Thursday, April 28, 2011

One potential resource for the survivors of the Alabama tornadoes is community based psychosocial support (CBPSP)

We are all shocked and worried for the survivors of the tornadoes that have hit the South of the United States, specifically Alabama. We are watching the news as the search, rescue, and recovery are taking place. The SPHERE manual (2011) indicates that disaster response is composed of two main pillars: protection and assistance. We surmise that the shelters are opened all the VOAD groups are in action, and the physical health is being attended. Most disaster-affected people are receiving assistance.

How about protection?  There are three principles that should be attended to: (1) humanitarian assistance should be offered in such a way that it keeps the disaster affected people out of harms way; (2) the assistance received by the disaster affected people should not affect their capacity of self protection, (3) the confidentiality of the disaster-affected people should be preserved (SPHERE Manual 2011, p. 33).

Community based psychosocial support (CBPSP) is one of the strategies recommended by the SPHERE Manual (2011). As I write this piece the health services should prevent or reduce the mental health problems that may arise from the disaster. Strategies such as psychological first aid and activities that promote community self-help and social support should be included in this initial stage of response (SPHERE Manual, 2011, pp. 3334-335. As time goes by other (CBPSP) strategies will assist in the recovery and reconstruction phases. These strategies include: (1) promote positive community coping mechanism (i.e. participation in clean-up, voluntarism, community and church focused activities to reduce stress), (2) activities for children, (provide formal and informal educational activities for children and adolescents in safe places) (3) assist and promote the organization of appropriate psychosocial support activities (at the neighborhood, community and city levels), and (4) establish and maintain a mechanism for referral for clinical support (SPHERE Manual, 2011, p.43).

This is a very prescriptive approach but the suggestions are based on evidence informed intervention in recent major world disaster. On the meantime we pray for the disaster-affected people, their neighbors, and the rescue workers an volunteers who have taken on the task of “Helping thy neighbor”.

Tuesday, April 26, 2011


As I read the SPHERE Project manual 2011 today I had ambivalent feelings. On the one hand I was overjoyed because community based psychosocial support is included as the third element of the Protection Principle 4 (p. 41-42).  The element reads, “assist affected people to recover by providing community-based and other psychosocial support” (p. 41). On the other hand I was saddened by a conversation I had with a Senior Manager in International Services of the American Red Cross on January 31, 2008. Shortly after what would be my last public presentation in support of Psychosocial Support as the platform for an integrated disaster response.  This presentation was based after years of field work in international settings. This person said: “Don’t waste our time, Psychosocial Support will never be a part of the disaster response of American Red Cross Disaster Services, because it will never be a part of the SPHERE Project manual”. Time has proven that person wrong.

In the 2004 SPHERE Project the support for community-based psychosocial support was Standard 3: mental and social aspects of health (p. 291-293). With this guidance some of us took on the development of a discipline that would probe to be a valuable tool in the Gujarat and El Salvador earthquakes, the Gujarat riots, the Bam earthquake and the 2004 Tsunami in South Asia.  The five guidance notes of this standard served as the guidance for the community support psychosocial support interventions until the MHPSS guidelines prepared by the IASC were prepared and widely disseminated in 2007. Probably the greatest support to provide evidence informed data for community based psychosocial support interventions that precipitated a synergy between clinicians and community based types occurred as a result of the Haiti and Chile earthquake.

Well the efforts of many has paid off, today community based psychosocial support interventions, is a well represented element in the Protection Standard, the Health standard, and it is mentioned in all the segments of the other standards (shelter, water and sanitation, and food and security).

Today the SPHERE 2011 mentions community based psychosocial support and provides those of us in the field with the following: (1) under Essential Health Services-Mental Health (pp. 333-335): (a) community self-help and social support (Guidance Note #1, p. 334), and  (b) Psychological first aid (Guidance Note # 2, p. 335); (2) under Protection Principle 4: (a) positive communal coping mechanisms, (b) activities for children, (c) appropriate psychosocial support, and (d) integrates support systems. A new group of responders will be found in future disaster relief operations or conflicts, the community based psychosocial support experts because Community Based Psychosocial Support is here to stay!

Wednesday, April 20, 2011

A nine year retrospective of a psychosocial assignment in Ahmedabad, Bhuj, Gujarat

Joseph O. Prewitt Diaz[1],[2], PhD


The Gujarat Riots of February 27, 2002 were the results of the burning of the Sabarnati Express carrying Hindu pilgrims returning from the Holy city of Ayodhya that resulted in fifty-eight (58) deaths. The months to come brought about retaliatory actions from the Hindu majority. As a result approximately 1000 people from all religious segments were killed, places of worship burned and many people lost their homes, properties and livelihood. While violence was rampant, and the damages widespread, the most affected community was Muslim.

The American Red Cross was conducting a disaster mental health operation as a result of the Bhuj, Gujarat, India earthquake. The delegates assigned to the operation initially responded as counterparts to the Indian Red Cross Society (IRCS) volunteer efforts and support to the affected people. I invited to go to Ahmadabad for a period of three weeks (April 16, 2002-May 10, 2002) that was extended by four days. During this period I conducted crisis intervention training[3] and supported the volunteers.


The purpose of this paper is to share impressionistic data on Indian Red Cross volunteers that served in the role of psychological first aiders after the riots in Ahmadabad, Gujarat, India in 2002. The information reported herein was gathered from evening defusing meetings, focused groups, and individual interviews. The volunteers report that as time has evolved they are beginning to introject some of the behaviors that are shared with them by the survivors. In some case the empathy of the volunteer changed to sympathy that lead to compassion fatigue[4]. Stressors are the result of; (1) violence inflicted on the Muslim community expressed in different ways, over an extended over a long time; (2) loss of family and friends; and (3) damage or destruction of property; (4) fears of continuation of violence by community members; and (5) segregation in public places are just some of the overt reasons for continued anxiety and stress.  Below is a discussion of the areas that most impacted the volunteer.

The anxiety of being hounded

The violence reported by the survivors to the volunteers was symptomatic of their traumatic experience. Every interview or focused group brought depressing news. The communal hatred and prejudices were so deeply rooted that the affected people of the three communities (Hindu, Muslim and Christian) were not ready to talk to each other. Anger and hatred were expressed and acted out. The faith and trust towards others were replaced and replaced by animosity and distrust.

Being a refugee in your own land

Having to take shelter in relief camps, on or near Muslim cemeteries, made the survivors feel as though, this one action, had granted them refugee status. The cramped space, lack of privacy, improper hygiene further deepens the feeling of loss of citizen status in one’s own village, city and state cause helplessness to increase. The volunteers reported a feeling of irritability as a result of having to sign-in upon entry to the camp, daily dependence on outside assistance, and the uncertainty of aid to run the camps.

The constant fear of reprisals led to continual insecurity, hopelessness and anger amongst the affected community. Having been driven from their homes, many of the residents of the camps, felt that the treatment they received from their neighbor and government officials made them feel as though they were no longer citizens of the state. Fear, anger, hopelessness and helplessness were commonly expressed feelings.

Disturbed routine life

The displacement into relief camps is usually sudden and forceful. Therefore people fleeing for their lives have no time to save their assets. When they resettle into new lives they have to start from a scratch. Often they are unable to pick up pieces of their old lives again and the effort to do so only exhausts them emotionally. The day is usually spent in sitting idle. This free time has no value attached to it. The survivors have no work to occupy them, instead they now complain over their conditions which in turn only causes them greater distress.

For the survivors in the relief camps life changes drastically. Overcrowding and weather made conditions very difficult. Their daily routines and lifestyles were disrupted. Survivors reported difficulty in performing even the simple everyday routines that they were an integral part of their lives.

The constant intrusion and questioning of lifestyles had different implications for different people. Women who are in mourning are not emotionally ready to meet others. Thus living in open in the camp distressed and offended them a lot. Women reported difficulty maintaining their personal hygiene especially when they had their menstrual cycles. Several women experienced disturbances in their monthly cycle, the irregularity attributed to the traumatic experience. Pregnant women and women with newly born babies were at risk to infections since pre and post natal care was not being offered.

Men and adolescent males sat idle most of the day since they had not been permitted to case for the management of their camps. Men expressed frustration at having to stay in camps. Living in the open meant an increase in sexual frustrations. The adolescent boys who were now at a stage of sexual awareness, living in the camps gave them plenty of proximity to girls of their age, something they were not accustomed to in their earlier lifestyles.

Children got little safe space to play. They are no longer able to attend their old schools or appear for their exams as a result one academic year has been lost. The relief camps do not provide an ideal environment for studying. Thus there are constant worries especially amongst the older children about their education. Several children reported witnessing rapes and killings of family members and friends. Some had even fought the mobs alongside the other family members. Nightmares and sleeplessness were common amongst them. They would cry at the very mention of their lost near and dear ones. Some were unable to yet comprehend the tragedy that had struck them and were numb and silent.

As the children have been displaced from their old localities and schools they miss their old life and they are unhappy. The sudden displacement from their homes perplexes many younger children initially. Their parents simply ran with them away to relief camps leaving behind their houses and all their possessions. The terrifying experience of witnessing violent crimes devastates the children emotionally, as they not yet developed the emotional maturity to deal with their feelings. This is manifested in behavior such as constant weeping or clinging to their mothers and other elders in the family. Some had become silent and were terrified to be alone or in the company of strangers. Many develop feelings of vengeance towards the other community to which the perpetrators of violence belong. Certain incidents might trigger off hidden fears and expressions of violent behavior.

Degree of vulnerability of the members of affected community

The effect of the riots differs depending upon the degree of vulnerability.  The under-represented group is composed of children, single women, women who lost their husbands and are now the sole bread winners of their family, women subjected to sexual violence, older women and men especially those who have none left to care for them and those disabled in the violence all have reacted differently depending upon the age and the type of violence and suffering inflicted on them. Several individuals were predisposed to emotional instability and they have suffered further.

For women who have to now shoulder all economic responsibilities, the trauma is severe. They have had to cope with loss of their husbands and other earning members of their family and also make efforts to keep themselves strong for maintaining their family. Therefore, while they perform their new roles, inside they remain emotionally fragile. They have developed somatic symptoms such as loss of appetite and disturbed sleeping patterns, pain or loss of movement in limbs, paralysis, and blurred  vision have been reported to the volunteers.

The survivors felt helpless to control their lives and also a very high sense of hopelessness. Many have lost interest in life. Those who were inclined to praying and fasting feel a great sense injustice and betrayal. Many report suicidal ideation. For the survivors the violence and displacement caused by the riots was a first ever occurrence, they had to develop new coping mechanisms. They did not know how to cope with the anger and fears generated by this experience.

Uncertain future

The survivors want to resettle in places that bring about a sense of psychological safety. Some shift to their old places or begin looking for newer localities, which are perceived as ‘safe’. Others have moved in with friends and relatives or stay in rented houses.

The shift to new localities has brought back old cultural, psychological, social and economic ties of the affected people. Their old friends from the other community are no longer perceived as friends. As families get displaced they lose contact with their extended family or get distanced from them. In several instances wedding engagements are broken due to deaths of the people to be married or lack of finances to arrange the weddings. This has been the cause of anxiety amongst the parents of such children.

With the earning members of the family out of work it is difficult to make ends meet. The avenues of employment have been reducing. The survivors have begun to lose hope of finding regular employment. Those who were gainfully employed before the violence now sit idle. Men and youth who have been unemployed for long may display unusual anger and aggression towards family, friends and the wider society. A feeling of helplessness exists amongst the survivors as they feel that they are unable to control their lives and their future.


Living this experience was like being inside of a bubble. Due to security reasons there was not community visits and limited times outside of the hotel for the American Red Cross delegate.  I was only able to meet with the volunteers twice a day and attend meetings with Project Harmony, the coordinating group for the psychosocial support response. The work with four volunteers was very rewarding; we shifted from teaching crisis interventions strategies to the simple principles of psychological first aid. This tool became successful for the community outreach. Attempts at individual counseling were substituted with some community activities with children and adolescent. Nine years to the day have elapsed since I experienced that assignment in India.  Over the years I have had occasion to visit Ahmadabad, the town has evolved the burned building that stood as a memory of the riots have been renovated, and the people have moved on.

[1] Dr. Prewitt Diaz is a Humanitarian Psychologist affiliated with the University of Puerto Rico School of Law. He was the recipient of the  2008 APA International Humanitarian Award.
[2] Trip report submitted nine (9) years after the assignment.
[3] Slaikeu, K. (1990). Crisis Intervention: A handbook for practice and research (2nd Ed.). Boston, MA: Allyn and Bacon, Inc.
[4] Figley, C. (200). Compassion fatigue as a secondary traumatic disorder. London, Eng: Brunnel-Rotledge

Monday, April 11, 2011

Psychological well being

Psychological well being  refers to the effectiveness of individual’s interactions and their relationships to others. People’s lives, communities, and societies are shaped by a combination of individual factors, social factors, and the interaction between the two.

Psychological well being refers to levels by which survivors are able to guide and take charge of their lives, moving beyond the disaster. It consists of a number of factors, which include a sense of control and a sense of being an active part of family and community networks, of engaging in active planning, and a sense of being able to manage the physical and psychological support and threat. These factors are psychosocial and interrelated in the sense that they are influenced by social and cultural factors as well as individual experiences. Each individual becomes a product as well as a contributor to the culture and its relationships to other cultures.

Psychological well being guides individuals as they interact with their external and internal realities. All individuals are engaged in resource exchange, resource enhancement, or resource diminution. Survivors tend to be involved in an exchange with other survivors, which include taking as well as giving.

Human beings use their individual experiences to construct their lives, identities, and relationships to their context. A person’s private experience occurs in a context with a meaning that is somewhat socially constituted, so they also have a social as well as an individual character. Psychological well being is contextual in the sense that communities have an active part in defining their needs and determining when those needs are met.

Figure 1: Overt behaviors and actions to achieve well-being

Overt Behavior


Community identifies the emotional tools to handle the adverse effects of a disaster

Support groups are trained and have a readiness to assist disaster affected people.

Community develops the tools to rebuild.

Teams have been identified and trained
to conduct assessment, clean up, rebooting infrastructure and psychological first aid.

Members have identified activities to improve the quality of life

Ecological plans are ready to implement even if resources are scarce.

Show ability to use social capital

Community social capital identified and assigned to work groups.

Community is inclusive of all members.
Open dialogue and shared responsibilities with all segments of the community.

Community members are knowledgeable of the five steps to resolve crisis.

All members have received training in psychological first aid. Activities are held without negative effects.

Improve economic well being through community planned projects

Ability to plan, develop, monitor and evaluate local projects

Community members are able to improve community health

Members of the community are trained in physical first aid, and principles of safe water.

Community members report that they live in a secure place

Disaster affected people have developed mutual support networks, and protocols that assure safety in the community.

Psychological well-being is the integration and transformation of knowledge about persons and community networks, about patterns of behaviors, relationships, values, practices and attitudes within a specific context that allows planning, implementation, and evaluation of community activities and projects that foster a sense of place and psychological well being.  

Psychological well being provides a guide for understanding and contributing in a variety of ways to the well being of individuals, communities and their interactions. It suggest that there may be ways for attaining particularly facilitative psychosocial attributes that can be developed for psychological well being and that there may also be a range beyond which psychosocial attributes cannot vary without producing detrimental personal and social effects. Identification of these limits and possibilities can benefit individuals and communities experiencing disaster related stressors, realizing their inner strengths and establishing supportive environments.

Bradburn, N.M. (1969). The structure of psychological well-being. Chicago, Illinois: Aldine Publishers & Co.
Jahoda,  M. (1958).  Current Concepts of Positive Mental Health. New York, NY: Basic Books.

Coelho, G., Hamburg, DA, & Adams, JE (Eds.). (1974). Coping and adaptation. New York: Basic Books.
Tyler, F.B.  (2001). Cultures, communities, competence and change. New York, NY: Plenum Publishers.

Saturday, April 2, 2011

Psychosocial Support in the American Red Cross International Service--An early history

Becoming a volunteer for Disaster Services  of the American National Red Cross, as a Mental Health worker was a dream come through. My mother who had worked with the American Red Cross encouraged my brothers and I to volunteer. We did. But in terms of my growth in the Red Cross, the opportunity to share my skills at a National level was a great honor. Since "Three Mile Island", I have actively responded to over 50 major National Disasters. It wasn't a surprise when I received a call late 1998 from Disaster Services asking my availability for a "short term assignment" in Central America in response to Hurricane Mitch. This assignment would mark the beginning of a  journey that would result in my professional growth as a psychosocial support expert, advocate, and scholar.

There has been great effort  in getting psychosocial support recognized as a viable platform for disaster response, reconstruction and community resilience building in the American Red Cross.

After the embassy bombings in Tanzania and Kenya in 1998, Dr. Gerald Jacobs, the world expert in disaster mental health was commissioned by the IFRC to develop together with the National Societies a response to address the emotional sequelae of the attacks on the affected population. Upon his return he met with personnel from International Services where he provided a briefing and presented a plan for immediate Disaster Mental Health response.

In 1999, Dr. Gordy Dodge, Alice Willard and a staff member from the IFRC Psychosocial Center in Copenhagen presented the results of an evaluation of a "Psychosocial Support Program" in Kosovo. The focus was of the report was on the psychosocial impact of a livelihood project (providing sewing machines in a community center setting, and informal schooling activities).

Late 1999, Dr. Rachel Cohen and others met to discuss the viability of Disaster Mental Heath in International Services responses. Dr. Cohen, a famous psychiatrist and Red Cross volunteer,  shared her vast experience in crisis intervention and in the States, Central and South America. The focus of this report was care for the worker and survivors.

In the aftermath of the El Salvador earthquake in 2001, Sandy Brady, planned a meeting with invited personnel from previous DMH or PSP responses. The goal of the meeting was to identify strategies to insert psychosocial support into International Services. There was a presentation of the American Red Cross sponsored intervention which included emotional support to all the volunteers that responded to the earthquake and their families, and psychological first aid as a tool for first order intervention in psyhcosocial support.

Late 2001, the Technical Assistance Unit of International Services hired Will Matthews, a veteran of the Psychosocial Support response after the Turkey earthquake. He was tasked with developing "Psychosocial support guidelines" for International Services. He held two meetings one with a group of experts in Geneva, and the other with the delegate and the Psychosocial Support Team from El Salvador, Honduras, Guatemala and NNicaragua. As a result of those meetings he prepared Guidelines and presented them to Senior Management.

The guidelines were shelved shortly thereafter. Senior management concluded that the Psychosocial Support experts couldn't reach an agreement. These conclusion may have been misguided and biased. Each one of the programs reported and developed by International Services in the 1990'2 and early 2000's had elements of psychosocial support--psychological first aid and crisis intervention activities in the early aftermath of a disaster and recovery, Self help activities to increase networking and resilience, informal schooling, training for local staff, and staff care activities--. All were part of what is today known as psychosocial social support for disaster affected people.