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Personal Perspective

The China–Australia training on psychological crisis intervention for medical aid leaders and volunteers after the Sichuan earthquake

For many thousands of years it has been recognised that disasters have significant physical and psychological effects on human society. Some of the earliest written records from Sumeria comment on the destruction of Nippur in 2000 bc and report on the anguish and suffering of the population.1 More recently, research has provided ample evidence of psychiatric morbidity in the wake of natural and human-caused disasters.2 Much of the research has focused on post-traumatic stress disorder (PTSD), but other conditions such as depression and anxiety disorder have also been reported. Initial high rates of distress usually diminish over the ensuing months, except for the people most intensely exposed to disaster stressors such as threat to life, loss of loved ones and loss of home. Earthquakes have been associated with enduring rates of PTSD as high as 25% in the affected population, highlighting the need for mental health interventions.3 Children are particularly vulnerable in such circumstances.4

These issues were again brought to prominence with the Sichuan earthquake that occurred on 12 May 2008: 69 000 people were left dead, 374 000 injured and 4.6 million homeless. Many Chinese psychiatrists, psychologists and volunteers gave up their normal duties to help the affected people, who were experiencing a high level of psychological morbidity. They faced overwhelming levels of distress in the affected population and were keen for further detailed information to carry out their roles more effectively.

A strong partnership established over the past 4 years between Peking University Institute of Mental Health and Asia–Australia Mental Health provided the basis for developing a collaborative program to support China’s response to mental health problems in the immediate aftermath of the Sichuan earthquake. Asia–Australia Mental Health is a consortium of St Vincent’s Health and the University of Melbourne’s Department of Psychiatry and Asialink, of which two of us (C N and J F) are directors. This partnership had focused on models of community mental health care more broadly, and before the earthquake had already established guidelines for supporting children in disaster situations.5 These were disseminated to affected regions in China and across the country.

Soon after the earthquake occurred, a group of experts with experience in the field of mental health in disasters and psychosocial response was formed in Australia to plan and develop an education program. The group consisted of core members of Australia’s national disaster mental health coordinating process, the National Mental Health Disaster Response Taskforce. They were invited to develop the program in partnership with senior members of the ongoing collaboration from China. The Australian training team dealt with concepts such as “psychological first aid” and personal support; planning, organisation and implementation strategies; resilience building; the needs of children and other vulnerable populations; evidence-based intervention strategies for trauma, grief and other stressors (such as dislocation, loss of home, and injuries); and multiple consequences linked to what was known about the impact of the disaster.

The Australian training team developed resources and presentation material in Australia, which were sent to the Chinese organisers through the leader of the process in China, Professor Ma Hong, of the National Centre for Mental Health, China Center for Disease Control and Prevention/Peking University Institute of Mental Health. The material was translated, shaped to suit local need, and prepared for an education and training program that took place in Chengdu in Sichuan Province in early July, 2 months after the earthquake.

Three of us (B R, an expert on mental health response to trauma; A C, a senior manager leading emergency management for the Australian Red Cross; and R M P, who played a significant role in mental health recovery of Australians affected by the second Bali bombing6) were invited to conduct the training in association with senior faculty members of the Peking University Institute of Mental Health, with representatives from the provinces and from volunteer organisations such as Hope China.

The training program was funded by AusAID and supported at a very high level in the Chinese Government, with Bai Huan, Deputy Director-General of the Bureau of Diseases Prevention and Control and Yang Gonghuan, Executive Director of the China Center for Disease Control and Prevention attending the opening ceremony. In his speech, Yang Gonghuan emphasised that mental health is an essential component of disease control in China.

Those attending the workshop had volunteered or been sent to provide assistance to the affected population, and most had been working intensively in the region from the earliest time after the earthquake. Apart from these workers, senior mental health professionals from every province in China attended the workshop, to make up a total of 280 participants. The stories of their experience movingly portrayed the huge extent of the disaster and the human distress engendered: families who had lost their only children; seriously injured children being cared for in hospital; and the multitudes who had lost their homes, their way of living, their communities, and their capacity to work. At the same time, there were many stories reflecting the enormous courage and resilience of the people affected, and the compassion and dedication of those who had dropped everything to help them. Workers themselves were stressed by the extent of suffering they had witnessed. There were also stories of the ongoing aftershocks, re-awakening the trauma experience and adding to the difficulties of managing the consequences. Many Chinese speakers as well as visitors contributed to the presentation at the workshop, reinforcing the value of the partnership approach.

Before the workshop, the Australian delegation was involved in preparatory work with teams of translators in the delivery of the lectures. This was a delicate and difficult task, with each line of text from 200 or more slides having to be worked through by the presenters and their allocated translator.

The workshop was jointly conducted over 4 days and consisted of lectures with simultaneous English and Chinese PowerPoint (Microsoft Corporation, Redmond, Wash, USA) presentations on a range of topics. The lectures were conducted in a spirit of equal partnership with Chinese faculty members, with shared responsibility for material (Box). It became quickly apparent to the training team that participants wanted more engagement with the training process than could be simply developed through a “lecture program”. As a result, the Australian training team developed role plays around specific aspects of psychological first aid as well as responding to participants’ “questions from the floor”.

In the evening, the Chinese faculty members provided supervision to the groups of volunteers and mental health professionals, helping them deal with their own emotional issues relating to working with the affected people.

The effect of the earthquake on ordinary Chinese people was apparent in conversations such as those with the people of Pengzhou, a town destroyed by the earthquake, during a visit by the Australian team to the reconstruction village there. One of our team (C N) summed up the thoughts of the Australian delegation when he stated:

The devastation of the earthquake that shook this province on 12 May will always be remembered. But the horror also brought a rare opportunity for all of us to rethink what really matters, to reach out to other humans who are suffering. People across China have responded with “one heart”. And people overseas, as far [away] as Australia, are moved to make a contribution.

The workshop concluded with a banquet, providing a wonderful, warm and joyous opportunity for the visitors to share their experiences and express their respect for and recognition of the achievements of their Chinese colleagues in responding to this catastrophe.

The ongoing effect of the training from the workshop was also evidenced by the further work done after the earthquake by Professor Xin Fang, a Chinese faculty member. Professor Xin, who has specific training in the psychotherapy of trauma, had given up her regular work to volunteer to help people affected by the earthquake. After participation in the workshop, she was travelling to Mongolia and Guangzhou to pass on the information she had learned to senior education officials and police, to help their organisations cope better with the psychological consequences of trauma.

Asia–Australia Mental Health and the Peking University Institute of Mental Health agreed to build on the success of the workshop by conducting further training, including consolidating the training of the participants in the initial workshop. Both groups have looked to the development of further research to evaluate the effect of the training as well as mentoring of senior Chinese academics and policymakers to continue the progress of the initiative.

Concluding comments at the workshop expressed the view that this model of partnership had been invaluable. It brought the strengths of mutual respect, and a recognition of the importance of continuing to develop new understanding that would be helpful, not only to China and Australia, but also for many other countries facing such disasters in the future.

The education program

• A systemic approach of psychosocial response to disasters*

• Assessment of physical injury and first aid†

• Team leadership*

• Disaster worker recruitment*

• Maintaining a functioning team*

• Information and communication*

• Psychological first aid*

• Personal support*

• Clinical programs and early intervention*

• Assessment and treatment of clinical disorders*

• Medication*

• Children and adolescent mental health issues*

• General population mental health issues*

• Medical ethics†

• Supporting people affected by the earthquake*

• Rebuilding communities*

• Assisting cultural minority groups†

• Multidisciplinary cooperation†

* Australia. † China.

None identified.

1 School of Medicine and Dentistry, James Cook University, Townsville, QLD.

2 St Vincent’s Mental Health Service, Department of Psychiatry, University of Melbourne, Melbourne, VIC.

3 Australian Red Cross.

4 Asia–Australia Mental Health, University of Melbourne, Melbourne, VIC.

5 University of Western Sydney, Sydney, NSW.

Correspondence: robert.parkerATnt.gov.au

1. Kinzie JD, Goetz RR. A century of controversy surrounding post traumatic stress-spectrum syndromes: the impact on DSM III and DSM IV. J Trauma Stress 1996; 9: 159-179.
2. Neria Y, Nandi A, Galea S. Post-traumatic stress disorder following disasters: a systematic review. Psychol Med 2008; 38: 467-480.
3. Kilic C, Aydin I, Taskintuna N, et al. Predictors of psychological distress in survivors of the 1999 earthquakes in Turkey: effects of relocation after the disaster. Acta Psychiatr Scand 2006; 114: 194-202.
4. Eksi A, Braun K, Ertem-Vehid H, et al. Risk factors for the development of PTSD and depression among child and adolescent victims following a 7.4 magnitude earthquake. Int J Psychiatry Clin Pract 2007; 11: 190-199.
5. Ma H, Ng C. Protecting children in disasters. Beijing: Peking University Medical Press, 2008.
6. Guscott WM, Guscott AJ, Malingambi G, Parker R. The Bali bombings and the evolving mental health response to disaster in Australia: lessons from Darwin. J Psychiatr Ment Health Nurs 2007; 14: 239-242.
7. Ursano RJ, Fullerton CS, Weisaeth L, Raphael B, editors. Textbook of disaster psychiatry. Cambridge: Cambridge University Press, 2007.

(Received 25 Sep 2008, accepted 15 Feb 2009)

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