‘It’s a marathon, not a sprint’

by Craig L. Katz, MD, and Asher B. Simon, MD

Ever since seeing a handwritten poster reminding US relief agency staff that “it’s a marathon, not a sprint” in post-tsunami Sri Lanka in 2005, we have included this quote in nearly every presentation we have given on the topic of disasters and mental health. The marathon was an apt metaphor for the long view and commitment needed to comprehensively address the mental health arc of disasters. Now, with the bombing of the 117th running of the Boston Marathon, the comparison haunts in morphing into inpenetrable fact.

Psychiatrists and other mental health professionals are experiencing an urge to highlight the mental health needs of those who survived or responded to the bombings in Boston. This rallying cry emerges out of emails, meetings, media interviews and journal articles that seem to greet each new disaster as though its mental health consequences, or at least what to do about them, are a new discovery (Katz and colleagues). This drive to help usually insinuates itself into disaster-stricken communities, like Boston, via psychoeducational handouts that beckon citizens to beware of the acute symptoms of trauma and disaster.

Craig L. Katz

But, human recovery takes far longer than the recovery of infrastructure, and perhaps as much as 10 times longer; and, within that, psychological recovery may stretch on even longer, if not indefinitely. Much of the immediate distress that befalls a community affected by disaster will be remedied by addressing basic needs for safety, medical care, food, shelter and the company of loved ones and friends. Mental health professionals may not be needed at all and, in fact, have little scientific evidence on which to base deploying their usual psychotherapeutic and, especially, pharmacologic tools in the name of treating recent disaster survivors.

At first blush, what may be seen as “altruism” may not, in fact, be so pure and heroic. As psychiatrists, we often practice in the shadows, quite solitary in our practice, and not feeling routinely “needed” by the public in substantive ways. Disasters change this, and there is something quite energizing and rejuvenating to be foisted into the popular press in a positive and hopeful light, in contrast to the well-worn spectre of stigmatization. Not only do disasters allow us to have a newfound public face and overcome the isolation induced by our private treatment settings, they allow us an active role to feel more in control of an uncontrollable situation. Our overdetermined response to disasters has many forebears, and, as psychiatrists, we should be aware of what goes into our decision making, not only as a model to our patients, but also to facilitate our provision of appropriate treatments.

Asher B. Simon

Before we expend too much energy tring to figuring out anew what to do to help the many people touched by the marathon bombings, the mental health community should pace itself. A very useful model for how to do this can be found in a paper by O’Donnell et al, which lays out a sustainable approach for systematically addressing the mental health needs of disaster survivors by focusing on those who have been most highly exposed. In the case of the Boston Marathon bombings, this would be the injured who were rushed to hospitals, followed by uniform and spontaneous responders and direct witnesses. These high-risk groups are relatively finite and can be followed with regularity, over time, to receive what are essentially mental health checkups and targeted, trauma-specific care.

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What about everyone else in the disaster community, outside of these core groups? Their reaction to the bombing is much more likely to be influenced by their respective vulnerabilities, including how their lives were before the event, their past exposures to trauma, and their psychiatric histories. Here, too, we should think like a marathoner who must commit endless hours to preparing for the race. With much the same force with which diagnoses of traumatic stress disorders hit the mainstream in times of war (eg, the Civil War’s irritable heart syndrome; WWI’s neurocirculatory asthenia, effort syndrome, shell-shock; WWII’s war neurosis or operational fatigue; the post-Vietnam syndrome or posttraumatic stress disorder; the Gulf War syndrome, etc), such psychological sequelae of terrorizing events are often forgotten in times of relative peace. Some have considered this oversight as a cultural collusion to avoid recognizing the daily trauma and abuse which serves to create highly vulnerable populations.

Far better than trying to convert a disaster-affected community into a mental health-oriented communty after upheaval, is to do so in advance of it. Disasters would be far less likely to have an enduring psychiatric impact if the pre-disaster community were mentally healthier to begin with, which is, of course, a desired end in itself. At the least, disasters provide opportunities to look at mental health systems and strengthen them and their communities for the future. May Boston find this if not other silver linings in the clouds.

For more information:

Chandra A. JAMA. 2010;304:1608-1609.

Herman J. Trauma and Recovery: The Aftermath of Violence—from Domestic Abuse to Political Terror. New York, NY: Basic Books; 1997.

Hyams KC. Ann Intern Med. 1996;125:398-405.

Katz CL. Adolesc Psychiatry. 2011;1:187-196.

Katz CL, Sederer LI. Psychological first aid: Mental health care after Hurricane Sandy. Huffington Post. Dec. 9, 2012.

O'Donnell ML. Clin Psychol Rev. 2008;28:387-406.

Disclosure: Katz and Simon report no relevant financial disclosures.

Craig L. Katz, MD

Associate Clinical Professor of Psychiatry and Medical Education

Director, Program in Global Mental Health

Icahn School of Medicine at Mount Sinai

Asher B. Simon, MD

Assistant Professor of Psychiatry

Associate Director of ResidencyTraining

Icahn School of Medicine at Mount Sinai