POST-DISASTER TRAINING EXPERIENCE: ICA REGION EARTHQUAKE

Raquel Eidelman Cohen MD, MPH

INTRODUCTION

Earthquakes are disasters that cannot be predicted and whose effect can be considered catastrophic depending on the severity and duration. The earthquake that occurred in the Ica Region of Peru on August 15, 2007 was such an event. I have been a participant and witness to similar experiences as the result of my birth and early life in Lima and because of the decision I made in 1970, following the catastrophe of the Callejon de Huaylas in the Andes, to apply my training and knowledge of psychiatry to learn how to best assist survivors of natural disasters. During the last 30 years I have worked in this area of trauma, having participated, learned, taught, published, trained and consulted with government and NGO professionals during many of the natural disasters which have taken place in North, Central, and South America. More information can be found at my web site, http://www.raquelcohendisaster.com/

Knowledge in the field of assistance to survivors has been enriched by the collaborative work of numerous professionals worldwide who have published and presented their findings, leading to a better understanding of survivors’ behavior, crisis reactions, stressor effects on the individual and stress responses, coping and adaptation to painful changes in their lives.

Individuals who have experienced a traumatic event oftentimes suffer psychological stress related to the incident. In most instances, these are normal reactions to abnormal situations. Individuals who experience these feeling may believe they are unable to regain control of their lives or that they may develop pathological manifestations due to the trauma. However, professionals who work in the field of mental health assistance in natural disasters now understand that for the most part, this behavior is an expression of both substantial stress plus an effort to return to normal function, although a small number of individuals will develop both somatic or psychological disorders due to variables of genetic origin, previous traumatic experiences, pre-morbid chronic conditions, or severe environmental lack of resources. Intervention techniques are constantly refined to help in the recovery of function of traumatized individuals.

Techniques available to help individuals after a disaster are defined as active interactions whose aims are to promote, complement and reinforce healthy functions and adaptive behavior of the survivors. Although expressions of empathy are helpful, care must be exercised not to reinforce or reward the “victim” role. Care should be taken not to interfere with psychological defenses, which the survivor needs during the initial period post-disaster. Establishing a relationship may be difficult in the initial period because the survivor often has distorted thinking due to high anxiety and cognitive blurring. They may be defensive, guarded and overwhelmed. Once a relationship is established, the worker can offer options in solving problems and can help the survivor by suggesting different methods to find the most feasible way of living day by day.

The worker needs to be aware that the survivor will face different experiences as the community is reorganizing and as individuals continue to return to function. This process is based on the passage of time after the impact of the event. Each period of time, generally referred to as “Impact”, “Post disaster phase”, and “Reconstruction”, has its own unique characteristics of adaptation behavior. Each phase will stimulate varying emotions and attitudes, presenting a challenge to the worker who needs to ascertain what this changed behavior means. What this increasing knowledge of behavior change in relation to the overall timeline indicates is that intervention techniques must be "in sync" with the stage of crisis resolution after the disaster impact.

THE EVENT: THE ICA REGION EARTHQUAKE

The earthquake surprised, frightened, and stunned Peruvians on August 15, 2007 at 6:41 pm. The event registered 7.9 the Richter scale, a major quake. Several days later, over 500 deaths, 1,500 wounded, and 80,000 “damificados”(survivors) had been reported, with at least 90,000 homes destroyed. The city of Pisco was severely damaged, the most tragic incident being the collapse of a church, burying many individuals who had taken shelter there, including several large families. Phone connections failed and electricity was interrupted, plunging large zones of the territory into darkness. Panic engulfed the citizens, partly due to rumors of an impending tsunami that was later denied. “Replicas” (aftershocks) continued to provoke fear and caused many residents difficulty sleeping indoors. Transportation and relief efforts were handicapped by the severe damage to the roads connecting Lima and the affected region. Food and water became scarce, aggravating the painful situation.

DEVELOPING A TRAINING PROGRAM (Aug.20 - Sept. 15, 2007)

I was able to follow the course of post-disaster activities through the TV program Sur Peru, and became aware of the need to train professionals to assist survivors traumatized by the unfolding events. Through e-mails and computer conferencing through the Skype network, I was able to offer assistance to several of the organizers of emergency programs and provide the training documents found on my web site. The Peruvian team and I hoped to implement a distance-learning methodology to train disaster workers, were able to successfully develop a curriculum based on several of my courses, and translate those materials into Spanish in record time. As the organization and operational planning advanced, the government leaders and academic professionals strongly urged that I should participate personally in the training program, and I accepted. The coordinating group prepared several educational activities including symposiums and a week of team training in Lima. They developed a planning document and agenda as follows:

(Peruvian governmental document translated and summarized)

The Directory of Mental Health of MINSA calls on the mental health professionals responsible for working with the affected population of the earthquake which occurred on the 15^th of August to a workshop to reinforce the plans of intervention for the provinces of Canete, Chincha, Pisco, and Ica. The workshop will be based on the experience and the activities of mental health professionals in natural disasters, will be led by experts and national/international agencies, and will strengthen the practices and knowledge of the assisting teams.

Based on the planning function, MINSA will be strengthening the local and regional health units in association with the mental health hospitals, organizing the work by operational zones. Within the first phase of work we have the following objectives:

1. Complete the evaluation of needs and resources that will include field visits to the disaster zone.

2. Train planning staff and decision-makers to complete and adjust the working plan

3. Train mental health disaster team leaders, the staff of mental health hospitals, and members of the government administration. The curriculum will include methods of working with different groups, children, adolescents, and adults in addition self-help methods for the trainees.

4. Develop monitoring and support systems for the mental health teams in the disaster zone.

The work will be supported with the technical and financial capacity of the Panamerican Health Organization and the faculty of the Univ. Calletano Heredia through their Program of Trauma - Global Health Research Initiative - Teasdale-Corti Team Grants Program and supported by the Douglas Mental Health University Institute and McGill University, directed by Marina Piazza PH.D. Staff of the National Coordination of Human Rights will also assist.

Experts invited to participate are: Dr. Carlos Martin Berestain from Spain, Dr. Duncan Petersen from Canada and Dr. Raquel E. Cohen from the United States. Dr. Cohen is a Peruvian-born psychiatrist, a graduate of San Marcos Univ. and the Harvard School of Public Health and the Medical School, and Professor Emeritus of the Dept of Psychiatry, Univ. of Miami Medical School. She is an expert in the psychological and social consequences of natural disasters and methods of therapeutic intervention, and will train teams working in each city as well as participating in several symposiums for government organizations.

TEAM TRAINING ACTIVITES – OPERATIONS coordinated by Marina Piazza

OBJECTIVES

*Delineate methodology and procedures necessary to help the survivors, respecting their culture, to recover its functional capacities.

*To increase the knowledge of the bio-psico-sociocultural processes that give support to the interventions in the resolution of crisis responses

*Identify the techniques of intervention for adults, children, and older adults.

*Present the methods of self- help to the professionals that work in disasters.

TRAINING Methodology - Lectures (PowerPoint and Exercises)

*Prioritize the important problems for survivors

*Interactive and participatory activities during the sessions.

*Orientation towards active role play

*Emphasis in the here and now.

*Emphasis in the practices and opportune solutions.

ORGANIZATION OF THE DAILY TEAM ACTIVITIES - 8:30 am – 6 pm

*Presentation of content.-trauma ,crisis, physiologic and psychology c defenses

*Practices - vignettes, modeling of roles, use of video-therapeutic intervention

*Presentation of cases and examples-based on actual cultural and earthquake experiences

*Discussion - question and answer periods—multidisciplinary perspective

Members of the teams will be asked to read the materials that were provided to them before the session so as to be prepared to discuss and to ask questions they have. Emphasis was focused on participation and interaction between the participants and presenter.

EXPERIENCE

After participating in several large symposiums composed of administrators, agency personnel, and professionals interested in the program for disasters, I began to meet with the staff from each city’s mental health team. We worked intensively for two days developing the details of the two day training that would be offered to each team. We wrote the scenarios for role-playing, the sequence of the PowerPoint presentations, time, and content.

It was anticipated that each team would receive copies of the curriculum, CD’s of training materials, and a bibliographic list of articles. We repeated these activities every two days, fine-tuning our approach as we determined what worked best, and balancing the time versus the number of attendees. The average number of trainees was between 50 and 70 multidisciplinary mental health professionals, including educators, administrators and police officers.

On the first day of training, as the “students” (who were also a mix of “damificados” assigned to assist survivors and Lima professionals) filed into the auditorium classroom, I could perceive a sense of weariness, sadness and somber mood. Later, after going through the initial lecture and exercises, they were attentive and eager to act out their role-playing assignments. I was surprised they had enough energy to ask questions or display strong spontaneous emotions while performing the characters in their scripted exercises. Some of the scripts, which they had chosen from real scenes of the earthquake, were so moving that all of us had tears in our eyes, and some of the “students” were so overcome that they had to leave the classroom sobbing. Through these shared emotions, at the end of the two days a strong sense of bonding had occurred between the team members returning to their devastated cities. This experience was repeated three times to provide training to each city team.

After the training in Lima, I returned to Miami, from where I continue in contact with Dr. Piazza to assist and consult with several of the programs in the reconstruction Mental Health Program.