Disaster Psychiatrist

Interview with a Disaster Psychiatrist

Wednesday, 31 January 2007

by Ayesha Sarfraz

I do not have a single journalistic molecule in my being, as you can tell by the unimaginative title.To pick someone like Professor Beverly Raphael for my debut was daunting. But she has always been very kind and encouraging, so I decided to test her patience. I wasn’t going to let a little thing as absolute embarrassment stand in the way of interviewing the person who is world’s leading authority on Trauma, Grief and Disaster response.She has helped shape not just Australia’s policy in mental health response to disasters but has also been asked to contribute her expertise to management of disasters such as Hurricane Katrina and the tsunami.And the best thing is, she is our very own Professor!

Ayesha: Thank you very much for your time. I’ll start with the standard question. Tell me a bit about yourself.

Prof Raphael:I started as GP, always wanted to be a doctor. I kept being curious about patients, what was wrong with them. That is how I came into psychiatry. My first job was at Royal Prince Alfred. I thought that I will do it for a while and then go back to General Practice but I was hooked, so here I am.

Ayesha: Do you like anything in particular about psychiatry?

Prof Raphael:I think it has always been about the person. What the individual issues are.How we can help them with those issues.I used to do a lot more clinical work than I do now but it has always been about the people. And I guess that’s how I moved into work I am doing now. In trauma; this is more relevant than ever.I was asked after my exams by David Madison, who was then Professor of Psychiatry, if I would like to do a research fellowship. I ignored that at the time because I didn’t see myself as a researcher but after he asked me a second time, I thought that the idea seemed interesting and that and that is how I started in Academic psychiatry. I have found it extremely interesting.I think I was very fortunate. I did my doctorate work on preventive crisis psychiatric intervention in recently bereaved widows. And I guess that led to my main area of interest, which is Grief and Disaster and terrorism.

Ayesha: So your first research project led to a lifelong project?

Prof Raphael:Yes, it did.

Ayesha: It is quiet an unusual choice.

Prof Raphael:(laughing) Yes, it is. And it was an early choice. It is quiet interesting. I never expected to be an academic either. But I find all aspects of it interesting, the excitement of research, the development of people’s minds and interests, the clinical side. I have been very fortunate in being able to work with very intelligent registrars, such as you.

Ayesha: Thank you.

Prof Raphael: No really, that is one of the joys, watching people get involved and getting excited by the development of ideas.During my work in New Castle and then in Queensland, and now here in ANU, I have had enormous opportunity to get people interested and curious. You don’t have to be an academic to do research. As a clinician you can learn so much from interacting with patients and their relationships. And you can bring that knowledge to research. And there are so many other things, of course, such as teaching and administration.When I was in University of New Castle, I was involved in the development of a truly innovative postgraduate training course called Problem Based Learning. It has been used widely now. Lots of my students from that time are professors now around the country.I took the job of clinical director at New South Wales, for nine and a half years. It was a challenging and stimulating job as well. It’s not just an administrative job; it is also an advocacy job and an instrument for political change.I think mental health is one of the most exciting fields, in the broad sense. Psychiatry and psychiatry spectrum, there are so many aspects to get involved in, to learn and to explore. So much more you can understand. And the problems are quiet significant problems, as long as one can take the time to see people in a broader spectrum. And there are so many ways in which people can be helped, the quality of their lives improved.

Ayesha: Through your career, have you seen psychiatry change and especially people’s understanding of what psychiatry is?

Prof Raphael: I think it goes through cycles of ups and downs. There is certainly a lot more open understanding now. I remember as a young child in a country town, people just vanished from the town. Later I understood that they went to Morisset or one of those big psychiatric institutions and never came back. When I first started in psychiatry, I worked in general hospital psychiatric unit and I didn’t know. It was not until I went to work in a psychiatric hospital that I realised how strange it could be!I think psychiatry often runs the risk of developing ideologies. That one thing will be the cure and will fix it all. And this is not in accordance with what we all know as clinicians, that it is a highly complex field.And depending on what is happening, psychiatry moves in and out of its relationship with the rest of medical field.Quiet so often, people who treat mentally ill have been horribly stigmatised, as being different somehow from the rest of the medical profession. And there have been situations where people have been sick of the conditions in the ward and the inadequate treatment that patients received.Now, I think the attitude is a lot more open. I was doing some talks for the Rotary Club, and to see Rotarians talk about mental illness in their own families, tells me that we have certainly come a long way.There is still stigma and people still talk about ‘lunatic’ without much sensitivity.I think, people don’t realise the scope of these illnesses. Given the prevalence of these illnesses and their spectrum, most of the people and their families have been touched by mental illness directly or indirectly.

Ayesha: Do you think that this causes some sort of identity crisis in psychiatry trainees? I think it was the Canadians who did a study on why psychiatry trainees drop out, and one of the main reasons was because they felt there was no respect from their peers and the community generally.

Prof Raphael: Yes, to some extent it is true. But I think it is much better now. There is still the part of psychiatry that is poorly understood by people who choose to go into other specialities. They think it is all about violence or drugging people up. They don’t understand the need for psychiatric expertise, and have no awareness of the complexities of neurobiology and genetics of psychiatric disorders that are being discovered now. So they see it as a simplistic and often limited profession rather than an exciting and challenging profession that it really is, a life long journey.

Ayesha: Talking about the scope of psychiatry and mental disorders, there are a lot of things that are looked at and investigated even if not actively treated by psychiatrists. The boundaries of psychiatry are sort of blurred in terms of where the pathology starts and normality ends. In your specialty, Trauma, how do you define those boundaries?

Prof Raphael: I am a spectrum person, I don’t think in terms of categorical classifications. And I think that these categorical definitions that we have, are very useful in talking to each other, say for example we say that someone has got PTSD because they have this number of symptoms in that category, this gives a sort of understanding of the kind of thing that the patient may have experienced but it does not give a full understanding of the individual person.I think psychiatrists have a great opportunity to look across that, and to balance what the individual patient has gone through and what we know of the categorical classifications and the spectrum of symptoms from the population studies. So they can decide what can be done to help the individual person, as well as look at the extent of it in the population and what we can do to assist at a broader level.So for me that is my interest in population and individual issues and not the one or the other. That is how I explain the difficult question of those boundaries. Of course, there are these boundaries and then there are professional boundaries where psychiatrists also get into trouble (laughing).Sometimes I think we run the risk of using labels when we haven’t understood the nature of the illness and the disease process. We have used boundaries developed either artificially or even developed with science behind them, to sometimes make ourselves more comfortable rather than to help the patients. For example, Borderline personality disorder, which has lots to do with trauma, is often is seen as a difficult woman, who seems to be not helped with the things which ordinarily seem to make people feel better. And we are putting a label to something we don’t fully understand. We don’t have answers to questions about why this happens and how to prevent or treat it. We use models like DBT which are about building the strengths of the individual and which seem to help people rebuild their lives without understanding a lot about the nature of the illness.

Ayesha: I suppose part of being a psychiatrist is about living with uncertainty. The feeling that I don’t know and that I am doing the best that I can. But then there is the other huge part where mental health is different from other areas, the part that deals with people’s image of themselves and of the society. There is a whole philosophical and social aspect to it and we may be able to live with it but how do we give people the sense that it is not a total loss. We don’t know everything but we are looking for the answers. Because people generally become very dichotomous. Either the psychiatrists know nothing and they are all talk or the view that psychiatrist will fix everything.

Prof Raphael: But the same applies in all fields of medicine except things are much simpler in other fields. Medication that takes cholestrol out of our blood if we take it. In Psychiatry, we don’t have answers that are that easy. And most of the answers aren’t very simple.I think we have to explain that to the patients and train them to live better with it. Going back to one of the things you asked me earlier about changes in psychiatry, this is one of the changes. We have become more accepting of the idea that we don’t have all the answers. And because our world is not quiet simple and because the boundaries aren’t always clear, I think that makes it more difficult for us.I don’t think there is any easy solution as to how we deal with that uncertainty.When I was at the University of New South Wales, we were screening for potential medical students. And one of the things that was part of the assessment at the time was, how do you deal with uncertainty in an ongoing way. And the field that I am working in now, Disaster management, one of the things we deal with is, how do you take the risk of a terrorist attack, a chemical or a radiation exposure and deal with the uncertainty of the outcome, in a shorter and long term.

Ayesha: This uncertainty will impact our interfaces with other fields, such as the legal system. In psychiatry we learn a little more in each decade or so and revise our classification systems. How do you think they will respond to these changes, for example, the definition of trauma from an objective concept to a more subjective one? Do we have a responsibility in this matter or do we just expect the judges and the lawyers to keep abreast of all the changes?.

Prof Raphael: In my experience of going to court for these matters, not in the criminal setting, more in the litigation setting, the lawyers are incredibly well acquainted with not only all elements of literature regarding the issue but also every thing that you may have written yourself.And this has been one of the changes. There was a time when doctors were sort of revered for their expertise; they are certainly not any more. There are usually experts from both sides and every question is debated in great detail. The lawyers are incredibly well informed about the minutia of all the definitions, not just in the DSM IV but also in the literature. So I think we get challenged pretty easily.And I don’t think it is a very simple matter.Take the example of hypertension, it used to be that a blood pressure of 90 diastolic was considered all right but now people have to take a pill to keep it lower.

Ayesha: You are right; I guess the boundaries keep changing everywhere.

Prof Raphael: Yes. We change as we learn more. We all started wearing hats and used sunscreen in Australia and now we are becoming aware of the Vit. D deficiency so I guess the boundaries do keep shifting.

Ayesha: we have gone from one extreme to the opposite.

Prof Raphael: And we have learnt that from the population studies. That is why they are so important and useful because we would not have understood these things otherwise.

Ayesha: What have we learnt from population studies about disaster management?

Prof Raphael: We have learnt just how resilient most of the people are. There have been interesting findings from studies looking at Sept 11, and the Canberra bush fires. And it is incredible just how much stress especially psychological stress, people can face and still manage to do all right in terms of their mental health.Population studies have shown us that there are patterns of strength along side the patterns of vulnerabilities. And people can grow as well as suffer terribly through these catastrophes.And the other thing that these studies have shown us is about allocation of mental health resources in acute situations, how difficult it is to find out what the people need and how to meet these needs in acute situations.One good example of that is here in ACT, of Canberra bushfires. Even though enormous resources came forward to help the people in their recovery, two separate studies have shown that there is ongoing Post Traumatic Stress Disorder in the community above the normal level, related to the bushfires. So the question is how to channel the mental health expertise better. That is one of the challenges faced by Psychiatry.

Ayesha: What are the other major challenges in terms of resources?

Prof Raphael: I think another challenge is that as a professional body, we now have a lot of different streams. So our voice has become quite diffuse and we focus more on our particular area of interest or our work rather than focus on more broad mental health issues.One other area that I think has to do a lot better is that of Child Psychiatry. So many of the mental health problems in adult life start in childhood and yet it is an area where there are quite minimal resources.

Ayesha: Do you think there is a role for primary prevention in disaster management, in terms of the psychiatric morbidity in disaster?Prof Raphael: We would hope that when people are exposed to massive trauma, there are things that we could do to make them better. There just hasn’t been enough research to show how effective the interventions can be. Though there is growing body of very good work in that field. And we know that interventions at certain times, can help people who have been acutely psychologically traumatised. What we haven’t learnt is how these interventions can be readily implemented and can be made available to those people at the right time.

Ayesha: What is the current status of the psychiatric disaster response in Australia? I mean, how many resources do we have?

Prof Raphael: Well, that’s a good question.I chair a National Committee which coordinates the national mental health response in disasters. And we have some very good resources. We are a Federation of Sovereign States in Australia and the committee is how we maintain consistency across all jurisdictions. The committee includes the directors of mental health from every state and we also have some international experts in the field. So we have quiet a high level of expertise to back what we do. How to do it when we need it, is not quiet so easy. I have been involved in trying to do this for more than thirty years, and to do that during a calamity is not simple.

Ayesha: What about different populations involved in disasters? Because their needs must be different, for example, adolescents. Do you think we are at a level where can have separate service streams for provide for them?

Prof Raphael: My team has got a separate child and adolescent subcommittee which has a very high level of expertise, from around Australia and from abroad as well.There is a growing body of evidence that intervention at that level can be very effective, especially the studies looking at models of intervention which can be implemented in schools, which I think are quiet valuable.One of the problems in this particular area is that there are various shortages of resources. Even though children are 25 percent of the population, they are allocated only 7 percent of the mental health budget.

Ayesha: And this is an area where we may be able to make a huge difference in outcomes.Do you think this is because psychiatrists don’t see it as the core business of psychiatry? They see it as more a job for psychologists and social workers than the medical profession?

Prof Raphael: I think you are spot on. It is almost like there is a cultural attitude that children don’t get mental illnesses and adolescents are just going through a troubled time or playing up. I think our cultural beliefs contribute both to the attitudes of the psychiatrists and the community in a larger sense.

Ayesha: Do you think that Trauma is a field that you would encourage psychiatry trainees to consider as a speciality?

Prof Raphael I think that it is a very important that all trainees look at it in their clinical work. The trauma their patients have faced, their strengths and personality styles, how they have coped and how that has affected their mental health.I would advise trainees to not look at trauma just as PTSD. It is much more complex and there are different levels of trauma and individual response.

Ayesha: And how do you think that can be incorporated into training?

Prof Raphael: Well, I think reading some of the other literature, like Judith Herman’s very good book, Trauma and Recovery. It is not a psychiatric book. It looks at the issue from a different perspective. It discusses the breadth of trauma experiences and its complexities instead of PTSD. And it is not just about veterans and men either; it also explores the trauma undergone by women who have been raped.

Ayesha: A lot of these issues may never reach a psychiatrist. Most of these people will probably see GPs or they may present with physical symptoms instead of psychological distress. Do you think that the response to these patients at a primary care level can be improved by addressing it medical student education?

Prof Raphael: You are very right. Unfortunately it is not something that has been well addressed. There just haven’t been enough people who have been interested. Though now there is a growing interest along with the awareness of the subtleties of trauma and grief.

Ayesha: Do you think that can be changed?

Prof Raphael: It is interesting. Here in ANU, I am doing a session with the medical students about Stress and Trauma but I think that it is how we address the issue at a broader level that will make a difference.In 1993, I was asked by Pat Swan if I would come around Australia and help develop the national mental health policy and I learnt an enormous amount from that. I went across several Aboriginal communities. And before that I thought I was the expert but what I knew was nothing compared to what I learnt from the trauma these people had suffered across generations and the everyday losses they go through.Trauma and grief is such a large scale issue that it needs to be addressed at both individual and community level.

Ayesha: I guess that the trauma can shape not just how individuals respond but also how communities adapt.

Prof Raphael: Yes. A colleague of mine has done excellent work on the concept of collective trauma as compared to individual trauma, and the damage it does to communities and the difficulties that may arise specially when it is perpetrated by a human agency, instead of being a natural disaster, for example terrorism .

Ayesha: What about the concept of trauma in a multi-ethnic country as Australia? Because people from different cultures will respond in very different ways to trauma.

Prof Raphael: Yes, we haven’t done that well yet, though there is an increasing interest. There is this emerging opinion that PTSD is a Western concept that it is transferred automatically to other populations. And there is a lot of basis for that opinion.Though there is some good work done on refugees that indicates that there may be some core components that are shared across cultures. For example the sense of safety that is lost, the detachment of supports when people are dislocated to another place. But the simple concept of PTSD may not fit every culture.And then there are differences in what different cultures see as a traumatic event. And there is an enormous need for more understanding of that. Specially because there is emerging evidence that there may be types of trauma which may not be as benign as perceived by a culture.

Ayesha: One last question. Where to from here? What are your plans for future?

Prof Raphael: Well, I am seventy two.(laughs)I must say I love this job here. I am only here two days a week, but it is fabulous. I find it very exciting working with you and the others registrars.

Ayesha: Yay! I am definitely going to put that in.

Prof Raphael: (very kindly) Well, it is true. My other job is totally different at the University of Western Sydney which while attached to the medical school, involves a lot of research on mental health issues. But that is interesting in a totally different way.I enjoy being here, you are all so bright eyed and bushy tailed. It is exciting being part of the teaching of trainees.I like new challenges. And I will like to continue working. But there is a lot of stigma about aging as well.

I had to stop there because I had already gone over time and her next appointment was getting impatient. So I packed my stuff and walked out, hoping that I can do justice to the interview.Hope you enjoy reading it as much as I enjoyed doing it. (Not the typing part of it or the proof reading.)any have written yourself.And this has been one of the changes. There was a time when doctors were sort of revered for their expertise; they are certainly not any more. There are usually experts from both sides and every question is debated in great detail. The lawyers are incredibly well informed about the minutia of all the definitions, not just in the DSM IV but also in the literature. So I think we get challenged pretty easily.And I don’t think it is a very simple matter.Take the example of hypertension, it used to be that a blood pressure of 90 diastolic was considered all right but now people have to take a pill to keep it lower.

Ayesha: You are right; I guess the boundaries keep changing everywhere.

Ayesha: we have gone from one extreme to the opposite.

Prof Raphael: And we have learnt that from the population studies. That is why they are so important and useful because we would not have understood these things otherwise.

Ayesha: What have we learnt from population studies about disaster management?

Ayesha: What are the other major challenges in terms of resources?

Ayesha: Do you think there is a role for primary prevention in disaster management, in terms of the psychiatric morbidity in disaster?

Prof Raphael: We would hope that when people are exposed to massive trauma, there are things that we could do to make them better. There just hasn’t been enough research to show how effective the interventions can be. Though there is growing body of very good work in that field. And we know that interventions at certain times, can help people who have been acutely psychologically traumatised. What we haven’t learnt is how these interventions can be readily implemented and can be made available to those people at the right time.

Ayesha: What is the current status of the psychiatric disaster response in Australia? I mean, how many resources do we have?

Ayesha: Do you think that Trauma is a field that you would encourage psychiatry trainees to consider as a speciality?

Ayesha: And how do you think that can be incorporated into training?

Ayesha: Do you think that can be changed?

Ayesha: I guess that the trauma can shape not just how individuals respond but also how communities adapt.

Ayesha: What about the concept of trauma in a multi-ethnic country as Australia? Because people from different cultures will respond in very different ways to trauma.

Ayesha: One last question. Where to from here? What are your plans for future?

Prof Raphael: Well, I am seventy two.(laughs)I must say I love this job here. I am only here two days a week, but it is fabulous. I find it very exciting working with you and the others registrars.

Ayesha: Yay! I am definitely going to put that in.