Disaster survivors are resilient. Many will say without thinking that they are fine. But many just aren't.

A traumatic disaster like a bushfire, a flood, a bombing or a shooting will leave about 5-20 per cent of survivors with full blown post traumatic stress disorder, needing extensive therapy. But around a third of survivors will suffer less intense, but still damaging, psychological hurt that can easily go unnoticed and untreated. Instead it nags away at survivors, undermining their relationships, health and work.

And the lifetime psychological costs of disasters are huge. A Deloitte Access Economics report estimates that the mental health costs of the 2009-10 Black Saturday bushfires in Australia that killed 173 people will exceed $1 billion. The total social cost will amount to almost $4 billion, larger than the material costs estimated at just over $3 billion.

Now, in the first major international effort to tackle the problem, the University of Melbourne's Phoenix Australia Centre for Posttraumatic Mental Health is leading a research initiative to develop and pilot a guide for doctors, nurses, social workers and non-government emergency response workers to help them identify and assist survivors who may not be coping. The pilot will outline a brief program of interventions, such as simple writing exercises, designed to help survivors process what has happened to them, as well as ways to address patterns of thinking and activities that may be blocking the way towards recovery.

The pilot will include "guided self-help", where survivors would complete an online program that includes a series of questions designed to identify those who aren't coping, and which may also include some face-to-face or telephone "coaching."

"At the moment there is no evidence base, or clear way for dealing with this problem," says Phoenix Australia Director Professor David Forbes, who is also deputy head of the Department of Psychiatry. "What we need is a guide that can assist health practitioners and community workers to identify patterns of behaviour when it isn't full blown PTSD or depression, and provide simple ways in which they can make a difference."

Using the right tools

While some sufferers will know they need psychological help, others won't. But with the right tools Professor Forbes says health services and disaster recovery workers will be able to recognise when someone isn't coping. He says it will be important that any resource be available beyond just primary healthcare workers, since a community worker helping in reconstruction will sometimes be best placed to identify people who are struggling.

"Most people are very resilient and have good coping strategies, so it is important not to cut across what people are doing to recover in their own way. But many will continue to experience difficulties such as strong feelings of fear, sadness, guilt, anger or grief. They don't need ten weeks of intense therapy, but what they do need is a short circuit so they recognise what they are suffering and receive help.'' Professor Forbes says.

"Ultimately, we want an evidence-based intervention that is flexible enough to be put on a national digital platform with materials for guided self-help along with coaching support. And we want it to be able to be delivered anywhere and be an accessible resource for primary health networks across the country and potentially around the world.

"Although initially designed for use following disasters, the program will also be applicable over time to emergency services workers and military personnel, or community members affected by a broad range of other traumatic experiences."

With funding from the Australian Government, Phoenix Australia will now lead a pilot program in September/October 2016 involving about 60 participants, all from a single, unnamed, area of Australia that was disaster affected in the last 12 months. The results should be available by April 2017 and will provide the basis for a larger randomised controlled trial.

"We want to be in a position to be able to tell government, with our hand on our hearts, that in the aftermath of disasters we know this works," says Professor Forbes.

So what are the signs of having trouble readjusting after a traumatic disaster? Professor Forbes says it can best be understood as much milder symptoms of PTSD, for which he says there are four broad signs:

1. Flashbacks: Survivors are haunted by recurring memories or nightmares in which they relive the traumatic experience.

2. Avoidance: In response to the flashbacks survivors will try to suppress memories of the disaster to the point where they may avoid any triggers that may remind them, such as staying away from the location of the disaster or avoiding some social situations.

3. Negative emotions: These include feelings or anxiety, guilt, sadness and anger. But at its worse it is having no feelings at all. "The feeling of complete numbness is possibly the most damaging because it is insidious and cuts to the core of a person's relationships with loved ones and friends," says Professor Forbes.

4. Being on edge: While the danger may have passed, a disaster survivor may still be on hyper-alert in anticipation of the danger recurring, leaving them stressed, irritable and prone to insomnia. "These people have been through a situation that has threatened their lives, and their mind and body remains on alert," says Professor Forbes.

"A survivor suffering readjustment problems but not PTSD or depression, might go on thinking that this is just how they are now without being aware they might benefit from simple treatment. But their relationships may be becoming strained because they are more irritable and prone to anger. They might find they aren't sleeping that well and they aren't working as effectively. They haven't got a clinical disorder but they are losing their quality of life," says Professor Forbes.

In assessing the lifetime social costs of Black Saturday, Deloitte estimates the cost of excessive alcohol consumption among those affected at $193 million and the staggering cost of family violence at almost a $1 billion. In addition to reducing the mental health bill of disasters, it is these other related and insidious costs that the researchers are hoping to reduce by being able to pick up psychological problems early.

The initiative came out of an international round table of mental health experts in Sydney in November 2015, including representatives from Australia, the US, UK, Canada and Asia. The round table was initiated by Phoenix Australia in partnership with The Prince's Charities Australia, and supported by The Prince of Wales, who attended and spoke with the experts. Professor Forbes is hoping that given the risk of natural disasters and terrorism around the world that the project can be discussed at the next Commonwealth Heads of Government Meeting in the UK in 2018.

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