Emergency and Disaster Management

H. J. PARAD

Bowie, Maryland: Robert J. Brady Co., 1976

Pages (375-382)

31

POSTDISASTER

MOBLIZATION OF A

CRISIS INTERVENTION TEAM

The Managua Experience

Raquel E. Cohen, M.D.

Increased attention is being focused on mental health intervention potential following catastrophic events that have serious impact on the affected population. Mental-health workers are aware of the challenging opportunities for service and prevention which can come about if they are able to mobilize themselves rapidly, gain entry into the mainstream of helping structures, and provide assistance during critical moments following series disasters (78, 80, 105, 106, 178, 308, 330, 333).

This chapter focuses on the experiences of the first of the series of volunteer teams of United States-Nicaraguan Emergency Mental Health Project. This team went for 1 month to Managua, Nicaragua, whose population had suffered the effects of a disastrous earthquake 3 months earlier. The following areas will be highlighted the:

1. The catastrophic impact of the earthquake on the socioeconomic structures, community services, and mental health of the population.

2. The team's activities, which included direct crisis services plus education and consultation within the human services system of a developing country.

3. A series of crisis intervention projects.

4. Tentative suggestions for further application of crisis intervention techniques and procedures.

NICARAGUA: A QUICK OVERVIEW

Nicaragua what is one of the smaller countries of the Western Hemisphere, although it is the largest of the Central American countries (459). It has an area of 48,000 square miles and a population of around 2.5 million people. The official language is Spanish, and the population is 95% Roman Catholic. The climate is tropical. The major causes of death are gastrointestinal and parasite diseases, infant diseases, and cardiovascular and respiratory ailments.

The society, consisting of the European-Indian ethnic and cultural mix, is homogeneous in comparison to that of other Central American countries. The traditional Hispanic pattern of family life, common to most of Latin America, prevails. The nuclear family forms the basis of family structure, but relationships among kindred are strong and influence many aspects of Nicaraguan life. Because few other institutions in the society have proved this stable and enduring, family and kinship play a dominant role in the social, economic, and political relations of the Nicaraguans. Business loyalties, social prestige, and political alignments generally follow kinship lines.

Like the rest of the Caribbean area, commerce and movement patterns tie Nicaragua principally to Anglo-America and secondarily to Western Europe. Although much less urbanized than many middle latitude countries, there's a significant concentration of urban population. Managua, the capital city, is growing at a rate faster than other urban centers in spite of its location in an area of seismic instability.

Before the disaster, the Nicaraguan mental health program was underdeveloped; the 14 psychiatrists serving the entire country had had little experience in crisis intervention of community psychiatry. The National Psychiatric Hospital, a 450 bed hospital with only one full-time psychiatrist on the staff, plus a group of part-time psychiatrists who work for the social assistance agency, was the main resource of the city. Very little integration of psychiatry into the general medicine programs existed, and little coordination of efforts to deal with the victims of the earthquake developed.

THE EARTHQUAKE

The Managua earthquake could be cataloged as one of the most catastrophic and bitter events experienced by a population in our recent past. This was due not only to the magnitude of the event and its impact on the city, but also because most of the country's administrative social supportive structures were centralized in Managua. The timing was also critical in that it occurred two days before Christmas when people were beginning to celebrate the holidays. The heightened expectation of pleasure made that crushing event psychologically more devastating.

The Richter scale recorded a magnitude of 6.2 with the epicenter in the heart of the city. There were three strong tremors. After the first one, around 10:30 p.m., many citizens left their homes; some made preparations to leave in case of stronger tremors: and others went back to sleep, as they had been accustomed to tremors from many months prior to December. A second earthquake, at 12:30 a.m. destroyed 80% of the homes and produced the first wave of intense panic, with the exodus of people rushing through darkness and choking clouds of dust, tripping on bricks and cement scattered by the coming houses. Many persons were injured or killed by falling debris. The last earthquake occurred around 3:00 a.m. razing the few houses that had not been damaged. Fires raged uncontrolled due to the interruption of water flow and the destruction of fire engines within their stations.

Within four to six hours after the earthquake, world aid supplies began arriving in planes which continued landing every 20 minutes for several days. Supplies included field hospitals (as the hospitals of Managua had been damaged or destroyed) plus milk, water, food, medication, and disinfectants for the water supply reservoirs. The destruction was of a magnitude that appeared overwhelming. Besides the immediate human and property losses, there remain the problems of the wounded, the displaced, and the unemployed. The following human statistics provided a framework for the magnitude of the reconstruction needs: 10,000 killed, 20,000 wounded, 250,000 displaced, 50,000 homes destroyed, and 24,000 badly damaged, 14 industrial plants leveled, and 95% of the slopes destroyed.

MENTAL HEALTH TEAM FORMATION

Two of the future team members, community psychiatrist who were aware of the potential for intervention and interested in the country by language and affective ties, immediately contacted the National Institute of Mental Health (NIMH) to organize a crisis team for Managua. The organizational problems included: 1) the no previous demand for this type of help to a foreign country; 2) lack of a central coordinating structure within NIMH; 3) the fact that NIMH is a national institution, and 4) the priority given by international agencies to physical aid. Negotiation and planning had to be completed, first within NIMH and then between NIMH and the Nicaraguan government. Thus, it took 3 months to assemble the volunteer team, obtain funding for basic expenses (food, shelter, and transportation), and establish relations with the Nicaraguan government to gain sanction for the entrance of the team and provide some shared economic support.

Two days of meetings were arranged (funded by NIMH) to acquaint team members with each other, develop a conceptual model for the crisis intervention program, and establish guidelines for the interrelationship with them and the Managuan institutions.

INFORMATION GATHERING

Answers were sought to the following questions:

1. What information was available to give the team a description of: a) the extent of the catastrophe, b) the manner in which the population sustained the impact, c) the immediate measures taken to develop the human support systems to direct the emergency programs?

2. What were the characteristics of the population's environment both before and after the event: a) physical, b) political, c) cultural, and d) economic?

3. What organize public and private structures were there at the time of planning to assist the populations functioning? (We learned that the Public Health Ministry, the National Assistance and welfare Board, and the Social Security Institute provided the main support services in the country. The Committee on Emergency, which was instituted after the earthquake, gave direction and coordination to broad human services in the city of Managua.)

4. Who would be giving the supporting sanctioned for team member activities?

5. What conceptual principles and guidelines would be used to design prices intervention activities within the native human services structure in Managua?

CONCEPTUAL MODEL FOR INTERVENTION

Theoretical formulations used to develop our procedures and methods were drawn from: a) open systems theory (14, 15), B.) psychosocial findings reported by Cassel (67, 68), and C.) principles and practices of community psychiatry (63, 64, 79, 217).

Intra-team organization was essential to divide responsibilities, develop linkages with key individuals in the Managuan community, and delineate specific activities and goals for each team member and for team as a whole.

Philosophical and practical approaches included the following:

1. All our activities would be directed towards developing procedures that would be found useful by the individuals with whom we would be working within the crisis intervention projects.

2. We would start with feasible and limited activities, working with the disaster aid network and then enlarge our scope as more knowledge and familiarity with the situation developed. To implement this we would identify patterns of service and link into them.

3. As we became familiar with the service structures in the city, we would try to collaborate and cooperate with the established organizations that had been set up to offer direct help to individuals traumatized by the earthquake, while also offering indirect services (consultation in education) to the caregivers.

4. We would continue to scan for further opportunities to participate in the broader areas of health, education, and welfare.

5. We would continue to develop relationships broadly at every level of organization and leadership in these systems.

6. We would accumulate and organize data emerging from our activities to be used as continuous feedback to keep the team's activity focused on the main objectives.

To implement these aims, we would have to develop a proactive and supportive stance. The design of the organization within the mental-health team had to be structured a priori, but it would be flexible, balancing immediate needs with clear direction and defined boundaries. We would present our area of expertise, and ask native caregivers to select their priorities and options from defined and clearly verbalized team positions. We did not ask what we could do to “help,” but gave them the definite inventory of our skills and asked them to fit it to the post-disaster situation.

What emerged, in broad terms, were two categories of project objectives: a) aid to individuals affected by the earthquake, and b) support to caregivers through role modeling, education, consultation, and catalytic activities within community agencies, including linking of systems that integrate their efforts in the crisis intervention projects.

TEAM OPERATIONS

On arrival of the full team complement, the first few days were used for orientation and for meeting key people in agency leadership and administrative roles. The fact that team members were bilingual and bicultural facilitated rapid establishment of relationships. Mindful of the leadership group's wishes and priorities, we identified the most practical areas for the beginning activities of the team intervention. The match and mix between the small team of United States mental health workers and the enormity of needs that had gone unheeded until we arrived, and which would continue after our departure, was the primary task to which we addressed ourselves. By matching some of our interest and knowledge with the array of choices, we eventually developed several clearly defined areas of intervention. The team then set up six specific projects.

CHILDREN’S PROJECT

The children's project consisted of ambulatory services for parents and children ranging from 2.5 to 16 years of age who presented symptoms of “post-earthquake traumatic neurosis.” Interventive techniques were applied, using individual and group therapy as well as medication.

LECTURE SERIES FOR CAREGIVERS

A series of lectures in Spanish were developed on the techniques of crisis intervention, community psychiatry, and short-term psychotherapy for mental health practitioners. This course offered both intellectual and emotional support to a group of workers who had been called on to be supportive to others, while themselves experiencing trauma. Many of them showed symptoms of delayed mourning reaction.

AID TO PROFESSIONAL GROUPS

Consultation and education were provided to the following groups: a) counselors at the National University, b) faculty of the Universities Central America, c) members of the Health and Welfare Council, d) students from behavioral science disciplines, e) educators from the Public Health Department, f) clergymen, and g) members of private community institutions.

INSTRUCTION FOR NURSING PERSONNEL

We offered consultation and a series of presentations on crisis intervention to public health nursing supervisors and special nursing personnel. Services were also provided to the 16 neighborhood health centers in Managua. Seminars, small-group presentations, role-playing, and individual supervision were offered throughout the month.

MENTAL HEALTH CLINIC

A mental-health clinic was established in the Camp America #2, a development of a thousand houses built in 3 days by Aid for International Development (AID) for displaced families. (Five similar camps were built around the city.) Using one of the houses as a base, three mental health workers participated in outreach programs. A psychologist provided backup services. This group also linked to several other organized supportive groups that had established themselves in the camp, and together they began to develop some educational and preventive programs. This clinic later became a major training setting for nurses and psychology professionals working with the governmental agencies of the city. Services offered at the clinic were screening, emergency treatment, individual supportive treatment, chemotherapy when needed, and group interaction.

PLANS FOR FUTURE

A planning project for “Emergency Help through Human Services” was offered to the Managuan government. A model provided for development of the human services support system within the already structured organizations of the Ministry of Health Education, the JNAPS (National Council of Assistance and ProVision Services), and the OCIP, a joint group of 12 to 14 national and foreign private service organizations in Managua. The project was based on the principle that outside consultants could help establish an emergency project but that responsibility for maintaining an ongoing operation should be carried out by a native director chosen by governmental and private agency units. The plan as established contained the following proposals:

1. Mobilizing a group of individuals already employed by the public institutions to be loaned to the work in the project

2. Using the team of mental health workers from the United States as consultants, educators, and project demonstrators, linked to their professional counterparts in Managua

3. Coordinating the efforts of public and private groups to attain the objectives of intervention; existing community activities were not organizing support of processes effectively to meet individual needs

4. These groups could follow up emergency mobilization with long-term planning for future needs.

This blueprint was implemented by subsequent teams from United States. Ten crisis centers were developed, manned by 30 Nicaraguan graduate students in psychology, nursing, and social work under the supervision of Nicaraguan mental health professionals. The centers were funded by the private agencies.

Other projects were developed, but the plans described here illustrate the types of activities started by the first-team. As of this writing, three teams have gone to Managua and have followed through with these projects as well as establishing new ones.

INTERVENTION PHENOMENOLOGY

The team was able to observe the problems faced by a population suffering from the aftereffects of a dislocated human systems network. The people we were seeing seemed to be still in the recoil stage or the gaining of the adaptive phase as described by Tyhurst (413). It appeared puzzling to us initially that there were still much data to document this phase 3 months after the disaster, but it became understandable as we realized that the people continued to experience the shaking of the earth's crust and learned of other earthquakes in Costa Rica and Hawaii. Another stimulus that threatened adaptive mechanisms was that newspaper headlines continue to describe their effects of earthquakes and portend potential disasters for Managua. The lack of supported human systems with trained manpower tended to prevent positive adaptation to trauma, and the real hardships such as lack of jobs, disrupted daily activities, and inadequate housing added to stress.

There were similar responses from many people, although there were differences in such factors as impact of stress, strength of personality and health at time of the event, extent of property and human loss, distress and discomfort in living following the earthquake, extent of empathetic identification with the trauma of the population, loss of social economic status, need to move out of the neighborhood or city, age, sex, and social network affiliations. The intensity of the emotional tonality, the manner of narrating the individual experiences to us three months after the earthquake, and the feelings of crisis of a large number of persons were very similar. This pointed out to the need for providing help not only to the citizens but also to the professional caregivers. Our intervention techniques with professionals were adapted to their individual coping styles. Some asked for help in overt manner, others within the settings of an egalitarian college situation. Unique group techniques, annotations of traditional crisis intervention, were developed. The focus of the group intervention was on both the cognitive and affective level of the individual’s functioning. Our objective was to support and enhance coping endeavors that had been inoperative. A clear message had to be signaled that individual professional or caregiver was not a patient but was reacting to extreme conditions of stress. A small fraction of our intervention was directed to individuals clearly diagnosed as suffering from different varieties of classical mental disturbance.

RESULTS OBTAINED BY THE TEAMS

The combined efforts of the American and Managuan mental health workers, sustained by the interest and sanction of the governmental and health leaders, led to the following results:

1.Implementation of a crisis intervention program to directly assist individuals traumatized by the earthquake.

2.Collaborative linking with human services structures.

3.Beginning consultative relations with health planners for long-term construction of new health institutions.