Technological disaster—Survival and bereavement

SK. SC;. Med. Vol. 29. No. 3, pp. 351-356, 1989 Pnnted in Great Britain. All rights reserved

0277-9536X49 S3.00 + 0.00 Copyright C 1989 Pergamon Press plc

SECTION G

TECHNOLOGICAL DISASTER-SURVIVAL AND BEREAVEMENT

PETER E. HODGKINSON*

Principal Clinical Psychologist, Bracton Clinic, Bexley Hospital,’ Bexley, Kent, England

Abstract-Differences between natural and man-made disaster are described, deleterious psychological effects of technological components catastrophe appearing to be longer lasting. The psychological components of the experience of survival are outlined, and the concept of post-traumatic stress disorder located within this. Bereavement reactions, complicated by enhancement of the factors accompanying sudden, violent death, are also described, and risk factors noted. Finally, the development of community- based preventative mental health programmes which are acceptable to victims are detailed, emphasising restoration of the victims’ sense of control over their own lives and the value of self-help. The role of counselling and specialist treatment is placed in this context.

Kqv words-man-made disaster, trauma, survivor guilt, post-traumatic stress disorder, bereavement, self-help

INTRODUCTION

Man-made disaster is a phenomenon of technological society. The development of increasingly complex systems enhances the potential for catastrophic mis- hap through human failure or system malfunction. Whilst such disasters often involve a combination of the forces of nature with human error, there appear to certain differences between natural and technological disasters [ 11.

Natural and technological disasters are both sudden and powerful. Whilst there is sometimes an element of warning in natural disaster, there is generally none in man-made catastrophe. Lack of warning makes avoidance difficult. There may only be seconds from the realisation that something is wrong to the impact, as in aircraft crashes. Alternatively, there may be awareness that a particular structure is in- adequate for its purpose, or a system may be known to have failed, yet no action is taken to substitute safer procedures, while those at risk remain unaware of the danger.

Both types of disaster can cause visible damage to a familiar environment, but some technological disasters do not have this effect. Transport disasters often occur in a location unfamiliar to the survivors and inaccessible to the bereaved or even the rescuers. Environmental poisoning, such as the Chernobyl accident, is the clearest example of an invisible threat causing no visible damage.

While natural disaster, such as volcanic eruption or flooding is often predictable to some degree, man- made disaster is not. Technological catastrophes are never supposed to happen, and hence predictability is not an issue-the Zeebrugge Disaster could not have

*Address correspondence to: Dr Peter Hodgkinson, Centre for Crisis Psychology (U.K.), 24 Old West Road, Gravesend, Kent DA1 1 OLJ, England.

been predicted as ferries are not supposed to sink. Both types of disaster may have a clear low point, generally the impact stage, but some technological disasters do not. Thus the effects of toxic pollution may manifest themselves at different times for people who have been exposed simultaneously. The importance of the ‘low point’ is that it provides a focus from which things may be expected to recover-without it, uncertainty about the process of recovery may be increased.

Natural disaster is not seen as controllable, indeed, such events are often termed ‘Acts of God’. As man is supposed to be the master of the technology he has created, man-made catastrophe signifies a dramatic loss of control. This may be of particular importance due to a possible relationship between a sense of loss of control and the feeling of helplessness, and the known relationship between helplessness and depres- sion [2]. The extent of the effects of natural disaster tends to be limited to the immediate victims, such as those made homeless in a particularly location, where- as the effects of technological disaster may not. Thus the Chernobyl accident may have increased the fears of many people about the safety of nuclear power. Lastly, the persistence of effects of natural and man- made disaster may differ. Disaster follow-up studies [3] show similar levels of psychological disturbance in both groups 3040% at the end of 1 year post- disaster, but with a persistence of difficulties after this time for victims of man-made disaster where there were high levels of shock and destruction, when over 30% continue to experience problems after 2 years.

SURVIVAL

Lifton [4] was one of the first to describe the experience of survival. The results of his work and that of others in the field of traumatic stress led to the

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352 PETER E. HODGKINS~N

establishment of the concept of post-traumatic stress disorder (PTSD) in the American Psychiatric Associ- ation’s 1980 DSM Ill categorisation, subsequently revised in 1987. PTSD may be thought of as having three main components: reexperience phenomena, persistent symptoms of increased arousal, and avoidance/numbing reactions. In his original work, Lifton identified tive elements of the experience of survival.

The death imprint

The death imprint consists of intrusive imagery occurring in the waking state or in nightmares. It comprises images of the impact, the sight of bodies dismembered or crushed, the sounds of screaming, the smell of burning flesh. In a mixed group of trauma victims [S], 5 1% had intrusive images, 5 1% had intrusive thoughts or images when trying to sleep, and 54% had bad dreams. In a group of veterans [6], 40% experienced ‘flashbacks’, 79% experienced post- traumatic dreams, and 100% experienced ‘forced recollections’. There was no evident connection between dreams and flashbacks. A study of civilian victims of terrorist attacks [7] found 84.5% of those with PTSD to have recurrent intrusive recollections as against 46.5% of those without, and 52.6% of those with PTSD to have recurrent dreams as compared with 33.9% of those without.

Another aspect of re-experience phenomena is acting or feeling as if the traumatic event were recurring, and intense distress at either symbolic reminders or events resembling the trauma. ‘As if’ phenomena were hardly present in the study of the victims of terrorist violence [7], suggesting that the type of trauma is crucial-when re-entry into the precise situation where the trauma occurred is a feature, such reactions are more frequent.

Separate from re-experience phenomena, but form- ing the second component of PTSD that reflects an anxiety reaction, are persistent symptoms of increased arousal. Startle reactions, for instance, occurred in 45% of the survivors of the 1981 Kansas City Hyatt Regency Hotel skywalk collapse [8], and concentration difficulties in 44%. In the terrorist bombing survivors [7] exaggerated startle-responses occurred in 66% of the PTSD cases and 53% of the non-PTSD cases. sleep disturbance of 96% of PTSD cases and in 84% of those without, and concentration/memory problems in 38% of PTSD cases and 18% of non-PTSD cases.

Surcit-or guilt

Death, or survivor guilt, where the victim questions why he or she survived when others did not can be of two kinds. First, what might be called ‘existential guilt’. where the victim dwells in a very general way on his survival-‘Why me?‘, or ‘Why did God choose me?‘, or perhaps ‘Why me when I am old and so many children died?’ Second, is a guilt which is more focused on one’s actions-‘Did I do enough, could I have saved more people?’

Lifton [9] distinguishes between ‘animating guilt’ and ‘static guilt’. Animating guilt is a spur to self- examination which can allow guilt to move ‘towards the anxiety of responsibility’. Static guilt keeps the victim bound to the experience, and unable to move

on, and the task of the professional may be to assist the patient to progress from static to ammating guilt ‘and then from guilt to responsibility and some behaviour which alleviates the guilt’.

In the victims of terrorist attacks [7], only 6.9% of those with PTSD experienced survivor guilt as compared with 1.3% of those without. This figure is low, but in the skywalk collapse victims [S]. 44% of victims suffered feelings of guilt, all of those who gave reasons (38 out of 45) reflecting aspects of survivor guilt.

Psychic numbing

Numbing is a defensive mechanism, preventing the victim from experiencing too much pain at any one time. It includes the defences of repression, denial and isolation, all of which may be natural and necessary, but for some these defences may persist. leaving the survivor ‘living dead’ emotionally. Indeed. such a state does not equate with survival.

This concept embraces the component of PTSD which involves reduced reactivity rather than increased reactivity, reflected in persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness. In the terrorist bombing group [7], diminished interest was present in 98% of the PTSD group (the most prevalent symptom) and 13% of the non-PTSD group. In the skywalk collapse victims (81 ‘loss of enthusiasm’ was present in 45%, ‘inability to feel deeply’ was present in 36% and ‘feelings of detachment’ were present in 29%. Avoid- ance phenomena were present in 40% of this group, in 53% of the bombing victims with PTSD, and in 36% of those without PTSD [7].

Nurturance conjicts

This conflict refers to the suspicion of offers of help from outsiders. Lifton [9] suggests that this is because of the feeling of weakness, and the sense of being demeaned, or made to feel less than human in a cruel world.

Quite simply, disaster survivors are a random selection of ordinary people, and the only reason for their victimisation is being in the wrong place at the wrong time. Such people may know nothing of emotional help or the professionals who offer it. They may never even have experienced intense emotions in their lives before-they may be ashamed of their feelings, or fear that they are going mad. This issue has major implications for the take-up of services, and emphasises the need to present help in a way that is acceptable to survivors.

Quest for meaning

As Lifton [9] states, “you cannot understand disasters of any kind without considering the need to give meaning and inner form to the experience, and to life thereafter”.

The search to understand the experience of disaster exists on a number of levels. Firstly, there is the need to understand why the incident happened, and this may be a feature enhanced in man-made disaster. Many survivors of the Zeebrugge disaster became fascinated by any reference to the accident and its cause. The verdict of the public inquiry was similarly important, not so much in justifying their blame or

Technological disaster-survival 353

anger, but in the public establishment of clear responsibility. This alone enabled some survivors to rehn- quish their quest for meaning. It may also be crucial to understand the means of survival. Counsellors took diagrams of the ship with them on visits to survivors, which enabled many to see for the first time their route of escape. Some who did not find this sufficient returned to identical ships, or even the wreck itself to achieve a clearer visual clarification. It also became necessary for many to trace those who had helped them survive, to build on their stories, or simply to thank them. The survivor’s life, however, has been irrevocably changed. The true meaning of survival involves finding a place for the experience in a new view of the world, including for example a re-appraisal of the value and meaning of life.

symptoms of post-traumatic stress may be long lasting. care should be taken not to pathologise victims at too early a point in their recovery.

BEREAVEMENT

Bereavement by disaster represents an in- tensification of the features of sudden, violent death. It is known that sudden, unexpected or untimely deaths [I l] and those that are painful or horrifying [12] represent risk factors for poor outcome in bereavement.

Shock

One poorly recognised area is the impact of survival on relationships. The account of the wife of a survivor of the Zeebrugge disaster sums up the possible problems succinctly.

Since that fateful day it is hard to describe just how much our lives have changed. We thought he was so lucky to have survived, not knowing he would never be able to return to the sea. We moved away hoping that by putting some distance between us and the Channel it might help-it hasn’t. The patience he once had is gone, he snaps at the children, some days I cannot do anything right. He gets depressed and isolates himself, sometimes he just sits and cries and all I can do is be there for him when he needs me. Sometimes we shout and argue over silly things that would have normally passed unnoticed and at other times there are long silences where once we would have talked things out.

Thus withdrawal and angry outbursts are frequent, particularly when one partner is a survivor of an event the other did not experience. The survivor feels that the partner cannot understand because they were not there, and comfort may only be found in the company of other survivors. Of terrorist victims [7] marital disharmony was present in 46.3% of those who had PTSD, and in 23.3% of those who did not.

Shock is an initial response in all bereavement. but this is enhanced in death in disaster. There is often a sense of disbelief and bizarre reversal in such situations-people are engaged in normally safe activities, such as returning from work, or enjoyment, such as going on holiday, and then suddenly perish in horrifying circumstances.

Guilt

Guilt may be for an actual action. A bereaved mother from the Granville train disaster [ 131 argued with her son, delaying his departure for the station, and refused to drive him there to get his usual train, a series of events which placed him on the doomed train in which he lost his life. Similarly, a woman who was the sole survivor of a party of four involved in the Zeebrugge disaster had organised the trip for that particular day against the wish of her husband (whose birthday celebration it was), to accommodate her two friends. She was hospitalised within 2 months in a psychiatric unit, repeating “I am a murderer”. Crew who had swapped shifts, putting friends in their place on the doomed ferry, faced particular difficulties in working through.

Two major questions arise: why are levels of symptoms so variable from one disaster to another and one individual to another. and when do these symptoms become abnormal, rather than a normal reaction to abnormal events?

Response to trauma will be governed by the inter- action between situational and environmental variables, and individual factors. Situational variables are of two main types. Firstly, aspects of the trauma, including threat to life. duration, potential for re- occurrence, whether experienced with others of alone, or whether the stressor was single or multiple. Secondly, aspects of the environment following the trauma, including societal attitudes and levels of support. These will interact with individual factors, including subjective emotional experience and cognitive structures within which this is appraised. Person- ality factors, such as neuroticism, introversion and being inner-oriented may influence these subjective factors adversely [lo].

Guilt may also be for a word or thought. A Zeebrugge widow, had a row with her husband the night before the disaster. He slept downstairs and came to her the next morning to tell her he was leaving. She retorted “fuck off, I don’t care if you never come back”. He died, and she found it necessary to attend many days of the 3 weeks of inquests, almost in some act of atonement. It is known that those who are excessively self-reproachful have increased difficulty in resolving grief reactions [ 111.

In bereavement by disaster, as in all sudden death, the sense of ‘unfinished business’ with the deceased may be intense, and things left unsaid may be equally as problematic in terms of guilt.

Anger

Anger is a normal part of many bereavement reactions, but those who are excessively angry are more at risk of a poorly resolved bereavement reaction [ 111. In man-made disasters there is often a very clear and justifiable focus for the anger of the bereaved.

DSM III states that symptoms must be present for one month before a diagnosis of PTSD is made.

Anger is natural in deaths where there is an

This seems arbitrary as there is little knowledge of identifiable perpetrator, such as murder, but this

the decay rate of these symptoms across a range often diminishes over time. When many die together,

of disaster situations. Whilst the concept of PTSD as in disaster, the possibility exists of a communal

is validating, in that it gives recognition that the uniting of anger. Foilowing the Zeebrugge disaster, parents who had lost adult children, for whom no

354 PETEKE. HODGICINS~N

compensation was indicated in British law, banded together to form the Herald Families Association. They were enraged that they were symbolically de- nied recognition that they had been bereaved. Their avowed aim was to see the prosecution of the ferry operator for negligence, and the institution of safer ferry standards. It remains to be seen whether this channelling of anger will prove an aid or a block to resolution. _.

Intervention of authorit)

The intervention of authority can enhance con- fusion and uncertainty. People may be informed that loved ones have survived when they have in fact died. The demand for statements which are necessary to aid later identification can feel like a persecution, or if guilt exists, may reinforce it. Bodies may be delayed in burial by seemingly unneccessary bureaucracy.

Helplessness

The sense of helplessness may be intense. This may relate to powerlessness to prevent the death, es- pecially if the bereaved was also the survivor of the impact. One Zeebrugge widow was able to climb on to a ledge where there was, however, no room for her husband. She held him by the hair to keep him from the freezing water until she had no further strength, whereupon she had to let him go to his death.

A second aspect of helplessness may be a loss of a sense of security in life, that a world which has previously been reasonably safe and predictable is now threatening.

Aspects of the death

Aspects of the death of the loved one may be particularly important. Firstly, there is the fact that in many bereavements by disaster. no body is recovered. Many bodies from the Zeebrugge disaster were not recovered until 5 weeks had passed, and during this period many of the bereaved were plagued by thoughts and dreams that the loved one had never been aboard, had swum ashore and was wandering in an amnesic state, or had in some strange way gone away to ‘think’. One mother was convinced that her 2-year-old had floated ashore and was being looked after by a family on the Dutch or Belgian coast. Such a fantasy was still present in the grand- parents of a 7-week-old baby whose body has never been recovered at the first anniversary.

For Norwegians [14] it has always been an un- breakable rule for families and relatives to search for people lost in accidents. Tradition suggests that such lost souls return to haunt the living, drifting restlessly and vengefully. The characteristics of these ghosts include the following: they cry dreadfully, search restlessly, cling to and press people down, and strike with sickness. These can be seen as projections of the feelings and experiences of the bereaved. In the total absence of a body, there exists for the bereaved a terrible struggle between the need for certainty, to allow an ending, and the inevitable irrational hope. It is like a search for someone who is missing rather than a laying to rest of someone who is dead.

Another problematic area stems from the fact that the badly damaged body may bear no resemblance to humanity, much less the physical appearance of the

loved one. In many circumstances relatives may be prevented by well meaning relatives from seeing the corpse. Following the Granville train disaster [15] 36 of 44 bereaved interviewed had not seen the body. The majority of those who had were widowers, and of 8, only one regretted this. Overall, those who saw the body had a more satisfactory outcome in terms of resolution of grief than those who did not. Twenty- two of the thirty-six who did not view regretted this, countering the argument of ‘Remember him how he was’ with the assertion that ‘Nothing could be as bad as my fantasies of how he looked’. The computer- aided precision of scientific detective work in identification is not emotionally satisfying. Some bereaved develop a ‘Questioning Syndrome’ [ 161, where doubt about the identification, or even the death, runs rife, and may block progress to resolution. The doubt of a number of Zeebrugge bereaved who had not viewed the bodies of loved ones, and who developed fantasies about misidentified bodies and empty coffins was put to rest by facilitating viewing photographs of the corpses.

The search for understanding

The bereaved also need to develop understanding of the meaning of the tragic events, and may begin with the reasons for the death and the events surrounding it. Information culled from death certifi- cates is an initial clue to answering questions about the cause and nature of death, such as whether the loved one might have died painfully or not. Similarly, attendance at the inquest may bring answers to many questions, from information from post-mortems, or witness statements. One family who lost a son in the Zeebrugge disaster were able from this information to retrace his last steps and stand at the point where he met his death on an identical ship. Similarly there is a pressing need to find out from other survivors what the loved ones were doing when they died, such as whether they were involved in rescuing people, which may give more inner meaning to the senselessness of the loss.

Multiple Ioss

Those who are multiply bereaved are most de- pleted. They are coping not only with the multipli- cative effects of several losses, but with wholesale reduction of social support networks, not only in terms of physical absence, but in terms of other relatives unavailable due to their own grief.

In the follow-up of bereaved from the Granville train disaster [I 51 a hierarchy of risk amongst the bereaved was established. Most at risk in terms of poor resolution of grief were mothers losing children (aged up to their early twenties) and next were fathers in the same position. Intermediate were widows, while widowers fared best.

PSYCHOLOGICAL HELP FOR DISASTER VICTIMS

It is evident that man-made disasters pose a major threat to the psychological well-being of their victims. The setting up of psychological support systems is therefore a basic preventative community health task.

Technological disaster-survival 355

Many disaster survivors are wary of accepting psychological help. This presents a problem for community outreach services. The outreach service to the victims of the 1977 Beverley Hills Supper Club Fire [ 171 was promulgated through the media, community case finding, special groups affected, and telephone contact. All efforts yielded only 5% of an estimated potentially available survivor population, the best response being from those contacted directly by telephone.

Proactivity is not a usual method of procedure for the helping professions, and the U.K.‘s 1985 Bradford Fire was the first attempt to mount a proactive outreach service by a statutory body (Social Services) in the aftermath of a British disaster. Pro- activity in this regard means contacting potential clients directly rather than waiting for them to refer themselves. Thus following the Zeebrugge Disaster, the Herald Assistance Unit visited each victim who did not actively refuse a visit, clients being informed of an intended visit at a specific time unless they contacted the unit to decline. In the passenger victim group, 69% of survivors and 84% of the bereaved accepted a visit [ 181. This acceptance rate would have been higher if all visits had been possible within the first 6 months. Evidence from Grampian Social Ser- vices’ response to the Piper Alpha Oil Platform Disaster suggests an across the board take-up of visits of 85% when offered within the first weeks.

One simple technique used in recent disaster outreach work is the use of a leaflet, ‘Coping with a Major Personal Crisis’, devised after the Australian Ash Wednesday bush fires of 1983, which lists the essentially normal experiences and symptoms which the victim might expect to undergo, and gives simple advice. Following the aftermath of the Welton near- miss, where an aircraft collided with private houses in a Lincolnshire village, without loss of life, the per- ceived helpfulness of this pamphlet was investigated [19]. 91% of those who received it (it was pushed through every door in the village), had made some effort to read it, and 27% had kept it. Women rated the pamphlet more positively than men and younger people more so than older. It gave a sense that ‘someone’ cared, and people appreciated the attempt to ‘normalise’ experience. It is possible that the more serious the event, in terms of loss of life, the more helpful the pamphlet to a wider group of people.

If the sense of loss of control and helplessness is one of the key problem elements, then actions which directly reinstate a sense of control, particularly in terms of self-help, may be extremely important. It has been noted that disaster survivors often feel most at home with other survivors, and this may form the basis for group work, either on a self-help basis, or with minimal professional input. Crew survivors from the ‘Herald of Free Enterprise’ wrote the following to survivors of the Piper Alpha disaster: “We found that getting together with others who were there with us on the night to talk and talk and talk helped enormously . . . ” but warned “we found when we met without leaders we didn’t talk about the feelings and thoughts we needed to get out into the open”.

One immensely powerful therapeutic tool used after both the Bradford Fire and the Zeebrugge

Disaster was a newsletter designed for victims by an editorial group of survivors and bereaved. It served as a vehicle for letters and poems sharing feelings and experiences, for requests for contacts, and for requests for information, particularly from the relatives of those who died. These were sometimes accompanied by photographs. and were concerned about the way the loved-one died, or what they were doing when they died. Such a newsletter addresses very effectively the problem of victims who are spread far and wide, as follow ing transport disaster, who inevitably feel intensely isolated. It is also highly acceptable to victims- less than 2% of victims of the Zeebrugge disaster asked not to be sent the newsletter, in comparison with the larger numbers who rejected personal visits.

An example of a community action programme is that developed in response to two sets of mass shootings in Melbourne, Australia [20]. Key elements included: (I) A public meeting to convey information, dispel myths and reassure. (2) Debriefing programmes. (3) Individual counselling. (4) A support group for those wounded or for bereaved families. (5) A public lecture on ‘Media Violence’. (6) A memorial service. (7) A television documentary about the shootings. (8) A community newsletter. (9) The for- mation of a gun control pressure group. (10) The development of a bereavement policy at local primary schools.

The value of talking about disaster experiences is not in doubt. In the aftermath of the Kings Cross Underground Fire, those who talked about the events within the first few hours had a better outcome reflected in later psychological testing (lower General Health Questionnaire and Impact of Event Scale scores) [21]. The overfree use of non-directive counselling techniques may however be counter- productive. “When a person’s way of interpreting and evaluating the traumatic events amounts to building a psychological trap. . . merely helping to clarify and understand can amount to reinforcing the structure of the trap when really it needs to be dismantled” [22]. For some, more directive cognitive- behavioural techniques are needed to radically challenge beliefs about self and world.

Lastly, for some, even more focused techniques may be needed. Systematic desensitisation has been successfully used, in conjunction with relaxation techniques, to reduce the frequency and intensity of anxiety-arousing nightmares [23] and the autonomic arousal associated with intrusive thoughts [24].

Traumatic stress reactions are often confused with formal psychiatric disorders such as “depressive reactions, organic disorders, adjustment reactions, an anxiety state, or a borderline disorder. Because depressive-like symptoms frequently appear, such as diminished interest, detachment, and sleep distur- bances, inaccurate assessments and ineffective treatment protocols may follow. Individuals with PTSD who are treated with antidepressants may show some improvement from those symptoms, while the under- lying condition is missed and progresses untouched” [25]. Psychotropic medication is rarely effective in helping such individuals-“minor tranquillisers are of little use and may be countertherapeutic.. .

356 PETER E. HODGKIN~ON

antidepressant medication is contraindicated for similar reasons” [25].

It thus seems that traditional medical treatment methods are of questionable value. This is com- pounded by the reluctance of disaster victims to come forward for help. As has been observed earlier, services have to be offered in a way that is acceptable to potential clients. This means assuming a more egalitarian, multi-professional approach to victims that is proactive and preventive in nature. Thus, in recent disasters in the U.K., the most effective efforts (at least in terms of reaching clients) have been outreach services provided by Social Services Depart- ments. These sorts of interventions are, however, not familiar to helping agencies.

Another sad factor of the post-impact phase is the failure of agencies to work co-operatively. Instead, agencies work competitively [26,27]. In the turbu- lence of the post-impact phase, what has politely been called ‘convergence’ on victims occurs, when agencies, both statutory and voluntary, descend in rapid succession upon potential clients. The consequencies are entirely negative-as one Zeebrugge widow re- marked, “when I saw the twelfth person coming down the garden path, I hid”. Therapeutic omni- potence and political advantage combine and lack of communication and normal interagency rivalry inten- sify. This is avoidable only with proper planning.

Disaster plans tend to be formed by particular agencies often without reference to others. Thus local government will have an emergency plan, the local health service may have another, as may the Social Services Department. All such plans cater only for the impact and immediate post-impact phases, and include little thought for the psychological care of victims, with no reference at all to the long term. Convergence and competition will only be reduced when agencies in a particular locality, emergency planning, social and health services and voluntary bodies, organise multi-professional across-agency teams, able to follow victims from impact to the long term. True international co-operation may be difficult in this area until such problems have been resolved.

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Technological disaster—Survival and bereavement