DEVELOPING STANDARDS FOR PSYCHOLOGIAL SUPPORT ACTIVITIES POST-DISASTERS: IS THEIR CLEAR GUIDANCE FOR SERVICE PROVIDERS?

Dr. Joseph O. Prewitt Diaz

Senior Functional Advisor

Psychosocial Support Programs

International Services

American Red Cross

Note to the Reader:  This monograph is part of the archival material collected from the inital years of the Tsunami Response by the American Red Cross. The mongraph became the approved program for psychosocial support response to the four tsunami affected countries (India, Indonesia, Maaldives and Sri Lanka) by Senior Leadership of the Tsunami Recovery Program on August 31, 2005 in a meeting held at the Taj Samudra-Colomo Sri Lanka. These early guidance materials were never considered or referenced by the "Psychosocial Programming Meta Evalaution-American Red Cross" prepared by Mr. Steve Powell (July 2010).

Introduction

The aftermath of a disaster is characterized by chaos, neighbors taking care of neighbors and outside agencies (both GO’s and NGO’s) arriving at the site to provide assistance. There is clear guidance of the how to provide for basic needs, medical response, and water and sanitation needs. What is still lacking in the field of disaster mental health and psychosocial support is clear guidance of what constitute the universal standards to define “quality of care” in psychosocial support programs.  The purpose of this paper is to discuss the existing standards for psychosocial support programs. The paper concludes that there are fairly clear standards for PSP response during the acute phase of a disaster. There is a need to identify standards for longer-term support during the reconstruction and development phases of the cycle of disaster.

Preventive and proactive coping as the corner stone of the American Red Cross PSP program

The role of the American Red Cross psychosocial support program is to assist survivors to develop preventive coping ability. Preventive coping is an effort to prepare for uncertain events in the long run. The aim is to build up general resistance resources that result in less strain in the future by minimizing the severity of the impact. Thus, the consequences of stressful events, should they occur, would be less severe.

In preventive coping, individuals consider a critical event that may or may not occur in the distant future. Examples of such events are job loss, forced retirement, crime, illness, physical impairment, or disaster. When people has a yearly medical check-up, save money, maintain social bonds, participate in community mapping or is part of a response plan in the community and school they cope in a preventive way and build up protection without knowing whether they will ever need it.

The other part of the psychosocial support program is to learn and practice proactive coping.   Proactive coping reflects efforts to build up general resources that facilitate promotion toward challenging goals and personal growth. In proactive coping, people hold a vision. They see risks, demands, and opportunities in the distant future. They perceive demanding situations as personal challenges. Coping becomes goal management. Individuals are proactive in the sense that they initiate constructive path of action and create opportunities for growth. The proactive individual strives for life improvement and builds up resources that ensure progress and quality of functioning. Proactively creating better living conditions and higher performance levels is experienced as an opportunity to render life meaningful or to find purpose in life.

Preventive and proactive coping are partly manifested in the same kinds of overt behaviors, such as skill development, resource accumulation, and long-term planning. Proactive individuals are motivated to meet challenges, and they commit themselves to their own personal high-quality standards.

“Sense of Place” or the search for meaning after a disaster

Lazarus (1991) reports that the process of appraisal constructs an emotional meaning of a person-environment relationship. Whether a situation is relevant to one's goals, beliefs, or values is determined by a number of more or less automatic decisions concerning a particular encounter. In terms of Lazarus’ theory, a situation would be appraised as or given meaning as being relevant or no relevant, posing a threat, harm/loss, or challenge (Lazarus, 1966; Lazarus & Folkman, 1984). Creating meaning in terms of appraisal is suggested to help determine the personal significance of an adaptation encounter.

Folkman and Moskowitz (2000) argue that the construal of meaning not only serves to estimate the relevance of a situation and choice of coping, but also plays a vital role for coping behavior itself, especially coping that supports positive affect.. Searching for meaning, can be considered a broad category of positive coping, including situational and global meaning, benefit-finding, and benefit-reminding, among others. Empirical evidence attests to the fact that.

Mollica, Lopez Cardozo, Osofsky, Raphael, Ager and Solama (2005) suggest that most relief organizations, including the American Red Cross, provide psychosocial interventions based on a primary concern for the psychological and social well-being of the individual, but extending to the repair of community social structures. The term psychosocial emphasizes the dynamic relations between psychological effects (e.g., emotions, behaviors, and memory) and social effects (e.g., altered relations as a result of death, separation, and family and community breakdown). Psychosocial interventions try to assist survivors to identify their “Sense of place”, on the assumption that meaning and positive emotions help to restore an individual’s world view and may build additional personal resources.

The standards developed by several agencies discussed below provide a “road map” to assist the survivors and program developers in introducing interventions that helps restore the worldview of survivors.

SPHERE Humanitarian Charter and Minimum Standards in Disaster Response

In October 2004, the SPHERE project proposed a standard 3 “Control of non-communicable diseases: mental and social aspects of health” under the Health section.  The underlying assumption is that it is recognized from previous disaster experiences that a disaster affects the social and psychological well-being of a survivor and therefore both components must be addressed within the context of community based interventions and in coordination with the community of survivors. The standard proposes two types of interventions:  social and psychological. The table below summarizes the interventions per category and includes a column for guidance notes.

Table 1: Table for psychological and social interventions and guidance notes in the SPHERE Health standard # 3

           

Psychological Interventions	Social Interventions	Guidance Notes
	People have access to credible information on the disaster and associated relief efforts	Information should explain the nature and scale of the disaster and on efforts to establish physical safety for the population. Information pertaining to specific types of relief activities being undertaken by the government, local authorities and aid organizations, and their location. Information should be uncomplicated (understandable to local 12-year-olds) and empathic.(showing understanding of the situation of the disaster survivor). (See Guidance Note 1).
	Normal cultural and religious events are maintained or reestablished. People are able to conduct funeral ceremonies (including grieving rituals conducted by relevant spiritual and religious practitioners).	Families should have the option to see the body of a loved one.  Unceremonious disposal of bodies of the deceased should be avoided. (See Guidance note 2).
Survivors experiencing acute mental distress have access to psychological first aid at health service facilities and in the community.		Acute distress following exposure to traumatic stressors is best managed following the principles of psychological first aid. Trained personnel provide basic, non-intrusive pragmatic care with a focus on listening but not forcing talk; assessing needs and ensuring that basic needs are met; encouraging but not forcing company from significant others; and protecting from further harm. This type of first aid can be taught quickly to both volunteers and professionals.  (see guidance note 3).
Care for urgent psychiatric complaints are available through the primary health care system. Essential psychiatric medications, consistent with the essential drug list, are available at primary care facilities. Survivors with pre-existing psychiatric disorders continue to receive relevant treatment, and harmful, sudden discontinuation of medications is avoided. Basic needs of patients in custodial psychiatric hospitals are addressed.		Psychiatric conditions requiring urgent care include dangerousness to self or others.  Recommendations should be made to family members to seek help for the survivor in the health care system. (see guidance note 4).
If the disaster becomes protracted, plans are initiated to provide a more comprehensive range of community-based psychological interventions for the post-disaster phase	As soon as resources permit, children and adolescents have access to formal or informal schooling and to normal recreational activities. Adults and adolescents are able to participate in common interest activities, such as emergency relief activities.  Isolated persons, have access to activities that facilitate their inclusion in social networks. The community is consulted regarding decisions on where to locate religious places, schools, water points and sanitation facilities. The design of settlements for displaced people includes recreational and cultural space.	Interventions should be based on an assessment of existing services and an understanding of the socio-cultural context. Interventions should include use of functional, cultural coping mechanisms of individuals and communities to help them regain control over their circumstances. Collaboration with community leaders and indigenous healers is recommended.  Community-based self-help groups should be encouraged. Community workers should be trained and supervised to assist health workers with heavy caseloads and to conduct outreach activities to facilitate care for vulnerable groups. (see guidance note 5).

The standard emphasizes the relationship between the social and psychological and encourages that both realms be attended too simultaneously. Social and psychological indicators are discussed separately. The term ‘social intervention’ is used for those activities that primarily aim to have social effects. The term ‘psychological intervention’ is used for interventions that primarily aim to have a psychological (or psychiatric) effect. It is acknowledged that social interventions have secondary psychological effects and that psychological interventions have secondary social effects, as the term ‘psychosocial’ suggests (SPHRE, 2004).  

While this standard is an important first step in providing psychosocial support post disasters it only provides guidance for the acute phase of the response. The standard falls short of suggesting indicators for the rehabilitation and reconstruction phases.  There are three major issues that need to be addressed in future revisions to this Social and psychological standard. (1) Although there are suggestions capacity building of community workers and other to provide psychological first aid as well as to assist heath care workers, there is no guidance as to duration, scope, sequence, or the nature of supervision post training session.  (2) Indicators pertaining to social interventions must be included, especiall as it relates to the isolated persons, and the internally displaced and host families. (3) The third down fall of the standard it the suggestion of formal and informal schooling without an indicator of type, place, and period of time acceptable for this intervention. 

World Health Organization

The World Health Organization has taken the lead in devising strategies that will provide relief from stress and lead to social and psychological wellness of communities and survivors. The three major points that have been brought to the fore by WHO: (1) Psychosocial support to disaster victims is crucial. (2) There can be no one “universal formula” for dealing with the social and psychological needs and for all types of disasters. (3) The realization that those delivering psychosocial support services need to be well versed with the culture and way of life of disaster survivors.

Immediately after a disaster, the community itself usually provides the support system, including psychosocial support. Strategies should be developed to enhance a community’s inbuilt capability to develop psychosocial support in the immediate aftermath of the disaster. Many times, community members may downplay the importance of traditional methods such as, chanting, meditation and counseling from within the community by senior members.

The WHO promotes a community-focused psychosocial approach to mental health care in disasters. The term 'social intervention' describes those activities that primarily aim to have social effects, and 'psychological intervention' for interventions that primarily aim to have a psychological effect. This distinction was made with the explicit acknowledgment that social interventions usually have secondary psychological effects and that psychological interventions may have secondary social effects. This approach addresses psychosocial needs in a holistic manner and places mental health interventions within a wider context such as education or health care.

WHO’s policy on mental health and psychosocial support to disaster victims is that it should be community-based and culturally appropriate and take into account the needs of special groups such as children, women, the elderly, etc. WHO recommends that psychosocial support be provided to affected communities by community-based workers who understand the needs of disaster victims and are trained by experts in psychosocial support methodologies.

The role of the WHO lies in defining the psychosocial and mental health needs of the community, establishing technical guidelines to be used, providing technical support to governments, NGOs and other stakeholders involved in psychosocial support, as well as training people for implementation of psychosocial support strategies, monitoring and evaluation of programs and working with governments to develop mental health services.

Van Omeren, Saxena and Saraceno (2005) represent the current thinking of WHO.  In there article entitled “Mental and social health during and after acute emergencies: Emerging consensus?” they propose a model for mental and social health for the post emergency phase of a disaster.  They suggest that there are two core social strategies that should be followed: (1) encourage continuation with normal activities, and 2) active participation in community activities. 

Organizing community self-help support groups will provide a powerful form of assistance by encouraging problem sharing, brainstorming for solution, and identifying effective ways of coping, generation of mutual emotional support, and promotion of local initiatives. The community members may focus on alleviating poverty and plan economic redevelopment activities such as income generations through community planning.

As part of the SPHERE project WHO has been instrumental in the development of standards of services The suggestions made by  WHO may be found included in the SPHERE standards (2004).

Interagency Network for Education in Emergencies (INEE) standards

The most stable institution after a major disaster it the concept of school be that actual or figurative.  INEE contends that All individuals have a right to education. Education in emergencies, and during chronic crises and early reconstruction efforts, can be both life-saving and life-sustaining. It can save lives by protecting against exploitation and harm and by disseminating key survival messages, it promotes psychosocial well-being. It sustains life by offering structure, stability and hope for the future during a time of crisis, particularly for children and adolescents. Education in emergencies also helps to heal the pain of bad experiences, build skills, and support conflict resolution.

The Minimum Standards for Education in Emergencies (MSEE) are designed for use in emergency response, and may also be useful in emergency preparedness and in humanitarian advocacy. They are applicable in a wide range of situations, including natural disasters and armed conflicts. The standards use ‘emergency’ as a generic term to cover two broad categories: ‘natural disasters’ and ‘complex emergencies’.  Access and learning environments Standard 2indicates that governments, communities and humanitarian organizations have a responsibility to ensure that all individuals have access to relevant, quality education opportunities, and that learning environments are secure and promote both protection and the mental, emotional and physical well-being of learners (INEE, p. 39).

The indicator provides for teachers and other education personnel to be provided with the skills to give psychosocial support to promote learners’ emotional well-being. Emotional and mental well-being is to be understood in the full sense of what is good for a person: security, protection, quality of service, happiness and warmth in the relations between education providers and learners. The activities used to ensure learners’ well-being should focus on enhancing sound cognitive development, solid social interactions and good health. Ensuring well-being also contributes to learners’ successful completion of a formal or non-formal education program. 

American Red Cross suggested indicators for community and school based interventions

The American Red Cross psychosocial support program is community-based, and the interventions promote well-being.  All activities suggested by the psychosocial support program recognize that ultimately, disaster-affected communities must be the architects of their own psychosocial recovery.  The participants in the program are expected to make the program sustainable at an individual and community basis by establishing their “Sense of Place” post disaster.

The PSP program falls within the realm of community psychology.  The program assists the community to identify person-environment interactions and the ways society impacts upon individual and community functioning. The community interface with social institutions, and other settings that influence individuals, groups, and organizations.

PSP staff assists the community to systematically examine the ways individuals interact with other individuals, social groups, clubs, churches, schools, families, neighborhoods, and the larger culture and environment. Community facilitators assist the community to examine various social issues including poverty, formal and informal education, community development, risk and protective factors, empowerment, diversity, prevention, intervention, high risk behaviors, and other topics as they are raised by the community support groups.

The American Red Cross personnel have conduced qualitative assessment in various countries in South and Southeast Asia and found that there are needs for behavioral health personnel as well as an infrastructure for mental health.  The table below presents the challenges and opportunities that were faced by program developers in the field.

Table 2:  Table for challenges and opportunities in helping survivors define their “sense of place”

Source	Challenge	Opportunity
Integration of program from theory to practice	Transference of a knowledge base from Western countries was easiest by using internet public domain articles vs. using consultation with the surviving communities to develop local models.	Systematized integration of ARC domestic Disaster Mental Health technology into each local reality. Develop a pool of “different” volunteers with specialized skills in psychosocial support Generate program infrastructure through the National Society as to guarantee the quality of “new” volunteers.
Determination of Needs	Needs assessment tools were quantitative in nature and did not yield the necessary data for psychosocial response.	Used participatory assessment and focused groups to develop a list of protective factors identified as facilitating recovery and reconstruction at an individual and community.
Materials development	Linguistic adaptation Cultural adaptation Technical adaptation	Translation and back translation of materials from outside of the country used committee approach. Material shared with various community members of diverse age groups in each country for cultural applicability. Materials reviewed by MoH, and Psychological Association in each country for technical appropriateness
Identifying a Capacity Building model	Capacity Building based on existing mental health infrastructure for clinically based mental health. Emphasis on referral to health facilities when there was no referral sources available.	A continuum of skills was developed. Re-certification process every six month.  Practicum for a certain number of hours with supervision.
Development of delivery tools	Most material available immediately after the tsunami were developed from the internet.  They were in many occasions not culturally or technical appropriate.	All materials have been developed in a format such that a 3rd grade level reading skill. Low content, high interest. •  Visual materials are included in all manuals •  Non-verbal tools available at every level.
Monitoring and Evaluation	Development of indicators that measure knowledge, behavioral and attitude change not readily available in the industry.	•  Utilized naturalistic methods to gather information of KAP from the community and schools. •  Utilized quantitative data to record the numbers of participants in capacity building activities, volunteer hours, and number and gender of beneficiaries.

The table above present areas of challenges and opportunities faced during the development of the psychosocial support program. The areas that were most critical were language and cultural competence of the staff.  A disaster of the magnitude of the super cyclone in Orissa, the Gujarat Earthquake of the Tsunami requires knowledge of language culture, recognition of protective factors, and the perceptions of “loss of place” expressed by the survivors.

Health facilities at the community level are ill equipped or non-existent, behavioral science professionals are not readily available and the hospital with psychiatrist units are ill equipped to handle the distress and practical needs of he many survivors. In visiting the affected communities and from preliminary assessments it was determined that schools were operational, and that teachers and others in the community could initiative the necessary support needed so that survivors could begin to address their practical, and psychosocial needs.

Some types of interventions will occur even without the assistance of first responders or behavioral health professionals. The survivors will almost immediately begin to address their practical needs such as self and family care. Survivors will utilize their protective skills to overcome suffering and tends not to depend on outside aid. It is important to mention that psychological first aid, a first order intervention, takes into consideration the physical and emotional energy, and provides food, water, and warmth to the survivors. The role of PSP is to set the stage for interventions in camps by other responders such as water sanitation, camp construction, and the clean up phase.

The American Red Cross PSP program has identified some social interventions, which can be instituted immediately after the disaster has stricken. Providing psychological first aid to the adult survivors. For children and adolescent the creation of a safe space for play, enabling formal and informal schooling, and involving community member of clean up activities and the beginning of finding “the sense of place” are identified in this realm.

Psychological support, in the form of psychological first aid, by teachers, healers and leaders and others in the community are extremely valuable. As time passes the operational training will have to be followed up, in the case of teachers, and community leaders with more formal activities. Each activity should include supervision. Each community and school should within the first six months post disaster have developed plans to take care of practical, medical and psychosocial needs in the event of a disaster.

Material development, staff development activities and the best delivery system will be defined together with the community and school. All activities must be culturally, linguistically, and technically appropriate, and should be reviewed by the community of survivors as well as the professional organizations of the country.

Having identified the challenges and opportunities and based on the existing standards, the American Red Cross made a practical decision to initiate programs in target schools and communities. The standards utilized was a combination of SPHERE, WHO, UNICEF, and INEE.  The table below presents behaviors that have been identified by the program as outcomes of the interventions, performance indicators, and impact indicators for communities and schools.

Table 3:  Table for behaviors to be supported by the PSP program with outputs and indicators

Behaviors that the program is going to reinforce	Performance Indicators	Impact indicators Community	Impact indicator School
Survivors participate in assessing, planning, and Implementing psychosocial support activities. Community resources are identified, mobilized and used to implement psychosocial support programs. Relevant and structured training on psychosocial support provided. Creative and expressive activities used to evaluate the psychosocial well-being. . Supervision and support mechanisms on a regular basis. Community activities take into account the psychosocial well-being.	Number of key decisions involving Survivors. List of community resources readily available and used in community reconstruction activities. Number of trained and re-certified teachers, community facilitators and Red Cross volunteers. Number of creative and expressive activities with participation of survivors. Evidence of supervision and follow-up training sessions. All community activities focus on psychosocial well-being.	Ensure that survival needs are met Return to work (Community members are active participants in their recovery and reconstruction). Normalize daily life (children go back to school, women to the chores at home and man back to work outside). Re-establish relationships among family and community members Religious and traditional ceremonies Family and community support work participate in planning for the future. Community human capital identified and engaged in the reconstruction of the community.	All school age children and adolescent return to school. Informal education is being conducted for community members and persons not in school. Play and recreation activities for all children. •School-based Psychosocial Support activities to include psychological first aid, self care, and information sharing with the families and community. •Drama, arts & cultural activities •Resilience activities

The table above looks at how the American Red Cross PSP program has made a practical decision to focus on communities and schools, to foster the identification of a “sense of place” by the community and school. The standard are a composite from SPHERE and INEE.  By using existing standards and developing activities well into the reconstruction phase, the ARC/PSP program serves as a resource to the target communities and schools while exploring new techniques of delivery based on existing standards. At the end of three years the evaluation of field activities will yield valuable information to generate a set of universal standards, indicators, and activities that lead to a systematization of psychosocial support as a core activity from immediate response to reconstruction after large disasters.

The community taking into account behaviors changes in all its members will measure the expected results of the suggested activities and expected outcomes. One way that the American Red Cross PSP program will be looking at these results by identifying five areas individual of sustainability.   It is expected that after three years the evaluation of the program will be able to identify these sustainability, and the resultant behavior changes in community members.

Table 4:  Table for Sustainability as a result of psychosocial support programs on survivors seeking to identify their “sense of place”

Area of sustainability	Behaviors associated with sustainability
Cultural sustainability	Sense of pride about cultural identity. Survivors have ways that encourage conversations and sharing stories, and information. Presentation of the community history in skits to all members
Ecological sustainability	Contribute to planting trees and shrubbery. Hydroponics farms in schools and communities. Participate in the establishment of outdoor seating, walking paths, visually appealing landscapes
Problem solving sustainability	Survivors experiment with new ideas and new cluster of ideas.   Survivors identify community problems, identify a solution and address the problems.    Survivors participate in information interaction with all community members
Human capital sustainability	Survivors identify economic opportunities in the community.  Survivors develop the necessary skills to become a resource to the community.
Solution oriented sustainability	Survivors try to understand the tsunami and its implications. • Younger survivors are encouraged to become creators of knowledge. • Survivors have a chance to create their own formal and  informal learning agenda. •  Teachers become guides, co-learners, and brokers of   community resources.

 

Summary and Conclusion

The American Red Cross has been engaged in the development of disaster mental health domestically and psychosocial support activities internationally for at least twenty-five years. The approaches have been tested in complex emergencies such as Kosovo, and in many disasters in the Americas and South Asia.  The framework has been identified and systematized. Currently the program is looking at the standards that have been set forth by international groups to make sure that any PSP program addresses the standards and surpass recommendations for quality services.

The one area that is still under preparation is how to conduct needs assessment that truly presents the needs of the survivors.  The suggestions that has been made by the field is that systematic assessment should be the norm, while administering psychological first aid for those in need.  A rapid assessment would tell us what is the magnitude of damage. The systematic assessment would give us suggestions from the community and survivors about what they need to feel resilient and to move forward.  Ethnographically informed quantitative measures will have to be generated for each community and each disaster to provide the information needed for planning, implementation, monitoring, and evaluation.

The coming years will make evidence based psychosocial support the norm. Only then will planners be able to determine unit of cost of providing culturally, linguistically and technically competent psychosocial support.

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