Post-Disaster Psychosocial Support

Community based Psychosocial Support programmes following conflicts or natural disasters are programmes that aim at psychological recovery of individual community members as well as social recovery of communities as a whole. Such programmes address the various psychological issues of affected individuals such as psychological distress and mental illness and the social issues such as displacement and disruption of social networks. They also strengthen the capacity of communities for future development. Such programming has been adopted by Humanitarian agencies since the last decade. In the last few years important milestones have been achieved in this sector such as the incorporation of minimum standards for psychosocial support by the Sphere Project (Sphere, 2004) ^{(See
footnote 1)} and the development of the Interagency Standing Committee Guidelines for Mental Health and Psychosocial Support in Emergency Settings (IASC, 2007) ^{(See
footnote 2)} . Other important achievements have been the implementation of numerous psychosocial support programmes and the constitution of significant number of forums globally discussing psychosocial issues. However, despite all these conceptual developments there continue to remain gaps in application of these concepts in form of projects at the grassroot level. Majority of post disaster projects implemented in this sector have been directed towards either mental health or towards economic development (such as livelihood projects). However, projects for enhancing the general psychological well being and the healthy social relationships have been rarely considered. Also longer term programmes addressing the changing needs in the different phases after disaster have been uncommon. Various projects (such as ‘Social Capital Restoration Project, by Orissa State Disaster Mitigation Authority supported by the UNDP in response to Orissa Super Cyclone-1999; Disaster Mental Health Psychosocial Care Programme, by Indian Red Cross Society in response to Gujarat Earthquake-2001 supported by American Red Cross; Psychosocial Support Programmes supported by American Red Cross in Indonesia, Srilanka, India and the Maldives after the 2004 Tsunami) have attempted to address broader psychosocial issues. There have been inadequacies in these approaches. Most of the above programmes were never preceded by an emergency psychosocial support response; most had fixed programme focus and were not designed to address the changing needs usually seen in post disaster communities with passage of time; limited portions of the spectrum of post disaster social issues were addressed; gradual transition from the immediate phase to the later phases was not built in; and sufficient efforts were not directed to issues of sustainability and enhancement of the existing disaster response mechanisms. This article aims to emphasize the need for comprehensive psychosocial support programmes and contribute towards clarity of approach in regard to the changing psychosocial needs arising with time after a disaster.

This article reviews the situation on ground following natural disasters in three South Asian countries, the programmes implemented and the lessons learnt. It also reviews literature on post disaster psychosocial issues and interventions. It proposes a framework of practical action steps that could be considered in line with the same. It also suggests benchmarks and guidelines for psychosocial support programming.

Review of Post Disaster Situations

Maldives:
After the Tsunami in the Maldives the very early reports by the Field Assessment and Coordination Team (FACT) of the International Federation of Red Cross and Red Crescent Societies (IFRC) indicated ‘psychological reactions’ in the affected communities and urgent need for psychosocial support. The report (IFRC, 2005) documented that “Support to minimize the psychological impact of the disaster was identified to the first IFRC delegates as a priority need by the Maldivian governmental agencies, and reported consistently to delegates since. There were many cited examples of stress/anxiety reactions, all anecdotal, but extensive, across numerous Ministries (Health, Education, Gender, Youth, etc)”.

Assessments and surveys conducted by the UNFPA in late 2005 involving 854 tsunami affected respondents in 14 islands in 7 atolls, using a 35 question questionnaire which included GHQ-12 and additional questions, concluded that the overall prevalence of mental illness had not changed significantly, 30-50% of the affected population had moderate psychological distress and 10-20% had mild psychological distress (UNFPA, Maldives, 2005). The assessment further indicated that in 84% of the population the major cause of concern was permanent shelter (60% had no information about it and 46% believed that permanent shelter will be completed by end 2006). 83% were concerned about the future of their children and 73% were concerned about the emerging community conflicts and deteriorating social relationships. 60% were concerned about financial status and employment and 40% had not gone back to daily work as before in the pre-tsunami situation. The assessment recommended provision of adequate information, management of community conflicts and improvement of community relationships, enhancement of supportive role of families and peers, enhancement of social support networks and social services, and intervention for psychological problems. Indeed in the later part of 2005, major conflicts broke out in Raa atoll Hulhudufaaru between IDPs and hosts (Minivan News, 2005).

Later in 2006 various assessments, conducted in islands targeted by tsunami recovery projects supported by British Red Cross, indicated that the most common issues in the population living in temporary shelters were unavailability of permanent shelter, lack of privacy, overcrowding, poor sanitation, disputes and lack of livelihood. The Tsunami Evaluation Coalition (2006) report also confirmed the growing tensions between host and IDP communities over resources, lifestyle and social behaviour and the increasing potential for conflict. It also indicated that the host families had started feeling the financial burden and their capacity and goodwill had been gradually eroded due to the little availability of assistance.

With 12% of the population internally displaced, issues between IDP and host communities such as community conflicts (as mentioned above), disagreement and non-cooperation in sharing resources such as school buildings, water supplies (desalination plants) and sewage systems, sabotage attempts such as purposefully stopping work on new sewage lines (Minivan News, 2007) and newly built community parks, and disagreement on allotment of land for new houses for IDPs, cropped up. The above were due to differences in perception of the IDPs and hosts – the IDPs considered it their due right to receive support form various agencies on account of their suffering and the hosts felt discriminated in view of the higher standard of support proposed for the IDPs. Permanent housing and community infrastructure were the major foci for dispute. In some islands with IDP population exceeding the host population (e.g. IDPs of Thaa Vilufushi were more than the host population in Thaa Buruni), situation was even more complicated. Such issues led to insecurity within communities sheltering IDPs and the pre-existing stable social structures were rendered unstable.

In reality permanent shelters only started being handed over to IDPs in phases from mid 2007 and is expected to continue till the end of 2008 (IFRC, 2008). In communities where resettlement was completed including adequate social integration the interest of the community shifted to community development. For example in an island called Laamu Gan where the IDPs of two other islands – Laamu Mundoo and Laamu Kalaidhoo – were permanently relocated after initial difficult relationship between the IDPs and hosts the communities are now harmoniously resettled and are collaborating with each other looking for support for future development.

Another important national level change deserving emphasis is that prior to the implementation of the tsunami recovery programmes there was no mental health policy or legislation (WHO, 2006). Also there was no disaster management act. The emphasis on mental health by WHO and successful implementation of psychosocial support programmes became instrumental in motivating the government of Maldives for the development of a draft Mental Health policy. WHO and American Red Cross country programme team among others became key contributors for the draft document (which is currently awaiting final approval and implementation) (WHO, 2007). A Disaster Management Act is also in the process of approval with ‘emotional’ and ‘social’ components included in the definition of disaster recovery. The advocacy by the American Red Cross psychosocial support programme played a crucial role for the same.

The American Red Cross programmes through its liaison with the Ministry of Gender and Family could develop sustainable groups of personnel and volunteers trained in the country to enhance community resilience and provide psychosocial support in future disasters (WHO, 2007).

Srilanka:
In Srilanka the rapid assessment reports (Disaster Management & Information Programme, 2004) indicated shock, post traumatic stress and anxiety symptoms in the affected population and concerns of secondary threats such as looting, violence against women, epidemics, psychological problems and unexploded landmines. Later assessment reports by the American Red Cross (2005) which included secondary data from various reports (RAT team report, FACT team report, Government guidelines and reports from the psychosocial support desk of the Center for National Operations, National Plan of Action for the management and delivery of psychosocial and mental health services) and their own assessment confirmed the need for community based psychosocial support.

Oxfam (2005) reported that “Many hundreds of thousands of families are still living in temporary shelters, and have no certainty about where they will ultimately live, or when they will be able to move. It is difficult for many of these families to restart their livelihoods. Governments and NGOs are making progress towards rehousing families in permanent shelters, but this is in itself a slow, complex, and ongoing process”. A joint report by Government of Srilanka and developmental partners (2005) identified several problems in housing including lack of consultation and communication between beneficiaries, local governments and development partners. The psychological condition of IDPs in mid 2006 was indicated in reports of NHS team of Scotland’s Buddhist Vihara where teams including mental health professionals visited 7 camps and found the survivors distressed due to the living conditions in the camps. The survivors expressed helplessness and little hope of moving out of the camps in the near future. Tsunami Information Project (2006) reported that IDPs in the north-east reported that during the rainy season camp shelters were getting flooded. Some refugee camps were in remote areas and snakes were entering in the night creating chaos in the temporary shelters. Problems such as unavailability of comprehensive information, lack of transparency on the targeting of beneficiaries, lack of consultation with affected community members, lack of clarification of decision making mechanisms and improvement of operational integration particularly at the local level, were identified. Further the report mentioned that IDPs reported of inadequate medical and sanitation facilities in camps and temporary shelters. Women were particularly affected and they had no privacy. Some camps lacked regular supply of water. IDPs in the east reported that the children had to walk several miles to attend schools and they lacked proper uniforms. In some camps, nine to ten people lived in a small rooms with no room or proper lighting for children to study. In many areas, schools had been damaged or destroyed and students had been sent to other schools where there were inadequate classrooms, furniture, educational equipment and teachers.

Increase in ethnic violence and changing political scenario in Srilanka added to the delays in the recovery process and problems faced by the Tsunami survivors, particularly in the northern and eastern districts.

In Srilanka, like the Maldives, there was no approved mental health policy and after the tsunami there were enhanced efforts by the government as well as the humanitarian agencies to finalize the National Mental Health Policy and action plan. It was approved in the national cabinet in late 2005 (WHO, 2007).

Bangladesh:
After Cyclone SIDR in November 2007 in Bangladesh, psychosocial assessment of the Cyclone SIDR affected areas was conducted by an ‘Assessment team’ along with the IFRC Field Assessment and Coordination Team from 3rd-15th December, 2007 (IFRC, 2007). The team conducted focus group discussions and key informant interviews in a sample of villages in the affected areas and also discussed with local authorities at district level. The ‘Assessment team’ reported finding post traumatic stress symptoms in the communities due to the cyclone and distress due to the dead bodies laying around, the lack of basic needs, the losses and the lack of security.

Under public health needs the UN Rapid Assessment Report (2007) documented that “Health promotion, trauma and psychosocial counseling are urgent”. Further to this the UN Assessment Report recommended that “Increased health promotion activities, trauma counseling, psychological/mental health support and immediate reproductive, maternal and child health are needed”.

Assessment by Government of Bangladesh assisted by World Bank, UN Agencies and the International Development Community (2008) under immediate needs stated that, “A disaster of this kind has significant immediate effects on the health of the population, particularly in the worst affected areas. Initial concerns focus on treating cyclone-related injuries, preventing outbreaks of disease, addressing mental health issues relating to shock, bereavement, and losses, and providing basic health services”. In the early recovery strategy the report stated that “Reconstructing the infrastructure and recovering the economy of affected areas requires a multi-pronged approach that restores assets and protects the most vulnerable members of society against future calamities”. The report further listed psychosocial health support and training in psychosocial support for mental health care workers as recommendations on early recovery under the sector of health.

Later in mid 2008, a report of the survey conducted after the IFRC relief operations (IFRC, 2008) indicated that the three most reported needs in the survey by the affected population were house, money and cattle in that order and the two most reported uncompensated loss were house and cattle in that order.

Like the Maldives and Srilanka, Bangladesh does not have a National Mental Health Policy and has a poorly functioning National Mental Health Programme (WHO, 2003). A draft National Plan for Disaster Management, 2008 -2015 and a draft Disaster Management Act, 2008 have been developed in Bangladesh as of this year.

The findings that emerge from the above three country situations are – psychosocial support needs extend much beyond the initial 3-6 months; there are changing psychosocial needs in the communities with passage of time following disasters warranting changes in programme activities to cater to changing needs; there are numerous psychologically stressful issues that arise secondary to the disaster itself; needs include management of social issues, especially towards the later post disaster phases, that are critical to recovery; most developing nations have gaps at policy level on mental health and psychosocial support and disaster recovery programmes provide an opportunity for speeding up processes to bridge such gaps; and there is need for comprehensive long term psychosocial support programmes.

The gaps that remain in the above review are – there is little reflection on the course of post traumatic stress and Post Traumatic Stress Disorder (PTSD) that is important for programme designing, the linkage between mental health outcome (and psychological recovery) and social factors, the feasible and effective community based basic psychosocial interventions that have been used to manage post disaster psychosocial issues, and the connection between disaster recovery and national developmental initiatives. Also, the phasic pattern that emerges from the three case studies needs to be further validated by literature review including estimate of time durations of the phases.

Review of Literature

Besides the individual psychological factors there are various social factors that influence psychosocial recovery process following disasters and are often overlooked during programming. Kılıç, Aydın, Taşkıntuna, Özçürümez, Kurt, Eren, Lale, Özel, and Zileli (2006) in their study of psychological distress following the Turkey Earthquake in 1999 concluded that relocation after a disaster may increase psychological distress by disrupting the social network. Assessments by Iranian Red Crescent (2004) following the Bam earthquake in 2003 indicated factors such as living in a tent, unemployment, lack of educational facilities and medical facilities and lack of recreational facilities were also contributing to the stress in the survivors. Forbes and Roger (1999) in their study indicate that the ability to make effective use of social support has been found to predict mental health outcomes following psychological trauma. King, King, Fairbank, Keane and Adams (1998), in their study of Vietnam veterans found that post war social support played the largest role as protective factor against the development of PTSD. Therefore evidence indicates that social factors play a big role in the prevention of post disaster psychological distress and also that a correlation exists between the presence of social support and the mental health outcome following traumatic events.

The various standards developed for humanitarian aid following disasters such as the Sphere Project (Sphere, 2004), the Interagency Agency Standing Committee guidelines for Mental Health and Psychosocial Support in Emergency Settings, 2007 have incorporated the provision of basic psychological support intervention at community level generally referred to as ‘Psychological First Aid’. In addition various agencies such as the SAMSHA (2005), Emergency Management Australia (1996); National Centre for Post Traumatic Stress Disorder (2006); FEMA (FEMA Standard CERT Training Course) are also promoting basic psychological support interventions at community level. Research on various post disaster situations in the recent past have confirmed the efficacy of community based psychological support interventions and have advocated for provision of the same. Reports of impact of community based psychosocial support interventions such as in Bam earthquake 2003 (IFRC, 2004b), and Tsunami 2004 in India (WHO, 2006) have also indicated the usefulness of the same in post disaster situations.

Nakagawa and Shaw (2004) state that, ‘Disaster recovery is not only about building houses but the reconstruction of the whole community as a safer place. To mobilize each member of the community in this collective action (community development), social capital is a crucial need’. Also, there is evolving conceptual models such as by Mayunga (2007) emphasizing on enhancing social capital of communities that contribute to enhanced disaster resilience. Additionally in post disaster situations existing social capital in the affected communities greatly impact disaster recovery (Nakagawa and Shaw, 2004 and Wright, 2007). Grootaert (1998) in his paper on social capital initiative considers social capital as one of the significant contributors to economic growth and development. Dynes (2006) in his research goes a step further to suggest specific interventions to enhance social capital in a community.

International Recovery Platform (2007) emphasizes that disaster recovery process should be in line with wider national planning and developmental objectives inclusive of social development. Nakagawa and Shaw (2004) also suggest in their research that post-disaster recovery processes should be considered as opportunities for development. The International Recovery Platform (2007) further cites the context of the recovery process of Tsunami disaster (2004) in Indonesia as an example of social development through the disaster recovery process and states that ‘the aftermath of the Indian Ocean tsunami and its total devastation in much of Sumatra, Indonesia provided a welcome opportunity that was seized upon by previously warring elements of the population to make peace and to use the recovery process to develop a new level of well-being, stability, and a more productive society for the entire community’. It also cites the example of the disaster recovery programme following the volcanic eruption of Nevado del Ruiz, Columbia in November, 1985, where the programme was oriented towards the full recovery of the people affected, the social, the economic, the material reconstruction and the rehabilitation of the communities.

Anecdotal reports by many disaster experts confer the psychosocial phases of disaster namely ‘the Heroic phase’, ‘the Honeymoon phase’, ‘the Disillusionment phase’ and ‘the Restabilisation phase’. The survivors express high energy, optimism and altruism during the Heroic phase and are actively engaged in understanding the disaster and coming out of confusion and emotional trauma. In the Honeymoon phase this optimism continues and there is unrealistic expectation of recovery. In the Disillusionment phase there is expression of anger and frustration due to delays in recovery efforts and conflicts break out. Finally, in the Restabilisation phase the survivors begin to move forward and return to rebuilding process of their community. Many authors, such as Raphael, 1986, and Myers, 1994, from different continents have used the concepts of psychosocial phases in their works. The organisations such as the Centers for Disease Control (CDC, 2005), Emergency Management Australia (1996), National Center for Post Traumatic Stress Disorder (Young, Ford, Ruzek, Friedman & Gusman,1998) and SAMSHA (DeWolfe, 2000) have also acknowledged the phases and refer to these phases in their publications. Research (Young, Ford, Ruzek, Friedman & Gusman, 1998) indicates that the Heroic phase lasts for a few hours to a few days and the Restabilisation phase begins for some by 6 months and others between 18 – 36 months. Myers (1994) further emphasizes that the psychosocial support interventions should be phase appropriate. Occurrence of such phases in the recent times has been documented following the Turkey earthquake in 1999 (Gokalp, 2002) and disaster response in the Philippines (Ladrido-Ignacio, 2006).

Summarising the findings of literature review, most cases of post traumatic stress and PTSD reduces over 1-2 years time; social issues have significant influence on psychological issues and need to be addressed; psychological first aid is an effective and feasible intervention in post disaster settings; psychosocial support programmes in disaster recovery should contribute to enhancement of social capital leading to overall community development; and psychological and social ‘reactions’ in post disaster communities can be categorized into four phases.

Discussion

Thus psychological distress continues to exist all through the phases, though the stressors are different in different phases; a pattern of psychological and social changes in post disaster scenario emerges (figure 1); and predictable key social issues in post disaster communities are identified. Programmatic interventions appropriate to the changing phases as a continuum of psychosocial support from the immediate aftermath through recovery is proposed in table 1 in lieu of the findings.

Psychosocial support programming, as proposed in this article, is categorised into three operational phases. ‘Phase I’ covers roughly the first 4 – 6 months corresponding to approximately the traditional “Heroic” and “Honeymoon” phases described above. The ‘Phase II’ covers from 4 – 6 months to 1 – 1 ½ years corresponding to the traditional “Disillusionment” phase and the early part of “Restabilisation” phase. Finally, ‘Phase III’ covers from 1 – 1 ½ years to 3 – 5 years roughly corresponding to the “Restabilisation” phase. (See figure 1).

The key issues for programme intervention in Phase I are identified as Post Traumatic Stress and PTSD, Grief and loss and reduction of chaos and restoration of temporary order in the communities, in Phase II as stress due to secondary issues, need for accurate information, conflicts in communities, and community mobilisation in the context of sudden social disruption and in Phase III as development of individual resilience, reestablishment of stable community structure in the context of the disruption of the social structure of the community and development of state support and/or capacity for psychosocial support.

The key interventions in Phase I should be Psychological First Aid for the post traumatic stress and referrals for mental illness and social support through community teams aimed at providing basic needs, restoring community order, rejoining family members and restarting community functioning through temporary structures. ( See table 1 for interventions, rationale and benchmarks for programme phase). These will bring the immediate restoration of order to the chaotic situation as well as immediate psychological relief to the affected individuals (the need clearly reflected in the cases of Srilanka and Bangladesh). Justification for use of ‘Psychological First Aid’ and social support in this phase and the later phase is as described in literature review above.

In Phase II Psychological First Aid should to be continued to address psychological distress due to secondary stressors and referrals continued for the mentally ill (including PTSD cases from Phase I). The changed social dynamics need to be assessed and compared with the preexisting in order to plan the resilience building efforts. The volunteer network established in Phase I should be strengthened and used to provide social support measures appropriate to this phase such as information dissemination, community mobilization and conflict resolution. By this phase survivors will be keenly looking for information and conflicts are likely to break out between communities over resources (as is reflected in the cases of Maldives and Srilanka). Focus should also be directed towards a smoother and quicker transition to a developmental mode. ( See table 1 for interventions, rationale and benchmarks for programme phase).

Activities in Phase III need to build upon interventions done in earlier phases and consolidate the developments achieved. Establishment of a permanent community volunteer network for psychosocial support, advocacy and national capacity building on psychosocial support programming and continued disaster resilience building in the affected and vulnerable communities, are the suggested interventions. This will help in the transition from recovery towards enhancement of social capital, disaster resilience and socioeconomic development as reflected in literature review. This will also support policy development and long term impact as reflected in the cases of Maldives and Srilanka. ( See table 1 for interventions, rationale and benchmarks for programme phase).

Table 1 : Interventions, rationale and benchmarks for programme phase

PHASE I

Programme Interventions

Rationale

Key Programme Benchmarks

Other Programme Benchmarks

Formation of Community Teams for Psychosocial Support

Restoration of immediate and basic community social support and/or state support to complement efforts to reduce stress and prevent stress due to secondary impacts

Psychosocial Support Teams are operational.

Proper burials done.

Schools restarted.

Regular sharing meetings (Emotional Coping strategy) started.

Adaptation of basic cultural coping mechanisms (praying, seeking communal identity etc) being promoted.

Offices restarted.

Temporary shelters and camps set up.

Community kitchens/food aid in place.

Temporary Primary Health Care in place.

Provision of Psychological First Aid (PFA)

Psychological support to reduce Post Traumatic Stress of large populations quicker and prevent development of PTSD and subsequent overloading of the Health Systems of country. Also addressing Grief and Loss to prevent complicated bereavement.

Reached all individuals through PFA.

Emergency referrals done.

Basic necessities made available (food, clothing shelter, medical services).

Tracing of family members is started.

Adequate information flow is started.

PHASE II

Programme Interventions

Rationale

Key Programme Benchmarks

Other Programme Benchmarks

Continuation of provision of Psychological First Aid

Psychological Support to help individuals with Post Traumatic Stress and Stress due to secondary impacts

Reached all individuals through Psychological First Aid.

Emergency referrals done.

Assessment of preexisting and evolving social dynamics

Identification helps in structuring resilience building efforts starting from this phase into reconstruction.

Focus Groups for assessment of social patterns and factors done.

Development of the community teams into sustainable community volunteer network.

Volunteers trained to provide more than just basic PFA interventions and other basic services. The community has to quickly prepare for the long term reconstruction efforts.

Regular sharing meetings (Emotional and problem solving coping strategy) ongoing.

Adequate Information system set up.

Reduced community conflicts (including Internally displaced persons and Hosts).

Community mobilized.

Community initiatives regularly supported.

PHASE III

Programme Interventions

Rationale

Key Programme Benchmarks

Other Programme Benchmarks

Establishment of Permanent Community Volunteer Network for Psychosocial Support

Establishment of permanent network helps in continuing psychosocial support and promoting psychosocial recovery in the communities.

Network for Psychological First Aid availability in the community established.

Regular promotion of Self Care methods in communities set up.

Psychological First Aid delivery for day to day stressor done and referrals made.

Advocacy for Psychosocial Support at National Level

In order to ensure sustainability of psychosocial support resources generated and optimally utilised in the future disasters.

Psychosocial Support incorporated into National Disaster Response Plans/framework.

Government/Community Leaders committed to Psychosocial Support.

National Capacity Building on Psychosocial Support Programming

Without national capacity even if there is national policy to implement psychosocial support programmes it won’t still be possible to implement programmes. Also it is essential to ensure building capacity on all aspects of psychosocial support.

Government Personnel preferably of the Disaster Management Centres trained in Psychosocial Support programming.

Psychosocial Support Sector response plan for Disasters are laid out.

Mental Health/Psychosocial Support Referral System strengthened

Community Resilience Building in the affected/vulnerable communities.

This ensures the development of community’s capacity to respond in the crucial first 72 hours after the disaster. Also enhances social capital within the community which contributes to overall community development.

Community Disaster Resilience enhanced.

Social capital enhanced.

Community socioeconomic developmental initiatives started.

Resettlement of Internally displaced persons (IDPs) and integration of IDPs into host communities achieved.

Conclusion

There have indeed been several attempts by researchers and agencies to come up with a phasic design of psychosocial support programmes some of which (Newport and Padma, 2007; WHO - India, 2006) have been more thematic than programmatic and others (WHO, 2003) do not cover the complete recovery process as is described in this article.

The author has proposed a simplified and generic model on the basis of review of post disaster situations in three countries available literature as well as on the basis of his own observations in his work in post disaster situations in India (Orissa Super Cyclone 1999, Gujarat Earthquake, 2001), Srilanka (Tsunami, 2004), Maldives (Tsunami, 2004) and Bangladesh (Cyclone SIDR, 2007) with various humanitarian agencies. There is limited research on long term impact of disaster response programmes themselves in the areas of psychological changes, social development and overall development in communities. The proposed model is a basic framework which can be supplemented by further research and modified to a more feasible and applicable model backed by adequate evidence base to be used in future psychosocial support programming by humanitarian agencies. However, for the time being the basic framework can serve as a field level guide for development and implementation of psychosocial support programmes and help sort out fundamental issues of phase lock in of interventions, mismatch of planned programme activities with the situation of post disaster community and clarity of programme intervention rationale for all stakeholders including donors. The Inter Agency Standing Committee guidelines on mental health and psychosocial support in emergency settings, 2007 includes more specific interventions that can be used through this programmatic approach.

References

PHASE I
Programme Interventions	Rationale	Key Programme Benchmarks	Other Programme Benchmarks
Formation of Community Teams for Psychosocial Support	Restoration of immediate and basic community social support and/or state support to complement efforts to reduce stress and prevent stress due to secondary impacts	Psychosocial Support Teams are operational. Proper burials done. Schools restarted. Regular sharing meetings (Emotional Coping strategy) started. Adaptation of basic cultural coping mechanisms (praying, seeking communal identity etc) being promoted.	Offices restarted. Temporary shelters and camps set up. Community kitchens/food aid in place. Temporary Primary Health Care in place.
Provision of Psychological First Aid (PFA)	Psychological support to reduce Post Traumatic Stress of large populations quicker and prevent development of PTSD and subsequent overloading of the Health Systems of country. Also addressing Grief and Loss to prevent complicated bereavement.	Reached all individuals through PFA. Emergency referrals done. Basic necessities made available (food, clothing shelter, medical services). Tracing of family members is started. Adequate information flow is started.

PHASE II
Programme Interventions	Rationale	Key Programme Benchmarks	Other Programme Benchmarks
Continuation of provision of Psychological First Aid	Psychological Support to help individuals with Post Traumatic Stress and Stress due to secondary impacts	Reached all individuals through Psychological First Aid. Emergency referrals done.
Assessment of preexisting and evolving social dynamics	Identification helps in structuring resilience building efforts starting from this phase into reconstruction.	Focus Groups for assessment of social patterns and factors done.
Development of the community teams into sustainable community volunteer network.	Volunteers trained to provide more than just basic PFA interventions and other basic services. The community has to quickly prepare for the long term reconstruction efforts.	Regular sharing meetings (Emotional and problem solving coping strategy) ongoing. Adequate Information system set up. Reduced community conflicts (including Internally displaced persons and Hosts). Community mobilized. Community initiatives regularly supported.

PHASE III
Programme Interventions	Rationale	Key Programme Benchmarks	Other Programme Benchmarks
Establishment of Permanent Community Volunteer Network for Psychosocial Support	Establishment of permanent network helps in continuing psychosocial support and promoting psychosocial recovery in the communities.	Network for Psychological First Aid availability in the community established. Regular promotion of Self Care methods in communities set up. Psychological First Aid delivery for day to day stressor done and referrals made.
Advocacy for Psychosocial Support at National Level	In order to ensure sustainability of psychosocial support resources generated and optimally utilised in the future disasters.	Psychosocial Support incorporated into National Disaster Response Plans/framework. Government/Community Leaders committed to Psychosocial Support.
National Capacity Building on Psychosocial Support Programming	Without national capacity even if there is national policy to implement psychosocial support programmes it won’t still be possible to implement programmes. Also it is essential to ensure building capacity on all aspects of psychosocial support.	Government Personnel preferably of the Disaster Management Centres trained in Psychosocial Support programming. Psychosocial Support Sector response plan for Disasters are laid out. Mental Health/Psychosocial Support Referral System strengthened
Community Resilience Building in the affected/vulnerable communities.	This ensures the development of community’s capacity to respond in the crucial first 72 hours after the disaster. Also enhances social capital within the community which contributes to overall community development.	Community Disaster Resilience enhanced. Social capital enhanced. Community socioeconomic developmental initiatives started. Resettlement of Internally displaced persons (IDPs) and integration of IDPs into host communities achieved.

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