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Psychosocial Support: A tool for empowering communities in Puerto Rico after a catastrophic event 

Joseph O. Prewitt Diaz, PhD

CEO, Center for Psychosocial Support Solutions

Alexandria, VA

Abstract

Puerto Rico was affected by Hurricane Maria in September 2017, and today, hundreds of thousand of people are experiencing fear, panic attacks, anxiety and night terrors. All related to the Hurricane. The paper proposes a community based psychosocial support structure that may be integrated into the National Disaster Response plan of Puerto Rico.

Introduction

On September 20, 2017 Hurricane Maria, the strongest hurricane to hit Puerto Rico in almost a century, struck the Island of Puerto Rico as a Category 4 hurricane with winds upwards of 150 miles per hour. For thirty-six hours the Hurricane crossed through the center of the town of Yabucoa in the north eastern part of the island exiting through the northwest near the town of Hatillo. Heavy winds, rains of up to 32 inches, and mudslides left the Island without electricity, potable water, access to health facilities and communication within and outside of the island. Four months later the recovery process is slowly reaching the towns located in the swath of destruction left by the Hurricane (1). 

A potential program that may assist people affected by a disaster is community based psychosocial support that impacts individuals, families, the affected community, and the larger community (2). Community based psychosocial support is based on three principles: (a) of providing safety and security (b) the importance altruistic behavior of psychological, social and spiritual tithing, and (c) the importance of speaking truth to power to support the underrepresented (3).

At an individual level, the program encourages people affected by a disaster to modify behaviors that reflect helplessness and hopelessness and to use community activities to adapt behaviors that lead to the production of greater personal effectiveness. Once the affected people begin to feel a sense of freedom and enhanced capacity to move forward as a result of their new behaviors, they will be encouraged to identify a group of peers that can assess their community’s needs and assets and collaboratively plan and implement contextualized recovery activities (4).

A community engagement process to involve the community was suggested (5,6).  The following six steps were used: (A) Assessing needs and existing assets, (B) Developing a shared vision, (C) Collaborative planning and action, (D) Networking for external resources, (E) the Outputs, and (F) the Impacts.

A.  Assessing needs and existing assets

In this stage, community volunteers are identified, and basic training is conducted over topics of psychological first aid, participatory functional assessment (Bolton & Tang, 2002), and community mapping that includes social capital as well as infrastructure. The premise for this activity is that people affected by disaster have first-hand knowledge of what their community looked like prior to the disaster, what has happened in their community, and what should take place to recover and enhance resilience.

B.   Developing a Shared Vision

In the initial phase, affected people were encouraged to (a) identify what activities inspire participation in all segments of the community, (b) sharing experiences, stories and traditions pertaining to how community crisis was dealt with in the past and (c) envision a future so that they may overcome the initial feelings of hopelessness and helplessness. Residents in disaster areas take an active role in the identification and analysis of needs, project development, and decision-making based on their priorities and vision for their future.

C.   Collaborative Planning and Action

(i)            Articulating strategies

In this stage, community members are encouraged to become engaged in activities that will foster their growth in an inclusive way. These activities may include but are not limited to the following: (1) provision of accurate and timely information about resources, services, and common reactions; (2) provision of human capital by the victims in the community; (3) provision of materials, cash, and labor by community residents in disaster zones and provision of technical assistance by outside stakeholders, or (4) independent action by the community residents, not external sources.

D.  Once the broad strategies have been identified, the interventions are then tested. This is the time to experiment with activities and identify the best match between disaster-affected people and the appropriate broad strategies. For example, some people will engage in sharing information, while others will want to construct. Still, others will implement psychological first aid, whereas others will conduct informal educational sessions for youth.

E.   When planning the initial interventions, the residents in disaster areas must cycle through the following five core interventions in a community based psychosocial support program: (a) providing accurate and timely information, (b) engaging in formal and informal educational experiences, (c) identifying and enhancing support and resources, (d) increasing access for all the community population, (e) monitoring, and (f) reporting.

After the initial response, the disaster affected people will be busy with initial and long term recovery of their respective places and communities. The two settings where most of the activities will occur are the community and the school. At the community level, activities include improving the environment and reconstructing places. In the schools, the efforts focus on re-establishing formal schooling for children and adolescents and conducting informal school activities for youth and adults in the community. The emphasis in this stage is getting everyone engaged in long term recovery. All projects are considered and supported by the coordinating committee, which is composed of community residents. Eventually, social capital is identified, and small communitywide projects and income generating activities can begin, and develop in conjuction with the recovery process planned by the community.

Usually, psychosocial support activities serve as a platform for additional activities that are more concrete in nature. This is a good time to initiate the documentation of the steps that community engagement in the recovery of their neighborhoods; in other words, the specific actions that have been taken are documented, and the changes led by the community residents are recorded. The adaptations made by the residents in order to settle into the new community life, the institutionalization of changes, and the capacity building activities are monitored and reported to the diverse groups in the community as signs of success and the ability to enhance resilience and well-being.

F.   Networking with external resources

Usually, the community participatory process introduces needs that had not been identified or that had not been addressed for a lack of community capital. Part of the planning process is to bring to the fore the needs of “all” segments of the community. Once it is clear that external resources, technical, financial and psychosocial are needed to promote the re-construction of  place through recovery activities, it is important for community members to approach external stakeholders and develop coalitions that will provide for the community’s ultimate goals to rebuild itself. This may include people having a home to share with their family, neighbors and community. People feel safe when they walk around the community, and are desirous to give volunteer time to improve the “place”. One area that external funds, and university research projects may help is to assist the community to rebuild itself psychologically and spiritually through the recovery of their history, community stories, and the past. Networking with the outsiders may be a way to understand where people came from, where they are now and where they see themselves moving forward.

G.  Outputs

The steps in the process to re-establish “ a sense of place” and develop the community do not occur in a neat, sequential manner. Important actions occur in sequences that are specific to the situation. If a community is able to successfully bring about changes, their capacity to create even more community changes related to the group’s mission should improve. Among the important outputs is the generation of trust to the extent where the community shares common risks and protective factors. Multiple communities can formulate a partnership to elicit funds from an external stakeholder in order to realize new community changes and desired outcomes.

Different initiatives may work well to foster growth in one disaster-affected community than another; thus, remaining flexible in the adoption of interventions is crucial. This ensures the creation of an approach that “belongs” to community members and has been modified to fit community needs. Moreover, by changing interventions to fit local needs, community members can improve their ability to take care of their own problems.

H.  Impact

A method for field personnel to follow up on the community re-establishment of place and to determine the effectiveness of the steps toward resilience is to assist the affected communities to identify the tools that they are going to use to follow the effectiveness of their process of recovery. Some of the perceptions of the community members may be that a sense of place has been re-established, resilience has been enhanced, and community well-being is on the rise, and that small businesses are back on line. This can be accomplished by developing a score card that may include information about community mobilization; willingness to share information with all segments of the community; ability to gather information, develop, and execute recovery plans; passion for immediate community action; and a desire to share their achievements. Ultimately, these programs should help residents in disaster areas to transform from victims to victors

Essential Components for a long term institutionalized recovery psychosocial support response 

In order for a community based psychosocial support program to be effective in Puerto Rico, we suggest it follows that the following steps be taken to include psychosocial support in the Puerto Rico National Response Plan (7,8) . 

A.  Psychosocial support is integrated in the National Emergency Plan.  Psychosocial support should be integrated into disaster preparedness and contingency planning. Capacity building workshops and quarterly drills should be considered, and all stakeholders and resources should be identified and listed 

B.   A Lead agency is appointed. One of the Government entities should be appointed to lead both mental health and psychosocial support response. Response should be cleared at the Central level before implementing at the lowest level, the community.

C.   Collaboration. Collaboration amongst all government entities is encouraged with a clear chain of command and responsibility for mental health and psychosocial support. The Lead government agency will be responsible for developing a plan and determining coordination mechanisms and responsibilities in consultation with stakeholders at the senior and community levels with a clear chain of command  to the municipal level,  and earmarked responsibility for psychosocial support emergency response. 

D.   Technical material should be developed and widely disseminated.  For use by government and non-government partners in all municipalities in Puerto Rico. If English language materials are going to be used, they should be translated to Spanish, and culturally and contextually validated and shelf ready to be used immediately.  Availability and dissemination of guidelines and psychosocial support intervention manuals for mental health professionals working in the community in private offices, Community Hospitals, general level health staff (doctors, nurses, and community health workers, and local volunteers).  Materials should be disseminated to human resources outside of the health field (teachers, religious leaders, volunteers). General documentation and guidance for media, general public focusing on psychosocial support issues, coping, sources of support, and available care. Guidelines for caring of children, the disabled, the disadvantaged and the elderly.  Guidelines for family tracing, reunification and child abuse, and gender based violence.

Summary

This paper introduces the psychosocial effect of Hurricane Maria in Puerto Rico related to the effect of Hurricane Maria in the Puerto Rican population. It proposes community based psychosocial support as a tool for immediate response and recovery. The paper also offers suggestions  for the development of wide encompassing plans to institutionalize psychosocial support in the Puerto Rico National Response  Plan.

References

1.    Conelly Holmes, R. (2017). Is been 10 weeks since Hurricane Maria hit Puerto Rico. Here’s where recovery stands. Washington, D.C., USA: PBS/WETA. 

2.    Prewitt Diaz, J.O. (2017). Hurricane Maria, personal and collective suffering, and psychosocial support as a cross-cutting intervention. J Trop Psychol, 7, 1-7. 

3.    Prewitt Diaz, J. O. (2018).  Individual and Community Psychosocial Support in the Immediate Response and Early Recovery of Hurricane Maria International Journal of Emergency Mental Health and Human Resilience,Vol.20, No. 1, pp 1-8 

4.    Prewitt Diaz, J.O. (2013). Community based psychosocial support: an overview. In Arora, R. & Arora, R. (Eds.) Disaster Management: Medical preparedness, response and homeland security. Boston, MA: CABI

5.    Silva Caraballo, F. (2017). Intervention of In CiCo in community response and recovery initiatives before the effects of Hurricane Maria on the Island of Puerto Rico. Trujillo Alto, PR: Institute of Sciences for the Conservation of Puerto Rico. Evaluative Report. 

6.    Inter-Agency Standing Committee (IASC). (2017). A common monitoring and evaluation framework for Mental Health and Psychosocial support in emergencies. Geneva: IASC, Reference Group for Mental Health and Psychosocial Support in Emergency Settings.

7.    MHPSS. (2010). Mental Health and Psychosocial Support in Humanitarian Emergencies: What should humanitarian health actors should know? Geneva, Switzerland: IASC Reference Group for Mental Health and Psychosocial Support in Emergency Settings, Interagency Standing Committee.