Wednesday, September 18, 2019

For Peer Review Only
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


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.


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.


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.


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. 

Psychosocial response to Las Casitas Volcano Mud Slides
November 5, 1998 to September 30, 1999
Chinandega, Nicaragua

Basic Information
·      Joseph O. Prewitt Diaz, PhD
·     Las Casitas Volcano-Mud Slides, October 30, 1998, Chinandega, Nicaragua, Central America
·      Affiliation: Disaster Mental Health Delegate- American Red Cross
·      Deployed from Puerto Rico where I was serving as DMH Coordinator in the Hurricane Georges Response and Recovery
·      Length of Involvement: 11 months

As I was growing up in a small town in Puerto Rico, my grandparents encouraged me to get involved in helping people after a storm, a fire, or a flood. My mother called this work “civic tithing.”  I carried this lesson with me into my post-secondary studies in the fields of religion and counseling, and my doctoral studies in Educational Psychology. 
Since 1990, with the establishment of the Disaster Mental Health function in the American Red Cross, I have served as volunteer and deployed at least twice a year. I served as an International Delegate for the American Red Cross International Services from 1999 to 2010. During this period, I responded to human-caused and natural disasters in three continents. I was awarded the American Psychological Association International Humanitarian Award in 2008.
When not involved in disaster response, I served as a professor at Penn State for 12 years. At the time of the call I was the Director of Psychological Services for the Chester-Upland School District.  On the day of the mudslides, I was serving as Disaster Mental Health Coordinator for Hurricane Georges in Puerto Rico.
The Pre-disaster Community 
The mudslides occurred in the Chinandega District of Nicaragua. New towns were built there after Nicaragua’s revolution (1979-1990); most of the population had relocated from the Atlantic side of the country.  The Nicaraguan government reported that approximately three-quarters of the population in the affected area came from the Autonomous Region of Nicaragua, comprising indigenous groups including Misquitus, Mayangnas, Ramas, and Garifunas. The two predominant languages among this population were Misquito, and Wiswis. They were by and large involved in agrarian tasks, and most lived in extreme poverty by Nicaraguan standards. 

The majority of the disaster-affected population was Catholic, while smaller groups were members of the four Apostolic Churches, and yet another group of healers and  “Espiritistas” were affiliated with the Yoruba tradition. There was an itinerant priest, and two local pastors in the community. Many impacted were farm workers whose only access to survival was the weekly acquisition of basic staples from the farm owners’ stores. The population lacked a public health system. Although there were visiting nurses, most health issues were dealt with by local healers. Issues of behavioral health were dealt with by local counselors or “espiritistas” (people who communicated with the spirits) and were able to cast spells to alleviate “evil eye.”   Most of the emergency services were provided by the Nicaragua Red Cross. 

The disaster 

On October 30, 1998, as Hurricane Mitch passed through the area, the excessive rainfall triggered a catastrophic landslide – a flank collapse of the Las Casita volcano. Las Casita is a complex and probably dormant volcano located 4,600 feet above sea level with a crater that is about one-half mile in diameter. The mud covered an area about 12 miles long and 1 ½ to 2 miles wide, on the southwest side of the volcano. The towns of Rolando Rodríguez and El Porvenir were the first to be hit by the mud, which continued to flow down the side of the volcano, destroying villages, settlements, houses, and farmland in its path. The municipality of Posoltega and the town of El Porvenir were completely destroyed.  

Approximately2,000 people were killed. Another 8,000 were displaced, of which 3,448 were housed in extended shelters. In terms of property damage, 653 homes, 10 schools, and the regional health center were destroyed. The affected area had lost its human, social, cultural, financial, and built capital.  Most of the agricultural lands, and thus the major source of employment, were lost, as were family and community heirlooms. The survival of the affected area was now dependent on external governmental and non-governmental stakeholders. 

Thoughts pre-response 

I was sitting at the Disaster Relief Operation for Hurricane Georges in San Juan, writing my final report, when I received a call from the Red Cross HQ. The voice on the other side wanted to know if I spoke Spanish and had an updated license and a passport. I answered in the affirmative, and the next sentence was “Well, we need you in Nicaragua.” I was then offered a one-year appointment to become an International Delegate to Nicaragua with primary disaster mental health duties.

For me personally, it meant going back home and dropping everything: taking a leave of absence from my job, putting my things in storage, and renting out my house. This phone call changed my life – what to do?

I was going to a country in Central America that had just been through a civil war, had a depressed economy, and where most of the population didn’t speak Spanish. I found out that mental health professionals were not readily available; there was one sole facility in the country that had a mental health clinic and ward. I was confronted with the possibility that every theory that I had read about, every practicum that I had experienced, and every consulting experience might be worthless in the setting where I was going to be deployed.

During my briefing, I was informed that I would have an experienced counterpart from the Spanish Red Cross (SRC) joining me. We would be working in tandem with the Nicaraguan Red Cross as external consultants. As my emotional reaction began to dissipate, I began to think about what we would do in the first 72 hours, in the first week, in the first month.  Of all stupid things, I wondered whether my blazer would be crushed in my bag, and what the people there would think of me.

Your response experiences 

I met my SRC colleague, a psychologist, who came with a lot of experience dealing with human-caused disasters in Africa. During the flight from Miami, we prepared a work plan. Our first order of business was to meet with the pertinent authorities in Managua and get our marching orders. We both agreed that once we reached the target site we would spend some time conducting an environmental assessment focusing on resources (human, social, environmental, and built). 

After two days in Managua and a three-hour jeep ride we finally arrived in Chinadega on November 5, 1998. We were assigned a “champa” (a blue tarp with sides in a central area reserved for responders). We were to be deployed for at least 10 months to support the immediate response and early recovery. We then began our tour of the five shelter sites: Los Tololares, El Tranon, Betesda, El Bosque, and Santa Maria-El Tanque. The sites seemed to have been established where they would have greater access to roads, communication, public and health services, electricity, and educational opportunities. 

We held small focus group meetings. Our objective was to identify the elders, healers, and counselors in the community. We then appointed individuals, who we referred to as community facilitators, whose primary role would be to mobilize the members of the shelter site. Each shelter site had up to five community facilitators who were trusted by their immediate neighborhood group and were the bridge to external stakeholders. These personnel received a 32-hour operational training that included the following topics: (1) community mapping, (2) needs assessment, (3) non-verbal communications (4) listening skills, (5) psychological first aid, and (6) simple psychoeducation strategies. Our expectation was that each community facilitator would be respectful, sensitive to the need of each community group within the shelter sites, aware of and sensitive to cultural and traditional boundaries, and willing to learn from what the established elders wanted to share. 

To address organizational issues, we asked for a planning meeting with all of the organizations that were working with the affected population in order to get to know each other, develop a service map, and foster a harmonious environment. We were not trying to bring proposals from different groups to the table, but rather to create an environment of reflection focused on the theme of rebuilding a safe and healthy community. By the fourth day we had a community service map with five sites, and a schedule of who would be in each site and what activity they would be undertaking. As we completed the preliminary community assessment there were 22 non-governmental organizations providing some type of mental health and psychosocial support. The Ministry of Health took over the responsibility of keeping administrative control of the recovery process. 

There were at least two immediate challenges regarding survivors’ mental health. First, there were referral needs, but nowhere to refer survivors with pre-existing mental health issues. Second, while well-intentioned, local organizations’ efforts were short-lived, usually only lasting one to two days or through a weekend clinic. 

We spent a good part of the first month meeting with survivors and in groups with helpers who were emotionally overwhelmed with the nature of the disaster. We used psychological first aid, emotional defusing tools and activities, and referrals to the Military Hospital in Managua (some three hours away). By the second month we found that the population of helpers had reduced significantly. Thus, we recruited a cadre of local volunteers, and initiated an operational training that included psychological first aid, community assessment, and the use of locally developed tools in the form of brochures (“Share your Feelings”), posters, and community plays (a simplified version of psycho-drama). The basic messages were: rest, eat, talk, recreate in groups, and work together. We addressed two basic sets of feelings: (1) survivors’ feelings of loss, grief, and fear; and (2) expectations for the future. We assumed that the mudslides caused a temporary state of emotional upheaval where the majority of the people would cope in a healthy and normal fashion. Providing a space where the disaster-affected people were able to talk about their response, to recreate, rest, and work together would set them on the road to recovery.  

We also had to consider the emotional needs of the helpers. Over the course of two months, over 100 spontaneous responders showed up at the recovery sites. Most of these people came from the capital in small brigades. They were not prepared to experience what they saw. They lacked the language skills to communicate with the affected people and thus they experienced both guilt and compassion fatigue. My colleague met with these day-volunteer groups as they were leaving and assisted them by conducting informal debriefings. One of the problems that emerged was that many of the spontaneous volunteers saw the disaster as an opportunity to show up for meals with small groups of survivors, to get rid of old clothing, to proselytize a religious belief, and in some cases to offer to hire young girl as house servant in their homes in Managua. The matter was reported to the personnel of the Ministry of Health; many of these groups left, never to return. 

In the third and fourth weeks two medical brigades from the U.S. Navy and the Honduran Army provided assistance. They attended to health needs, and dispensed vitamins, antibiotics, creams for mosquito bites, and some anti-anxiety medication and sleeping pills. Several weeks after they left there was an underground market of un-prescribed medication in the sites. Red Cross was informed about this situation by the Ministry of Health dispensary staff.  We immediately began a campaign of psychoeducation on the effects of non-prescribed medication in all the sites.

We organized a numberof focused activities to meet specific groups’ needs. One involved creating safe spaces for children. The teachers and caretakers were women or men who had lost limbs and couldn’t work in the fields, or in carpentry or road construction. This became a much-celebrated activity in the area. People who had thought that their life was through were now called “professor” by the children and parents alike. In conjunction with the World Health Organization, we organized a project called “Return to Happiness” where small groups of children wrote, drew, and acted out their stories, and small groups formed teams and played. 

We also created safe spaces for community groups. One was for people who had lost limbs and were now adjusting to a new lifestyle. Another group was composed of widows and widowers and their respective families. The identified problem was that this population was dedicating all their time to helping family members adjust to the losses rather than addressing their own needs. We funded a Fun Day for this group, including a discussion about missing a significant other and letting go. They would have lunch and then some space to reflect and talk about their feelings, and at the end of the afternoon everyone would draw or compose a letter to the lost loved one which was then sent either in a balloon or through fire to their dear one in heaven. These “encuentros” (encounters) became very popular among adults in that it allowed them to share their feelings openly and normalized their “new normal” in the emerging communities. 
We paid a great deal of attention to the importance of spirituality in the recovery process. 
Survivors struggled with difficult questions such as “why am I alive,” or “why did I lose my dear ones, property, and source of work?” We were able to help them address these issues through the different religious groups and the Yoruba tradition best represented by Santeria, Orswha and Candonble practices. This was an essential task for us: The sooner we could contact elders, healers, and cultural counselors, the sooner we could begin providing support activities. 

We had a request for a tarp where the Catholic Church could hold mass during Christian holidays. The Apostolic pastors protested, and as a result, we all agreed to the construction of a large tarp that would be used at different times of the week for different religious experiences. The Yoruba followers would hold their meetings in their residential tarps; the focus was to communicate with the spirit of lost loved one. 

One essential part of our entire response was working to augment mental health and psychosocial support through local personnel. We needed to multiply the trained local community facilitators so that they could use simple tools to alleviate fear and foster resilience. Most of the tools for training were locally developed with the advice of the elders and counselors. The training was composed of assessment and community mapping; Psychological First Aid; and psychoeducation.

For the assessment and mapping, common reactions to the disaster were elicited from community elders representing each of the language and cultural groups. The community facilitators elicited information about what situations were causing stress; was there a local name for the problem; how does it manifest itself, what causes it, and who gets it; how is it treated and how effective is the treatment; and how can the problem be avoided. 
PFA was described as a first order intervention designed to reduce disaster related stress. Our model consisted of five steps: (1) intervene immediately; (2) listen, and respond with words that provide a sense of hope; (3) validate the person’s feelings (encourage the affected person to begin to identify a personal strategy to move forward; (4) plan for next steps, and (5) refer to existing community network.

Three non-verbal psychoeducationaltools were developed and used in Las Casitas. Each tool consisted of five parts so that the participants could use their fingers as a learning aide. The first, “Share your feeling,” was a pictorial trifold with five basic suggestions: talk to your friends, eat, rest, recreate and play sports, and work with your friends. The second tool was a pictorial trifold for “Psychological First Aid.” The five components were PIES interventions (proximity, immediate, experiential, and simple);, listen, validate feelings, plan, and refer to community support group. The third tool was a six-page booklet used for planning small community resilience-building activities.

The methodology used in the training sessions was participative and interactive, with more emphasis on brainstorming, group work, role-plays, and the workshop method rather than lectures and presentations. This encouraged discussion and led to interaction between participants on the one hand, and with the facilitator and the community on the other. Each group made a list of psychosocial supports and self-care activities, as well as the mechanics of organizing group meetings and community activities. 
Building on those initial capacity-building activities, my colleague and I identified the most advanced of our community volunteers, government community aides, and some of the community facilitators and began a course for mental health technicians. The focus of the two-week course was to help people understand the loss of place and how to develop a psychosocial recovery plan through community initiatives and participatory techniques. We trained a group of 20 technicians who could conduct participatory assessment, engage specific marginalized and vulnerable community groups, organize community activities that improved emotional well-being, and engage community members in “resilience enhancement brigades.” Three months later we opened a course for community mental health specialists who had a basic professional degree (teachers, nurses, psychologist, social worker). These personnel were trained in PFA, stress management and self-care techniques, non-verbal communication, and resilience development with diverse sectors of the communities. Seventeen people graduated and were left in charge of the psychosocial support program in Las Casitas as we completed our assignment ten months later. The role of the specialist was to involve the affected people in a process that is controlled by them, and responds to the resources and needs of the community. With time, this process improved community mental health using strategies selected by the people. 

Our final psychosocial capacity building initiative involved creating a “resilience support brigade” composed of affected people who provided cultural, linguistic, and contextual competence by identifying human and social capital among the affected people. They worked with members of the Nicaraguan Red Cross who provided management, administration, and technical support to the program. This cadre conducted rapid environmental assessments, reunited loved ones into specific camps, conducted small group activities to facilitate sharing of feelings, conducted recreation activities for diverse community groups, and organized and funded resilience projects in the community.
Post-response adjustment

It is always difficult to adjust to the back-home scene after working in a major disaster. The most difficult thing for me is to share the sights, sounds, and action during the disaster with people back home so that it doesn’t sound like a series of scenes from a horror movie. One thing that helps quite a bit is taking time off to do something different. I try to take breaks during the day, and take every third day off, away from work.  

I try to switch channels to the home front – to understand what happened to the relationships that were left behind. It’s like you will never be the same, but the people that are around you have also had their experiences and will never be same as you left them. I feel like I must re-construct my physical and emotional center every time I return from a disaster experience.  
Probably the most important thing I do is to keep a diary. I use my daily reports to reflect back on my own feelings, what I learned, and how I would do things differently. I check myself so that my role as a technical assistant doesn’t get intertwined with the population I am serving, in this case the Nicaraguan Red Cross. It’s kind of difficult to be in the recovery site, share meals and living accommodation with the affected people, and not get personally involved with the situation, the people, and my knowledge of the steps that need to take place to achieve the goals of community-based psychosocial support. 

Lessons learned

·     Factor in a gestation period before jumping into response activities. My role was as an external technical advisor, not a direct provider to the affected people, although I was living in the field with the Nicaragua Red Cross personnel. It was important to conduct an environmental assessment to figure out population, including diversity in culture, language context, age, and marginalized groups. It’s also important to figure out your team’s strengths and weaknesses: How people learn, common cultural manifestation, diverse problem solving skills, and solution focused approaches. More importantly, what is expected of you as mental health workers? Define your operational parameters. 

·     Tailor the psychosocial response to the specific disaster. Identify social, human and political capital. Identify strategies and activities to provide multi-dimensional psychosocial care that is considered appropriate by the diverse community groups (ethnic, cultural, social) of affected people and that also meet national and international standards. 

·     In your immediate response plan and moving forward into recovery, identify and proactively address barriers in access to care. But also recognize the social dimensions and sources of resilience, including utilizing community elders, healers, and religious leaders as your allies in developing a service plan that is appropriate for the whole community.

·     Coordinate and integrate disaster response services into the country’s mental health response plan, and where possible integrate the World Health Organization and other international groups that advocate for mental health services, psychosocial support, the protection of women and children, and the reduction of stigma toward those considered different and “less-than” in the affected area.