Jan. 21, 2010 -- When people in Haiti pause from helping the hungry, injured and homeless the near impossible task of stopping their own emotional trauma from the last week's earthquake becomes apparent.
"Most people are just in shock and disbelief of what has happened. Most people are still sleeping outside. They are scared to sleep inside the houses," Lisa Betor, who runs a shelter for 70 malnourished children in a village called Cazale outside of Port-au-Prince, wrote in an e-mail to ABCNews.com. "You see a lot of people sleeping during the day as well. Everyone is saying that it's hard to have a peaceful sleep time."
Dr. Richard Besser, ABC News' Senior Health and Medical Editor who is in Haiti, said he has seen varied reactions in Port-au-Prince.
"Many who have lost family members and friends sit passively with vacant stares. Other people pray and sing," said Besser. "There is little time to process what has happened or to properly grieve when there is not adequate food, shelter, and water."
"I've been looking in the tent cities and hospitals for programs or specialists in mental health but haven't found them. If they are here, they are not in abundance," he said.
Months may pass before symptoms of Post Traumatic Stress Disorder (PTSD) or clinical depression emerge, and months before volunteer counselors can reach those in distress.Yet post-disaster mental health experts say the way the international relief workers handle the situation could support or erode the mental resiliency of the earthquake victims in months to come.
Dr. Amir A. Afkhami, of the Global Health Division at George Washington University's School of Public Health, said the prevalence of PTSD after a major disaster historically ranged from 1 percent to 11 percent of the population. But rates of clinical depression, crippling anxiety and other issues after a natural disaster might reach up to 30 percent of the population, according to Laura Murray, a clinical psychologist at the Johns Hopkins Center for Refugee and Disaster Response.
With the type of destruction seen in Port-au-Prince, mental health experts wager a large number of people will suffer from debilitating mental health issues afterwards.
Relief Strategy Could Sway Mental Illness Risk in Haiti Survivors
"We are in this phase where obviously the most important things are still meeting very basic needs that people have," said Farris Tuma, of the National Institute of Mental Health Traumatic Stress Disorders Research Program.
But, "there is now a knowledge base that suggests that aid can be done in a way to promote mental resilience instead of erode it," said Tuma.
From subtle communication tactics, to long term strategy for refugee cases, Tuma said the way people deliver help in the next days and weeks could influence how survivors of the Haiti earthquake manage their trauma.
Murray agreed, pointing out that he has found that relief workers can even influence how a person feels about the tragedy in the way they communicate.
"One of the most important things is providing accurate information," said Murray. "Don't say things like 'everything is going to be fine,' or 'I know what you are going through' and it's not a time to ask them what they're feeling."
Murray said many who survived Hurricane Katrina were deeply shaken when promises of aid didn't come, or didn't come soon enough. Rather than build false hopes, Murray said it's best to give the most accurate information possible.
Tuma said another common mistake is to rush to deliver medical care and accidentally separate people from their family or friends.
Maintaining Family Bonds and Social Order
When it comes to getting a broken bone or some other health issue addressed, Tuma said it's human nature to start "picking up that person and whisking them off to get medical care," but relief workers need to be aware if the person they're helping has communication with his or her family, and whether a community is dependent on that person for leadership.
"It's a pretty universally documented thin, that connection to friends and family -- to the extent it is -- possible is a very strong influence on future mental health," said Tuma.
As of Tuesday, Betor said missing family and friends are dominating the thoughts of people in her town.
"There are so many that have not heard from their family members. There are so many that will never know what really happened to them," Betor wrote in an e-mail to abcnews.com. "No one has heard of places helping to find family members. They think the best thing to do is send one person into town to check on several different homes of family members. Then that person reports back to the village on the news they have found."
Haiti Earthquake Victims Find Ways to Help Themselves
Five people in Betor's town have been getting calls or text messages from people trapped under the rubble in Port-au-Prince. Each of them asks her to forward the locations to a U.S. military contact to search on the ground. Even if their loved ones aren't found, Betor said every rescue uplifts the spirits of the town.
"They are SO happy when they hear on the radio that another person has been rescued. They cannot believe that they could stay alive that long," she wrote.
Betor says people are sharing food when they have it and coming together to sing and pray. However, her three sons, all born in Haiti, are reacting to the morbid images and destruction around them.
Visions of Dead, Mass Graves
"They began to have bad dreams, they did not want to go to sleep at all and did not want to go in any houses. They were having problems doing their school work," said Betor. "They might be watching a cartoon and then pictures of mass graves were coming up on the TV. We live right above the medical clinic and there were bad injuries coming in. The staff and other talk freely about injuries and people dying."
Betor now made the tough decision to send her three sons to live with family in the United States and spare them from the scenes unfolding in Port-au-Prince.
Indeed, Tuma said that observing mass graves and serious injuries will put people at a higher risk for prolonged mental distress after a disaster. It's only one of the reasons why he is particularly worried about the future of Haiti.
"Having observed mass death and dead bodies, is a serious risk factor," said Tuma, who added that Haiti's recent hurricanes and poor public health before the earthquake also put its population at a higher risk for PTSD and depression.
"The fix here is not dispensing psychiatric medication, it's not sending armies of psychologists and mental health experts into the society," said Tuma.
Feelings of Helplessness Worsen Mental Trauma
Instead, Tuma believe aid workers must design the earthquake relief with the long-term recovery of Haiti in mind.
"People come together in these tent communities, which helps in the short term, but in the absence of something to do that is helping themselves, the environment really becomes quite toxic," said Tuma.
Judith Bass, a psychiatric epidemiologist at the Johns Hopkins Center for Refugee and Disaster Response, agreed.
"Dignity. Giving the people a level of dignity is something that can be hard," said Bass, who recommended relief workers respect the universal human need to have a livelihood and provide for themselves and their families.
"The more the relief workers can give people some semblance of control, the better," said Bass.