about it.

Can the volunteers working in this kind of disaster also be affected?

They may suffer from so-called exhaustion syndrome. This is why they should not work more than six days in a row. If they do not rest but rather devote all their time and energy to their relief work, they may start suffering from irritability and automatic behaviors.

San Salvador, January 23, 2001

© 2013 Doctors Without Borders/Médecins Sans Frontières (MSF)