Emergency and Disaster Management
H. J. PARAD
MOBLIZATION OF A
CRISIS INTERVENTION TEAM
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).
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
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.
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
Like the rest of
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 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 , 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 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 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
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
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.
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
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
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
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.
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
The children's project consisted of ambulatory services for parents and children ranging from 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
education were provided to the following groups: a) counselors at the
INSTRUCTION FOR NURSING PERSONNEL
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
MENTAL HEALTH CLINIC
clinic was established in the
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
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
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
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
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.