On July 16,1990 at 4:26 p.m. an earthquake occurred which delivered one devastating blow that significantly affected six provinces and involved 1.2 million people. The destruction ranged all the way from the collapse of high-rise buildings, dwellings, and school houses to the breakup of highways; to landslides and cracking of earth surfaces; to flooding of farms; and to the injury of innumerable people and the death of at least 1,100 victims.

The physical desolation that followed forced its presence into the consciousness of a stunned nation, and everybody jumped to contribute what he could to help. The physical destruction, which was readily seen and thus more dramatic, was easily captured by mass media and projected to the rest of the country. There were, however, changes that occurred in the inner recesses of the victims that were not as obvious but were nonetheless important. These were the psychosocial consequences that necessarily accompany any sudden, significant disruption in the established relationship and activities of people.

The necessity of helping the hungry, sick, and homeless, was easy to understand: They needed very concrete interventions that everybody could relate to. Thus, widespread participation was generated in bringing this kind of help.

The psychosocial trauma, on the other hand, was more hidden and subtle. Being so, it was very difficult to identify and, on occasions, difficult to understand and empathize with. However, if no action is taken to prevent, minimize, if not altogether eliminate the abnormal manifestations of this trauma the psychosocial stresses could lead to a disability far worse than the consequences of a physical dislocation. I am sure there will be no disagreement if I were to say that the common pathway, after all, of all the physical effects of the earthquake is ultimately man himself, with all his feelings, emotions and consciousness. Thus, ultimately, man must be the focus of aid and rehabilitation.

These insights were not lost to President Corazon Aquino who on July 20, 1990, after visiting the earthquake-destroyed areas, convened a group of behavioral scientists to specifically address the human side of the disaster. This gave rise to the creation of the Mental Health Task Force on Disaster under the National Program for Mental Health. The activities of the Task forces were thereby coordinated under the structure of the Department of Health. Its mandate is to assess the psychosocial effects of the earthquake and to design and implement intervention packages so as to prevent the development of abnormal reactions and manage those that have already arisen.

Now, let us go into the psychosocial consequences of the disaster.

After an extreme life experience such as a disaster, one can expect an immediate and normal psychological stress response. As a consequence of the earthquake, there were loses: of loved ones, of properties, of livelihood, of community relationships, of heritage and others. These losses created an inner disequilibrium and feelings of fear, helplessness, dependency, and sometimes anger rooted in a deeper loss -- the loss of control over one's life and one's destiny. This loss brings about bereavement. Figure 1 shows the typical grieving process that we can expect under such conditions. It divides the whole process into (1) the event itself; (2) the aftermath; and (3) the recovery period. Note that during both the event and its aftermath, lack of control is present: This, in fact, is the one overriding characteristic of any disaster.

The graph shows that, as a consequence of a loss, there is a downward swing of the curve indicating a decrease in the energy available to the individual. The characteristic reactions are shock, denial, panic, numbness, bargaining, avoidance, fear, and helplessness. This is also accompanied by a disruption or deterioration of ordinary life activities and some physical symptoms. At the moment of and a few seconds after the earthquake, we may have found our minds going blank or racing furiously trying to think of what to do. Perhaps there was a moment when we were a bit confused or unable to concentrate. These are all normal cognitive expressions of the stress response that one can expect in situations like this.

Soon after the event, during the aftermath, as shown in Figure 1, there us an upswing of the curve signifying an upsurge of energy. There is an emotional release, misdirected anger, and a splurge of energy and emotion. This is the period wherein there are such manifestations as excessive chatter, uneasy laughter, undirected or purposeless activities, and blaming of people or institutions for the person's sufferings. It is at this point that people get angry with the government, with the church or any other agency for not being organized or responding quickly enough to the disaster as they give vent to this upsurge in energy. This was the stage of a man that our group saw in Cabanatuan. He is a member of a clan which lost 19 of its members in the earthquake. He was seething with anger and could find no relief for his tension. He blamed everything and everybody including those were considered by some of the people in Cabanatuan as heroes. He saw in the identification and honoring of some, the ignoring or rejection of others.

However, as time wears on and there is no Relief, the curve slowly goes down bringing out again the sense of helplessness with resentment, depression, withdrawal, unresolved feelings, and hopelessness among others...During this period, what has been termed "survivor guilt" emerges. "Why did I survive?" or "Why did they, and not I perish in the disaster?" are questions asked during this period. We have school teachers who do not want to ever teach again because it happened that they were not inside the buildings when they collapsed and claimed the lives of their students. Of course, there are other forms of guilt. A teacher was inconsolable because she was instrumental in getting many children enrolled in a school that collapsed.

Going back to the graph, we can see that after the aftermath, there is a period of recovery. With recovery, there is a regaining of control. Recovery starts with the self, followed by the family, and then the community . So the recovery process starts with the self and moves on to the community. This is a very important process to remember since it will have critical implications on intervention strategies.

Table 1 shows some of the typical acute reactions to stress. these are subdivided into physical, emotional, and cognitive and behavioral symptoms. These are manifestations that we can see whether the stress is a near-miss car accident, a typhoon that results in the drowning of many people, or the earthquake that occurred on July 16,1990.

As you will notice in Table 1, stress brings about physical symptoms such as increase in heartbeat and respiration, elevation in blood sugar level, increase in perspiration, and slow digestion. The emotional symptoms, on the other hand, include fear, anger, and frustration. The cognitive and behavioral reactions consist of the actions we take to solve the problem. As stated earlier, however, the mind may become blank or get confused.

In psychiatry, the further aggravation of a normal response to a disaster which could lead to a psychiatric illness has been termed Post-Traumatic Stress Disorder (MD). Some. of the symptoms associated with this are hyper-alertness, exaggerated startle response, and difficulty in sleeping. And when one finally gets to sleep, recurrent nightmares occur during which the traumatic event is relived over and over again.

All these are powerful emotions produced by powerful disruptions to our ordinary lives. Unless these emotions are handled properly, they could lead to long-standing disability and personality difficulty. Table 2 lists the chronic reactions to stress. The categories follow closely those of Table 1 except for an added dimension of spiritual reactions. It will be noticed in the enumeration that there are many possible consequences of a crisis or disaster should the individual continue to be exposed to the disruption and its aftermath without arriving at a resolution. It must also be pointed out that the aberration, if left unattended, becomes more deep-seated in the long-term, affecting the very personality structure of the individual. As shown in Table 2, some of the personality disruptions are declining interest in others, doubt of value systems and religious beliefs, questioning of major life areas, and disillusionment.

Thus, we must be able to cope if we are to proceed to the phase of recovery where the most important accomplishment is to regain control. Ultimately, the person accepts the loss and finally lets go of a loved one, whether it be a person, a possession, or a heritage. As one person who grew up in Baguio poignantly stated, "Baguio will never be the same again. I shall never recapture my lost childhood "

Luckily for most, this recovery occurs spontaneously. We Filipinos are specially fortunate because we have extended kinship relationships on which we can fall back for emotional support.

As I said earlier, recovery starts with the self, leads to the family, and finally leads to the community. Thus, it is important that we address the individual's needs first and foremost if we hope to be able to establish a sustained and relevant rehabilitation of the communities affected by the earthquake.

But who are the people whom we should seek out? Who are the victims? The direct victims are easy to identify since they are the ones entombed inside a collapsed building or those injured, or they are the parents and relatives of the dad and injured. Certainly, the parent who lost 6 of his 7 children in the school reduced to rubble in Cabanatuan is a direct victim. His 7th child did not perish because he was only 6 months old. But beyond these direct victims are the indirect victims. These people, although not personally affected by any loss, nonetheless shared in the tragedy of the moment. I believe this will involve all those who read about the disaster or listened to the almost hourly report on all the miseries occurring in the affected areas. Although the emotional stress of these indirect victims is not as great as that of the direct victims, nonetheless they must also be recognized as victims because they may also develop some psychosocial reactions to the disaster.

Finally, we have the hidden victims. These are the care givers who are busy helping others. They look like the paragon of strength, fulfilling the dependency needs of those who are unable to cope. An example of this is the midwife who single-handedly evacuated a whole barangay to higher grounds during the earthquake and who remained for two days the people's sole anchor as they starved in the evacuation site. She maintained a stoic bearing, believing that it is not good for her to show any sign of "weakness" by giving vent to any emotion. It was only when she participated in a group intervention handled by Task Force and found out that it is all right to have emotional reactions to the disaster that she let go and cried interminably.

Crying was an opportunity to release pent-up tension which would otherwise have resulted in some disability in the long-term. This time, she was consoled by the other midwives in the group.

Hidden victims are usually not recognized as victims. They are the rescue workers who have been exposed to all the injury and death as they try to out bodies. They are the health workers: doctors, nurses, and other paramedical professionals who take care of the sick and the injured. They are the teachers and social workers who try to care for those who try to regain their lost anchors. All these care givers, after so much exposure, develop what has been termed a "burnoutsyndrome"which is predominantly characterized by exhaustion and depression but also sometimes with manifestations of a post-traumatic stress disorder.

This burnout phenomenon is apparently so pervasive that among the Ifugaos they even have a ritual to relieve people of this. I read somewhere that the Ifugaos lave a ritual called "duo-es" which must be performed for those who have plug out a dead body to stop their nightmares. The nightmares sound like a post-traumatic stress disorder and the Ifugaos have their own version of psychiatric treatment, I believe it is important for: us to know more about this and other similar practices that are truly Filipino.

In addition to the stress arising from exposure to injuries and death, the care givers may have the second stress of being direct victims themselves. The first thought of a social worker in Dagupan was how to give relief goods the victims. She half-forgot that her own ifamily was also victimized. A sanitary inspector in La union burst out crying as instructions were being given on need to build latrines because she was worried about her children who were also in die in distress.

The stress if care givers may be severe. Three months after the California earthquake, there was a four to fivefold increase in consultations for psychosomatic illnesses among the rescuers and the number of applications for a change of job rose abnormally high.

A look at how victims are responding away be glimpsed from a preliminary analysis of the answers to the self-rating questionnaire (RCI) administered to students in Cabanatuan which revealed a 94.08% presence if symptoms among 355 persons in one group and 78.55% in another group of 387. This can be seen in Table 3. Actually, the first group are the stu dents from the CPP and the second are students from another school which did not collapse. It is interesting to note that even chose people who were not involved in the collapsing of a building also suffered a tremendous amount of symptoms or disturbance. The most common symptoms noted were physical symptoms like fatigue, headache, sleeplessness, stomach discomfort, and poor digestion. Also noted were emotional/cognitive reactions like depression, fearfulness, nervousness, difficulty in thinking and making decisions, and suspiciousness. Table 4 shows the common reactions of the students tested in Cabanatuan. As you will notice, the symptoms of the students are similar to the usual symptoms of the students after a disaster which was discussed earlier.

These findings show how very important it is to institute some active interventions to prevent the occurrence of more severe psychological impairment and help the victims resolve their psychosocial reactions.

In designing the program of intervention, we took into consideration the following guiding principles (see Table 5):

1. There is a variety of psychosocial reactions to the earthquake, ranging all the way from normally expected changes to the more severely manifested psychological aberrations.
   
2. This being the case, there is a need to offer several forms of interventions requiring different skills and levels of specialization. Particular consideration is given to-the design of a module that addresses our unique cultural distinctions.
   
3. There is also a need to reach out to as many people and in as quick a time as possible since the time within which psychosocial support is given is critical in achieving the desired results.
   
4. In doing this, care must be taken to match the psychosocial need of a person with the help being offered. Thus, case finding must go hand-in-hand with, the provision of different types of psychosocial services. The process of relating one to the other should be put solidly in place in the shortest possible time.
   
5. Should it happen that the needs cannot be matched by the resources at hand, there should be a referral system that can be activated.
   
6. Care should be taken to organize individuals in the provincial areas belonging to different sectors and to train them sufficiently so that, at a certain point in the future, these individuals can take care of the needs of the area sufficiently. This institution building is critical because the ultimate aim of the Mental Health Task force on Disaster is to create a systems at the local level that should be able to sustain itself, not only to answer the psychosocial problems created by the earthquake but also to respond to other similar needs that may happen in the future.
   
   We believe that this is one of those instances when a problem has been turned into an opportunity and an event which could prove devastating has been turned around to spur development.
   
7. Because of the enormity of the problem, the Mental Health Task Force on Disaster, which started as a small group, should expand exponentially and function within a well-established government structure dedicated to service. It is in this context that the Task Force quickly became a multisectoral and multidisciplinary concern involving not only psychologists and psychiatrists but also social workers, spiritual counselors, family therapists, and other similarly minded concerned professionals coming from the academe, the government and non-government sectors. Each one contributed his own skills, expertise, and insight into a program which will be described later by Dr. Ignacio.
   
8. And finally, the documentation of the process, which is a special concern of the Secretary of Health, has to be institutionalized so that we can learn from our experience and establish an institutional memory.

The next figure (Figure 2) shows in a diagram, the series or cycle of interventions. It shows the overall strategy that we adopted and the different levels of interventions.

As can be seen in the diagram, we started with what we call a process - the Critical Incidence Stress Debriefing or CISD Intervention. This will be discussed in greater detail as Dr. Ignacio describes the implementation of the program. Suffice it to say, however at this point, that this procedure is used for training as well as for giving the psychosocial support needed by the victims. With the Critical Incident Stress Debriefing, one can develop subtrainors and, at the same time address the needs of the victims, who may be direct ones or hidden ones. This process, however does not preclude shortcirculating the cycle so that a person can go directly into the more intensive program when needed, as shown in Figure 3. The victims can either. have only one or several CISD interventions before becoming well, or they may need more intensive .treatment including medication. The progress of these people will be followed up and monitored.

Let me point your attention to some of the features of the cycle of intervention as shown in Figure 2.

1. The training of subtrainors is an ever-expanding circle. The subtrainors themselves train other subtrainors. This is the way we try to rapidly expand the circle of people who are able to attend to the problems of disaster. Four things, however should be closely monitored:
   
   1.1 The qualification and background of those chosen to "'subtrainors."
   
   1.2 The certification of those who will be allowed to train others. In this particular instance, they can either just help the victims or become trainors themselves. But training requires special skills and to be able to do this, the candidates must first be certified.
   
   1.3 The maintenance of a level of quality in the conduct of the CISD.
   
   1.4 The proper identification of those who will need more intensive intervention. Subtrainors should have the capacity to identify the victims who will need more intensive intervention.
   
2. Victims may require one or more exposure to CISD depending on the need of the individual.
   
3. The system provides for different kinds of interventions ranging from CISD to the more intensive therapy not necessarily done by psychiatrists, to psychiatric intervention and medication.
   
4. There is continuous monitoring and documentation of the processes as well as the outcome of the intervention to ensure quality as well as provide a basis for expanding our knowledge anal understanding of the psychosocial issues in disaster.

Figure 3 indicates how victims are identified. This, actually, is a recapitulation of Figure 2, except that this follows the different steps that a patient can take. He is perhaps referred by a group or a government agency. He goes through a CISD and is identified as a person needing no more intervention or referred for more intensive treatment.

The mass media also informs people who are then able to identify themselves or others as victims needing CISD intervention or a more intensive kind of treatment. Finally, we have the trained "subtrainors", conducting discussions at the community level, who might be able to identify and then refer victims for more intensive treatment:

Taking all these into consideration, the Mental Health Task Force on Disaster went out to do its job fully aware of the enormous responsibilities that lie ahead-The work cannot be done by us alone. Its concerns do not belong only to the province of the social scientist but to all of us ordinary Filipinos who must bear the burden of the devastation and emotionally support each other in this time of trial. I am sure, however, that given the strengths of the Filipino, this moment shall prove to be both a challenge and opportunity for development.

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