UNICEF programme provides trauma counselling in Nicaragua

The sorrow and the guilt: Psychological help for disaster-affected children
CHINANDEGA, 9 August 1999 (UNICEF)

An eight-year-old boy said he felt remorseful because he had been unable to save his family's cat, dog, pig, and harvest. A mother recalled how she had to remain standing because she was surrounded by dead bodies, including her daughter's. A 14-year-old teenager explained how he had used an ox to save people, momentarily forgetting he was now the last surviving member of his family. Dr Ruth Romero, a soft-spoken clinical psychologist who works in north-western Nicaragua, says she will never forget the tales of the victims of Hurricane Mitch. The disaster that devastated entire Nicaraguan towns and villages in late October 1998 did not only wreck bridges and roads. It also shattered children's lives -- especially in the Chinandega department where landslides engulfed entire communities. Dr Romero asked children who had witnessed death and destruction to describe their feelings. Their answers poured out of them like the mud that poured down Chinandega's volcanoes. They spoke of their sadness, their tears and their grief. Many felt disheartened, no longer hungry, perpetually tired from lack of sleep and hellish nightmares. They admitted they felt insecure and fearful, terrified by the very thought of future landslides, loud noises and even rain. Some also confessed their guilt about having survived when so many around them had died. "I met an entire family that felt guilty about having survived," Dr Romero recalls. Hundreds of traumatised children were identified across Nicaragua in the aftermath of Hurricane Mitch through a UNICEF psycho-social programme known as "The Return of Happiness" (El retorno de la alegria). The programme's goal was to identify children who had been psychologically wounded -- and to make sure that all children affected by the natural disaster would return to class after school resumed in February. Nicaragua's drop-out rate is high already. An astonishing 24 per-cent of pupils leave school after grade one. And UNICEF wanted to make sure that the pupils' grief and pain would not fuel a hopelessness that might lead them to leave in even greater numbers.

Suicide attempt

Thousands of children saw their world collapse when Hurricane Mitch struck. Many lost a parent. Some lost both. Some boys and girls were themselves carried away by the rising waters, narrowly escaping death. It was felt that recovering from such an experience would take time and effort, and that ignoring this would lead to more tragedy. At least one traumatised boy in the Chinandega department, the hardest-hit by the catastrophe, attempted to commit suicide, Dr Romero noted. Concretely, the Return of Happiness programme starts with a day of children's activities known as a "Carousel." The Carousels, which were organised in disaster-stricken communities, alternate between serious and fun. Boys and girls are divided into three age groups (under-sevens, seven to 14, 14 to 18) that move from one activity to the next. Children race and shout in play. But they also take part in serious business. In an attempt to capture on paper the harsh scenes that they witnessed, they are asked to draw. In small discussion groups, they are also encouraged to express their emotions in their own words. "We try to focus on feelings because we already know what happened," remarks Dr Jorge Ivan Lopez, a physician and UNICEF consultant who has worked on a similar scheme with traumatised children in war-torn Colombia. UNICEF trained volunteers, mostly teachers and university students, who themselves trained yet more volunteers in an effort to reach up to 200,000 Mitch-affected children. Participants are taught to look out for tell-tale signs that something might be wrong. Are the children playing with the others? Are they withdrawn or silent? Are they aggressive or violent? Are they crying? "Tears do not necessarily mean very much," explains Dr Ivette Sandino, a UNICEF paediatrician. "Children cry when they fall. But tears can also mean: 'Pay attention to me.' And that's when we have to take the child aside and ask a few questions." Throughout the day, children who show symptoms of psychological scarring are referred to a team of psychologists and psychiatrists from Nicaragua's Health Ministry. These are the people, including Dr Romero, who determine what kind of follow-up attention is needed for those who need help most desperately. The "therapy" is usually directed at the family as a whole, including the parents, because they play a key role in shaping the child's perception of the hurricane and its consequences.

House calls

By and large, parents are co-operative when psychologists, psychiatrists or social workers conduct follow-up visits, according to Dr Jacqueline Beker, a Health Ministry physician in Matagalpa. "There hasn't been a single case of refusal to co-operate because the parents -- usually the mothers -- have already seen us at the Caroussel," she notes. But the psychologists themselves sometimes find this approach to therapy somewhat challenging. It is not always been easy for some Health Ministry employees who seldom go out to remote communities to see patients in their homes or shelters. "Many of them are used to seeing patients in their office -- not in the field," observes Dr Beker. "For some it was an eye-opening experience." In Chinandega, more than 330 traumatised children were identified. Their parents sometimes describe their children's problems with an all-encompassing word -- "nervios" (nerves) -- and psychologists have to probe for details. They usually find that these boys and girls harbour feelings of anxiety, that they suffer from headaches and that they have difficulty concentrating. As if their experience of the hurricane was not bad enough, many children whose families lost their homes wound up in a shelter for the homeless where -- as if often the case in refugee camps -- family violence increases. This came come out when Dr Romero asked small children to play with raggedy puppets used to personify their parents. "So you're drunk again!" a child had his "mother" say. "Shut up or I'll hit you!" the "father" responded. Although it has been generally favourable, the communities' response to the Carousels has varied considerably. In one village, Las Conchitas, south of Managua, the local people decked the only road leading into the community with colourful flags and arches. The village's festive airs helped contribute to the spirit of the "Return of Happiness" programme. In another town, however, a boisterous group of children suddenly became aggressive for no apparent reason and turned against one of the psychologists who was thrown into a basin of water. Specialists were not able to provide an explanation for such behaviour.

'Educational bridge'

The main difficulty in organising a psycho-social programme on such a scale was time. It was quickly realised that the Carousels, which involved hundreds of people, take a lot of time. Out of 10 Carousel s that were to be held in the department of Matagalpa, for instance, only four had gone ahead in the six-month period that followed the hurricane. But going ahead too quickly sometimes proved hazardous. In Ciudad Dario, north of Managua, the Carousel was carried out without any professional psychological help because of poor logistics. The Return of Happiness, however, is not only meant to identify children in need of special psychological attention. Its purpose is also to encourage children at large to remain in school by establishing a link between the regular school year, which was disrupted, and the new school year. Targeting children whose schools were destroyed or damaged, UNICEF organised non-formal educational activities that were carried out by volunteer teachers on their "summer" (dry season) break. Teachers focused on basic health and sanitation, child rights and the environment. Children were reminded, for example, that hurricanes are an extreme but natural phenomenon and not "monsters" or "God's punishment," as some small children sometimes said. This programme, known as an "educational bridge" (puente educativo), trained 700 volunteers, primarily elementary and secondary school teachers from the seven municipalities that had suffered the most -- municipalities where schools were partially or entirely destroyed. Their job was to teach thousands of children about the environment, child rights, and emergency preparedness in a non-formal setting. To reach the largest possible number of young people, these "classes" were conducted in parks, plazas, and playgrounds -- wherever schoolchildren are found when they are not in school. "The main message was that many people were busy rebuilding roads that had been destroyed, and that it was our job to rebuild children," recalls Juan Jose Montenegro, an educational bridge organiser and Education Ministry official. "Teachers had to adapt to a new setting, and they had fun. So did the pupils." It was also a useful exercise for the teachers themselves. Many maestros lost pupils in this national tragedy and they were apprehensive about going back to class and facing empty benches. The educational bridge eased them back into their jobs. Despite initial fears, children have not been dropping out of school in droves. Although a cause-and-effect relationship is difficult to demonstrate, Montenegro believes the educational bridge played a key role in convincing pupils whose lives had been dramatically disrupted that school remained a worthwhile endeavour. Montenegro is also hopeful that the thousands of students who participated might be active in the second phase of the educational bridge, which is only now getting off the ground. With the help of firemen, the Nicaraguan Red Cross and the Boy Scouts, it is hoped that up to 8,000 children could be part of volunteer brigades that will receive basic training in first aid, community leadership, and education for peace. "We live in an area where there will always be natural disasters," says Montenegro. "In the past few years, we have been confronted to earthquakes, tidal waves, mudslides, and volcano eruptions. We have to learn to look ahead so when the next catastrophe arrives, we will have youth brigades to work with."

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