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Psychosocial Support: An overview

Psychosocial support: An overview of a program to enhance resilience and improve well-being in disaster-affected people
Joseph O. Prewitt Diaz1

. Dr. Prewitt Diaz is a humanitarian Psychologist with over 30 years of experience in community based psychosocial programs in disasters. He served as the Senior Advisor for Psychosocial Support for the American Red Cross during the 2004 South Asia Tsunami, and developed a program that served over 750,00 beneficiaries. Currently Director of the Disaster Law Center and Visiting Professor at the School of Law, University of Puerto Rico. He is the recipient of the 2008 APA International Humanitarian Award.

Psychosocial support: An overview of a program to enhance resilience and improve well-being in disaster-affected people

This paper discusses how a community based psychosocial support program increases participation of disaster-affected people in their reconstruction as a result of an improvement in their psychosocial well-being. The article is divided into three parts: (1) the early beginning of community initiative and civic engagement approach called VESPRA, (2) the systematization of the model into a community based psychosocial support approach and (3) a practical application of the model in a real disaster. The paper concludes that the development of a theoretical and practical model called VESPRA, the systematization of that model into a community based psychosocial support approach and an the application of such an approach enhanced the psychosocial well being of disaster affected people.

Key Words: psychosocial support, resilience, well-being, disaster affected people

Psychosocial support: An overview of a program to enhance resilience and improve wellbeing in disaster affected people Introduction
Psychosocial support has been identified as a positive tool to alleviate suffering of disaster-affected people, enhance resiliency and foster psychosocial well-being (Hobfoll et al. 2007; Prewitt Diaz 2010). This paper provides a historical overview of community based psychosocial support (CBPSP), proposes a model of the sector as a platform to foster community resilience and enhance well-being, and concludes with an operational community based psychosocial support program.

I. Emergence of community initiatives and civic engagement

In early 1965, psychosocial support was chosen as a viable strategy for community development in Puerto Rico, through a group that called itself VESPRA (Voluntarios en Servicio a Puerto Rico en Accin) (Pond, 1968). VESPRA was a

community program that used principles of psychology, participatory actions, and voluntarism to re-establish sense of place and improves well-being among target communities. The methodology evolved rapidly to a systematized approach better known today as community based psychosocial support (American Red Cross, 2002). This model has been successfully used as a disaster response tool (See SPHERE, 2011, pp. 14-77). Three principal theories were used in the formulation of the VESPRA psychosocial support program: (1) Client centered and non-directive theory used to work closely with the community (Rogers, 1951: Rogers, 1961); (2) the introduction of

4 therapeutic communities (Jones 1962), and (3) the use of group therapy as a model that focused on the promotion of well being in community groups (Slavson, 1962). This non-directive method permitted assessment to be carried out where the neighbors expressed themselves and were inspired to believe that there future was in their hands, their actions led to improved lifestyle and the community was improved (Bolton & Tang, 2002) . The volunteers established relationship with community members in a supportive environment where the volunteer and community member saw themselves as equals. The volunteer was not perceived as an outsider, and the community members were perceived as inherently good, and therefore should be encouraged and supported to achieve their full potentials. By assuming responsibility for their own actions, community members became resilient, moved forward, grew, and achieve their full potential, thus achieving a sense of well being. Through common activities, community members tended to be concerned for one-another, behave in an honest, dependable and constructive manner. The first strategy used from the 60s was small group training sessions. Basic to VESPRA training and field operations is the small group of peers. VESPRA basic tool for training, and community groups was the T-group pioneered by Kurt Lewin (18901941) and researchers in the National Training Laboratories in Washington. The group methodology was used in an eclectic fashion by many different trainers and community settings. The results of the theories developed by Rogers were gauged by improved selfesteem, reported increase in trust in ones inner feelings, and the experiences as valuable sources of information for decision making; increased ability to learn from experiences and not make mistakes, and more positive and comfortable relationships

5 with others. In a recent meeting former volunteers sharing their VESPRA experience of their 70s and 80s reported that the training had increased their capacity to experience and express feelings at the moment they occurred, and an openness to new experiences and new ways of thinking about life. They felt that they were more resilient and attributed their current success to their volunteer experience. A second strategy adopted from the 60s was the consideration of the community as a therapeutic environment. Jones (1962) introduced into the field of social psychiatry the use of groups in communities, hospitals and prisons. The Therapeutic Community offers a safe environment with a clear structure of boundaries and expectations where members have the opportunity to come to terms with their past through re-enactment within a treatment setting involving other members and staff. Therapeutic communities offered the individual experiences to awaken creative and social abilities. Members tend to learn much through the routine interactions of daily life and the experience of being therapeutic for each other. Through the strategy of therapeutic community, the aim is to encourage members towards a better understanding of their previous behavior and to enable them to improve their inter-personal functioning, first within the therapeutic community and ultimately in the wider community. Encouraging and reinforcing the notion of personal responsibility and sharing, members and staff meet together on a regular basis to discuss the management and activities of the community. Understanding mechanisms of action in group psychotherapy was beneficial for the growth of the group. During training sessions, the facilitator, recognize that the success of individual group members is intimately linked to the overall health and well being of the group-as-a-whole. Indeed, a sizable portion of the clinical and empirical literature delineates therapeutic factors and mechanisms that have been linked with

6 healthy well-functioning therapy groups. Mechanisms of action are interventions that are considered to be causal agents that mediate client improvement. These mechanisms take many forms, including experiential, behavioral and cognitive interventions. VESPRA started out with the premise that human beings are responsible for themselves. Human beings have the legal and social responsibility to make decisions affecting their behavior and impacting their future. The goal was to confront the poor with this reality, and it gave the poor the tools of group motivation to begin the process of changing their traditional responses toward their internal and external environment. The program addressed the following social and psychological needs: 1. In the individual: Thee technique encouraged disaster

affected members to change their own attitudes of helplessness and dependence. The disaster-affected people are encouraged to test out new modes of behavior that lead to produce greater personal effectiveness. Once the community members have begun to feel a sense of freedom, and capacity springing from their own behavior, the disaster affected people are encouraged to join a group and conduct assessments in their communities to search out and assist other community members who felt the same way. 2. In the family: The disaster affected families are encouraged

to engage in community activities that will increase the security in which children and adolescents can develop and family solidarity can become more of a reality, not only an ideal, day care center for children of working mothers, recreational programs of all sorts, neighborhood health promotion organizations, evening vocational training classes for adults and adolescents are some of the most common projects that were

7 implemented during the first ten years. Especially important is developing protected and secure environments where the weaker members of the community could develop themselves become resilient. Once family members identify an interest of fostering community growth, then all the disaster-affected families can come together and progress toward collective well-being. 3. In the community: Develop, with community organizations

that will learn to function effectively in solving identified problems of the neighborhood/place which can be tackled by the people themselves using the community human capital, without outside assistance. At the same time, work to establish a place/neighborhood that can represent the disaster affected people in confronting outside stakeholders. 4. In the larger community. Identify the social capital

available outside the place that might be brought to bear on the social, environmental and psychological needs of the community. The one benefit in this four-pronged approach was that in building the capacity of the community members to care for themselves and all other neighbors, to train themselves in leadership skills and to involve all the members in self-help solutions to the internal situations and community problems, produces a feeling of resilience and well-being that breaks barriers and reduces the outside society efforts to isolate, suppress, and exploit the disaster-affected people. In the next forty years the program evolved into a community and school based psychosocial support program that was adopted in Central and South America and Asia during major disasters.

II. From community initiatives through VESPRA to community based psychosocial support

In 1998, with Hurricane Mitch hitting the Central American countries and causing thousands of deaths, loss of properties in the millions of dollars and extensive human suffering, a psychosocial support model was developed following the VESPRA model. This model required a minimum amount of per person cost, and was potentially a mechanism to empower the community to organize, protect and reconstruct itself. This model was unlike standard models of aid giveaway programs. The evolution of psychosocial support programs has corresponded with the increasing severity of disasters and the emergence of international guidelines (SPHERE Project 2011, IASC/MHPSS, 2007). The American Red International Services adopted the proposal of developing psychosocial support programs and generated draft guidelines to systematize the program within the repertoire of disaster response options (American Red Cross, 2002). In Posoltega, Nicaragua (1998), the psychosocial support program coordinated the response of 21 local Non Government Organizations (NGOs) to a major mudslide that killed over 2,000 people and left over 13,000 injured (Prewitt Diaz & Saballos Ramirez, 2000). Lessons learned as a result of this experience focused on types of intervention and early coordination among stakeholders. In another major disaster, i.e. the El Salvador earthquake (2001), the psychosocial support program-focused on developing an immediate psychosocial response mechanism and psychological first aid was used as a tool during the relief and response period (Jaquemet, 2001). In 2003, the Indian Red Cross Society (IRCS) and the American Red Cross defined the psychosocial personnel needs during a disaster and designed a course of study for technicians, specialists, and professionals

9 (Prewitt Diaz, Srinivasa Murthy & Lakshminarayana, 2004). By 2004, the Indian personnel had developed a systematized approach for community based psychosocial support that included group training; community participatory assessment, staff development (from the community to the University), and monitoring and evaluation mechanism have been developed. Community based psychosocial support was implanted in parts and as an integrated model during the 2004 tsunami by the American Red Cross International Services. The figure below introduces a schematic of an integrated model, where psychosocial support is used as a platform to initiate community response immediately after a disaster. The integrated program is a follow-up to the guidance proposed by the Health Standard of the SPHERE Project (2004, p.197-199), and the request from the funding agency to utilize the project cycle methodology to plan and develop the program.





10 The goal of community based psychosocial support program to Improve the capacity of the community so that it becomes Physically, mentally healthier and become a better-prepared community. There are six steps in the process of engaging the community in the project development: (1) assessment and planning, (2) articulating the strategies, (3) defining the interventions, (4) community engaging in small projects to identify the interest of existing human capital, (5) the outputs, and the (6) impacts. Assessment and planning Community volunteers are identified and a basic training is conducted in topics of psychological first aid, participatory assessment and community mapping. The premise for this activity is that disaster affected people know best 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. The activities during this initial phase are to encourage disaster affected people to be active in identifying what activities provides participation to all segments of the community, look forward so that they may overcome the initial feelings of hopelessness and helplessness, and by taking action steps, plan projects that will shift the power dynamics and foster resilience. The disaster affected people take an active role in the identification and analysis of needs, project development and decision-making about their priorities and the vision about their future. Articulating strategies Community members are encouraged to become engaged in activities that will foster their growth in an inclusive way. These activities may include, and are not limited to, (1) providing accurate and timely information about resources, services, and common reactions, (2) the disaster affected people provide human capital, (3) the disaster

11 affected people provide materials, cash and labor, while technical assistance is provided by outside stakeholders, or (4) the disaster affected people may act independently from external sources. Defining Interventions Once the broad strategies have been identified then the interventions are tried out. This is time to experiment with activities and identify the best match between disaster-affected people and the broad strategies. For example some people will engage in sharing information, others will want to construct, others do psychological first aid, and yet others conduct informal educational session for youth. In planning the initial interventions the disaster-affected people have to cycle through five core interventions of a community based psychosocial support program. These interventions are: (1) providing accurate and timely information, (2) formal and informal educational experiences, (3) identifying and enhancing support and resources, (4) increasing access for all the community population, and (5) monitoring and reporting.

Community and school activities

The initial response has been initiated the disaster affected people are busy in the rehabilitation and reconstruction of their respective places and communities. The two settings in which most of the activities will occur are the community and school. At the community level activities include improving the environment and reconstructing place. In the schools, the efforts are in re-establishing formal schooling for children and adolescent and in conducting informal schooling activities for youth and adults in the community. The emphasis is on getting everyone engaged in reconstruction. All

12 projects are considered and supported by the coordinating committee of the disasteraffected people. Eventually the social capital is identified, and small community-wide projects, and income generating activities get on their way. Usually psychosocial support activities serve as the platform for other more concrete projects. This is a good time to initiate to document community engagement in its rehabilitation and reconstruction, specific actions taken are documented, and change by the disaster affected people are recorded. The adaptation of the disaster affected people into the new community life, institutionalization of changes, and capacity building are monitored and reported as a success toward enhancing resilience and well-being. Outputs Re-establishment of place and community development dont occur in a neat sequential manner. Important actions occur according 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 that trust is generated to the point where the community works in shared common risks and protective factors. More than one community formulate a partnership to elicit funds from an outside stakeholder may be related to new community changes and desired outcomes.

Different initiatives may work well in the disaster-affected community and foster growth thus the importance of being flexible in adapting interventions. This

13 creates an approach that "belongs" to community members, has been modified to fit community needs, and through changing interventions to fit local needs, community members improve their ability to take care of their own problems.


The impact of a community based psychosocial support program can be measured by the amount of involvement of the disaster affected people in the reconstruction activities, the development of trust in thee actions of all segments of the community, and the desire to volunteers to achieve well being for the total community. Re-establishment of place as measured by sharing of cultural activities, problem solving, solution-focused activities, identification of social capital, and care for the environment is a second impact. The third impact is an increase of physical and emotional well being amongst the disaster-affected people.

III. An operational Community Based Psychosocial Support Program (CBPSP) model

This section presents a case study of an actual project that was implemented in Sri Lanka after the 2004 tsunami. It explains the school and community-based interventions. These types of activities were used throughout this program in order to facilitate the involvement of the whole community of disaster-affected people including elderly, physically handicapped, widows and children in its recovery process. The activities were geared to assist the survivors to rediscover their psychosocial well-being by enhancing their own protective factors. All the activities were planned, executed,

14 monitored and evaluated by the community members along with personnel from a local Non-Government Organization to ensure that they are culturally appropriate and sustainable. An external stakeholder provided financial and technical assistance to conduct interventions in target communities and schools. Not everyone felt comfortable expressing him or herself verbally after the tsunami. Creative and expressive activities such as story telling, art and crafts provided creative ways for disaster-affected people, often children or older members of the community, to communicate their feelings. Community based skits and story telling proved to be a powerful and effective way of venting feelings; its a simple healing process with enjoyment and togetherness. These types of activities were used in both the school and community focused activities to facilitate expression of feelings, to reduce distress and to enhance a sense of belonging. They provided a conduit for disaster-affected people to have a sense of place by: (1) accepting responsibility for their place (village or community), (2) developing a knowledge base about their physical, psychological, social and human village, (3) living in the place and enjoying the available facilities, (4) mapping the place, (5) building the physical infrastructure of the place, and (6) taking action to preserve the place. The project goal was to: Enhance resilience through a

community based psychosocial support program (CBPSP).

The following objectives and activities supported the development of the project.

Objective 1: Promote psychological and social well-being of the community through schools
Resilient Schools In order to recognize and enhance resilience in the school community the program facilitated psychosocial activities in target schools. The objective of these

15 activities was to involve the school community in creating a Happy School. A Happy School is defined as a school building that is secure provides space for dialogue between teachers and students, and where students were encouraged to become actively engaged in all activities. Eventually, the activities were channeled towards preparing the school to face a crisis, emergency or disaster. The skills of the students, teachers and volunteers were enhanced to develop a School Crisis Response Plan, with the help of school mapping and formation of four school committees composed by students, teachers, other school personnel and parents. During the first year and a half of the program the Resilient Schools program was implemented fifty-one schools in target districts. This model was replicated during the second half of the program. Each participating school received three school chests, one recreational kit, and one large first aid kit per classroom per year, one individual first aid kit per student, and financial support for two school resilience activities and six student-parent activities per year. Model Schools During their third, year of teacher training, pre-service teachers are paired with an inservice teacher, generally at a government school, in order to gain practical experience. Working with each National Colleges of Education, the program selected up to 5 schools receiving student teachers in each district to be Model Schools. In order to be selected, the school met the previously established criteria of being partially damaged by the tsunami or hosting Internally Displaced children. The program provided support to these pre-service teachers and their in-service mentors to implement aspects of the Resilient Schools program in their classroom. Each classroom in these model The CBPSP

schools received a first aid kit, recreational kit and school chests.

Educational Specialist monitored the student teachers and provided them support to

16 practice their new skills in order to organize model schools in target areas. In year one the model school component reached forty classrooms as preservice teachers were trained from Jan to May 2005. In years two and three 825 inservice teachers were trained annually. About 40,000 students were served through this program.

Objective 2: Strengthen community protective factors

Resilient Community program The objective of the activities under the Resilient Communities program were to bring diverse groups within the community together to prepare for, respond to and recover from crisis, emergency or disaster. This program began with participatory focus groups with groups of ten families. A Community Liaison team led these focus groups in planning the activities. During these focus groups, participants were given an

overview of the goals of the CBPSP program and worked together to identify community needs, possible solutions and resources available within, as well as outside the target community. During this period the focus group leader identified those members of the group with an interest in becoming a Community Facilitator. The 4,000 trained Community Facilitators were divided into groups of five. Each group of five worked with 50 families units; defined for the purpose of this program as a village. The Community Facilitators received a variety of support materials to assist them in preparing their village to recognize potential psychological risks among members and to develop a plan to address those issues. They worked with their village to identify two skills building activities annually. The nature of these activities were determined by the village members and included training, tutoring for children or income generation activities. The objective of these activities was to facilitate a sense of security and unity and to recognize and enhance resilience factors

17 within the village. Villages were required to submit a proposal for these activities to their Community Liaison for review and approval. Informal Schooling The CBPSP program supported informal schooling for children under five and out of school youth in the target communities. This aspect of the CBPSP program brought together several marginalized groups; handicapped individuals, elderly, widows, out of school youth, and children under five. Structures were identified within the community to house the informal school. Each of these schools were provided with a recreation kit and other CBPSP materials. Education within these schools were facilitated by the Community Facilitators and led by the trained Informal School Teachers. During the morning, activities focused on education for children under 5. The Community Facilitator and Informal School Teacher included adults and adolescents from a variety of marginalized groups in providing education to and activities for this group. In the afternoon activities focused on education for out-of- school youth and tutoring for children who needed extra attention. In addition these informal schools served as a venue where community elders came together to educate children about culture and to enhance vocational skills. Breakfast and a fortified snack will be served to students and teachers attending the school.

Objective 3: Assist Community Members to establish a sense of place

The program provided and environment where disaster-affected people were able to establish a sense of place by providing opportunities to engage in social encounters, encouraging movement between social groups (individual to social interaction, small group to large group), providing opportunities for self expression through creative and expressive activities, and opportunities to express a full range of

18 behaviors including exploration, competition, and collaboration. All planned activities improved social comfort, collective well-being, social equity and respect and the opportunity to make sense of an environment, changed by the tsunami. In order to facilitate a sense of unity within the community, the program supported the development of community centers. These centers brought together representative from all parts of the community to plan and implement community wellbeing strengthening activities. The centers became the hub for CBPSP activities; from planning activities, to bringing persons together and linking with external organizations. These day-to-day interactions motivated disaster-affected people to establish a sense of place by: (1) accepting responsibility for their village, (2) developing knowledge about their village (watershed, soils, climate, plants, and animals), (3) enjoy the facilities available, (4) mapping the village, (5) building the physical infrastructure of the village, and (6) taking action to preserve their village.

Summary and Conclusion

This paper narrated the formation of an idea for community development using volunteers, participatory approaches based on the teachings from the field of psychology and mental health. The paper relates how the original idea (VESPRA) evolved into a community based psychosocial support model. The systematization of the model in Central and South America by the American Red Cross was conducted in the early part of the 21st century. Finally, using CBPSP as a platform for disaster response during the 2004 tsunami in Sri Lanka, the methodology was fine-tuned. The third part of the paper presents an example of how CBPSP was used in schools and communities in Sri Lanka.

19 The beginning of the 21st century ended the debate over the role of disaster response. It has been agreed by humanitarian actors need to address assistance and protection (SPHERE, 2011). The project described herein is one alternative that proved successful in alleviating suffering and enhancing psychosocial well-being using strategies that provided assistance and protection to all. Bibliography American Red Cross (2002). Psychosocial support guidelines. Washington, DC: International Services, American National Red Cross. Bennett, M. (1967). VESPRA: A voluntary program for Puerto Rican slums. Washington D.C., Office of Economic Opportunities. Bolton P, Tang A. (2002) An alternative approach to cross-cultural function assessment. Social Psychiatry. 37(11):537-543. Folke, C. (2006). Resilience: The emergence of a perspective for social-ecological system analyses. Global Environmental Change, 16: 253-247. Hobfoll, S. E., Watson, P. E., Bell, C. C., Bryant, R. A., Brymer, M. J., Friedman, M. J., et al. (2007). Five essential elements of immediate and mid-term mass trauma intervention: Empirical evidence. Psychiatry: Interpersonal and Biological Processes, 70, 283315. IASC (Inter-Agency Standing Committee) (2007). IASC guidelines on mental health and psychosocial support in emergency settings. Geneva, Switzerland: inter-agency standing committee. Jackemet, I. (2001). Psychosocial support luxury or necessity? RCRC-The magazine of the International Red Cross and Red Crescent movement. 3(3), 3-11. Jones, M. (1962) Social psychiatry in the community, in hospitals and in prisons. Charles C. Thomas, Springfield-Illinois. Lawson, D. M. (1967). An evaluation of training procedures of the Voluntarios en Servicio a Puerto Rico Asociados. Washington, D.C. Office of Economic Development. Paton, D. & Johnston, D. (2006). (eds.) Disaster resilience: An integrated approach. Illinois: Charles C. Thomas publishers, ltd. Prewitt Diaz, J.O. & Savallos Ramirez, M. (2000). Salud psicosocial en un desastre complejo: el efecto del huracan Mitch en Nicaragua. Managua, Nicaragua: Cruz Roja

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