Buried Alive: How Will Mental Health of Chilean Miners Fare?

Ron Zimmerman

October 13, 2010

October 13, 2010 — Buried alive. A horrific experience that could radically shake even the most robust mental constitution. Thirty-three ordinary men went down into the San Jose mine in Copiapó, Chile, on August 5 and didn't come back out of the ground until October 13, forever transformed by their shared disaster.

These 33 men are now national heroes and media icons in their own country. But will they be able to conquer the potentially serious psychological effects of their ordeal, including the risk for posttraumatic stress disorder (PTSD)?

"The initial 17-day period after their entombment was definitely part of the traumatic event," says John Fairbank, PhD, professor at Duke University Medical Center, Durham, North Carolina, and co-director of the National Center for Child Traumatic Stress.

Miner Jose Ojeda is helped out of a capsule during his rescue from the collapsed San Jose mine. Hugo Infante/Chilean government, via AP

Psychologically, the worst part, he says, "was when they were completely cut off from the outside world and they were struggling with near certain death. That is the beginning of their traumatic narrative and was part of the experience with which they now have to deal."

Underground, there was crowding, with 33 men shoulder to shoulder in a 600–square foot space, smaller than a New York apartment, and there was sweltering 90° heat, stagnant air, and pitch darkness relieved only by the occasional headlamp beam.

Perhaps most damaging, there was the inevitability of a ticking clock — the certainty of death if rescuers could not reach them before the air, food, and water or their wits gave out, and the longer they were cut off, the greater the psychological damage was likely to be.

"Each Disaster Has Its Own Character"

But once communication was established through a tiny borehole, the miner's spirits lifted.

"The most important part of the initial contact the men had with the surface world was the fact that the Chilean government brought in experts who instilled hope in the men while they were enclosed, and hope is a major component of most interventions in most disasters. From a mental health perspective, the government did everything right," Dr. Fairbank told Medscape Medical News.

Studies show that after natural disasters such as earthquakes or hurricanes, 15% to 30% of those affected experience posttraumatic reactions for months afterward.

About 5% go on to experience more severe symptoms that last a year or more. The same rates may turn up in these miners, who faced an unknown future and the possibility of death.

"Among the miners, PTSD is possible, since they’ve been through a terrible existential crisis," said David Spiegel, MD, associate psychiatry chair at Stanford University. Dr. Spiegel, who directs the Stanford Center on Stress and Health, points out that these miners are a resilient group and there are strong mitigating factors that may protect them against PTSD.

"The mitigating factors include their social support — clearly they were not alone in their ordeal — and the fact that as miners they are self-selected against claustrophobia," he said. Dr. Spiegel reasons that a worker who suffers from fears of being closed in or buried would be unlikely to accept underground employment. Therefore, he concludes, "Among soldiers in combat, PTSD runs about 20%; among these miners one might expect it to be somewhat lower than that."

"Based upon prior research, there will likely be a wide range of reactions, from incredible resilience to varying levels of distress, such as mood disorders, PTSD, and substance abuse. That's what we would expect," said Dr. Fairbank.

Dr. Spiegel agrees, noting affected miners could present with nightmares, flashbacks, anxiety, depression, and hypervigilance. "There are 3 categories of mental disturbance [in PTSD]: intrusive, such as nightmares and flashbacks, avoidance, going out of their way to avoid reminders of their recent experience, and hyperarousal, being bothered by loud noises, bright lights and sudden events."

According to Dr. Fairbank, what's not known is to what degree the support the miners received while they were underground might mitigate these adverse reactions.

"They had national, international, and family support, and that's both important and different from other disasters. Each disaster has its own character, this one is unique, and how unique is what we'll learn over time. No matter how well they cope now, it could be different for them a year from now, 5 years from now," he said.

PTSD may in fact be hidden in these men until the national celebration in Chile fades and they are left to deal with their fears alone. Quoted in the New York Times, Dr. Charles Marmar, a psychiatrist at New York University's Langone Medical Center in New York City, said, "All the attention is likely to camouflage reactions to the trauma itself in some members of the group. It may resemble this honeymoon effect, like in the young kid who suffered some trauma in Iraq or Afghanistan and returns as a hero, wanting to drop right back into family and community as if nothing had changed."

Delayed Reactions?

Dr. John Fairbank

Dr. Fairbank agrees and added that the "outpouring of attention may delay those [stress] reactions, but that attention is not going to last forever."

"I suspect that a few miners will have trouble adjusting to the new normal,” he said, "particularly in families where roles have changed since the ordeal started."

One well-recognized symptom of PTSD is irritability and a feeling of alienation from previous close family members. Dr. Spiegel points out that that strain is already evident with some miners. "I think it's been reported that a marriage or two has already broken up while the men were entombed. Although if a marriage was troubled before the event, it was probably more so during." Some marriages, paradoxically, may endure as even stronger, Dr. Spiegel believes, because of the long period of separation and the level of commitment demonstrated by wives on the surface waiting, praying, and hoping day by day for their loved ones to survive.

To help support the miners, the Chilean government assigned Alberto Iturra, a psychologist, to talk to them, sometimes several times a day, to sort through their frustrations and depression. The National Aeronautics and Space Administration (NASA) was even consulted on planning to avoid long-term negative consequences.

"Our doctors are already working with their doctors on this," said NASA spokesman Bill Jeffs. "We have a lot of experience in protecting people in enclosed environments for extended periods."

Chilean officials also closely monitored the physical health of miners, sending them nicotine patches and even cigarettes along with blood pressure medication. But they stopped short of sending antidepressant medication.

The government immediately had medical personnel monitor each man after they emerged from the rescue shaft, and that monitoring will likely continue.

Coping Mechanisms

Another factor is the dynamics of the group itself. The group reportedly found coping mechanisms underground that worked to buoy their spirits. One of the miners, Mario Gomez, reportedly took charge and built a tightly organized hierarchy, rationing food and work so that the miners each felt they still had a job to do and a place in their forced society underground.

Some of the miners took refuge in their faith. The youngest miner, 19-year old Jimmy Sanchez, told media there were really 34 miners in the small 600-foot chamber. "God was with us. He never left us."

Each of the 33 men will have his own tale, his own way of coping with a transformed identity and a life story forever stuck nearly half a mile below the earth. But the fact that the men came through their experience together could give each of them mental strength.

"Groups can be a positive influence or a negative one," said Lawrence Palinkas, a professor of social policy and health at the University of Southern California in Los Angeles. "But here it appears that there were recognized leaders, shared goals, among men who came from similar background and were able to keep stress at a minimum."

"Except for a few miners who find reminders of the experience too painful, this group will become the most powerful social network these men have," Dr. Marmar told the New York Times. "They're bonded for life, like any group of cops or firefighters or war fighters who have shared a threat to life and united to survive it."

Yet the loss of the sense of group membership, the loss of the underground brotherhood, may in itself affect the miner’s future mental health. According to Dr. Spiegel, they may feel an intense sense of loss of the other miners’ closeness and companionship.

"We see that in combat veterans, feeling that no one else can possibly understand them,” said Dr. Spiegel. “There may be a reluctance to talk, so they will probably get together because they may feel their family members don’t have the same shared experience."

First Responders May Also Be Affected

Something else very few people have looked at is the stress and strain not only of the miners but also of the rescuers. "We know that first responders experience stress and that it's very important to monitor their health. They've gone days without sleep, without knowing the outcome of their work," said Dr. Fairbank.

Dr. Fairbank believes the rescue went better than expected and that with the government's promise of 6 months of psychological care the miners may have good outcomes.

"I'm confident because of how the Chilean government took care of the rescue that they will be very thoughtful of the miners' psychological recovery. One good thing is that over the last 20 years, we've development many good PTSD treatments, starting from basic skills that can be taught to very specific treatment plans," he said.

The basic skills can be thought of as psychological "first aid" and are part of an evidence-informed approach. The trauma treatments are based on cognitive behavior therapy and take the form of a 20-session psychotherapeutic intervention.

"What we've all watched on our televisions is the miners being greeted warmly by their families and then getting immediate medical attention. What we're seeing is best practices for PTSD treatment unfolding in front of our eyes," Dr. Fairbank concluded.

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