A Qualitative Study on the Process of the Mental Health Assessment and Intervention after the Sewol Ferry Disaster: Focusing on Survivors among Danwon High School Students (original) (raw)

Sociodemographic characteristics

In January/February 2017, 31 months after the Sewol Ferry Disaster, we performed face-to-face interviews [average duration: 52.86 min (±7.86 min)] with 21 survivors [all aged 20 years old; 10 men (47.62%), 11 women (52.38%)]. All of them went to university, and one of them was in social service (alternative military service) (Table 1).

Table 1

Demographic characteristics of the subjects (n=21)

Necessity of post-disaster mental health assessment

The subjects’ opinions on the post-disaster mental health assessment can be categorized into five types: 1) necessary and helpful because my feeling could be different from others (n=6, 28.57%), 2) partially necessary but not helpful because it did was not worth it for me (n=4, 19.04%), 3) probably necessary but difficult to fill up (n=5, 23.81%), 4) not necessary for me but potentially helpful for someone (n=3, 14.29%), 5) refused because it was not necessary (n=3, 14.29%).

Perceived demand for mental health intervention

The subjects’ opinions on the levels of their motivation for the mental health intervention were categorized into three types: Type A, “I need mental health care” (n=10, (47.62%), Type B=“I myself have no need for mental health care but others might need it” (n=6, 28.57%), and Type C, “I refuse mental health care (n=5, 23.81%) (Table 2).

Table 2

Needs of mental health service of the survivors (n=21)

Preferences for mental health intervention

As for the subjects’ preferences for mental health intervention, we rated the degree of preference for the individual (1:1) or group interview, inactive or active intervention. The degree of preference was rated on a four-point scale: ◎: much preferred, ○: preferred, △: neutral, and X: not preferred (Table 3). Four preference options were presented according to the individual vs. group interview and inactive vs. active intervention: 1) individual interview+inactive intervention, 2) individual interview+dynamic intervention, 3) group interview+inactive intervention, and (4) group interview+dynamic intervention (Fig. 2).

Table 3

Analysis of mental health service preference of the survivors (n=21)

GA: group-active, GI: group-inactive, IA: individual-active, II: individual-inactive

Fig. 2.

Chart of the mental health service preference of survivors (n=21).

Experiences of mental health intervention by phase

The first two weeks: hyperacute phase, hospitalized in the university hospital located in Ansan City

The subjects’ experiences of mental health assessment in this period were divided into two higher order categories, namely, “difficulty of event recognition” and “unwillingness regarding questionnaire survey,” conceptualized in five lower order categories (Supplementary Table 1 in the online-only Data Supplement).

We categorized their experiences of mental health intervention and hospital stay into six higher order categories of “refusal to participate in intervention programs,” involuntary and unwitting participation,” “awareness of others’ eyes on patients,” “helpful/positive aspects,” “experiences of program activities,” and “outings and visits without permission,” conceptualized into 18 lower order categories (Supplementary Table 1 in the online-only Data Supplement).

The survivors remembered the difficulties that they had in recognizing the situation in the hyperacute phase, showing unwillingness toward mental health assessment (n=19). They mostly preferred individual counseling with a face-to-face interview structure (n=17) and expressed discomfort with group counseling. About 52% (n=11) found the help offered during the hospital stay to ease them of their overwhelming emotional burden. Some of them (n=4) practiced stabilization techniques with psychiatrists during the hospital stay. About 43% (n=9) found having group interactions in a safe and comfortable environment prepared in the hospital for the survivors, engaging in art activities, watching performances, and playing board games to be positive. Some complained (unasked) that they could not leave the hospital, not even to participate in their friends’ funerals. Some obeyed and voluntarily stayed in hospital (n=4), others sneaked out to the funerals (n=5), and still others were forced to stay (n=8).

Three to six weeks: This was the acute/subacute phase, where participants retreated in an training institute in Ansan City

The survivors were transferred immediately after hospital discharge to a boarding training institute. According to a published report, they were exposed to therapeutic, educational, and recreational intervention programs during the retreat [16]. None of the interviewees received mental health assessment during the retreat.

With regard to mental health interventions during the retreat period, we classified the interview contents into seven higher order categories (“synergy of being together,” “homogeneity of a group,” “positivity of group activities,” “difficulties in adapting to a new environment,” “participation in various programs,” “negative perception of programs offered,” “hope and preparation to return the daily life”), formulated in 25 lower order categories (Supplementary Table 2 in the online-only Data Supplement).

The earlier days of the training institute were an acclimation phase, and most of the surviving students found it difficult to participate in the group activities offered (n=16). With days passing by, they expressed their dissatisfaction more frequently (n=7). In addition to post-traumatic symptoms, they were faced with the task of rebuilding their comradeship (n=7). However, most of them found comfort in the fact that they could share their feelings and thoughts, living in the same space, as students of the same high school that went through the same experience (n=15). In the mid- and late-phase of a training institute retreat, school classes were added to the daily activities to prepare them for a return to school. However, they found it difficult to concentrate on studies (n=13). Moreover, most of them had to go regularly to the outpatient clinic of the university hospital for continuing counseling and care (n=19).

Regarding the counseling process, both positive and negative experiences were shared. They could pour their heart out to the designated counselor. They thought highly of the counselors who did their best to listen to their needs and interests (n=6) and preferred those who treated them as any other students rather than patients (n=4). On the other hand, they had negative opinions of the counselors who repeated the questions about their experiences of the event or asked them to imagine circumstances to recall their memories of the event or even compelled them to tell their stories to the public (n=11). One of the programs with positive reports from most students (n=15) was a self-initiated program in which a group game popular among the peers was presented by several teams with the rules set out by themselves. To sum up, the students reported a high level of satisfaction with the group life with peers in the hospital and camp (n=12), but they also had deep longings to return to their daily lives (n=4).

From the seventh week to the eleventh-grade year end (about eight months): subacute/chronic phase, return to school

A few days into the return to school, a school-based mental health center, consisting of one psychiatrist and two clinical psychologists, began its intervention programs. Additionally, the students could continue to receive counseling and care at the university hospital.

We analyzed the subjective experiences of the students about the mental health assessments administered in this period for both providers. Those administered by the school-based mental health center were classified into four higher level categories (“familiarity with questionnaire administration,” “discomfort with questionnaire administration,” “administration of various types of assessment,” and “understanding of the assessment results”) and seven lower level categories. Those administered by the university hospital were classified into two higher level categories (=lower level categories) of “regular assessments” and “memory of the assessment results (Supplementary Table 3 in the online-only Data Supplement).

Regarding the mental health interventions, three higher level categories (“formation of rapport with the counselor,” “regular counseling schedule,” and “positive perception of counseling”) and 14 lower level categories could be extracted for the school-based mental health center, and three higher level categories (“relaxed counseling,” “regret/frustration about counseling,” and “consultation for medication”) and nine lower level categories could be extracted for the university hospital. As miscellaneous items, we extracted three higher level categories (“participation in trips and programs,” “efforts on school work,” and “griefs”) and six lower level categories.

Most interviewees had positive memories of the staff of the school-based mental center (n=18). The mental health center created an environment where a puppy was provided to accompany them as emotional support. Back to school, the students were provided with various psychological support programs and curricular and extracurricular activities, including trips, choirs, plays, and career guidance. Many of them continued to receive counseling at the outpatient clinic of the university hospital (n=13), which was allowed during class hours (n=9). Some students found it difficult to participate in the programs offered by the school (n=7), and others answered that they enjoyed activities in which they were interested (n=6). In particular, they showed greater interest in active programs than in inactive programs (n=8).

Twelfth-grade year (one year starting from the 10th post-disaster month): chronic phase, continuing intervention programs in and out of school

We classified the mental health assessments administered by the school-based mental health center into two higher level categories (“improved perception of assessment” and “difficulty of assessment administration”) and four lower level categories and those administered by the university hospital as one higher level (=lower level) category (“administration of questionnaire survey”) (Supplementary Table 4 in the online-only Data Supplement).

The mental health interventions provided by the school-based mental health center can be classified into four higher level categories (“continuation of counseling,” “decrease in the frequency of counseling,” “provision of necessary information and activity opportunities,” and “refusal of counseling”) and eight lower level categories. Those provided by the Ansan Mental Health Trauma Center were classified into one higher level category (“experience of various programs”) and four lower level categories. Those provided by the university hospital were classified into four higher level categories (“regular outpatient care,” “end of treatment,” “refusal of in-depth care,” and “refusal of outpatient care”) and six lower level categories. We analyzed the remaining interview contents in four higher level categories (“difficulties with school work,” “the first memorial ceremony,” “hard preparations for university entrance exam,” and “gratitude for helps received”) and seven lower level categories.

This period corresponds to the chronic phase, and the majority opinion was that there was little difference between the mental health assessments and interventions they received the year before (n=16). Some said that they became with familiar with the questionnaire administration (n=5), whereas a few others still found it difficult to go through the assessment (n=3). The school-based mental health center provided medication education and career guidance, and the Ansan Mental Health Trauma Center provided various learning programs, such as scented candle making and makeup classes. On April 16, 2015, the students prepared and participated in the first memorial ceremony, and a few students experienced psychiatric symptoms such as depression (n=2). This period was packed with activities typical of all high school seniors (12th graders) in South Korea preparing for the university entrance exam, i.e., obtaining necessary knowledge and information, such as focused learning, career guidance meetings, presentation letter writing training, and mock interview training.

After university entrance (10 months starting from the 22nd post-disaster month): from graduation to immediately before the in-depth interview of this study

The school-based mental health center was closed, and its staff opened a Maumtodak Psychiatric Clinic in Ansan City. The programs offered by this clinic were classified into two higher level categories (“continuous assessment” and “increased willingness for assessment”) and three lower level categories. Those offered by the Ansan Mental Health Trauma Center (Onmaum Center), which was created in the aftermath of the Sewol Ferry Disaster, were classified in the single higher/lower level category “no assessment” (Supplementary Table 5 in the online-only Data Supplement).

The mental health interventions were analyzed in two higher level categories (“experience of continuous counseling” and “concerns about symptoms”) and four lower level categories. Those provided by the Ansan Mental Health Trauma Center were extracted as three higher level categories (“positive memories of the trip,” “meetings with the counselor,” and “no communication with the center”) and eight lower level categories. The programs offered by the international NGO Salvation Army can be classified into three higher level categories (“tutoring program,” “joint activities,” and “decision about future participation”) and seven lower level categories. As miscellaneous items, we extracted four higher level categories (“continuous outpatient care,” “burden of medical bills,” “psychiatric medication,” and “sense of responsibility and independence”) and five lower level categories. Experience of university life was analyzed in two higher level categories (“initial adaptation difficulties” and “familiarity with university life”) and nine lower level categories.

After graduation, most subjects continued their follow-up visits for mental health assessment every six months (n=14). By contrast, some of them continued the counseling provided by the former school doctors at the Maumtodak Psychiatric Clinic (n=4), and many students rarely went to counseling, as they were busy with university life (n=7). Considering the subjects’ voluntary reports, six of them (28.6%) were most obviously in need of treatment even without a diagnostic interview. Many students were hesitant to visit the outpatient clinic due to the financial burden after the discontinuation of medical cost subsidies simultaneously with graduation (n=9). About half of the students had great concerns about adapting to the new environment in the earlier months into university life (n=11). Some of them felt uneasy and embarrassed when asked during new student orientation about their high school (n=3), and some students were also under psychiatric care due to exacerbated anxiety and stress symptoms after beginning university (n=2). Some extreme cases were missed most lectures (n=2), only stayed at home (n=1), or had difficulties in learning (n=3).

Regarding mental health assessment, some subjects found such assessment positive as an opportunity to look into their own situation (n=7) or to understand their current situation through the questionnaire items (n=5). However, most of them expressed strong negative feeling about the questionnaires, primarily due to the numerous items (n=19). Some voiced the opinion that it would be better to administer a questionnaire survey selectively to those assessed necessary (n=6). As an appropriate interval of mental health assessments, once every six months was the majority opinion (n=14). Regarding the duration of assessment, some opined that it may continue as long as they feel the need (n=5).

Psychiatric symptoms reported during the interviews

The psychiatric symptoms reported by the subjects during the interview included depression, anxiety, insomnia, nightmares, poor concentration, phobia, aggression, and game addiction. The most frequent symptoms were depression and insomnia (19.05% each), followed by anxiety (14.29%), nightmares and phobia (9.52% each), poor concentration, aggression, and game addiction (4.76% each) (Table 4).

Table 4

Analysis of observable psychiatric symptoms during the in-depth interview* (n=21)

*

multiple response items; grade response percentages are based on the total sample