Community Mental Health in disaster situations. A review of community-based models of approach

A review of narrative literature is performed, aimed at exploring psychosocial intervention models in disaster situations. The documents reviewed were retrieved from PubMed, SciELO, GoogleScholar, and Medline, correspond to the period 1980-2014, and are written in Spanish, English and French. Web pages of international and government organizations were also searched. Four types of psychosocial interventions in disaster situations were identified: based on time, centered on a specific type of disaster, by spheres or levels of action, and person-centered. This review detected differences and similarities arising from the theoretical conception of disasters and the integral vision of the phenomena. The importance of creating and supporting programs based on community empowerment and participation as the basis for psychosocial intervention is stressed.


introduction
Natural disasters have affected Latin America throughout history, with various effects on society; this has originated in the region a widespread concern for the prevention and minimization of such effects 1 .For many persons, disasters constitute a personal tragedy that entails the loss of loved ones, homes, possessions, health and jobs.Their occurrence makes it necessary to deploy a series of strategies and concrete actions aimed at reinforcing individual, family and community support systems in order to increase their capacity for coping with possible mental health crises.
For a variety of reasons, which include political, economical, and administrative ones, many Latin American communities currently lack suitable preparations for coping with disasters, and these shortcomings entail the impossibility of a quick and effective response to the various effects of some catastrophes.
An increasingly important approach to the study of disasters is related to their psychosocial effects on the persons affected.Thus, the main challenges in the field of mental health are posed by the necessity of coping with these psychosocial effects in the heterogeneous array of Latin American countries, by the international experiences that have been carried out in the region, and by the available models of psychosocial intervention that might be adapted to a particular affected area by taking into consideration the cultural peculiarities of each country.
This review aims at examining the models known so far for approaching mental health issues in disaster situations.

Method
This study consists of a review of the narrative literature on disasters, which in our opinion is the most appropriate type of publication for describing and discussing the development and state of the art of this particular subject matter, both from a contextual and a theoretical point of view 2 .Due to the specificity of the topic of psychosocial interventions in disaster situations, the selection of documents for the corpus was based upon intentional criteria.The papers, book chapters, reports, and institutional reports were traced to various sources.For book chapters and papers published in scientific journals, the following databases were searched: PubMed, SciELO, Google Scholar, and Medline, using key words such as "disasters", "emergencies", "mental health", "community mental health", "mental health services", "disaster relief planning", "psychological intervention".The period selected was 1980-2014, so as to include some disasters which, for their importance, were worth reviewing.The languages of the documents searched are Spanish, English, and French.
Besides, the websites of governmental agencies and international organizations (WHO/ OMS, PAHO/OPS, UNISDR/EIRD) were searched to gather data on documents related to experiences and results in disaster situations.
The literature was analyzed on the basis of the theoretical conceptions of disaster and of experiences of working with persons who have undergone disaster situations.
The EM-DAT database was also accessed.EM-DAT is a database that contains data on emergency events.It was developed by CRED, the Centre for Research on the Epidemiology of Disasters, based in Belgium, and contains essential data on the occurrence and effects of more than 18000 large-scale disasters around the world, from 1900 to the present, which has been gathered from various sources, including United Nations offices, non-governmental organizations, insurance companies, research institutions, and news agencies 3 .Data was retrieved from this database on those geophysical and hydro-meteorological events that occurred in Latin America and the Caribbean, in the period 1900-2011, resulting at least in 10 people dead and 100 people affected, and which involved international assistance and declaration of the state of emergency (Table 1).

History of disasters in Latin America
In the American continent, the combination of a complex geographical configuration with political, social, cultural and economic conditions has configured different disaster scenarios according to geographical regions.Thus, hurricanes and tropical storms have a higher frequency of occurrence in Central America and the Caribbean, whereas earthquakes and volcanic eruptions take place in the Andean countries.On the other hand, the areas adjacent to rivers that flow through steep slopes are affected by floods, mudslides, and landslides.In recent years, tsunami alerts have been reported with increasing frequency in countries of the Pacific Coast 4 .
The following is a list of the disasters that caused the highest death tolls in some countries of Latin America and the Caribbean from 1900 to 2011, classified per type of event, which has been retrieved from the EM-DAT international database 3 (Table 2).

Disasters and vulnerability
First, it is necessary to clarify the concepts associated to the terms "disaster" and "vulnerability".Romero and Maskrey 5 distinguish between natural events occurring with some regularity, such as summer storms and tropical hurricanes, and unusual disasters, such as tsunamis, avalanches, mudslides and floods.The irregular occurrence of the second group does not imply that they are not foreseeable -it is commonly accepted that all disasters have a certain degree of foreseeability, which is mainly dependent on historically constructed social processes which are peculiar to the communities affected by those disasters.
According to Wilches-Chaux 6 , the occurrence of a natural event, whether ordinary or extraordinary, will not necessarily cause a disaster in the community.It is acknowledged that for a disaster to impact on a community there must be a combination of two factors: the natural threat and the vulnerability of the community to the effects of disaster.These elements interact in a network of active and dynamic relations: society-menace-vulnerablity.
The United Nations Organization has noted that disasters cause a serious disruption of the functioning of a community or a society, involving widespread human, material, economic or environmental losses and impacts, which exceed the ability of the affected community or society to cope with them using their own resources 7 .Disasters also entail a marked reduction of the development potential of the affected areas both in the medium term and in the long term [8][9][10] and, in the future, their impact on populations may be aggravated by the effects associated to climate change 11 and to the complex emergencies that follow the original impact 12,13 .

effects of disasters on the mental health of communities
The response of people to disasters and other traumatic situations in which they perceive a danger to their lives or suffer the loss of material assets, family and loved ones, may include mental disorders.These, as described by Buckley et al. 14 , may include a reliving of the trauma, and the cognitive-behavioral avoidance of stimuli associated with trauma.
The reviewed literature points to the psychosocial effects as some of the most weakening long-term results of disasters on individuals [15][16][17] .Despite the fact that a considerable number of persons experience situations of danger and anxiety, most of them go back to their daily activities and continue to function normally.Yet, some of them may experience the persistence of stress symptoms that affect their behavior and functional capacity and may progress to Post Traumatic Stress Disorder, depression and other mental disorders 18,19 .The World Health Organization acknowledges that disasters pose a heavy burden on the mental health of the affected persons, the majority of whom live in developing countries, where the capacity to cope with those problems may prove very limited 20 .
This has led some authors to research the characteristics of psychosocial interventions in disaster situations, and to conclude that the most common types of interventions are group assistance and workshops.Other authors point to the precariousness of organizations for coping with catastrophes 21 .
There are descriptions of the most frequent consequences on the mental health of the affected communities, including Post Traumatic Stress Disorder (PTSD) and depressive disorders 22 .In this area, the Pan-American Health Organization (PAHO) 23 has noted that emergencies and disasters entail a psychosocial disturbance which exceeds the coping skills of the affected population.The impact of disasters is also dependent on the social and economic dimensions: people who suffer severe housing damages, especially those belonging to the lower-income strata, and those who lose their work and livelihoods are likely to have a more pronounced psychological impact.
The literature also points to the association of pre-existent vulnerability factors to more pronounced negative consequences for the mental health of the affected persons.Thus, poverty and gender differences, combined with the level of exposure to disaster, may be decisive for the presence of symptoms of depression, anxiety and Post Traumatic Stress Disorder 24 .There is also evidence of the relationship between post traumatic mental disorders and physical alterations such as fatigue, cephalea, gastralgia, and cardiopathy 25 .resilience Resilience is conceived as the ability of a person or a group to recover from the effects of adversity and continue planning for the future 26 .It is commonly accepted that resilience varies depending on personal characteristics and environment peculiarities which will be dealt with below.There is evidence that, after certain traumatic experiences, survivors may show resilient behavior both in their physical and mental health, as evinced by the fact that they do not develop chronic pathological symptoms 26 .

Factors influencing psychosocial impact
According to PAHO 27 , the psychosocial impact of disaster on people may depend on many factors; some of them may be classified according to the following categories: • The nature of the event.
• The personality traits and degree of vulnerability of the affected persons.
• The environment and the circumstances.

The nature of the event
The events that produce the strongest impact are the unexpected ones, those caused by man, those entailing situations of prolonged stress and affecting people collectively.Events such as earthquakes, avalanches and mudslides do not allow time for deploying individual or collective prevention strategies and may result in feelings of helplessness, and emotional reactions like seeking someone to lay the blame on; this reactions somehow inhibit the capacity to reflect and make appropriate decisions.

The personality traits and the vulnerability of the affected persons
Large-scale disasters, which entail emergencies of a collective nature, generate a major impact, because people live not only their personal tragedies but also those of friends and relatives; besides, the social and family support network is affected 27 .Some age groups are more vulnerable than others, such as children and advanced-age people.Age, gender and the characteristics of the population affected should be taken into account, since catastrophes will have different consequences for children, adolescents and senior adults 28 .Moreover, psychosocial needs and coping resources will also differ, depending on the roles they play in their ethnic and social environments 29 .

environment and circumstances
Disasters do not choose their victims, but they obviously hit harder in the case of families belonging to poorer communities, who are in situations of social vulnerability, and who may have serious limitations of access to social and healthcare services [30][31][32][33] .
Assistance should be provided with a maximum of organization; delayed assistance may become an additional problem, and it may trigger social conflict.Another aspect to take into account is the media treatment of disaster situations, since this is a factor that may foster the social processes arising from humanitarian emergency crises.
In cases requiring population displacement measures 34 , it is necessary to assess the possibility of relocating families in houses of relatives who reside in areas that have been less affected by the event; it has been shown that coping is more effective when accompanied by family support 35 .Group management is a valuable skill for those in charge of refugee camps, particularly when it becomes necessary to handle problems that derive from the coexistence of various social groups having heterogeneous cultural patterns and practices.
According to PAHO, individual responses in coping with disasters may be differentiated in three phases or moments: the pre-disaster phase, the disaster or impact phase, and the post-disaster phase.
Those events that develop unexpectedly and over a very short period of time practically leave no room for individuals or families to put up some type of preparation for coping with the disaster.
During the impact phase of disasters, individuals must cope abruptly with potentially terrifying incidents.Emotional reactions are intense, individuals feel that their lives have been disrupted and their reactions range from paralyzing fear to inordinate agitation, and from sensory anesthesia to extreme pain 36 .This implies that people may experience some degree of difficulty for making decisions.
In the post-disaster phase, there may remain in the community a latent fear for the recurrence of the event; this may originate sleep disorders, loss of appetite, and difficulties in the normal performance of daily activities.
Sleep disorders may persist for a few days, a frequent occurrence in persons who have been moved to refugee camps that shelter a great number of families; feeding and personal hygiene may also pose problems in cases of delayed humanitarian assistance or faulty distribution organization.
In cases of severe collective impact, PAHO 27 states that in this phase, the damage to family and social cohesion is already noticeable, which obviously makes it difficult for individuals to overcome the trauma.If there is additionally a persistent threat of or need for evacuation, it is easy to understand that readjustment processes may be delayed and psychological symptoms may be aggravated to become permanent sequelae.In this case, each individual undergoes internal processes mediated by the need to simultaneously handle their personal emotions (mourning, losses) and interpersonal relations (compromise with the other); during this phase, the performance of daily activities may constitute a heavy burden for some of the affected, whereas for others these activities may provide an opportunity to start healing the gap in their routine life experiences.

Models of psychosocial intervention in disasters in Latin America
In the international literature, it is observed that there are various models of psychosocial intervention in disaster situations, which have been implemented from different conceptual perspectives.There are models based on a human development approach, on a biological-epidemiological approach, and on a community approach.They stem from what is conceived as mental health and from the meaning ascribed to the term "disaster".In recent years, a change of paradigm has led to an emphasis on the conception of integral mental health, which shifts the focus from the individual to the community, and from the deficiencies to the potentials of the community 37 .
Intervention models may be classified in four groups: interventions based on time, interventions that are centered on specific types of events, interventions according to levels of action, and interventions centered on persons.The following is a brief description of the distinctive features of these approaches.

interventions based on time
This model emphasizes the moment of intervention: before, during, and after the disaster.Responses prioritize two aspects: the consequences of disasters for the community and the actions that may be carried out by the professionals of that community.This leads to the implementation of actions and strategies in accordance with the evolution of the disaster in its different phases 38 .
Despite the fact that international experiences in interventions appear so far to be focused on the emergency (event-centered), in recent years the model has began a change towards a transverse-in-time approach, in which the concepts of integrality, promotion, prevention and recovery have become prevalent 39 .

interventions centered on a specific type of disaster
Within this model, interventions are focused on a specific type of disaster, and they develop action strategies based on the precipitating factors of the event.The following are some examples of international experiences exhibiting strategies of this emergency-focused approach.: • Ecuador, through the PAHO 40 , in a document which focuses on volcanic eruptions.
• Peru 43,44 in the cases of the Pisco and Ica earthquakes.
• Chile, in the case of the earthquake and tsunami of February 27, 2010 45,46 .Also, the earthquake and mine rescue of 2010 47 .
• Dominican Republic's humanitarian assistance to the people evacuated as a result of the Haiti earthquake of 2010 48 .
• The 1999 floods in Venezuela, known as the Vargas' Tragedy 49 .

interventions by levels or spheres of action
In this model, interventions are no longer centered on survival and material recovery, but on integrated levels according to the needs of the affected population, and taking into account the various sectors of action.An important asset is the capacity to bring together the affected community and other social actors into the processes carried out by various institutions to solve the needs of the different levels in a disaster situation.The Sphere Project 50 is an international initiative based in Geneva that has pioneered the implementation of integral strategies in disaster situations.

Person-centered interventions
Models related to this type of intervention put the stress on the empowerment and participation of the affected community in order to integrate it to the assistance activities.The focus is centered on community potential rather than on its deficiencies.Mental health is conceived as having a community component which seeks to integrate promotion, prevention, assistance and recovery, both at family and community levels of the population affected.An instance of this model is a manual and guidebook for mental health developed in Colombia 51 .

The orientation of psychosocial interventions in the face of disasters
In recent years, the change of paradigm has raised a growing concern over the capacity and quality of response to the impact of emergencies and disasters on the mental health of affected communities.This concern, which is shared by governments, international organizations, scientific societies, and intervention teams, has favored the coordination of various fields of knowledge and led to an integrated approach to interventions.
The American Red Cross 52 has developed the concept that it is not necessary to have professionals or specialists in the communities to deal with the emergencies caused by a disaster, provided there is availability of a working group of persons who are sensitive to the emotional needs of the victims and who are prepared to listen and interact with others around them and to create an atmosphere of safety and hope.For this institution, it would be highly beneficial that the first intervention in disaster crisis situations be in charge of persons belonging to the community, who are in a position to make immediate contact with the victims.
According to PAHO 27 , the interventions on persons affected by traumatic events may be developed following two modalities.
One is the so called Emotional First Aid, which aims at restoring immediately the person's psychosocial equilibrium.PAHO recommends that this help be offered by non-specialized personnel who get in touch with the persons affected by the disaster in the first moments following the event.The other modality is a Specialized or Professional Intervention for Psychiatric Emergencies.
This organization also points to some strategies to be considered for intervention in crisis situations: • Intervention should be prompt and efficient: assistance should be provided with propinquity.
• It should have well defined short-term objectives, with realistic expectations.The intervention should aim at reducing symptoms and stabilizing the psychosocial status of the person and their family.
• It should be done using simple and clearly aimed methods, with pragmatism and flexibility, offering support and empathy.It should foster group, family and social solidarity.
• Intervention approach should be integral; besides the therapeutic action, it should be preventive and have a social perspective.
Some specific technical resources for the care of mental health are also mentioned 27 : • Selection or triage: procedures for the selection of cases to be given assistance immediately after the disaster, aimed at reducing cognitive and emotional disorganization.
• To help the person restructure and redirect their life in the face of the crisis being experienced, and to reflect on the critical incident in such a way as to counteract excessive emotions.
• To allow free disclosure of emotions and trauma verbalization, which helps reduce symptoms.Many techniques for treatment of posttraumatic reactions are based on the person's skill for recalling and integrating traumatic memories through verbal expression.
• To foster understanding of loss of control as a possible normal reaction in a crisis situation.
• Use of spiritual or religious resources.Well conducted crisis interventions based on spiritual help offer highly favorable prospects.
• Group work.Disasters disrupt daily routines of persons, families and communities, and heighten perceptions of isolation and helplessness, which in turn may increase the need to socialize.In this case, the sense of belonging to a group serves to strengthen the self and facilitates support through dialogue and exchange.PAHO 27 states that groups may participate and help in community management work, coordination, and networking.Group formation fosters confidence and creates environments for sharing experiences, expressing feelings and seeking coping alternatives.Groups allow persons to externalize and verbalize emotions and to acknowledge feelings.They foster solidarity and mutual support, and help to develop a sense of belonging and identification with the group.

Discussion
This review of the literature detected issues such as social vulnerability as one of the factors that influence the psychosocial impact of disasters, and the effects of disaster on the mental health of the affected persons.Various perspectives were identified as regards disaster conceptualization, which in turn have a bearing on the psychosocial approaches.
This study also reviewed a series of models for approaching mental health issues in disaster situations.Several perspectives for community mental health in these situations were included: interventions based on time, interventions centered on specific types of disaster, interventions by levels or spheres of action, and person-centered interventions.
The models analyzed evinced substantial differences, since they were developed starting from different perspectives such as time, type of disaster, persons, and actions.Also, some similarities were detected among those strategies based on levels of action and those centered on persons, since both of them favor an integral vision of the phenomenon.It was also noted that, as a result of such differences and similarities, some models of approach to community mental health may be more debatable than others, on the basis of the theoretical conceptions of disaster, particularly as regards the issue of the origin of disasters: the social construction of disasters and, as its counterpart, the emergency-centered approach.The majority of the documents reviewed are addressed to the professionals involved; few of the documents retrieved suggest interventions in which community participation is the fundamental asset (besides the recommendations of international organizations.)This suggests the need to advocate and generate programs in which community empowerment and participation are at the core of psychosocial interventions.
All of the above has led to the conclusion that both the ambiguity in the conception of disasters and the preventive conception may lead to different results.It was also detected that the purposes of the interventions are defined in a general way whereas the objectives and goals are not clearly defined, which may cause serious difficulties in the evaluation of the intervention results 37,38 .
As regards the quantity of the interventions ascribing to the various perspectives, it was observed that a greater number of publications corresponded to interventions whose core strategy was the specific type of disaster, as in the case of the Chile earthquake and tsunami of 2010, and the mine rescue in the same country and year, as well as earthquakes in other Latin American countries.
The systematization of experiences and models of approach to psychosocial problems in communities affected by disaster situations is still incipient, and its importance should be stressed for making available documents that may serve as a guide to professionals, communities and organizations 37 .
According to Osorio Yepes et al. 37 , though the majority of experiences of interventions originate in institutions and independent organizations, it should be stressed that the main responsibility for these strategies lies in the governments and their institutions, because the success of such strategies depends primarily on their sustainability over time, on the political and economic support that permits their steady and integral execution, and on the decentralization of decision making in the management of intervention programs.It is also necessary to generate community networks 53 based on intersectoriality; though these networks are recent and incipient, as a result of the characteristics of the event, they have a potential to facilitate multisectorial work for emergency intervention; besides, other elements are necessary, such as community involvement, sustainability over time and government support 45 .
Finally, it is important to take into account that the social and economic circumstances that cause vulnerability play a key role and affect the mental health of the persons involved in disaster situations.In other words, social gradients cause the emergence and persistence of mental disorders and, therefore, programs and interventions that purport to protect mental health should aim strongly at reducing social inequalities, which stresses the importance of supporting preventive and participatory interventions 54 .

Table 1 .
Distribution of reviewed articles per source and language of publication

Table 2 .
Disasters with highest death tolls per country and type of event in Latin America and the Caribbean.Years 1900 to 2011.EM-DAT database.