2.       Introduction 

On September 20, 2017, Hurricane Maria, the strongest hurricane to hit Puerto Rico in almost a century, struck the Island of Puerto Rico as a Category 4 hurricane, bringing winds upwards of 150 miles per hour. For 36 hours, the hurricane crossed through the center of the town of Yabucoa in the northeastern part of the island, exiting to the northwest near the town of Hatillo. Heavy winds, rains of up to 32 inches, and mudslides left the island without electricity, potable water, access to health facilities, or communication within and outside the island. After 4 months, the recovery process slowly reached the towns located in the swath of destruction left by the hurricane [1]. 

3.       Community-Based Psychosocial Support and Community-Centric Interventions During Immediate Recovery (October 2017-January 2018) 

A mental health and psychosocial program has been in operation in Ponce, Puerto Rico (the second-largest island) since the first decade of the century [2]. A program that might assist people affected by a disaster is community-based psychosocial support for individuals, families, the affected community, and the larger community [3]. Community-based psychosocial support is centered around three principles: (a) providing safety and security, (b) teaching the importance of altruistic behavior of psychological, social, and spiritual tithing, and (c) teaching the importance of speaking truth to power in support of the under-represented [4].

At the individual level, the program encourages people affected by a disaster to modify behaviors that reflect helplessness and hopelessness and to use community activities to adapt behaviors that lead to the production of greater personal effectiveness. Once those affected begin to feel a sense of freedom and enhanced capacity to move forward as a result of their new behaviors, they will be encouraged to identify a group of peers that can assess their community’s needs and assets and collaboratively plan and implement contextualized recovery activities [5].

An engagement process that involves the community has been suggested, using the following six steps [6,7]: (A) assess needs and the existing assets, (B) developing a shared vision, (C) collaboratively plan and take action, (D) network for external resources, (E) determine the outputs, and (F) determine the impacts. 

3.1.  Step A: Assess Needs and the Existing Assets 

At this stage, community volunteers are identified, and basic training is conducted on topics of psychological first aid, participatory functional assessment, and community mapping, including social capital as well as infrastructure [8]. The premise for this activity is that people affected by disaster have first-hand knowledge of their community prior to the disaster, what has happened in their community, and what should take place to recover and enhance resilience. 

3.2.  Step B: Develop a Shared Vision 

In the initial phase, affected people are encouraged to (a) identify activities that inspire participation in all segments of the community, (b) share experiences, stories, and traditions pertaining to how community crisis was dealt with in the past, and (c) envision a future so that the initial feelings of hopelessness and helplessness can be overcome. Residents in disaster areas take active roles in identifying and analyzing needs, project development, and decision making based on their priorities and vision for their future. 

3.3.  Step C: Collaboratively Plan and Take Action 

3.3.1.         Articulating strategies 

At this stage, community members are encouraged to become engaged in activities that will foster their growth in an inclusive way. These activities can include, but are not limited to, the following: (a) providing accurate and timely information about resources, services, and common reactions; (b) providing human capital from the victims in the community; (c) providing materials, cash, and labor from community residents in disaster zones and providing technical assistance from outside stakeholders; and (d) taking independent actions, to be completed by community residents, not external sources. 

3.3.2.         Defining interventions 

Once the broad strategies have been identified, the interventions are tested. This is when activities are experimented with and the best match between disaster-affected people and appropriate broad strategies are identified. For example, some people will share information, while others will want to construct. Some will implement psychological first aid, whereas others will conduct informal educational sessions with youth. 

When planning the initial interventions using a community-based psychosocial support program, the residents in disaster areas must cycle through the following six core interventions: (a) providing accurate and timely information, (b) engaging in formal and informal educational experiences, (c) identifying and enhancing support and resources, (d) increasing access for the entire community population, (e) monitoring, and (f) reporting.

3.3.3.         Community and school activities 

After the initial response, those affected by disaster oversee both initial and long-term recovery in their respective places and communities, and these activities occur primarily in community and school settings. At the community level, activities include improving the environment and reconstructing places. In schools, efforts focus on re-establishing formal schooling for children and adolescents and conducting informal school activities for youth and adults in the community. The emphasis at this stage is getting all the people engaged in long-term recovery. All projects are considered and supported by the coordinating committee, which is composed of community residents. Eventually, social capital is identified, and small community-wide projects and income-generating activities can begin and develop in conjunction with the recovery process planned by the community. 

Psychosocial support activities typically serve as platforms for additional activities that are more concrete in nature. This is a good time to initiate documenting the community engagement steps of the neighborhood recovery process. In other words, the steps taken are documented, and the changes led by the community residents are recorded. The adaptations made by the residents to settle into life in the new community, the institutionalization of changes, and the capacity-building activities are monitored and reported to the diverse groups in the community as signs of success and having the ability to enhance resilience and well-being. 

3.4.  Step D: Network with External Resources 

Usually, the community-based participatory process introduces needs that had not been identified or that had not been addressed for a lack of community capital. Part of the planning process is to bring the needs of all segments of the community to light. Once it is clear that external resources, technical, financial, and psychosocial needs are necessary to promote the re-construction of place through recovery activities, it is important for community members to approach external stakeholders and develop coalitions that will provide for the community’s ultimate goals to rebuild itself. This might include people having a home to share with their family, neighbors, and community. People feel safe when they walk around the community, and they want to volunteer time to improve place. One area that external funds and university research projects can facilitate is in assisting the community to rebuild itself psychologically and spiritually through the recovery of their history, community stories, and the past. Networking with outsiders can be a means whereby people can understand where they came from, where they are now, and how they see themselves moving forward. 

3.5.  Step E: Determine Outputs 

The steps in the process to re-establish a sense of place and develop the community do not occur in a neat, sequential manner. Important actions occur in sequences that are specific to the situation. If a community is able to successfully bring about changes, its capacity to create even more community changes related to the group’s mission should improve. Among the important outputs is the generation of trust to the extent where the community shares common risks and protective factors. Multiple communities can formulate a partnership to elicit funds from an external stakeholder so that new community changes and desired outcomes can be realized. 

Some initiatives might work well to foster growth in one disaster-affected community but not in another; thus, remaining flexible in the adoption of interventions is crucial. This ensures the creation of an approach that belongs to community members and has been modified to fit community needs. Moreover, by changing interventions to fit local needs, community members can improve the ability to take care of their own problems. 

3.6.  Step F: Determine Impacts 

Field personnel can follow up on the community re-establishment of place and determine the effectiveness of the steps toward resilience by assisting the affected communities in identifying the tools needed for following the effectiveness of their recovery process. Some of the perceptions of the community members might be that a sense of place has been re-established, resilience has been enhanced, community well-being is on the rise, and small businesses have returned. This can be accomplished by developing a scorecard that includes information about the community: its mobilization; willingness to share information with all its segments; ability to gather information, develop, and execute recovery plans; passion for immediate community action; and desire to share its achievements. Ultimately, these programs should help residents in disaster areas to transform from victims to victors. 

4.       Essential Components for a Long-Term Institutionalized Recovery Psychosocial Support Response 

For a community-based psychosocial support program to be effective in Puerto Rico, we suggest that the Puerto Rico National Response Plan include the following steps [9,10,11]: (a) integrate psychosocial support into the National Emergency Plan, (b) appoint a lead agency, (c) collaborate, and (d) develop and widely disseminate technical material. 

4.1.  Integrate psychosocial support into the National Emergency Plan

Psychosocial support should be integrated into disaster preparedness and contingency planning by considering capacity-building workshops and quarterly drills, and all stakeholders and resources should be identified and listed. 

4.2.  Appoint a Lead Agency 

One government entity should be appointed to lead both mental health and psychosocial support responses. This response should be cleared at the central level before being implemented at the lowest level, the community. 

4.3.  Collaborate 

Collaboration amongst all government entities should be encouraged, specifying a clear chain of command and responsibility for mental health and psychosocial support. The lead government agency should be responsible for developing a plan and determining coordination mechanisms and responsibilities in consultation with stakeholders at the senior and community levels with clear chains of command to the municipal level and earmarked responsibility for psychosocial support emergency response. 

4.4.  Develop and Widely Disseminate Technical Material 

If originally in English, materials to be used by government and non-government partners in all Puerto Rican municipalities should be translated to Spanish, validated both culturally and contextually, and made shelf ready for immediate use. Guidelines and psychosocial support intervention manuals should be disseminated to mental health professionals working in community private offices and community hospitals and to general-level health staff (doctors, nurses, community health workers, and local volunteers). Materials should also be disseminated to human resources outside of the health field (teachers, religious leaders, and volunteers). General documentation and guidance should be made available to the media and the general public, focusing on psychosocial support issues, coping, sources of support, and available care. Guidelines should also be available for the care of children, the disabled, the disadvantaged, and the elder population. Finally, guidelines for family tracing, reunification, child abuse, and gender-based violence should be available. 

5.       Summary 

In this paper, the psychosocial effect of Hurricane Maria in Puerto Rico was introduced. Community-based psychosocial support as a tool for immediate response and recovery was proposed. Finally, suggestions for developing wide-encompassing plans to institutionalize psychosocial support in the Puerto Rico National Response Plan were proposed.

1.       Conelly Holmes R (2017) Is Been 10 Weeks Since Huracane Maria hit Puerto Rico. Here’s Where Recovery Stands, PBS/WETA, Washington, DC, US, xx-xxx.

2.       Jimenez J, Rivera D, Benitez P, Tarrats H, Ramos A (2013) Integrating mental health services into a general hospital in Puerto Rico. J Clin Psychol Med Settings 20: 294-301.

3.       Prewitt Diaz JO (2017) Hurricane Maria, personal and collective suffering, and psychosocial support as a cross-cutting intervention. J Trop Psychol 7: 1-7.

4.       Prewitt Diaz JO (2018) Individual and community psychosocial support in the immediate response and early recovery of Hurricane Maria. Int J Emerg Ment Health 20(1):1-8.

5.       Prewitt Diaz JO (2013) Community based psychosocial support: an overview. In: Arora R, Arora R (Eds.) Disaster Management: Medical Preparedness, Response and Homeland Security, CABI, Boston, MA, US, xxx-xxx.

6.       Silva Caraballo F (2017) Intervention of In CiCo in Community Response and Recovery Initiatives before the Effects of Hurricane Maria on the Island of Puerto Rico, Institute of Sciences for the Conservation of Puerto Rico, Trujillo Alto, PR, xx-xxx.

7.       Inter-Agency Standing Committee (2017) A Common Monitoring and Evaluation Framework for Mental Health and Psychosocial Support in Emergencies, IASC Reference Group for Mental Health and Psychosocial Support in Emergency Settings, Geneva, CH, xx-xxx.

8.       Sharifi A (2016) A critical review of selected tools for assessing community resilience. Science Digest. Ecol Indicators 69: 629-647.

9.       Schwab JC, Editor (2014) Planning for post-disaster recovery: Next generation. PAS report 576, American Planning Association, Chicago, IL, US.

10.    MHPSS (2010) Mental Health and Psychosocial Support in Humanitarian Emergencies: What Should Humanitarian Health Actors Should Know? IASC Reference Group for Mental Health and Psychosocial Support in Emergency Settings, Interagency Standing Committee, Geneva, CH, pp. 32-96

11.    Institute of Medicine (U.S.) Committee on Post-Disaster Recovery of a Community’s Public Health, Medical, and Social Services (2015) Healthy, Resilient, and Sustainable Communities after Disasters: Strategies, Opportunities, and Planning for Recovery, The National Academies, Washington, DC, US, pp. 432-496.