MILITARY MEDICINE. 163. 6:353.
1998
Volume 163 June 1998
MILITARY MEDICINE
ORIGINAL ARTICLES
Authors alone are responsible for opinions expressed in the contribution and for its clearance through their federal health agency. If
required.
Mental Health Nursing Support during Operation Sea Signal:
CubanIHaitian Humanitarian Mission
LTC Deborah A. Hughes, AN USA (Ret.)*
MAJ J. Ann Hohner, AN USAf
Joint military humanitarian missions provide challenges and
rewards for mental health nursing not found in the garrison
mission. A primary challenge is to develop and implement
programs that benefit the various populations inherent in
such missions. During Operation Sea Signal, several pro-
grams, such as migrant adult day treatment, halfway house,
outreach, and inpatient, led to the overall enhancement of
mental health nursing care for the Cuban and Haitian mi-
grants. It also gave the participating mental health nursing
team of professionals and enlisted technicians the opportu-
nity to develop their nursing expertise and sensitivity in a
culturally diverse situation.
Introduction
oint military humanitarian assignments are becoming more
Jster'scommon in the changing nature ofmilitary operations. Web-
defines humanitarian as "concern for human welfare as
manifested through philanthropy." Aune, in her paper about
the humanitarian mission Operation Babylift, described the
commonality found in all ofthese missions: "the use ofdefense
resources to alleviate human suffering. "2 Operation Sea Signal
was a humanitarian mission to assist the U.S. Justice Depart-
ment in the management, treatment, and containment of ap-
proximately 50,000 Cuban and 2,000 Haitian migrants. These
individuals had arrived at Guantanamo Bay, Cuba, Naval Base
(GTMO) by rafts, military air transport from Panama, or after
interdiction bythe United States CoastGuard.TheCubanswere
housedin two areas ofGuantanamo Bay, in the Bulkley training
area and on the McCalla airfield. The Haitians were housed in
the McCalla area. Joint Task Force (JTF) 160 was tasked to
*Unit Administrator. SanFrancisco General Hospital. Mental Health Rehabilitation
Facility. SanFrancisco. CA.
tAssistant Professor. Community Mental Health Nursing. University ofSouth Al-
abama. Mobile. AL.
[lleadNurse. Eisenhower Army Medical Center. Fort Gordon. GA.
This manuscript wasreceived for review in May 1996. The revised manuscript was
accepted for publication in August 1997.
Reprint & Copyright © byAssociation ofMilitary Surgeons ofU.S., 1998.
353
Number 6
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Maj Jason Jones, USAF NC (Ret.)t
provide medical care and outpatientmental health care at both
locations. All ofthese people from Cuba and Haiti wantedto be
allowed to migrate to the United States.
The Guantanamo Bay Mental Health humanitarian mission
was initialized in December 1994by elements ofthe 85th Med-
ical Detachment, Combat Stress Control (CSC), and the 616th
Medical Company (CSC) from Fort Gordon, Georgia. The 616th
was assigned the outpatient mental health mission and the
85th was tasked with providing the inpatient mental health
treatment.Theseunits cameunder the umbrellaofthe JTF 160
Mental Health Team. In early June 1995, the 98th Medical
Detachment (CSC) from FortLewis, Washington, the 83rd Med-
icalDetachment (CSC) from FortCampbell, Kentucky, and other
mental health assets from the Army, Air Force, and Navy as-
sumed responsibility for the mission. At that time, there were
approximately 18,000 Cuban and 500 Haitian migrants still at
GTMO. Thispaperis intendedto provide a general description of
mental health nursing services beginning in June 1995forOp-
eration Sea Signal and to describe howthe programs provided
were turned over to the installation military health care provid-
ers and civilian organizations as Operation Sea Signal ap-
proached its end.
Mental health services were divided into fourcomponents: (1)
inpatient, (2) outpatient, (3) children's services, and (4) out-
reach. Mental health services provided by the nursing staffwere
inpatient treatment, outpatient day treatment and halfway
house, and outreach services. Inpatient treatment initially was
located in tents and then wasmoved to an antiquatedNavy brig.
Thefacility had numerousseriousproblems that, withingenuity
and innovation, were remediated to allow for adequate patient
care. Despite its problems, the building provided a largeamount
of indoor space that ultimately allowed us to conduct all pro-
grams from one location.
Professional association with the JTF 160 and the GTMO
departments of nursing proved to be beneficial, enlightening,
informative, and supportive for all of the programs delivered
from the Naval brig. As the drawdown ofmilitary forces at GTMO
Military Medicine, Vol. 163, June 1998
354 Mental Health Nursing Support during Operation Sea Signal

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Fig. 1. Psychiatric admissions.

continued, both nursing departments assisted in providing ized that it was not in their interest to feign psychiatric illness.
nurses to augmentthe inpatientstaffmg requirements. The op- In fact, the migrants beganto be more cautiousabout admitting
portunityto work in a joint service environment provided excel- to signs and symptoms ofany psychiatric illness.
lent learning experiences. Despite the low census, there was the continued needto staff
for a 24-hour period. This required a registered nurse and at
Inpatient Treatment least two psychiatric technicians on each 12-hour shift. All
ancillary services had to be provided by the Naval Hospital,
The mentalhealth inpatient unit census, as shown in Figure which was approximately one-quarter mile from our location.
1, varied drastically during the lengthof the mission. The high Laboratory specimens had to be delivered there, and our staff
census in February 1995was the result of an influx of Cuban had to pickup meals forthe patients at the hospitalgalley. The
inpatient psychiatric patients beingtransferred to GTMO from inpatient program consisted of milieu therapy, individual ses-
Panama. The decrease in the census, beginning in June 1995, sionswitha nurse or enlisted technician, occupational therapy,
has been directly attributed to Attorney General Janet Reno's diversional activities such as volleyball, and physician rounds.
announcement that 20,000 Cuban migrants would be allowed Community meetings were held three times per week.
to enter the United States. This decreased the stressor of that Bythe end ofJune 1995, the inpatient professional nursing
particular unknown, and the migrants began to feel that they staff consisted of four Anny clinical nurse specialists (CNSs),
could handle the camp stressors, knowing that they would at two Air Force CNSs, and two Navy psychiatric nurses. There
some pointbe able to realize their dreamofentering the United were approximately 15psychiatric technicians from the various
States. Second, duringthe same period, a decision was madeto services also assigned to the inpatient unit. In addition to the
no longer send psychiatric patients to the United States using nursing staff, there was one Anny occupational therapist and
the medical parole system. (At onetime, there had beena rumor one Anny occupational therapy technician on the unit. Cuban
in the migrant camps that verbalizing the presence of halluci- migrant peercounselors, two ofwhom were registered nurses in
nations or other signs that might indicate mental problems Cuba, assistedthe staffand were assigned daily to the inpatient
would earn the individual a medical parole and enhance the unit. When welooked at the number ofhighly qualified nursing
probability ofmedical evacuation.) Themigrants therefore real- and occupational therapystaffmembers onthe inpatientunit in

Military Medicine, Vol. 163, June 1998

Mental Health Nursing Support during Operation Sea Signal 355

relation to the census, we had to stop and ask ourselves some a degree that it affected his or her ability to cope on a day-to-day
very important questions. Were we efficiently using our re- basis and presented problems for those who lived around the
sources?And couldthe mental health services be improved? individual. The exclusion criterion were: (1) Camp X-ray mi-
grants (the GTMO migrant detention area for individuals ac-
Program Assessment cused of crimes); (2) migrants exhibiting violent behavior of a
physical nature toward U.S. military personnel; (3) migrants
The McCalla outpatientmental health area was largeenough who were actively psychotic; and (4) migrants in the manic
to be used formorethan simply outpatientappointments. Itwas phase ofbipolarillness.
here that the staffers whodeployed in December decided to set
up a day treatment and worktherapy program. However, these
two programs, being separate from the inpatient setting, suf- Halfway House
fered greatly during the June rotationofpersonnel. Staffnum- Halfway house treatment was defined as partial hospitaliza-
bers decreased dramatically, resulting in a lack of qualified tiontreatment.Thepatientcameto the Naval brigdaily, Monday
individuals to maintain these programs. During reassessment, through Friday from 8:00 a.m. to 5:00p.m., and participated in

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it was determined that both the day treatment and the work the inpatient unit program until able to tolerate the day treat-
therapy program could continue to operatebut that the struc- ment program. Theinclusion criterion forthis program was any
ture of the day treatment program would be changed signifi- patient whowas unable to tolerate camp life rigors and/or the
cantlyand that both programs would be located with the inpa- stimuli of the day treatment program but who required close
tient unit at the Naval brig. Combining the nursing and the observation and supervision. This assisted in preventing need-
occupational therapy staff enhanced our ability to continue less lengthy hospitalizations.
these mentalhealth services by allowing us to use the inpatient
staffto cover both the inpatient unit and the daytreatment and
worktherapy programs. Advantages and Disadvantages of the Proposed
Through assessment, it was determined that we needed to Program Changes
add a program previously unused at GTMO: a halfway house-
typeprogram that would allow individuals to be discharged from The continuation of valuable mental health care to the mi-
the hospital and live in their camps. However, during the day, grants was an obvious advantage. In addition to enhancing the
the individuals would return to the inpatient unit to receive the migrants' coping skills, the migrant adult day treatment pro-
addedsupport needed to enablethem to continueto function in gram also provided a needed respite from the daily camp life.
an outpatient setting. Therefore, a new adult day treatment Finally, and ideally, the migrant adult day treatment program
program and a halfway house program were created for the and the halfway house program would prevent needless inpa-
prevention ofunnecessaryhospitalizations. tient hospitalizations and provide care at the level of dysfunc-
tion. Disadvantages included the transportationdifficulties and
the chance that the migrants would be resistant to attending
Development of the New Migrant Adult Day because of the belief that any contact with mental health per-
Treatment Program sonnelwould exclude them from going to the United States.
Thepurposeofthe newdaytreatmentprogram was to provide
quality mental health care in a controlled environment that Migrant AdultDay Treatment Program
allowed the migrants to continue to cope with the stressors of
camp life. The goal was the prevention of psychiatric hospital- Together, the nursing director, the clinical head nurse, and
ization through the enhancement of the migrants' knowledge the seniorenlisted technician set out to buildan overall concept
base and coping skills. ofthe typeofprogram that would be mostappropriate at GTMO.
Several assumptions were made during program develop- A l-day team-building seminarwas conducted at the inpatient
ment:(1) staffing wassufficient to provide the typeand qualityof unit to obtainstafffeedback and encourage staffparticipation in
program that was planned; (2) inpatient hospitalization would this new, innovative way of providing mental health services.
continue as needed with the goal of returning individuals to During this time, the actual classes were determined, and the
outpatient treatment as soon as possible; (3) the facilities, al- professional staffwastaskedwithteaching the paraprofessional
though bent with age, were adequate to meet our needs (these staff how to prepare and teach the classes. Two of the clinical
included the freestanding, open-air building and two general nurse specialists were assigned supervision ofthe staffas they
purpose medium tents within the secure fenced-in area); (4) wrote and preparedthe classes, overheads, and handouts.
sufficient numbers oflinguists, both Spanish and Creole, were The procedure forenrolling the migrantsin the program was
available on a 24-hourbasis; (5) lunch couldbe provided by the fairly simple and user friendly. Anyone whoworked in the out-
Guantanamo Bay Naval Hospital; and (6) transportation, al- reach program, from a behavioral science specialist to a mental
though difficult, was available at the camps to ensure that health professional, could identify a migrant and give the indi-
patients couldattend daily classes. vidual an appointment slip, which was required to leave the
The migrantadult day treatment program would be operated camp, to go the next day for the intake interview. The U.S.
on a daily basis, Monday through Friday, for a 2-week period, Justice Department camp support teams, the camp mayors,
with the migrant clients returning to the camps at the end of called Jefes, and the military camp commanders were encour-
eachday. Theinclusion criteriawere: (1) anyadult migrantolder aged to identify those individuals in the camps who could use
than 18years; and (2) any migrantexperiencing stress to such extrasupport.Military, civilian, and migrantministerswerealso

Military Medicine, Vol. 163, June 1998

356
important sources of information and client referrals to the
migrant adult day treatment program. Fliers and advertise-
ments about the program were placed at the chapels and other
gathering placesto announcethe availability ofthe program. As
was mentioned above, rumors in the campsspread that mental
health involvement mightdelay immigration. However, success-
ful participants in the program soon began referring other mi-
grants to the program. Perhapsthe most importantadvertisers
for the migrant adult day treatment program were the Cuban
and Haitian migrants themselves, together with the mental
health outreachnurses. Thework ofthe mentalhealthoutreach
nurses also led to preventing the spread of misinformation
about the migrantadult daytreatmentprogram. Transportation
was provided either by the camp commander or by the regular
bus service that ran daily between the camps and the medical
facilities.
One mental health technician on day shift coordinated the
logistics of meals, transportation, records management, client
absences, and appointment slips for the next day. If a migrant
failed to attend, his camp military company commander was
informed.
The classes were written in Spanish and English. This was
done to facilitate the projected transition ofthe program to the
World Relief Organization (WRO) during the military drawdown
at GTMO and to ensure that the program wasavailable until the
last migrants had vacated the base. Having the classesin Span-
ish also made it possible for the Cubans themselves to give the
classes in the camps.
Each class was taught by one primary and one backup staff
member. Occupational therapy was conducted daily, and an
all-day outingwas scheduled every other week. Upon comple-
tion of the 2-week class, the migrants were given graduation
certificates, and frequently, special treats were purchased by
the staff. Table I lists the classesand the amountoftimeallotted
for each.
Atthe completion ofthe program, the patients were provided
an evaluation form and asked to give their opinion of the day
treatmentprogram and to specifically describe howthe program
could be improved to meettheir needs. They were very enthusi-
asticin their responses, mostgiving the program extremely high
ratings. Themost requested classeswere those that focused on
TABLE I
ADULT MIGRANT DAY TREATMENT PROGRAM CLASSES
Class Duration
SUrviving in the United States 6 hours
Anger management 2 hours
Stress management 2 hours
Camp survival 1 hour
Relaxation therapy 1 hour
Domestic violence 2 hours
Problem solving 1 hour
Conflict resolution 1 hour
Assertiveness training 1 hour
U.S. government 1 hour
Men and woman's support group 2 hours
English as a second language 4 hours
Communication skills 2 hours
Alcohol and drug abuse 1 hour
Military Medicine, Vol. 163, June 1998
Mental Health Nursing Support durtng Operation Sea Signal
United States survival skills and English. According to the mi-
grants, these classes and the short relaxation exercises, done
daily, held the most value in terms of providing the necessary
coping skills and hope that they would soon be going to the
United States.
Work Therapy Program
Thework therapyprogram alsomoved to the Naval brig. After
completing the migrant adult day treatment program, clients
were given the opportunity to attend this program. Individuals
enrolled for 1 month. Many tookadvantage ofthis opportunity
because, again, it provide a respite from the camps. Absences
were very infrequent, and work assignments were undertaken
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with perfection as the self-imposed standard.
The mission of this program was to assess skill levels and
train and monitor migrants who were given work therapy as-
signments eitherat the Naval brigitselfor out in the camps. The
use of English, learned in the day treatment program, was ex-
panded and incorporated into the daily work to help the mi-
grants learn to communicate about work-related subjects. In
addition to actual work such as carpentry, lawn maintenance,
and animal husbandry, the migrants learned about jobs that
might be available in the United States, how to write resumes,
and taxes.
eNS Outreach Services
Two psychiatric clinical nurse specialists were assigned to the
migrant camps. They monitored patients discharged on psy-
chotropic medications to ensure medication compliance and
were frequently in contact with the community health nurses
working in the camps. Thementalhealth nurse duties involved
(1) collaboration with many individuals and agencies working
withthe Cubanand Haitian migrants; (2) assessmentofneeds;
and (3) appropriate referral/liaison withthe health caresystem.
Additionally, they also identified those migrants in the camps
who could benefit from the adult day treatment program.
Collaboration wasthe keyto successforthe outreachactivity.
Outreach nurses established and maintained excellent rapport
with the Jefes and military administrative personnel who often
referred clients to the mental health nurses during outreach
activities. Military, civilian, and migrantministers were an im-
portant source ofinformation. Cuban migrants physicians and
nurses also provided assistance to the mental health outreach
nurses.
Assessment of the migrants' needs included holistic aspects
of their human experience. A variety of methods were used to
build rapport with the migrants. Impromptu slng-alongs, dis-
cussiongroups in tent meetings, lectureson health care topics,
and walking in the camps to talk with the migrants about their
daily concerns builttrust in the nurses. Communication created
an assessment barrier at times. Some dialects of Spanish and
Creole were not always understood by the linguists. Creative
methods ofgestures, sign language, and aid from bilingual mi-
grants were very helpful. Physical needs were also assessed.
During daily walks within the camps, migrants would approach
the nurses to ask about medical problems. Access to other
medical services was often arranged. Noise throughout the day
and nightmadesleep a primary problem. Marriage and relation-
Mental Health Nursing Support during Operation Sea Signal 357

ships with others sharing living quarters wereother majorcon- efforts. All of the nursing personnel had to make adjustments,
cerns. Listening to the clients'concernswas the most important particularly in the forms that were used daily. Otherthan forms
tool for assessment and intervention. Many migrants just standard to the Department ofDefense, our inpatient unit charts
wanted to voice their frustration, concern for the future, and became a mixture ofthose used by the three branchesof servtce,
anger at the present Cuban government. Working with individ- The staffhad to learn how to use all ofthe different forms. When
uals and families from different cultures provided the nurses the JTF 160 department of nursing closed, those of us on the
with unique, rewarding challenges to their skills. inpatientunit had to adjust some crucial parts, such as the con-
trolled substance log, to meetthe Naval Hospital standard. Addi-
Transition of the Programs and Services tionally, as weinteracted withthe hospital forpatientmeals, our
Air Force and Army personnel learned different Navy methods.
Beginning in June, with the migrant population decreasing Onerecommendation for resolving thisissueis thatjointtask force
and inpatient services in less demand,the vision ofturning over regulations bewritten to decrease the differences between services
all services and programs from JTF 160 to either the Naval and the amountoftimeneeded forallto adjust.These regulations
Hospital or to civilian organizations was continually main- shouldbe written in such depththat the day-to-day operations of

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tained. Extensive networking and discussionofthis vision dur- field medical personnel are included.
ing the 4-month period resulted in its accomplishment. At the A good grasp of cultural issues is required to adequately
time of the transition, all ofthe Haitian migrants had departed provide mental health nursing care. Before deployment, it is
GTMO and there wereonly5,000 Cuban migrants remaining. recommended that military personnel take the time to learn
The inpatient program was efficiently turned over to the Naval about cultural aspects ofthe population that will be served and
Hospital. Hours ofgroundwork were laid, in the form ofa proposal use the deployed timeto continueto build on their basic knowl-
and discussions, withthe hospital director ofnursingservices and edge and understanding.
unit officer-in-charge. Thehospital unit staffhad oneexperienced The U.S. military was responsible for maintaining securityin
mental health professional, one psychiatrist, and one mental and around the migrantcamps.Military personnelmanagedthe
healthparaprofessional in the outpatient clinic. OurJTF 160men- entrances to all camps. Therefore, it was essential that the
tal health nursing staffspent 2 weeks working with the hospital battalion and camp commanders were briefed on the mental
unit staff. During that time, there were two admissions. This al- health programs. Informing them and answering their questions
lowed thehospital unit stafftogainhands-onexperience underthe regarding the programs increased understanding and created
watchful eye ofthe JTF 160mentalhealthnursingstaff. Addition- excellent working relationships. Assistance from the military
ally, to assist the hospital unit staffin becoming comfortable with commanders to maintaintransportation forthe migrantsto and
providing mental health inpatient care, 5 hours of classes were from our location and identification of those in need of the
taught. These classes included basic assessment, diagnoses, in- services greatly enhanced the productivity of our efforts. It was
terventions, uses and side effects of psychotropic medications, also important to communicate with the civilian organizations
therapeutic communication, and interventions to be used with to ensure that efforts were not being duplicated and to receive
violent patients. Theclasses were videotaped so that theycould be additional feedback from them about how our programs were
reviewed at any timeby the staffmembers. affecting the migrants.
Themigrant adult day treatment program was turned overto
the WRO. Muchtimewas spent coordinating this transition, but Conclusion
the WRO staffwas veryexcited to havea "canned" program that
could be used to continue to assist the remaining migrants. The preparation and institution of the migrant adult day
Assistance was given to adapt the program to their capabilities treatment program, the halfway house program, and the CNS
and the needs ofthe remaining migrants. Additionally, our staff outreach program proved challenging and rewarding. The op-
actuallytaught the classes and precepted the WRO staff in the portunities afforded the Cuban and Haitian migrants through
initial days of the transition. This allowed them to gain confi- the migrant adult day treatment program seemed to enhance
denceand experience in the administrationofthe program. The their ability to copewith campand life stressors and prepareda
tworemaining Cubanpeercounselors alsocontinuedtheir work largenumber ofindividuals forlife in the United States. Because
in conjunction with the WRO staff. we recognized the tremendous amount of potential residing in
the mental health nursing assets, we were ready and able to
Lessons Learned transcend the inpatient setting and positively affect the lives of
people anxiously hopingand waiting to become U.S. citizens.
A good working relationship with all departments of nursing
is essential. JTF 160 had its own nursing department com- Acknowledgments
pletely separate from that of the Naval Hospital. The depart-
ments had their own specific missions and locations. As the Sincere thanks to MAl David Schenk, Me USA, and MAl John
drawdown progressed, the JTF department of nursing turned Mackey, Me USA, for their review of this article.
the JTF mission over to the hospital department of nursing.
Maintaining opencommunications withboth departmentsfacil- References
itated the remediation of staffmg difficulties, ensured that all
nursing personnel were kept informed of any issues affecting 1. Webster's New World Dictionary, Third College Edition. New York. Simon &
Schuster, 1988.
them, and assisted in resolving any nursing issues. 2. Aune RC: Reflections on a humanitarian mission 20 years later: Operation
Working in ajointtask force broughtchallenges inherentinjoint Babylift. Milit Med 1995; 160: 584.

Military Medicine, Vol. 163, June 1998