Friday, November 6, 2015

What we learned in Haiti about psycho- social disaster assistance


I arrived to Haiti a week after a 7.0 earthquake struck Haiti in 2010. I was part of an Israeli aid group, FIRST & Israaid, specialized in medical and psycho-social support, and later continued to work with the local NGO PRODEV, while collaborating in one camp with JPHERO.

As we started work in the first two camps in Port-au Prince, we immediately noticed that information given to children and adults was not received in a holistic way, for example, the use of the terminology "earthquake” referring to a geological phenomenon was problematic. The people of Haiti were processing the event in the context of their cultural and religious perceptions. Thus, we felt that they needed  to hear the information we were presenting in their own language and with their own terminologies. Accordingly, we adjusted our response.

Our team designed a questionnaire based on proven psychological tools and anthropological fieldwork methodology. The overall aim of the questionnaire was to help us better understand the Haitian people’s perception of the disaster. I assumed that, if we understood the cultural perception of the people and their perceived needs, we would be able to provide them with information they could understand, which in turn would reduce their stress and  feelings of uncertainty. For instance, we found that the people called the earthquake "gulu gulu", so we started using that word in addition to “earthquake” in our psycho-education sessions. We found that using local words and phrases helped us communicate better and build trust. Adding that we spoke about the universal phenomenon by giving examples that earth quake happen all over the world to all religions.

Key findings of our January 2010 survey
Over a two-day period in January 2010, we carried out a random survey based on the questionnaire we had designed of 100 volunteer participants in Petion Vile Club camp,consisting of a diverse camp population in terms of different age group, sex and socio-economic background. This resulted in the return of 73 completed questionnaires and the completion of six interviews. Among others, we found that 80% of the population believed that God had caused the earthquack and were surprised to learn that around 60% believed that another disaster would strike soon.
We also found that 95% of the survey participants had a wide range of physical symptoms, ranging from increased heart rates, to sleeping problems, nervousness and fear of noise (Figure 1).

Figure 1           Survey results: Types of physical symptoms experiences

Our cultural-based model for psycho-social disaster assistance
We integrated the findings of the survey into a modification of our program to better reflect the Haitian culture and belief system. We understood that if we wanted the community’s cooperation we needed to accept their basic perception of the world, their religion (both Christianity and voodoo, and triggers for reward or punishment). This new psycho-social approach respected the beliefs and knowledge of the community and, at the same time, facilitated the processing of universal and natural information, and also supported more appropriately self-coping and family-coping tools. The resulting model comprised of  three-stage intervention model (Figure 2) that allowed us to reach different community groups. This structure also enabled us to "fade into" the rehabilitation phase, particularly in the education sector facilitating the rebuilding of communities around shared institutions.

 Figure 2           Three-stage psycho-social intervention model

The three-stage psycho-social intervention model comprised of activities that were designed to be built on top of each other, starting with activities for children, followed by work with parents and adults, and finally joint community activities.

First circle of intervention: Children
1.      Social games that emphasize cooperation, positive experience, a sense of success, group encouragement and building trust between group members;
2.      Games that incorporate local songs and dances and emphasize creating common ground, mutual creativity, and incorporating group members as leaders and participants;
3.      Drawing and providing a psycho-social explanation for earthquakes, common reactions to trauma and tips for further treatment;
4.      Intervention for younger children focusing on drawing scary/ happy images;
5.      Older children (from second grade onward) drawing with a wider set of instructions.

Second circle of intervention: Group psycho-education for adults and parents
1.      What is an earthquake? Universality and objective geological explanations, using cultural objectivity;
2.      Explanations on common reactions to trauma and stress;
3.      The parental role and its derivative complexity after disaster;
4.      Ways to deal with stress and uncertainty.
Third circle of intervention : Mass community activities
1.      Restoring hope, mainly for children but including the whole community;
2.      Mass sport, drama and music activities, which also involve parents in order to create activeness and joy within the community [restore hope].
We witnessed that this activity was becoming more popular every day. More and more members of the community took part as dancers, assistances and watchers.

The theory behind the model
Children after disasters need interventions that support the functional continuity of life (Klingman, 1992). The impact phase creates high emotional insecurity and may cause anxiety and physical changes. In recent years, interventions are implemented within the community settings, and for children, schools are the primary institute that can provide help (Leo and Rato Bario, 2010).
The usage of physical education is fundamental. Physical activities include many elements that can improve the lives of those affected at the physical and mental level, but also enable improvements in other aspects, such as: body image, social skills, self-confidence, persistence and more. Physical activity is a combined factor inside a group that can create inclusion and equality between the participants (Ley and Rato Barrrio, 2010).
Siedentop (1994) has suggested sport education as a method of developing social skills and managing skills. Hellison (2003) has developed a focused model aimed at teaching responsibility through physical education. His model uses five levels, built of different levels of responsibility- from understanding to performing, in different circles - me,  and others  and transit it to real life. Eldar (2006) applied a wider model, using physical activity as "support context" for teaching and obtaining learning habits, social habits and emotional abilities.
Thus, physical education creates a "safe zone" for children and adults, while creating opportunities to determine a shared status and common goals . After playing together it is easier to raise common worries and needs.
The psycho-social education component was based on giving information and creating a safe space for raising questions, observations and developing solutions. It was a mechanism, through which we were able to identify needs and refer people to other organizations for specific assistance.

We wanted to implement a psycho-social interventions with a a different approach, that could offer an easy transition to rehabilitation:
§  We used local language phrases, because we believed that language is crucial for trust, understanding and perception of situations, feelings and action.
§  We built the intervention upon community characteristics.
§  We hired local educational staff members that implemented the program together with us from the fifth day, and continued on to lead the activities by themselves with us present 50% of the time after 15 days. We made arrangements so that they could continue for at least three months after our departure. Training the trainers was a main component of our program, so that local staff members would become proficient.
§  After a month, we opened schools in two camps as a focal institution and safe place for the children and the community. It was important to us that the program would have continuity for at least three months to help the community and identify children/ and adults, who needed more focused help.
§  We did substantial work through physical activities - an empowering intervention that matched the Haitian culture and the people’s perceptions and experiences they shared with us. The majority of those we interacted with said they were "feeling it in the body"- the fear, the stress, the memories from the quake. [Therefore, also working on improving physical well-being became a natural priority.?]
§  Consequently, using physical activity was a frame for the psycho-social program, and not a tool by itself. Although we knew that physical activity is an effective way to cope with stress, we knew that it could be much more useful in combination with other techniques.
Implementation into the psycho-social program
-          For the psycho-social program, we identified two areas – (1) religious beliefs and (2) physical stress - as the main important targets. We re-organized our psycho-social meetings accordingly:
1. The explanation of earthquakes was rebuilt as an international phenomenon that occur everywhere and in all religions.
2. We drew a map of the earth and provided scientific explanations for the occurrence of  earthquakes.
3. We used balls to explain the aftershocks.
4. We collaborated with the physicians to offer a detailed explanation of the physical symptoms they experienced, as individuals and as parents.
5. We explained how the stress may influence the children and the family.
6. We empowered the family and the community as the primary responders by talking on the situation and reflect that the community shares same "basket" of problems, and teaching stress coping mechanisms on several subjects:
- Sleeping problems.
- Physical calming by breathing, easy physical activities.
- Children in stress and how we can help them as family.
   and more.

We aimed at transferring "control" back to the people through information and education, and away from rumors. We did not argue with the perception of the "act of God", but we provided information and taught skills to help them gain active behavior for their own well-being.
The next steps were to train local community members to lead the psycho-social intervention and rebuild schools as core institutions for the children that would provide a safe place and give parents time for themselves to cope, work and start rebuilding their lives.
Concretely, we started looking for community members to replace us. We aimed at young educators or persons with therapeutic or community experience who knew English and were open [to learn?], so we could apply a two-directional learning process and would be able to give feedback to each other. We identified three community members and trained them, learned from them local games and songs and, after ten days, the mobilized groups took over and carried out the interventions with our guidance. 
After three weeks, we decided to open a school in our main IDP camp (Petion Ville- club). At the time, we were collaborating with the  local NGO, PRODEV, and the camp manager NGO- JP HERO, and agreed to open a school, which would also serve as  a first community rehabilitation point.
The school program was design together by an Haitian education expert and myself. We integrated the basic core subjects of the Haitian education system and our psycho-social program, art, music and sports. We developed a teacher’s training program and an administrative component.  We gradually enlarged the school, added classes and opened a community center. Between February and April 2010, PRODEV opened 12 schools and 8 kindergartens in different camps and neighborhoods. All staff members were Haitian, to whom we provided intensive training and guidance, as the main leaders and resilience builders of the school.

Based on our experience in Haiti, I suggest a time line of psycho-social intervention post-disaster that includes four main components:
1. Fast intervention to reduce post trauma and stress symptoms.
2. Reliance on local community members.
3. Adaptive program to local needs and culture.
4. Fast progression to the rehabilitation stage.

Suggested timelines:
Day 1-5 after the disaster- entering the field: starting working with the community, mainly the children on "first aid" small interventions.
Day 3-10: cultural assessment and adjusting of programs accordingly.
Day 10-20: program implementation, connecting to local organization/NGO and the start of training local community members
Day 25-30: the opening or delivery of knowledge to the education system and to professional therapeutic organizations.

The Haiti model taught us much about  the implementation of psycho-social interventions based on a cultural understanding of the affected local community, that we believe re transferable to other disasters. I believe that the perception of the local community is the key factor in rebuilding community resilience. I found that building trust in the community by working with different age groups, relying on community members, advising the community and having a sound exit strategy were key elements in effective coping and the overall successes of the program. In Haiti, the main intent was to shift the weight from outside forces to internal individual forces, but in other cultures the main focus might be different. Integrating psycho-social interventions in the educational system offers the parents a safe place for their children, gives the community a new local center, and is the catalyst for building community resilience. The strength of this approach was the building of the intervention "language" while understanding the real needs of the community by working with them daily, and transferring the leading to them.


Eldar, E. 2006. Educating through the physical- Procedures and implementation.
            International Journal of Behavioral and Consulting Therapy2(3): 399-415.

Hellison, D. 2004.  Teaching Responsibility through Physical Education. Human

Klingman, A. 1992. The contribution of mental health services to community- wide
emergency reorganization and management during the 1991 Gulf War. Social Psychology International, 13: 195-206.

Ley, C., & Rato Barrio, M. 2010. Movement, Games and Sport in Psychosocial
intervention: a Critical Discussion of it Potential and Limitations within Cooperation for Development. Intervention8(2): 106-120.

Siedentop, D. 1994.  Sport Education; Quality PE trough Positive Sport Experience.
            Human Kinetics.

Wolmer, l., Hamiel, S., & Laor, N. 2011. Preventing Children's Posttraumatic Stress
After Disasters with Teacher- Based Interventions: A Controlled Study. Journal of the American Academy of Child & Adolescent Psychiatry50(4): 340-348.

 About the Author (me):
B.A. in special Education
M.A. in Geography of Disaster Areas
M.A. in Anthropology
Project manager of education in emergencies, community emergency preparedness and response, and psycho- social intervention.
Haiti- January- October 2010 with FIRST & Israaid and PRODEV- project manager- psycho- social intervention and camp schools project.

Published in Sharon's Hebrew Blog- Flexibleducation 

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