I  WOKE UP THIS MORNING WITH STRESS REACTION THAT OCURRED TEN YEARS AGO: THE TERRORIST ATTACK TO THE UNITED STATES ON 9/11/2001

Joseph O. Prewitt Diaz[1], PhD
September 9, 2011
Cayey, Puerto Rico

In the morning I was awakened by a dog barking in the distance. I had a slight headache, stiff neck, was shaky and hyper-vigilant. The first thing I did was make coffee and check whether the tanks were full of the generator, then I looked at the cuvert where I keep the emergency equipment. As I sat down to take my blood pressure, I realized it was a sunny day and the weather forecast, was not calling for bad weather today or the rest of the weekend. After deep breathing seeveral times I was relaxed enough to reflect on my actions this morning.

I realized that my actions were consistent with traumatic stress reactions, these reactions were due to an event that happened ten years ago. The terrorist attacks of September 11, 2001. Around that time of the year,  I always get up experiencing the transitory experience.

My name is Dr. Joseph O. Prewitt Diaz, born in Cayey, Puerto Rico. I am a psychologist specializing in humanitarian assistance. I spent most of my life working on the Disaster Services American Red Cross (ARC). The night before the attack I had returned to my daughter’s in State College, PA for a  two weeks leave from my current  position as an International Delegate serving as  ARC Regional Coordinator for recovery for Central America after Hurricane Mitch.

In my role as Coordinator of Disaster Mental Health within the Disaster Services Human Resources (DSHR) , I was part of the National Team that responded air transportation events. The decade of 1990-1999  I served in many of  the traumatic events that would change the way the nation prepares and responds to natural and manmade disasters. Some of these events were Hurricane Andrew, the attack on Murray Federal Building in Oklahoma City, several plane crashes, floods, storms, hurricanes and tornadoes. I felt sure that with the level of theoretical and practical experience I could phase any disaster, do my job and move on.

That night (Sept 10^th) my daughter and I sat down to plan my days. The next day I had to drive her to work, pick up a prescription, take the car to change two tires and meet for lunch. I took her to work, and when  I arrived at the pharmacy I saw on a TV a plane hitting one of the Twin Towers in New York. I remember I told the pharmacist "this movie is very realistic what it is called" the man looked at me with a dull expression, and said “that not a movie it is an accident: a  plane crashed into the twin towers" and continued to fill the prescription, a few moments after the second plane crashed. Not sure of what I had seen, I called the Headquarters of the  Red Cross in Washington to ask what was going on, the voice at the other side answered, "seems to have been a fatal plane crash in New York, give me your phone number in case we need you." I called my boss in International Services and I he told me "this is an accident, do not think you need, just relax on your holiday, thanks for checking in."

When I reached the garage, I noticed a commotion in the waiting room. No one was attending the reception desk, all customers and employees were glued to the television. No sooner had the door open when I received a call from my daughter, she said "Dad, America is under attack, a plane just crashed into the Pentagon and I can not find Joito and Jerry." I told her not to worry that I would get in tuch with them, I commented that maybe this was a drill. Several days later I learned that my son and brother had gone unscathed  from such  ominous event.

Not a minute had passed when I received a call, the voice on the other side had a serious tone "we are under attack, two planes crashed in New York, one in the Pentagon, and they are tracking a fourth plane to somewhere over Pennsylvania, report to your nearest Chapter and call me back." I understood intellectually that it was a real issue. Pancho de la Roche was not a hype man, his ability to communicate in times of crisis was accurate.  This was the real thing a thousand thoughts ran through my mind and I felt an adrenalin rush.

When I reached the chapter in State College, PA.  I checked in and immediately called Washington.  Fred forwarded my call to the Emergency Operations Center. I heard  the familiar voice of Dr. Susan Hamilton who greeted me cordially and efficiently. She explained what was happening and wanted me to prepare to leave for New York immediately. At the moment I heard from the other side "Oh my God”,” Jose hold one." Within seconds, the voice said, "José report to emergency management in Somerset, Pennsylvania, a plane just crashed there. By now you're in charge of mounting the mental health services in disasters, we will send staff when we can. " I asked how many hours" and she said, "In two or three days”.

When they arrived, I found that I was the only person from National”. I proceeded with the help of local volunteers, and the guidance from Washington to set up the DMH services that would be offered for the next four weeks, a clearinghouse for the rescuers, coordinating mental health services for the morgue, open the Family Reception Center and reported to the Center Federal Command. The next day Dr. John Weaver arrived and took over the operation, on day two Dr. Margaret Pepe who was in charge of the operation, John was in charge of dealing with the Family Center, and I was in charge of assigning the 27 volunteers.

I was sitting in the Command Center when the personnel from United Airlines put the names of the passengers of United 93. One of those passengers was a Puerto Rican professional who worked at the Census Bureau in Philadelphia, and happened to be on the plane on her way to California. In my previous trip, had the opportunity to make a presentation in Harrisburg, Pa on migration patterns of Puerto Ricans in Pennsylvania, a member of the panel had been that person.

Needless to say how difficult it was to receive this family and make notification of what happened and what we expected to happen in the coming days. The mom had a heart condition and the Red Cross made arrangements to bring a Puerto Rican cardiologist Scranton, who happened to be a volunteer, to be with family during the four days they were in Somerset.

 The commemoration ceremony was very moving. Family members were driven in a bus to the place where the plane crashed. There was not much to see, only men dressed in white uniforms and a large crater in the ground in the distance. Personalities  like representing the United States, such as  Congressman John Bertha, members of the Executive Branch, the President of the Red Cross, Laura Bush, President Bush's wife were present and offered the condolences to each family on behalf of the Nation. Then we went to a place where there was a prayer meeting, and informal visits with each family. Each family received a little crystal box with soil from where their dear one’s had come in contact with the earth. That night I met the Puerto Rican  family and had a meeting to give closure to this part of the process and make sure that all formalities had been fulfilled.

Three weeks after returning to State College, I returned to meet with my children, and that afternoon I went back to Guatemala. I stayed  in touch with my collegues, at both formally and informally with the recovery process in New York and Washington. One year later, in August 2002 I returned to Washington for an official visit of "debriefing" with peers who worked in the early days of the response. I still had not realized my traumatic response to that operation until this morning—when 9/11 came to life in my awareness.

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[1] Dr. Joseph O. Prewitt Diaz is the recipient of the APA International Humanitarian Award and the Government of India Certificate of Distinguished Service (Silver Award). He is Adjunct Professor and Director of the Disaster Law Center, School of Law, University of Puerto Rico. He continues to be an active volunteer with the Puerto Rico Chapter American Red Cross

SUPPORT FOR THOSE LEFT BEHIND

Joseph O. Prewitt Diaz[1]

We take great pride in sending or younger man and woman on combat missions to different parts of the world. We have welcomed back troops from Iraq and Afghanistan. The injured are handled differently, and the psychosocial support for the next of kin and extended family are not clearly articulated.  At times we have had to receive the remains of fallen heroes. On at least twenty occasions in the last three years, I have witnessed how the rites of mourning are at times not culturally, linguistically or psychosocially appropriate. There are at least three basic moments that support is needed: (1) the mechanics of handling the notification, (2) the funeral, and (3) the support received by the next of kin and extended family after the event.

The notification is frequently handled in two segments; first a warrior shows up to the home of record, gives the news of the loss and leaves. The second part is the arrival of a chaplain, and a liaison to assist the family in preparing the funeral services. In that very first private moment where “shock” sets in, the television cameras show up and begin a process of intrusive inquiry.  The respect paid to the grieving next of kin is a “camera on you face”. The format is that they show the next of kin crying, they show someone reading a recent email, and that ends the appreciation of a grateful nation for the sacrifice of one of its hero’s.

The funeral services come out of the “standard book” and culminate with a folded flag handed to the next of kin. That folded flag signifies the sacrifice of the fallen warrior, and the beginning of a new life of loneliness and despair for the next of kin and the extended family.

The support phase because of its length and complexity needs to be carefully planned. The official support system is located in a military installation, the Veterans Administration, and the Office of the member of Congress. The focus is on how the insurance monies are invested on behalf of the survivor. There are no visits to the home. Veterans Administration is located in the capitol city and there are limited outreach services. Local government doesn’t have the wherewithal for serving the survivors needs and rely on Veteran’s organizations for support. On all cases the focus is survival, the spiritual and psychosocial support needed available to the survivors is limited or non-existent. I was told by a government official recently “we are well prepared to handle the funeral, but can’t assist the survivors for an extended period of time that is the role of the family and the church”.

To continue to expand and fine-tune psychosocial support programs for the survivors of heroes I suggest that we study the words of a great Soldier and Statesman called Pericles. He teaches us in his Funeral Oration after the Peloponnesian War (Thucydides (c.460/455-c.399 BCE): Peloponnesian War, Book 2.34-46):

"Comfort, is what I have to offer to the parents of the dead who may be here. Numberless are the chances to which, as they know, the life of man is subject; but fortunate indeed are they who draw for their lot a death so glorious as that which has caused your mourning, and to whom life has been so exactly measured as to terminate in the happiness in which it has been passed. Turning to the sons or brothers of the dead, I see an arduous struggle before you. When a man is gone, all are wont to praise him, and should your merit be ever so transcendent, you will still find it difficult not merely to overtake, but even to approach their renown. If I must say anything on the subject of female excellence to those of you who will now be in widowhood, it will be all comprised in this brief exhortation. Great will be your glory in not falling short of your natural character; and greatest will be hers who is least talked of among the men, whether for good or for bad”.

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[1] Dr. Prewitt Diaz is a Visiting Professor in the School of Law of the University of Puerto Rico, and Director of the Disaster Law Center. He was awarded the 2008 APA International Humanitarian Award.  He is a trainer for disaster mental health professionals and chaplains in Puerto Rico. 

CRISIS COMMUNICATION, PSYCHOSOCIAL SUPPORT AND THE AMERICAN WAY

Crisis Communications is a required subject to achieve a “Certificate in Emergency/ Crisis  Management”. Most bureaucrats and politicians are trained in the subject. I became increasingly interested in the subject when the Director of FEMA had to resign in the high of the Katrina response. As I recall the TV clip, he was more interested in the color of shirt that he was going to wear for the interview, and spent precious hours with previous appointments that had nothing to do with the thousands of people displaced from New Orleans in the aftermath of Katrina.

The last week has been a time of crisis in the United States, and very little crisis communication has taken place between those that created the crisis that has sent millions of Americans on the road to despair. We began with the approval of laws regarding the external debt of the United States, continued with a down turn in the market, leading to a decrease S&P credit rating the rating of the United States to AA+.  The politicians decided that they needed a rest, and so Washington closed down for a five-week rest, where members of Congress went back to their District or on junkets so that they could conjure new ways to continue to take money out of the common man’s pocket. Thank you God!!! Between the rightist from the Tea Party, the Moderates from both parties and the populist from the left only God knows what now measures they would have concocted to “save the country” that would have resulted in greater calamity for the American people.

While politicians covered or scratched each other’s back, the real Americans, the patriots were at work. Yesterday morning we woke up to the news that 30 Americans had lost their life in the battlefield. All the President could offer to those American families that have been sacrificing so much was an a acknowledgement that their dear ones had fallen in the battlefield. I wonder if, whether or when the Nation will honor those heroes with the same intensity as that wasted to make a political point in the Halls of Government the last few weeks. You see most of those men were “Navy Seals”, heroes only known to God!

Crisis communications suggest that in spite of great odds and difficulties the interlocutor has to provide accurate and timely information. It also recommends that for the well-being of all communication has to be such as to create an environment that fosters safety, connectedness, and has a calming effects on the individual and the community as a whole. It further suggests that a small group of people will be so affected that they may need to be referred for psycho-education and/or professional assistance.

Well the time has come to acknowledge that crisis communications have failed; there is a perception that government has failed its people (except the rich and power brokers). There is no longer a feeling of safety in our country. Those who can defend us are deployed half way around the world, and they too have been led down by the chain of command. There is no calmness, joblessness is on the rise, the economic measures suggested by the President have not worked, State governments are shutting down, elected politician are running away to other States so that they don’t have to make hard choices, the blame game is being played all over. How can we be calm? To boot, the programs that are being earmarked for cuts are the community mobilization, community clinics, and community mental health.  What are the elements of psychosocial support needed in such a sick environment?

Fortunately tomorrow is Monday, a new week begins with people in the corners of little towns and cities and freeway exits with cardboard sign saying “Handiman, busco trabajo!”.  Farmers will be cited for providing employment to children. And yet, another committee will be formed to offer solution to the psychosocial support needs of our population. 


All the while politicians and CNN, will continue, under the guise of transparency, to inflame the psyche of the common man/woman, probably increasing the symptoms of high blood pressure, heart conditions and strokes, while the politicians in Washington continue to fund raise for the next election and reduce the funds for physical and behavioral health programs, and many of our heroes die in the battle field to preserve freedom, safety and our rights of free speech. This is the American Way!!!

Psychosocial Support in the aftermath of the Oslo Bombings

Joseph O. Prewitt Diaz[1], PhD

I was astounded and saddened with the news of the bombing and shooting incident in a campground in Oslo yesterday. Our sincere and deepest condolences, to all the citizens of Norway.

Terrorism, whether from the right or the left, as a way to shake world order, seems to be on the increase.  The message to the world was “loud and clear” – terrorist will attack soft targets, to make themselves heard. The question for the world to ponder is what are the appropriate actions to reduce violence against the vulnerable civilian populace. Certainly peaceful actions will lead in-kind to peaceful results.

At prima-facia the bombing and shooting will certainly have an effect on the affected population, and on the Norwegian nation as a whole. The affected people are (1) the family and friends of those that lost their life or were injured, and (2) those that are watching the drama unfold on TV or through other media sources, without enough information wondering about their safety and well being.  

Three common reactions that will emerge are

•  Hatred, prejudices, animosity and distrust may increase due to person-blame behaviors.
• Some will unable to yet comprehend the tragedy that had struck them and will be numb and silent. Certain incidents might trigger off hidden fears and expressions of violent behavior.
• As the survivors return to their places many will feel psychological safety. A small group will feel uncertain and hopeless about their future. They will begin looking for a new place that they perceive as ‘safe".   

Psychosocial strategies:


As the first responders and mental health professionals approach the event-affected people. There are three needs that they may have. (1) Develop faith and trust. (2) An understanding that while most of the youth may recover, in the next few days, much stronger and more resilient. Others may not recover as quickly and will need grief counseling, and/or consultation with mental health professionals. (3) Potential short term response may include psycho-education, adequate and timely information, active participation in grieving rites, and an opportunity to share their feelings will lead to a feeling of comfort, well being, and an emerged hope for a safer future.

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[1] Dr. Prewitt Diaz is a humanitarian Psychologist who serves as a Visiting Professor and Director of the Disaster Law Center, School of Law, University of Puerto Rico. Her served with the American Red Cross as a Disaster Mental Health officer during the Oklahoma City Bombing and the 9/11 response in Somerset, PA.  He was the recipient of the APA International Humanitarian Award in 2008.

Top 10 Articles Published in Community Based Psychosocial Support since 2008

Prewitt Diaz JO: Integrating psychosocial programs in multi-sector responses to international disasters. Am Psychol; 2008 Nov;63(8):820-7.


North CS: A tale of two studies of two disasters: comparing psychosocial responses to disaster among Oklahoma City bombing survivors and Hurricane Katrina evacuees. Rehabil Psychol; 2010 Aug;55(3):241-6. 


Henley R, Marshall R, Vetter S: Integrating mental health services into humanitarian relief responses to social emergencies, disasters, and conflicts: a case study. J Behav Health Serv Res; 2011 Jan;38(1):132-41.

Williams R, Alexander DA, Bolsover D, Bakke FK: Children, resilience and disasters: recent evidence that should influence a model of psychosocial care. Curr Opin Psychiatry; 2008 Jul;21(4):338-44.

Te Brake H, Dückers M, De Vries M, Van Duin D, Rooze M, Spreeuwenberg C: Early psychosocial interventions after disasters, terrorism, and other shocking events: guideline development. Nurs Health Sci; 2009 Dec;11(4):336-43. 


Udomratn P: Mental health and the psychosocial consequences of natural disasters in Asia. Int Rev Psychiatry; 2008 Oct;20(5):441-4.

Smith E, Wasiak J, Sen A, Archer F, Burkle FM Jr: Three decades of disasters: a review of disaster-specific literature from 1977-2009. Prehosp Disaster Med; 2009 Jul-Aug;24(4):306-11.

Walsh DS: Interventions to reduce psychosocial disturbance following humanitarian relief efforts involving natural disasters: an integrative review. Int J Nurs Pract; 2009 Aug;15(4):231-40.


Ray-Bennett NS: The role of microcredit in reducing women's vulnerabilities to multiple disasters. Disasters; 2010 Jan;34(1):240-60.

Findley SE, Sanchez M, Mejia M, Ferreira R, Pena O, Matos S, Stockwell MS, Irigoyen M: Effective strategies for integrating immunization promotion into community programs. Health Promot Pract; 2009 Apr;10(2 Suppl):128S-137S. 

Psychosocial support is a simple tool for protection and community development

Joseph O. Prewitt Diaz[1] PhD

An increase in natural disasters and conflicts, an awareness of disaster-affected peoples needs, and a group of people that assured that the human rights of disaster affected people are protected has created the synergy for psychosocial support to be acknowledged and placed at the forefront of disaster response.

This synergy has created guidelines and standards that are to be upheld in responding to a disaster. But, what is community based psychosocial social support? Form my optic it is a set of activities that involves psychosocial actions, planning and establishing of  “place”.

Psychosocial actions are the result of community members joining together to identify those activities that impact the quality of life. After a disaster, community mapping, and gathering of data through inclusive community meetings leads to identifying projects that will increase voluntarism, contribute to change, and fosters social planning.

Psychosocial planning consist of three phases: In the first place establish dialogue between all segments of the community, decide the risks and resilience factors, and describe strategies to influence leadership and external stakeholders to develop policies that will impact eh affected-community. Secondly, move from developing policies to implementing policies by identifying programs that are needed to address risks factors and the mechanics of developing the program, Thirdly, engage the community members in activities that will address the needs of all segments of the community. These activities lead people by defining their “place” by focusing on feelings, motives and purposes of the affected-people.

Community based psychosocial support is a developmental cycle by transforming victims into practitioners, and new arrivals into volunteers. There changing knowledge, skills and communication within and without are part of a developing identity--- a re-established place.

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[1] Dr. Prewitt Diaz is a Visiting Professor and Director of the Disaster Law and Policy Center, School of Law, University of Puerto Rico. He was awarded the Distinguished Service Award from the Indian Red Cross Society for the development of psychosocial support programs in several Indian States. 

Learnings from Psychosocial Supports projects managed by external “Experts” after disasters

Joseph O. Prewitt Diaz,[1] PhD

I just completed over fifty after action reports of psychosocial support programs during the 2004 South Asia Tsunami and the January 2010 Haiti Earthquake. We were trying to understand the impact of external psychosocial experts in diverse groups ranging from community organizations (local NGO’s and GO) to work organizations (INGO’s representing the UN family the Red Cross family and the Faith based family).

Findings:

1.     Many projects were conducted to achieve justice (defined as equal opportunity or equity within a given context). Societal equity in several cases was defined based on the world-view of the external experts rather than consulting the disaster-affected people. Shared resources and mutual concerns for each other were not considered in the development of the projects.  This resulted in a lack of knowledge about shared but unspoken values, norms and cultural practices. The projects lasted as long as the ex-patriate expert remained in-situ and disappeared or was reformulated as soon as the expatriate left the area.

2.     Extensive and excessive use of participation in coordinating groups created a “we-they” relationship with the disaster-affected groups. This let to strong monolithic team culture that focused on the groups “own” job and a self-protective stance (ie. PSP group, WASH watsan groups or the protection cluster).

Lessons learned

1.     Reach out and develop connections within the context of the affected-people. This will foster mutual respect, and a desire to work together, volunteer, identify and use own social capital, and rely on community leadership and skills to improve the well-being in their communities.

2.     Neutralize the “we-they”. Some of the most mentioned suggestions were: (a) community meetings and “melas” (focused meetings), (b) assure representation of all segments of the community (women, children, elderly and differently abled among the most important), and (c) through needs assessment and community mapping activities identify and prioritize particular problems or concerns, and identify the methods on how to tackle the challenge.

3.     Spend significant time building trust and showing respect for the disaster-affected people.

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When feeling afraid brings out the best in you!

Joseph O. Prewitt Diaz[1]

I have spent a large portion of my life feeling afraid and reacting to that feeling. Insecurity, not feeling secure after a catastrophic event, is a normal reaction to an abnormal event. But when you spend a large portion of your life feeling afraid, in spite of external or environmental stimuli, the normal behavior is responding to every stimuli (good, bad or indifferent) by being hyper vigilant, hyper tense, and over reacting constantly, in everyday life, these types of individuals react abnormally to a normal event.

Four sources may cause feelings of insecurity: (1) mother, (2) immediate family, (3) religious leaders, or (4) teachers. External control begin with “Don’t get wet, you will get sick” or don’t walk in the dark room “te coje el cuco” (the buggy man will grab you), or “good boys don’t do this or that”. Implying that since you were doing and unwanted action you were not a good boy. As you grow older you go to church with your elders, while you are quiet, prayful, and do what adults do, everything is good. The minute you start acting out your boredom, you are bad “the devil is surely going to get you boy!” My father used to say.

As you grow up the external stimuli get more sophisticated and hard to follow. “Joe is a good boy, he is at times misguided”. Boy that teacher really treated me well she said I was a good boy. I proudly walk out with my mother and as we turn the corner to go down the stairs, my mother’s hand hit me in my “cachete”. “What did I do”, I ask. My mom responded you made me look bad, it is as thought I “never redirect your behaviors” (my mother was a teacher too, and more difficult to understand).  !Mamii “she said I was  a good boy.” “Yeah, did you hear the rest”. “No mom I forgot”. That initiated an hour length discourse into all the bad things I did, and how many times I embarrassed her.

As I grew older, I was skinny, shock a lot (no me podía estar quieto) and kept quiet.  Well, soon after my 15^th birthday, experiencing personal difficulties in turns of understanding what satisfied the adults around me I went away. The little fish had outgrown his pond.

In the ebb and flow of life, I found that I was very good in crisis situations. I was perceived as functioning in a normal way during abnormal times. I had found my calling, as time went on I volunteered in community initiatives. At times I took on more than I could, just so that I could find a solution to the situation. “Yo era diferente” for sure. I became a very good initiator, but very bad at follow through.

Even though I am older and my energy is dwindling, there was a time when at the sound of a radio tune, you would see the white and red jeep speeding down the road. This big guy, got off, ran to the Job Manager and said “Disaster Joe at your service sir.”

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[1] Dr. Prewitt Diaz is the recipient of the 2008 APA International Humanitarian Award for service rendered through the American Red Cross in disaster situations. 

PSYCHOSOCIAL SUPPORT PAVES THE PATH TO A NEW WORLD

Joseph O. Prewitt Diaz[1] PhD

Psychosocial support is a cross cutting issue in the SPHERE Project 2011. The main role of psychosocial support is to assure that the emotional needs of affected-persons are addressed as they recover from major disaster or conflicts. Community based psychosocial support is a tool that provides support and equal assess to services to the oppressed and the oppressors. It is participatory in nature and providers a mechanism where all segments of the community are able to identify the risk and resilience factors in their geographic, ecological, cultural, economical, spiritual, social and psychological place. The activities provides a space for all members of a community to identify their losses, what they need to rebuild, their social capital and what the affected-communities need from the outsiders and  other stakeholders.

The approach has two predominant segments: a clinical and a psychosocial segment. The clinical approach begins with psychological first aid, and then the small groups of disaster-affected people that need further clinical evaluation are referred for counseling. In a small number of cases, medical personnel that may use medication to alleviate the traumatic stress, anxiety and depression raising from the difficulty of coping with the disasters and the feelings of hopelessness and helplessness experienced by some.

The psychosocial support segment provides for participatory community assessment. Most of this work is qualitative and relies on community mapping and narratives using pictures as stimuli for community members to express their needs. Volunteers are the backbone of this segment. They will develop safe space for children to play, and informal schooling for adolescents, women, and the elderly to develop skills to rebuild their “place”. Slowly, slowly, the disaster-affected people regain their desire to move ahead and enhance their resilience. The narratives with small groups every six-months give a glimpse of the movement made by the affected-communities from their own perspectives, and needs to continue to change and to be modified.

Psychosocial support is synonymous of constant activities, increased communication, ownership for the process and product, voluntarism and re-establishment of place. Psychosocial support  paves the  path to a bright new world!

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[1] Dr. Prewitt Diaz is Visiting Professor in the School of Law and Director of the Disaster Law and Policy Studies Center. He is the recipient of 2008 APA International Humanitarian Award.

Contextually appropriate psychosocial support

Joseph O. Prewitt Diaz[1], PhD

A couple of months ago SPHERE 2011 was unveiled in several capitals around the world. This document provides the understanding of the humanitarian field about the standards to use to assure the “Do no harm” maxim. This event signaled a quantum leap in humanitarian assistance. It recognized that humanitarian assistance had two significant parts: (1) assistance and (2) protection. The importance of psychosocial support was recognized in the document as an important tool that will assure protection through (1) contextual sensitivity, (2) culturally appropriate techniques, (3) the strengths of local networks, and (4) focus on emerging victorious.

Contextual sensitivity. Bolton and Tang (2002) were trying to understand how a village fostered mental health support using qualitative research tools. They decided that the best way to gather their data was to sue the community members as key informants. A by-product of the study was a model on problem identification, symptoms, solutions and monitoring of the work being conducted. Sharing this work with some colleagues, the issue of time in developing a project arose. We know from successful models after disasters that the time it takes to identify the needs, prioritization, and project development are psychosocial support tools in themselves. They strengthen the capacity of the community to trust each other, identify social capital, and enhance their solution focused capacitates.

Culturally appropriate techniques. These have a great value in helping the outsiders understand what works and how it works within the local norms, culture, and spirituality.  While we are trying to comply with donor intent and requirements, we must recognize that we are outsiders in the disaster setting and must rely on development of trust, a two-way communication system, and a desire to truly belong to the community you are trying to help.

Strength of local networks. I reached Banda Aceh with a contingent of mental health workers. I went to the local Red Cross and asked where were the local personnel. The man looked at me with puffed eyes “they are no more”. It took a year to get a new group on-line, community and school groups functioning in their respective settings. It was hard to explain to my “higher ups” why it was taking so long. The correct answer was that the local community would take as much time as needed to develop the necessary networks, to get a semblance of what was, before they were comfortable accepting assistance from the outside.

Focus on emerging victorious. I am vehemently opposed to the use of standardized testing to measure the effects of psychosocial support programs. Without taking much time: “it is simply wrong”. The basic problem is the reliance on a deficit model. Most of the people have a “problem” generated or exacerbated by the disaster. The focus on providing psychosocial support to affected-people is to help them recognize their resilience, feel victorious and achieve well-being. Most communities want to return to “place”. It seems that in assessing risks and resilience factors, people gain a self-respect, capacity for problem solving, and the capabilities to use local skills to achieve solution focused activities. At the end of the day, the disaster affected people need to feel victorious.

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[1] Dr. Prewitt Diaz is Visiting Professor of the School of Law and Director of the Disaster Law and Policy Center, University of Puerto Rico. He was awarded the 2008 APA International Humanitarian Award. 

Pictorial tools encourage dynamic processes that permit a holistic evaluation of risks and resiliency factors

Joseph O. Prewitt Diaz[1], PhD

Pictorial tools in disaster-affected communities promote, participatory processes and dynamic processes that encourage disaster-affected people to initiate a self-propelled process of recovery. Disaster-affected people have the freedom to device their own methods of resolving problems by developing intervention that will work for them.

Pictorial tools are simple and provide a powerful space to elicit complex solutions. They keep the affected people active by providing the opportunity to think about the information being presented. These tools are used to search and identify different alternatives to attend to community needs.  One such tool, community mapping, promotes self and community knowledge that leads to community guided decision-making.

Participatory processes are used in such a way that they enhance the perspective between and within gender, and diverse community groups. Marginalized people may use illustrations to formulate a story and communicate their needs to stakeholders. Using illustration has increased group thinking and encouraging proposing organizational approaches.

The results of establishing equivalence lead to highlighting the importance of visual literacy amongst the affected people. By attempting to use pictorial tools universally, disaster-affected people develop the ability to (1) understand and make visual statements, (2) understand the world around them visually, (3) understand relationships, and systems of which they are part off, and (4) integrate personal experience and imagination with social and psychological experience.

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[1] . Dr. Prewitt Diaz is Visiting Professor and Director of the Center for the Study of Disaster Law and Policy, School of Law, University of Puerto Rico. He is the recipient of the 2008 APA International Humanitarian Award. 

Better days are ahead for tornado-affected Communities

Joseph O. Prewitt Diaz[1] PhD

It was not until I saw, smelled and heard the stories of disaster-affected people in Sri Lanka, Banda Aceh and Chalang, after the 2004 South Asia Tsunami. It was through daily exposure that understood the meaning of the phrase “root shock”[2].

As we look at the future of Joplin, Missouri and Jarell, Tuscaloosa and Birmingham in Alabama clearly these towns and its people have experienced “root shock”. The loss of the home itself may not be the only indicator of negative psychological consequences. The roots that were left exposed will certainly influence their well-being: (1) loss of property, (2) loss of income, (3) loss of job, (4) loss of family, friends, and neighborhood, (5) loss of the way of life, and (6) limited access to essential services such as health care. If this were not enough, the disaster-affected people currently in shelters are at elevated risks for reduced hygiene, exposure to communicable diseases, insufficient water, rest and malnutrition.

I have had the opportunity to provide psychosocial support in different settings in the United States and many countries around the world. The lesson learned is that when the families resettle and caring networks are built around them, they whither for a while, but emerge stronger, more resilient, and appreciate of the newfound well-being.

Time is of the essence to put places together and get the disaster-affected people into some kind of normalcy. The community structures, and local networks will have to walk the proverbial extra mile to accept and care for the disaster-affected people. One thing is for sure:  “BETTER DAYS ARE AHEAD”. Disaster affected people will re-establish their place. The root shocked families with the right kind of nutrients and nurturance will succeed. I pray that day comes soon.

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[1].  Dr. Prewitt Diaz is Visiting Professor and Director of the Disaster Law and Policy Study Center, School of Law of the University of Puerto Rico. He is the 2008 recipient of the APA International Humanitarian Award.

[2] The phrase “Root Shock” was formulated by Dr. Mindy T. Fullilove in her book “Root Shock” 2004 published by Random House. 

IS THE JOPLIN EMERGENCY OVER?

Joseph O. Prewitt Díaz[1], PhD

The news today was positive regarding Joplin, Missouri. The number of dead has stabilized at 130+, the hospital had reopened with another name, and the disaster-affected people were photographed looking through the rubble for whatever memories were left. My neighbor saw me in the afternoon and yelled from the other side of the street: “Good news today, does this mean that the Joplin emergency is over? I just smiled and walked on. I didn’t have the courage to say, “bad things are just beginning”.

I reflected about the psychosocial effect of this terrible catastrophe over time. The disaster-affected people had (1) developed a personal identity with Joplin, through the churches, schools, shopping centers, and the hospitals (2) purchased a property and through hard work, collaboration of friends and neighbors, had turned it into a home, and (3) developed social and cultural aspirations and expectations.

There are some hard times now. The tornadoes have not only destroyed the physical “place” they have attacked and broken the bonds of continuity, familiarity and attachment to the home, neighborhood and community. I heard people say: “we are homeless”, “we belong nowhere”, “live in the shelter make us feel like we are outsiders”. The personal identity, and belongingness have been broken by the loss of control over the tornadoes and the outside organizations that have come to town introducing themselves as “Hi, my name is------,  I am with -----------, and I am here to help”.

But...better days are ahead.  Important actions taken by the community today will carry you all a long way.  Establish networks with family, neighbors and community. Volunteer your time and skills to help each other. Seek practical help, and timely information. In as much as you can listen to others, share a meal and a smile. Through your neighborhood groups join clean-up, and planning activities for the future. Soon you will realize that valued experiences and mutual understanding, bonding and learning will emerge. Soon the feelings of “despair” and “impotence” will shift to a “can-do feeling”.  You all will shift from victims to victorious!

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[1]. Dr. Prewitt Diaz is a Visiting Professor and Director of the Disaster Law and Policy Studies Center, School of Law, University of Puerto Rico. He was the recipient of the 2008 APA International Humanitarian Award.

News stories on CNN inspired this note

The spiral of psychological well being after the tornado whirlwinds

Joseph O. Prewitt Diaz[1], PhD

The last two weeks I have been in an emotional Roller coaster watching Anderson Cooper and the request of the CNN team describing the effects of the tornadoes and flooding in Middle America. As a psychologist who specializes on disaster management and humanitarian assistance every word, action, and strategy displaced by the government to resolve the crisis was brought a comment from my side on how to do it better. After watching the Memorial Service in Missouri this afternoon I realized that maybe there wasn’t a clear understanding of the psychological effect of these disasters, so let me share so points related to this topic.

The psychological meaning of the disaster had do with home. Home as our place provide us with privacy, comfort and security. Home is a place for development and maintaining social relationship and lasting attachments that bring strong ties to home. It is where the children grew, where the young bride and groom came together to make a family. It is here the neighborhood group got together to watch the football game, or to play poker, or to have a prayer meeting.  The tornadoes not only destroyed the physical home but the social relationships that the home represented.

There are three points that I would like to discuss based on the comments I heard on TV. All of this comments I have heard over the last two weeks I heard in CNN.

1.     Disruption, destruction and displacement.  Disaster-affected people have reported (a) suffering devastation, (b) being heartbroken, (c) feeling that this was a traumatic experience, (d) feeling unmotivated, or  (e) having lost interest of staying here. We may decide to reconstruct elsewhere.  The life of the disaster-affected people has been disrupted. Private houses have become public and personal possessions have become public property. Everything has been destroyed: property, possessions, people’s life identities, personal histories and attachments. People report that they are outcasts in their own homes and communities. They share there fears that the may not belong in the new place. They copying the best they can but feel alienated in their community. 

2.     Reconstruction, restoration and return to the routine. One comment caught my ear: “we have spent a lifetime building our home and lovingly restoring those part that we felt had to be restored, only for it to be thrashed”. The process of reconstruction is not simple. Once the FEMA and Red Cross representative have filled out all the paperwork and the insurance companies have been notified, then is the parade of new and strange people in our lives.: (a) the insurance company, (b) loss adjusters, building contractors, and retail outlets where we can get better prices for construction materials to name a few.  As disaster-affected people begin the restoration process, they report being scared of all that was ahead of them. At least they now that the relation toward “home” has changed, they don’t quite identify with the new place, and express their worry of “being stuck here”. “What if this happens again in a year or two?” Returning to the routine is a “chore”. Disaster-affected people normal lives and costumes have been suspended. They will have to build new lives and customs, and a new place. They were all part of the “relationship” with the old home. “Where to go?” “What awaits for my family and I?” are some of the concerns.

3.     Psychological response or achieving well-being.  There are at least three areas of psychological concern: (1) personal and familial identification, (2) personal and social identification, and (3) boundary issues as represented by a perception of private and inclusive domain as opposed to “public” and exclusive domains.

I am well aware that the impact of the psychological health are more severe and longer lasting that the physical sequalae of the tornadoes and that everybody doesn’t respond in the same way to the same stressors.  Maybe it is important to begin to think publicly about the three factors mentioned above. CNN you are the leaders in communication, can you take on this challenge?

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[1] Dr. Prewitt Diaz is a Visiting Professor and Director of the Disaster Law and Policy Center, School of Law, University of Puerto Rico. He is the recipient of the 2008 APA International Humanitarian Award. 

Psychosocial support in Missouri with 100+ deaths and counting

Listening to the news and watching TV news  this days is like watching a horror movie: tornadoes, floods, conflicts and the little gal and her children trying to survive. The psychosocial consequences of a disaster of the magnitude of the Missouri tornadoes is very difficult to assess. We know that the majority of the disaster affected folks will experience transitional distress. The good news is that a majority of folks will show a number of reactions to included resilience, a desire to re-establish "place", and an improvement in their community relationships.

Hobfoll (2009) suggests that there are five essential elements that facilitate recovery: (1) a sense of safety, promoting calm, promoting a sense of collective efficacy, promoting connectedness and promoting hope (p. 223).

The first responders, emergency management, the media, and the family members can join together at this time to strengthen the safety nets, listen, and plan for a day in the future when things will be back to a semblance of what they were prior to the disaster.

Joseph O. Prewitt Diaz, PhD

SPHERE 2011 proposes specific Community Based Psychosocial Support Interventions

The new SPHERE Project 2011 has included a new section entitled “Protection Principles” (SPHERE, 2011, pp. 24-44).  The following community-based and other psychosocial support is recommended.

Positive communal coping mechanisms such as culturally appropriate burials, religious ceremonies and practices, and non-harmful cultural and social practices should be supported.

Activities for children: Where appropriate, communities should be encour­aged to organize structured, supportive educational and protective activi­ties for children through non-formal means such as child-friendly spaces. Community protection mechanisms should include self-help activities that promote psychosocial well-being.

Help organize appropriate psychosocial support for survivors of violence. Ensure that survivors have access to community social networks and self-help activities. Access to community-based social support should be complemented by access to mental healthcare.

Integrated support system: Those agencies working on psychosocial support and mental health in various sectors should collaborate to build an integrated system of support for the population (see Essential health services – mental health standard 1 on page 333).

Clinical support: Establish mechanisms for the referral of severely affected people for available clinical support.

Psychological first aid should be available to workers who have experienced or witnessed extremely distressing events (see Essential Health Services—Mental Health Standard 1, p. 335).(SPHERE 2011, p. 73 & 335). Acute anxiety after exposure to extreme stressors (e.g. traumatic events) is best managed following the principles of psychological first aid, which is often mistakenly seen as a clinical intervention. Rather, it is a description of a humane, supportive response to a fellow human being who is suffering and who may need support. It entails basic, non-intrusive pragmatic care with a focus on listening but not forcing talk, assessing needs and concerns, ensuring that basic needs are met, encouraging social support from significant others and protecting from further harm.

SPHERE 2011 proposes concrete guidance for Community based Psychosocial Support

The new SPHERE Project 2011 has included a new section entitled “Protection Principles” (SPHERE, 2011, pp. 24-44).  The following community-based and other psychosocial support are recommended.

Positive communal coping mechanisms such as culturally appropriate burials, religious ceremonies and practices, and non-harmful cultural and social practices should be supported.

Activities for children: Where appropriate, communities should be encour­aged to organize structured, supportive educational and protective activi­ties for children through non-formal means such as child-friendly spaces. Community protection mechanisms should include self-help activities that promote psychosocial well-being.

Help organize appropriate psychosocial support for survivors of violence. Ensure that survivors have access to community social networks and self-help activities. Access to community-based social support should be complemented by access to mental healthcare.

Integrated support system: Those agencies working on psychosocial support and mental health in various sectors should collaborate to build an integrated system of support for the population (see Essential health services – mental health standard 1 on page 333).

Clinical support: Establish mechanisms for the referral of severely affected people for available clinical support.

Psychological first aid should be available to workers who have experienced or witnessed extremely distressing events (see Essential Health Services—Mental Health Standard 1, p. 335).(SPHERE 2011, p. 73 & 335). Acute anxiety after exposure to extreme stressors (e.g. traumatic events) is best managed following the principles of psycho­logical first aid, which is often mistakenly seen as a clinical intervention. Rather, it is a description of a humane, supportive response to a fellow human being who is suffering and who may need support. It entails basic, non-intrusive pragmatic care with a focus on listening but not forcing talk, assessing needs and concerns, ensuring that basic needs are met, encouraging social support from significant others and protecting from further harm.

Psychosocial Support is one of the cross cutting themes in SPHERE 2011

SPHERE Project 2011 identifies psychosocial support as one of the cross-cutting theme for all sectors. This is the description offered in the Handbook. Some of the greatest sources of vulnerability and suffering in disasters arise from the complex emotional, social, physical and spiritual effects of disasters. Many of these reactions are normal and can be overcome with time. It is essential to organise locally appropriate mental health and psychosocial supports that promote self-help, coping and resilience among affected people. Humanitarian action is strengthened if at the earliest appro­priate moment, affected people are engaged in guiding and implementing the disaster response. In each humanitarian sector, the manner in which aid is administered has a psychosocial impact that may either support or cause harm to affected people. Aid should be delivered in a compassionate manner that promotes dignity, enables self-efficacy through meaningful participation, respects the importance of religious and cultural practices and strengthens the ability of affected people to support holistic well-being.(SPHERE 2011, p. 17).

WHEN……


Joseph O. Prewitt Diaz

Disaster cause stress in the family,

the children are the most impacted.

Children show signs of stress,

the family behaviors are stressed.

Parents seek emotional an spiritual fortitude,

Emotional and spiritual support reaches them.

Parents encourage their children to release stress,

they are able  to better manage their own stress.