Book Review

Interventions Following Mass Violence and Disasters: Strategies for Mental Health Practice

N Engl J Med 2007; 356:1386March 29, 2007

Article

Interventions Following Mass Violence and Disasters: Strategies for Mental Health Practice
Edited by Elspeth Cameron Ritchie, Patricia J. Watson, and Matthew J. Friedman. 430 pp. New York, Guilford Press, 2006. $48. ISBN: 978-1-59385-256-6

The response to a major disaster is beset by logistical problems, not least of which is that the means of implementing interventions that are meant to aid the victims are also disrupted. One of the strengths of Interventions Following Mass Violence and Disasters is that it places the response to concerns about mental health within the fragmented environment that follows a catastrophe. Although the book contains useful advice on practical mental health interventions, its real goal is to outline what we know and what we do not know about this kind of intervention. Chapter 5 provides an excellent discussion of how to monitor and evaluate the mental health services offered in the aftermath of disaster, stressing the importance of getting “buy-in” on the plan of action from all parties involved throughout the course of the intervention.

The authors of each chapter provide clear summaries of the literature about mental health interventions in the wake of terrorism, tsunamis, and other catastrophes, tending to focus on research related to post-traumatic stress disorder. The section on preparation and assessment contains several excellent papers on resilience and assessment of needs. The chapters in the middle section of the book neatly divide strategies into immediate, early, intermediate, and long-term interventions. They review the literature on each, providing practical recommendations and acknowledging the limitations of each strategy.

The last two chapters of the book discuss future directions. Authors Litz and Gibson examine the ethical imperatives for studying and learning from postdisaster initiatives in a concerted way. They assert that “it is arguably the failure to conduct RCTs [randomized, controlled trials], rather than to implement them, that represents an ethical problem.” A case in point is psychological debriefing and clinical incident debriefing, which are well-studied postcrisis interventions. Several of the book's contributors note that these techniques have been shown to lack efficacy and that they “may be associated with more adverse outcomes.”

Ursano and Friedman, in the final chapter of the book, point out what is at stake: “the disaster community is often flooded with outsiders” who can not only disrupt the community further but also consume valuable local resources. Given that most people and communities appear to recover after a disaster, the outsiders and the professionals who offer services are obliged to make sure that they are really needed. This book reminds us that ignorance and good intentions are no excuse for doing harm.

There are many lingering questions. To what extent do acute stress disorder and post-traumatic stress disorder account for the psychological suffering in the wake of a disaster? And by collecting symptoms under the rubric of specific disorders, however reliable and valid the rubric may be, are we not also making the assumption that treatment can be generalized? This is a field full of questions that need to be answered not only very carefully but also in great depth.

Schuyler W. Henderson, M.D.
Columbia University, New York, NY 10030
henderss@childpsych.columbia.edu

Andrés Martin, M.D., M.P.H.
Yale Child Study Center, New Haven, CT 06520