NCM 120 – Disaster Nursing

Small Group Discussion 5: The 2017 Marawi Siege

The Siege of Marawi was a five-month-long armed conflict in Marawi, Philippines, that started on May 23,
2017, between Philippine government security forces and militants affiliated with the Islamic State (IS),
including the Maute and Abu Sayyaf Salafi jihadist groups. The battle also became the longest urban
battle in the modern history of the Philippines.

According to the Philippine government, the clashes began during an offensive in Marawi to capture
Isnilon Hapilon, the leader of the IS-affiliated Abu Sayyaf group, after receiving reports that Hapilon was in
the city, possibly to meet with militants of the Maute group. A deadly firefight erupted when Hapilon's
forces opened fire on the combined Army and police teams and called for reinforcements from the Maute
group, an armed group that pledged allegiance to the Islamic State and which is believed to be
responsible for the 2016 Davao City bombing, according to military spokesmen.

Maute group militants attacked Camp Ranao and occupied several buildings in the city, including Marawi
City Hall, Mindanao State University, a hospital and the city jail. They also occupied the main street and
set fire to Saint Mary's Cathedral, Ninoy Aquino School and Dansalan College, run by the United Church
of Christ in the Philippines (UCCP).

The Armed Forces of the Philippines stated that some of the terrorists were foreigners who had been in
the country for a long time, offering support to the Maute group in Marawi. Their main objective was to
raise an ISIL flag at the Lanao del Sur Provincial Capitol and declare a wilayat or provincial IS territory in
Lanao del Sur.

On October 17, 2017, the day after the deaths of militant leaders Omar Maute and Isnilon Hapilon,
Marawi was declared "liberated from terrorist influence." On October 23, 2017, the five-month battle
against the terrorists in Marawi had finally ended.

Source: https://en.wikipedia.org/wiki/Siege_of_Marawi

Objectives:
1. What are the common psychosocial effects following a major disaster?
2. Identify populations that may have special needs for mental health services following a
disaster. How would you attempt to meet these needs?
3. What type of reactions do disaster relief workers experience?
4. Describe the purpose of mourning, milestones and anniversaries in dealing with the aftermath
of a disaster.
Question:
How does a disaster affect one’s mental health?
- Natural Disasters or man-made disasters are large-scale events that are often unexpected and
cause death, trauma, and destruction of property. These disasters affect millions of people around
the globe and we can consider these events stressful and almost everyone exposed to a disaster
will experience some immediate biological and psychological effects.

COMMON PSYCHOSOCIAL EFFECTS FOLLOWING A MAJOR DISASTER

- There are different types of disasters and each disaster can cause either similar or different
psychological effects on the victims and also there were various factors which lead to the
psychological vulnerabilities of the sufferers such as the displacement of the family, death of a
loved one, socio-economic loss, environmental loss, and lack of mental preparedness for
disaster, disruption in the family bond, lack of social support and negative coping skills.
Natural Disasters may put its victim in a variety of psychological effects such as:
● a state of despair and shock - traumatic experience disrupts the fully-functioning life of the
victims and brings loss for individuals, families and communities.
● Severe stress – after a traumatic experience a person may develop various psychological
symptoms such as severe stress. uncontrollable stress, and feelings of grief and sadness for a
prolonged period of time, which could sometimes lead to substance dependency, and also
adjustment problems which can affects the proper functioning of the individual as well as the
community resulting in family conflicts.
● Anxiety – Victims of a traumatic experience may develop anxiety for the fear of another disaster
may happen, this anxiety my have different triggering factors such as rainfall, loud sounds or
even a small ground shaking.

Man-made disasters can cause a more severe psychological effects on the victims, and this includes:
● Unnecessary fear and shock
● persistent grief
● maladjustment and dysfunctionality
● Feeling of hopelessness or helplessness
● Changes in thoughts and behavior patterns – Victims of a man-made disasters had
experienced a traumatic and uncommon event in their lives and as a result they tend to become
suspicious or paranoid on everything and everyone, due to fear of experiencing it once again.
● severe stress, severe mood swings, depression and forgetfulness - The most commonly
reported symptoms of a man-made disaster such as terrorist activity are the feelings of not being
able to feel one's own self, lack of awareness of the reality, lack of sleep, guilt, loss of interest,
fear of encountering situations, emotional flatness, self-blame, suicidal ideations and consistent
worry about future.
● Post-traumatic stress disorder - Man-made disasters significantly cause PTSD than natural
disasters. Serious injury or death of someone close is also a significant predictor and being
displaced by the disaster, serious injury to the victim and the victims witnessing death can further
aggravate the problem.
The other common psychological effects that victims may experience includes:
● Irritability
● Substance abuse
● Changes to interpersonal relationships
● Intense or unpredictable feelings
● Flashbacks
● Difficulty making decisions
● Problems sleeping
● Difficulty eating
● Compassion fatigue
● Burnout

POPULATIONS WHO HAVE SPECIAL NEEDS FOR MENTAL SERVICES FOLLOWING A DISASTER
Mental health disorders noted during disasters can be classified into acute phase (1-3 months) and
long-term phase (>3 months). Majority of the acute phase reactions and disorders are self-limiting,
whereas long-term phase disorders require assistance from mental health professionals.

Common disorders are: Adjustment disorders, depression, post traumatic stress disorder (PTSD), anxiety
disorders, non-specific somatic symptoms and substance abuse.

Earlier studies predicted the following high risk variables: Severity of the disaster, threat to life, loss of life,
loss of family members and duration of exposure. Recent additions are: Female gender, children, elderly,
physically disabled, single, ethnic minority, displaced population, poverty, substance use like smoking,
loss of economic livelihood, poor social support and family support.

I. Most children and young people are resilient, but also very vulnerable to the psychosocial effects
of disasters.
II. People with pre-existing mental disorders are well known to relapse during disasters.
III. People with poor coping capacity, substance use and chronic general medical conditions are also
at high risk.
IV. disaster rescue workers are at high risk of developing psychiatric morbidity

WAYS TO MET MENTAL HEALTH NEEDS

WHO-endorsed interagency mental health and psychosocial support guidelines for an effective response
to emergencies recommend services at a number of levels – from basic services to clinical care. Clinical
care for mental health should be provided by or under the supervision of mental health specialists such as
psychiatric nurses, psychologists or psychiatrists.

1. Community self-help and social support should be strengthened, for example by creating or
re-establishing community groups in which members solve problems collaboratively and engage
in activities such as emergency relief or learning new skills, while ensuring the involvement of
people who are vulnerable and marginalized, including people with mental disorders.
2. Psychological first aid offers first-line emotional and practical support to people experiencing
acute distress due to a recent event and should be made available by field workers, including
health staff, teachers or trained volunteers.
3. Basic clinical mental health care covering priority conditions (e.g. depression, psychotic
disorders, epilepsy, alcohol and substance abuse) should be provided at every health-care facility
by trained and supervised general health staff.
4. Psychological interventions (e.g. problem-solving interventions, group interpersonal therapy,
interventions based on the principles of cognitive-behavioural therapy) for people impaired by
prolonged distress should be offered by specialists or by trained and supervised community
workers in the health and social sector.
5. Protecting and promoting the rights of people with severe mental health conditions and
psychosocial disabilities is especially critical in humanitarian emergencies. This includes visiting,
monitoring and supporting people at psychiatric facilities and residential homes.
6. Links and referral mechanisms need to be established between mental health specialists,
general health-care providers, community-based support and other services (e.g. schools, social
services and emergency relief services such as those providing food, water and housing/shelter).

TYPE OF REACTIONS DISASTER RELIEF WORKERS EXPERIENCE

Disaster relief workers help people or the victims meet immediate needs and restoring basic services,
disaster relief workers help with economic recovery.
Typical Stressors for Disaster Response/Crisis Counseling Staff
● Personal experience with the disaster
● Direct exposure to the negative effects of the disaster
● Cumulative stress from repeatedly hearing survivors' stories
● Chronic stress from approaching strangers who may reject their help
 ● Feeling overwhelmed by the depth of others' grief and sadness
● Feeling unable to alleviate the pain of others
● Working long hours in difficult environments
● Lack of or insufficient supervision
● Inadequate or inexperienced management and leadership that negatively affects crisis
counseling staff

Warning Signs of Excessive Stress (signs that last for more than 2 to 4 weeks)
● Bodily sensations and physical effects - Rapid heart rate, palpitations, muscle tension,
headaches, tremors, gastrointestinal distress, nausea, inability to relax when off duty,
trouble falling asleep or staying asleep, nightmares or flashbacks
● Strong negative feelings - Fear or terror in life-threatening situations or perceived
danger, anger, frustration, argumentativeness, irritability, deep sadness, difficulty
maintaining emotional balance
● Difficulty thinking clearly - Disorientation or confusion, difficulty problem-solving and
making decisions, difficulty remembering instructions, inability to see situations clearly,
distortion and misinterpretation of comments and events
● Problematic or risky behaviors - Unnecessary risk-taking, failure to use personal
protective equipment, refusal to follow orders or leave the disaster scene, endangerment
of team members, increased use or misuse of prescription drugs or alcohol
● Social conflicts - Irritability, anger and hostility, blaming, reduced ability to support
teammates, conflicts with peers or family, withdrawal, isolation

Some disaster-specific warning signs include high adrenaline, physical euphoria, numbness—the
endorphin effect (a reduction in feeling) disguises distress. Coupled with fatigue, cognition can change
and create an inability to recognize poor judgment. Anger is a common defense against recognizing these
problems.

What to Do if Post-Traumatic Stress Reactions Don’t Taper Off

While post-traumatic stress reactions usually taper off within a few weeks of the traumatic incident, some
people may continue to experience post-traumatic stress reactions, and these can worsen over time.
Specifically, the emotional reactions can become so intense that they impair the person’s functioning.
Therefore, if a person continues to experience post-traumatic stress reactions for more than a month, it is
recommended that he/she should consult the family doctor or seek psychiatric help as he/she may be at
high risk for developing post-traumatic stress disorder or depression. Counselors and other mental health
professionals may also assist the affected person by making appropriate referrals to a psychiatrist if the
post-traumatic stress reactions persist and medication is needed.

Question: Does one have to go to hospital for psychiatric treatment? -Elvy

One may need to stay in hospital when he can't cope with his mental illness symptoms at home and need
more intensive help. Most people living with mental illness will never need to go to hospital for treatment.
But if he does have to go, hospital can be the best place for him to rest, feel safe and receive the help he
needs. Staff at the hospital are trained to help one get through what can be a stressful time for him and
his family.

Purpose of mourning, milestones and anniversaries in dealing with the aftermath of a disaster

Mourning, milestones, and anniversaries are essential to recognize as it provides insight into the potential
effects of disaster anniversaries on survivors and provides ways for communities to build resilience.

MOURNING
 ➢ Is the act of sorrowing or expressing grief, especially for the dead, but disaster survivors can and
also do mourn other losses, such as material possessions, homes, and jobs.
➢ The ultimate goal of mourning is to take you beyond your initial reactions to the loss. The
therapeutic purpose of mourning is to get you to the place where you can live with the loss in a
healthy way.

Through the normal process of mourning, individuals will be able to:

● Express emotions
● Begin to detach from the deceased
● Eventually, to reinvest in life
○ Including the possibility of another close relationship

The normal process of mourning is often facilitated by the use of rituals such as:
● Funerals
● Memorials
● Events making key time intervals

Community-wide ceremonies
- Can serve to mobilize the supportive network of friends, neighbors, and caring citizens and
provide a sense of belonging, remembrance, and letting go.
Newsletters
- Nonintrusive way of maintaining links among survivors and the bereaved and can also provide
support during important anniversaries or milestones.

Grieving such losses is important because it allows us to ‘free-up’ energy that is bound to the lost person,
object, or experience—so that we might re-invest that energy elsewhere. Until we grieve effectively we
are likely to find reinvesting difficult; a part of us remains tied to the past.

Milestones is a significant event or stage in the life, progress, development, or the like of a person, nation.
A milestone is a synchronization point. Major milestones mark the transition of a project from one phase
to another.

Question:

What is the difference between mourning and grieving?

ANNIVERSARY OF A DISASTER
The anniversary of a disaster can provide an opportunity for emotional healing. Individuals can make
significant progress in working through the natural grieving process by recognizing, acknowledging, and
paying attention to the emotions and issues that surface during their anniversary reaction. These
emotions and issues that surface during the anniversary can help individuals develop perspective on the
event and figure out where it fits in their hearts, minds, and lives.

● As the anniversary of a disaster or traumatic event approaches, many survivors report a return of
restlessness and fear. The anniversary reaction can involve several days or even weeks of
anxiety, anger, nightmares, flashbacks, or depression.
● Common disaster anniversary reactions are memories, dreams, thoughts, and emotions, grief,
sadness, frustration, guilt, avoidance, remembrance, and reflection.
● Psychological literature defines the anniversary reaction as an individual's response to
unresolved grief resulting from significant losses.
 ● It is important to note that not all survivors of a disaster or traumatic event experience an
anniversary reaction.
● Recovery from a disaster takes time, and it requires rebuilding on many levels—physically,
emotionally, and spiritually.

Mourning, milestones, and Disaster anniversaries are a time to:

● Acknowledge, normalize, and respond to painful memories and triggers that are natural and
common.
● Recognize and remember losses associated with the disaster.
● Stop, assess, and acknowledge success and accomplishments.
● Recognize stakeholders who support the recovery process.
● Promote resilience and healing.
○ How?
■ The community will continue to work through grief and come to terms with
disaster losses ideally by developing constructive coping strategies and building
a new post-disaster life. This process can often take years.
■ Validating loss
■ Partnering with media, cultural brokers, community agencies, schools, and
behavioral health providers to provide positive coping skills information and
access to needed services across the lifespan.
■ Helping communities and individuals appreciate that with patience, time,
understanding, and support from family members and friends, survivors and
communities can emerge from a disaster stronger than before.

Question:

1. Does mourning ever come to an end? If yes, how do survivors say that they’ve already
moved on?