(p. 46) Delivering Mental Health Assistance in the Wake of Natural and Manmade Disasters
These days it seems hard to escape the frequent news of disaster events occurring with ever-greater frequency around our country and across the entire planet. Hurricanes, tornados, cyclones, tsunamis, extreme flooding, and wildfires, along with transportation accidents, mass shootings, and other deliberate hostile and terroristic attacks, are in the news so often that it can be very difficult to see and hear the reports. Just in the U.S. it has been estimated that 60% or more of adults and 40% of children and adolescents will experience some type of traumatic event in their lives (Everly & Mitchell, 2008; Halpern & Vermeulen, 2017; National Institute for Environmental Health Services [NIEHS], 2015).
While there is no one definition of “disaster,” the word generally refers to catastrophic events of a certain size and scope that are not typically part of one’s ordinary experience. Destruction of property and/or loss of life affecting large numbers of people and even whole communities are generally the hallmarks. The demands of such events, individually and collectively, exceed the usual capacity of personal or local resources. As such, most people would be subject to significant stress and trauma following such an experience. In addition to local response, outside assistance is frequently utilized. Often the media will descend in force. People must deal with their crises in the public domain, so there are personal, collective, and public elements to their suffering and loss. Communities and even larger regions may be devastated and permanently reshaped (Das-Brailsford, 2010; Everly & Mitchell, 2008; Halpern & Vermeulen, 2017; Miller, 2012).
In spite of considerable resources and experience, a variety of barriers exist that impede the timely and effective delivery of sufficient services to address the needs of those affected. This chapter discusses some of these challenges from a mental health perspective. Given the size, scope, and number of disaster events and the effects they have on so many people, meeting the psychological needs of survivors and others affected is a monumental task. Assessing those needs and delivering important mental health interventions can be crucial in facilitating recovery in individuals, families, and communities. Cultural and historical factors (p. 47) that will influence reactions and responses at individual and community levels are also important considerations that must be addressed to improve the delivery and utilization of services. In addition to immediate and short-term response, assisting communities in preparing for potential disasters and following up with their recovery are crucial components.
Professional disaster mental health (DMH) focuses on crisis intervention and enhanced psychological first aid (PFA) delivered in the field. Traditional psychotherapies are not the first line of mental health response. Although they may be indicated and useful for some in the months and even years following a disaster, they are less effective in the immediate aftermath (Everly & Lating, 2017). Certainly most of those affected are not looking for anything resembling “psychotherapy” in the short term; they have pressing concrete social and community concerns to address and will welcome assistance in meeting those needs. Most mental health professionals are not trained in disaster response. Efforts to expand the numbers of, and disaster response training for, mental health providers have been increased in recent years, yet still more needs to be done.
The Scope and Description of the Problem
While generally unpredictable in their timing, during the past 20 years worldwide, over 7,000 natural disasters have occurred, affecting over 4 billion people (Center for Research on the Epidemiology of Disasters [CRED], 2017). 2017 was a record hurricane season, with the three most significant, Harvey, Irma, and Maria, all hitting the United States. They were only three of 93 natural disasters to hit the Americas that year (CRED, 2018). Hurricane Irma alone affected 10 million people in the United States and the Caribbean (CRED, 2018). Mass shootings in Las Vegas; Sutherland Springs, Texas; Parkland, Florida; and Santa Fe, Texas followed, all in less than a year.
Just in the latter half of 2018, the news was full of reports regarding Hurricane Florence (primarily in North and South Carolina) and Hurricane Michael (primarily in the Florida panhandle and Georgia) and the wildfires in northern and southern California. There were also mass casualty shootings at a synagogue in Pittsburgh and a country music club in Thousand Oaks, California, and the crash of a stretch limousine that killed 20 people in a rural small-town area in upstate New York. On a much smaller yet still significant scale, local Red Cross chapters all across the country responded to floods, tornados, transportation accidents, and fires to single- and multiple-family homes.
Research on past disasters has demonstrated that many people affected by disasters will have notable psychological reactions and a significant minority may subsequently meet criteria for a mental health diagnosis (HIEHS, 2015; (p. 48) University of Albany, 2017). A Centers for Disease Control and Prevention (CDC) poll taken shortly after 9/11 in the New York City metropolitan area reported that 75% of respondents acknowledged problems related to the attacks (Everly & Mitchell, 2008). A study after the Oklahoma City bombing found over 90% of survivors symptomatic to some degree (North, 2017). One study following Hurricane Katrina found that half of the parents in Gulf Coast areas indicated that at least one of their children had psychological problems related to being displaced (Knapp, 2010). Overall, as many as 30% to 40% of direct disaster victims (and 10% to 20% of rescue workers) are likely to exhibit a psychological disorder such as acute stress disorder (ASD), post-traumatic stress disorder (PTSD), depression, anxiety, or substance abuse (National Institutes of Health [NIH]/NIEHS, 2011; Substance Abuse and Mental Health Services Administration [SAMHSA]/American Red Cross [ARC], 2015; Watson, 2017).
The frequency and magnitude of disaster incidents, the huge number of people affected, and the significant breadth of psychological impact all speak to the tremendous need for DMH response capacity. While most disasters elicit major response efforts to assist in basic needs, which are certainly helpful, the demand far exceeds the supply. The need for mental health interventions following disasters is greater than ever (Halpern & Vermeulen, 2017; Knapp, 2010). Even when available, matching resources to need and promoting greater utilization are great challenges. Increasing the availability of sufficient services requires considerable planning and training in many communities and greater collaboration among agencies and providers. More public education and other efforts to expand knowledge and awareness and to encourage people to be more receptive and accepting of interventions are also needed.
This requires attention to expanding awareness of and sensitivity to cultural and historical factors in affected populations. The limited number of providers with appropriate training; lack of sufficient funding to provide free or low-cost treatment; client resistance based on financial, cultural, and historical concerns; and stigma may inhibit sufficiently reaching most of those in need. One study found that six months following Hurricane Katrina, only 6% of people affected had received mental health services (Das-Brailsford, 2010). Greater allocation of financial resources is, of course, necessary to accomplish all of this.
Barriers to Service Delivery
Clearly, meeting the psychological needs of the many people affected by so many disasters requires more available responders from all quarters, with adequate preparation and training. DMH, as an organized, targeted, and comprehensive discipline, is a relatively new phenomenon (Halpern & Tramontin, 2007; Weine (p. 49) et al., 2002). While efforts to address the psychological effects of combat in war go back at least to World War I (Salmon, 1917, cited in Everly & Lating, 2017), and some earlier efforts were made to address some specific public incidents (North, 2017), it was not until the early 1990s that the ARC initiated a specific DMH function, making it the first disaster relief agency to incorporate attention to psychological needs into its mission (Everly & Mitchell, 2008; Halpern & Tramontin, 2007). At first, even this was focused more on addressing the psychological concerns in other responders than on meeting the psychosocial needs of disaster survivors in general.
As formulated by the ARC today, “The mission of Disaster Mental Health is to respond to the psychosocial and emotional needs of people affected by a disaster, including Red Cross disaster workers, across the continuum of disaster preparedness, response and recovery” (ARC, 2018, pp. 1–3).
Since DMH is a relatively new specialty and as it is often difficult to study in the midst of disasters, quality research is limited on immediate and short-term psychosocial responses. Yet there is some empirical support, along with considerable consensus on many aspects of what is typically done (ARC, 2017a; University of Albany Center for Public Preparedness & State University of New York at New Paltz Institute for Disaster Mental Health, 2017; Watson, 2017). Some treatments of the most common diagnoses—ASD, PTSD, depression, and grief—have more solid data (Benedek & Wynn, 2017; Foa et al., 2009). Most survivors of disaster will not reach a level of distress over time to receive a diagnosis and fewer still will receive psychotherapy. Yet we often overlook the broader interventions, both before and after disasters, that are so important in helping individuals and communities heal.
DMH is not psychotherapy, and it can be very demanding work under trying conditions. Specific training is required, and not all clinicians will be interested in doing or prepared to do this work. It takes most psychotherapists out of their typical role, requires much patience (and no “patients”!), considerable flexibility, and a willingness to put the needs of not only the clients but also the organization ahead of one’s own. It is important not to push services but rather to be available and reach out as survivors and fellow responders may be open to speaking and to accepting what DMH workers have to offer. Clinicians may become frustrated or disappointed, not feeling fully utilized or appreciated for their professional expertise.
This work requires the emergency mental health professional to follow the incident command system format and table of organization, something many mental health professionals may not find easy to do. “Stay in your lane” is an expression meant to highlight the importance of recognizing and adhering to one’s role toward the more efficient and effective operation of a relief response. Not adhering to this precept may create resentments that leave people less open (p. 50) to receiving services and can interfere with the effective delivery of services. Particularly on national deployments, mental health clinicians may be subject to physical hardships, lack of usual comfort or good food, limited sleep, and much stress, along with financial concerns if they are volunteering for the deployment.
Mental health providers unaffiliated with a relief organization are often not wanted on a site, as they may have no expertise in DMH, have not been vetted in any way, and may interfere with the response operation. While undoubtedly well intentioned, such unaffiliated responders are not part of the incident command structure and may disrupt the organized delivery of services and confuse survivors. ARC does have a process, in some situations, for accepting event-based volunteers, which can be used to provide expedited yet partial vetting and training so they may be quickly deployed on a response. Remote DMH work by telephone is sometimes another option for professionals who cannot deploy to assist in the response. However, this is not the same as being there in person and limits situational awareness and the local knowledge base of the provider.
Volunteers do much of the short-term response work, and even people who are employed by response agencies are not likely to be well paid. Volunteers make up 90% of the ARC workforce, for example. It is not easy for someone with a full-time job and a family to find much time to devote to disaster response, especially if it means being away from home for an extended time. The ARC requires at least a 10-day commitment to a national deployment. Local responding may be more feasible for many clinicians but still requires a certain level of commitment and availability. The emotional toll can also be substantial, particularly in mass casualty incidents, so it is important for clinicians to recognize their own realities in deciding whether or not to do this work in general and also in response to any particular disaster. Most DMH responders will attest, however, that the work can be quite rewarding in spite of the difficulties and challenges.
While local clinics and other agencies often make staff available when disasters strike their communities, they are frequently underfunded and already busy, with long waiting lists. There are neither enough of them nor enough mental health staff, and, again, they have rarely engaged in the requisite training or planning. Even though DMH capacity is widely recognized as an important component of public health preparedness, one study found less than one third of public health departments even offer mental health services. Research in New York state following Hurricane Sandy found that a lack of staff trained to offer psychological services was a serious gap in the storm response (University of Albany, 2017). In addition, many local mental health providers may be affected by the disaster themselves, as may be the infrastructure in their area. In rural communities, readily available mental health resources may be few and far between (Everly et al., 2014).
(p. 51) It is also not uncommon for some tension to develop between local agencies and outside DMH responders related to roles and authority during the immediate response. In spite of the desire to assist in the short term and help connect residents to services for when they leave, out-of-area responders may be seen as interlopers trying to displace some local providers who naturally want to help. There may even be tension among the local and national responders within the same organization. However, as the local providers will be around for the long haul and may be affected by the event themselves, the outsiders can offer them a brief respite in the early days and refer clients to see them for the longer term. It is often true, however, that because of their training and extensive experience, major relief organizations and their personnel are more knowledgeable and skilled at the immediate steps and often prefer to exercise greater control of the initial operation. Effective collaboration is essential for optimal delivery of services yet is difficult if the groundwork has not been established beforehand, which is too often the case. Training and collaborating with other responders, such as rescue, health care, and spiritual care professionals, can expand the implementation of basic and early interventions to address psychosocial issues. Not understanding the functions of other disaster workers or coming to some agreements about prioritizing and sharing delivery of services may lead to tension or conflict among responders and confusion among clients, which will interfere with effective and efficient assistance.
Creating Cultural Competency
“Every disaster has a unique social ecology that influences perceptions and experiences before, during and after the disaster” (Miller, 2012, p. 8). Cultural histories, beliefs, and practices; economic infrastructure; dynamics related to status and power; and intra- and inter-group relations all affect reactions and response and even aspects of the event itself. For example, it was not simply an accident or coincidence that the lower Ninth Ward of New Orleans was the most affected area of the city from Hurricane Katrina. With little assistance directed there, at least initially, it has probably been the slowest neighborhood to rebuild. Lower-income residents often inhabit the most vulnerable areas, and civic resources are often arranged to favor the wealthier sections of a city. The residents have fewer sources of assistance to help mitigate and recover from the effects of the storm and often face cultural insensitivity in how aid is provided (Boyd-Franklin, 2010). Internationally, developing countries have more frequent and more destructive disasters than developed countries (CRED, 2017). They may be more vulnerable because poverty leads people to live in more exposed or (p. 52) dangerous areas, environmental planning in development is poor, and fewer warning or protection systems are in place.
Disaster responders tend to be middle-class or upper-middle-class and White (ARC, 2017; New York State Office of Mental Health, 2017), which means there is often a mismatch with people seeking assistance following disasters. In addition to race and socioeconomic status, ethnicity and nationality, language, religion, gender, sexual orientation, age, and developmental and ability functioning are all cultural factors that may influence one’s interactions with others. Being aware and respectful of differences (as well as similarities) and being open to examining one’s own background and perspectives are ongoing processes necessary to more effectively assist survivors. Responders need to learn more about the populations they will be encountering, through ongoing training and often by listening to survivors or other community members to ensure that services and information are provided in a culturally and linguistically appropriate manner (Boyd-Franklin, 2010; Miller, 2012). This also relates to the importance of planning and training to improve cultural knowledge, sensitivity, and collaboration.
Health and health care disparities, along with stigma regarding psychological disturbance, are often barriers to both provision and utilization of mental health services for many members of lower-income and minority communities. Concern about negative stereotypes regarding aspects of one’s culture and about mental illness, histories of inadequate treatment (and worse), and limited knowledge about and expectations of effective treatment lead to mistrust of government and other agencies and resentment of outsiders (Boyd-Franklin, 2010). All of this may contribute to resistance to seeking help. Concerns about cost, including those related to time away from work or transportation and childcare expenses, also impede the ability as well as the inclination to utilize services. The ARC can provide some financial assistance to facilitate mental health services and it tries to make clear that it is independent of any government entities. For immigrants, concerns about the ramifications of speaking with even nongovernmental agencies, along with difficulty finding services in their language, may be real impediments to seeking assistance. In communities that largely consist of immigrants (and if responding in other countries), it is also important for responders to be aware of social and political hierarchies and customs related to culture and religion. In these situations, utilizing cultural intermediaries who speak the language and engender sufficient trust may be crucial (Halpern & Vermeulen, 2017).
For many cultural groups, religion and spirituality play a major role in their lives and may be more relevant in their reactions to disaster. Referring to and collaborating with chaplains or clergy may be more important than traditional psychological interventions at this time. The ARC has disaster spiritual care as a specialty working alongside DMH. Although still in development, this has (p. 53) proven to be a useful alliance in responding to communities where faith is a prominent part of the culture. A focus on extended family and community is often another component of many cultures that differs from the more typical Westernized individual orientation. In addition, many cultures have particular expressions of emotional and psychological distress and a reliance on traditional ways of healing that may appear unsettling to those unfamiliar with those practices (Miller, 2012).
Many disaster relief organizations, along with mental health associations, have guidelines and training on cultural competence and consider it an ethical responsibility for their members to develop (see the list of websites in the reference list). They also make efforts to diversify their workforce and membership and to actively collaborate with the members and leadership of the communities they serve.
Cultural considerations also apply to other populations at risk, including children, frail elderly, and those with disabilities, who may require special attention and consideration in all phases of disaster work (Halpern & Vermeulen, 2017). The ARC, in fact, has recently created a role for a disability integration specialist in disaster response.
First responders also have their own cultures. Not only are they exposed to some of the worst sights and situations imaginable, they may question or lament what they were or were not able to do in terms of rescuing or protecting civilians. In disasters, they often have to work long hours and be away from their families. This can all take a significant psychological toll, particularly in mass casualty incidents and especially if children are victims. Yet the ethos of being strong and stoic may make it hard for them to seek help; so do concerns about stigma, confidentiality, and how their job assignments might be affected. Fortunately, some literature indicates more openness to acknowledging and addressing emotional reactions among these groups. Utilization of trained peers in collaboration with the deployed mental health professionals has been quite helpful in this regard (Everly & Mitchell, 2008).
Effective Strategies and Empirically-Supported Treatments
The Disaster Scene: What to Expect
When disasters occur, aid is mobilized right away. Governmental agencies move to help as soon as they can. First responders are on the scene immediately, engaging in search and rescue, possibly assisted by state and national personnel, depending on the size and scope and type of disaster. Local resources, when and where available and if still functioning, spring into action to provide assistance. (p. 54) Churches and community groups offer their buildings for shelters or assistance centers. People who can help step up to provide food, clothing, blankets, and other supplies to help take care of those affected and in need.
Regional, national, and even international organizations will deliver supplies and personnel to assist survivors, generally over the immediate and short term. The ARC, for example, will open and/or assist in managing shelters and assistance centers, provide food and supplies, and engage in outreach to the communities to help in any ways they can. This will include health services, mental health, and spiritual care. Services are offered to everyone affected by the incident, including those who respond to assist.
Most of the outside help is relatively short term, weeks, even days, or possibly a few months in situations with more extreme and extensive destruction. It is designed to assist populations in addressing their most significant needs through the most disruptive time period. In addition to material supports, this will include efforts to connect people with family and friends and to local resources, and possibly to help build capacity for communities to continue moving forward in their recovery (Miller, 2012). The aim is to enhance people’s natural abilities to cope in the present and future.
Not surprisingly, reactions to disasters cover the range of human functioning—physical, cognitive, emotional, behavioral, and spiritual (Halpern & Tramontin, 2007; Miller, 2012; HIEHS, 2015)—and they will differ among individuals and within individuals over time. Yet many reactions are to be expected. Aside from potential injury, survivors may experience shock and a host of somatic reactions, including palpitations, sweating, shaking, restlessness, fatigue, difficulty breathing, pain, biochemical changes, and weakened immune systems. They may be disoriented or confused and have difficulty with memory, clear thinking, or decision making and problem solving. They may feel fearful and anxious, sad, angry, vulnerable, guilty, overwhelmed, or out of control. Behaviors may be tearful, irritable, hyper-vigilant, isolating, or erratic. Disturbances in appetite, sleep, activity level, substance use, and self-care may be present. People may question their purpose or meaning in life or their religious views (ARC, 2017a&b, 2018).
In spite of strong initial reactions and distress, most people will be quite resilient over time (Bonanno, 2004; HIEHS, 2015), though many will have some long-term effects that may impair functioning, even if they do not constitute a diagnosable disorder. Early interventions are generally designed to help survivors utilize and build upon their natural resources and resilience. They can help people cope more effectively in the immediate aftermath and reduce the likelihood of persistent and more severe sequelae (Fox et al., 2012; SAMHSA/ARC, 2015; Watson, 2017). Yet even a small percentage of survivors with longer-term impairment will mean there will be a significant demand for intervention over (p. 55) time, especially for diagnosed disorders such as ASD, PTSD, depression, anxiety, and sometimes overwhelming grief. It is important to pay attention to and make referrals for these people as well (Halpern & Vermeulen, 2017).
Elements of the disaster combine with personal characteristics and experiences, as well as with aspects of the response itself, to determine the ongoing reactions of any individual survivor (Benedek & Wynn, 2017; Halpern & Vermeulen, 2017; Joshi & Cerda, 2017). One’s strengths and vulnerabilities, preexisting conditions and circumstances, history of other disasters or trauma, coping styles and support networks, and education and financial resources are all important. Proximity and level of exposure to the event and the degree of personal loss will also influence post-disaster functioning (ARC, 2017a; Miller, 2012; World Health Organization, 2011).
Regarding the response, relevant issues include the degree of resources and planning that were developed prior to an event, along with the scope and effectiveness of the initial response from municipal, state, and perhaps national governments, as well as from nongovernmental agencies (Halpern & Tramontin, 2007). The extent, intrusiveness, and duration of the media presence may also be a factor (Halpern & Vermeulen, 2017). In some cases, communities will galvanize to protect survivors and mourners from being filmed or photographed in their time of grief. Yet some individuals may want to express their thoughts and feelings publicly (Applebome & Stelter, 2012).
Disasters differ in many respects that are important to consider in responding. The size and scope of the destruction includes the extent of damage and the number of people affected, as well as the length of the disaster itself and of the recovery process. This will determine the number of responders and amount of resources that may be required, as well as the ability to place them in the location and the duration of the response. Whether or not the event was expected and, if so, the period of warning and steps available and taken will also have an impact. These affect the possibility of pre-positioning supplies and personnel, the number of casualties, and the reactions of survivors based on the degree to which they did or did not respond to the warnings. Even the season and the time of day may be quite salient, as related to weather conditions and to where people are located when the disaster strikes (e.g., at school or work, at home, with family members together or apart).
Of great relevance will be the cause or causes. Events caused by human behavior, in whole or in part, are likely to lead to much greater psychological distress over a longer period of time (ARC, 2017b; Halpern & Vermeulen, 2017; Miller, 2012; HIEHS, 2015; although see North, 2017, for an alternative view), as are those in which more people have died. This is especially true of intentional infliction of mass casualties. More intense and extended grief, anger, and blame, as well as ongoing or renewed trauma due to media coverage or if legal proceedings (p. 56) ensue, may all be expected in these cases. The experience of a DMH responder is often quite different—for example, working in shelters for those displaced by hurricanes or flooding as compared to family assistance centers or other settings following a mass shooting or a transportation accident. Not only specific tasks and functions but also the whole emotional overlay of the experience will reflect the nature of the event and the response. Mass casualty incidents will have a much greater proportion of mental health responders than natural disasters.
Today the ARC has some 5,000 DMH volunteers (Halpern & Vermeulen, 2017), and there are many other organizations that provide disaster relief and/or training and information for responders. Quite a few of them incorporate mental health services into their response (e.g., Green Cross, Medical Reserve Corps), as well as education for survivors and responders regarding reactions to disasters and how to address them (these include the International Society for Traumatic Stress Studies, the National Child Traumatic Stress Network, the New York State Office of Mental Health, SAMHSA, and many others). Many local mental health services do exist that will respond to the needs of their communities to the best of their ability, should disaster strike. While a focus on trauma-informed treatment has become fairly widespread, this is not the same thing as knowledge and experience in treating survivors of large-scale disasters (SAMHSA, 2015). It is important to note that while providing a range of psychosocial supports to survivors is certainly valuable, this includes acknowledging and promoting the natural resilience of most people as a crucial element of disaster response (ARC, 2017a, 2018). We are primarily there to help people help themselves.
Interventions and Phases of Disasters
Most discussions of disasters refer to phases—before, during, and after; or threat/warning, impact, rescue, and reconstruction (Das-Brailsford, 2010); or prepare, respond, and recover (ARC, 2018; SAMHSA/ARC, 2015). Following a disaster, reactions and response will vary in the immediate, short term, and longer term. During the event, more dramatic reactions will occur that may both help and hinder one’s functioning. In the midst of great shock and horror, some people take heroic actions in the rescue phase. A honeymoon phase often follows in which expressions of gratitude and optimism may be present along with efforts to assist one another. With the recognition that recovery will be long and difficult, this gives way to disillusionment, accompanied by distress, frustration, anger, blame, sadness, and grief. Then comes the long road to recovery, with greater acceptance and integration of the event and its consequences, as well as rebuilding of lives and communities (ARC, 2017a; SAMHSA/ARC, 2015). It will be here that many more serious psychological diagnoses will come to the fore. (p. 57) While there is not always a clear delineation, interventions are generally related to the phases in the disaster cycle.
Critical Incident Responses
Initial responses focus on addressing basic needs and safety. Food, water, shelter, information, and organization, as well as other forms of assistance that can be provided under difficult circumstances, are crucial first steps. Helping survivors to feel safe and to connect with family members and other social supports and community resources helps them use their natural strengths in service of self and collective empowerment. The ARC, for example, will pre-position people and supplies when possible, and otherwise respond immediately to disasters. Much of the early DMH work involves providing material comfort (often water and blankets) and direction. Simply making contact and being a calm, kind, and compassionate presence helps to stabilize those directly affected. “Water therapy,” just handing a bottle of water to someone, can provide an initial connection and possible opening for more conversation. The ARC frequently provides an emergency response vehicle with hot coffee and food to support first responders as well as clients at disaster scenes, vigils, or memorial services. The goal is to provide comfort and to facilitate recovery and healing in disaster survivors and others affected (ARC, 2018).
Surveying the situation, gathering what accurate information is available (and sharing it with survivors if appropriate), making brief assessments, and considering triage when necessary are all vital first steps in implementing mental health interventions, the most basic of which is PFA. This is taught to all ARC volunteers and is a prominent component of education in other organizations as well (e.g., Institute for Disaster Mental Health, National Child Traumatic Stress Network, New York State Office of Mental Health, SAMHSA).
The Interagency Standing Committee of the United Nations (2007) suggests an intervention pyramid for mental health and psychosocial support in emergencies. The base consists of security and basic needs, followed by strengthening family and community supports. Then come focused supports that may be provided individually or in small groups by non-specialized workers who have been trained and supervised. This would include PFA and psychosocial interventions by general health services staff. Given that the great need outstrips the capacity of available mental health professionals, teaching PFA to all responders and even to other community members has become increasingly important. The ARC also collaborates with health service and spiritual care providers. At the top of the pyramid are the specialized services of professional mental health clinicians that may be directly required for the small percentage of people who have significant symptomatology or impairment or who are at greater risk thereof (Interagency Standing Committee, 2007; Miller, 2012).
(p. 58) PFA, as its name implies, is a knowledge base and set of tools (many of which are mentioned above) that responders can use in the early phases of a disaster to assist survivors and first responders in managing and reducing stressful reactions and fostering more effective coping. Often-cited key elements of disaster responding include fostering a sense of safety, calming, facilitating connectedness and self and group efficacy, and instilling hope (Hobfoll et al., 2007; Miller, 2012; Watson, 2017). Such early intervention may also reduce post-disaster symptoms and impairments (Birkhead & Vermeulen, 2018; North, 2017; Watson, 2017). While controlled studies are difficult to conduct in disaster settings, considerable support exists for elements of PFA, including enhancing coping, social support, and problem solving (Foa et al., 2009). In addition, substantial experience and expert opinion lead PFA to be considered an “evidence-informed” intervention (Fox et al., 2012, p. 251). Further support for early intervention comes from research on treating service members in combat zones using the principles of proximity, immediacy, and expectations (Everly & Mitchell, 2008). In those circumstances, the more quickly treatment can be provided close to the front and with expectations of return to duty, the more likely warriors are to do so. While one does not have to be a mental health professional to provide PFA, for other responders, knowing when and how to make a referral to DMH workers is an important component.
The basic skills of PFA, after ensuring safety and basic needs, include empathic listening and attending as survivors talk about their experiences and circumstances; knowing what reactions and risk and resilience factors to look for; staying in the present; providing realistic reassurance and accurate information; and ending conversations so one can move on to assist others. Regulating one’s own reactions, remaining calm, and maintaining boundaries are also important, as is knowing what not to say or do. Well-meaning responders may want to help survivors feel better and, perhaps unwittingly, to feel better themselves. Efforts to get people to talk about their experience before they are ready, or comments that include unrealistic reassurance or expectations, comparative or self-referenced, and irrelevant diversions are not helpful and may cause harm. One cannot undo the calamities that many survivors are facing. Responders can only help them bear the burdens and let them know they are not alone, buttress their natural strengths, and impart hope.
Mental health professionals offer a higher level of intervention, which includes crisis intervention and psychoeducation components, as well as connections and referrals to local services that will be able to further assess and assist clients over the longer term or for those who need a higher level of immediate assessment and care. They can help survivors recognize that their reactions are typical and to be expected in the face of such events and assist them in understanding and utilizing positive coping skills and techniques. They also provide guidance (p. 59) on dealing with children and family members or with particularly difficult situations.
DMH workers will be active in providing crisis intervention and an enhanced PFA and will assist in other functions as well. Understanding and collaborating in other relief tasks is a good way to make connections with survivors and especially with other responders whom DMH clinicians are also there to serve. Outreach is often an important component as well. Going to community centers, houses of worship, schools, police and fire facilities, small business establishments, and even door to door in hard-hit neighborhoods allows providers to assess and assist a wide range of the affected public and to collaborate with community leaders.
Again, the ARC stresses that DMH workers are not to do psychotherapy or formal psychological assessments or diagnosing in disaster responding. Reasons for this include the difficult conditions and the limits on privacy, time, and number of contacts with clients, which may not allow for sufficient information, informed consent, building an alliance, or ensuring follow-up (ARC, 2018). In fact, establishing too close a relationship with a client might lead to yet another experience of loss when the responder leaves. Disaster mental health professionals are there to provide immediate relief and to assist and collaborate with local agencies, not to stand in their stead.
Preparation and Planning
Too often, communities overlook or lack the resources for building effective capacity to respond to disasters. Just as, sadly, many schools today hold active shooter drills in case such a potential (yet still unlikely) tragedy might occur, preparation can be vital (ARC, 2017a, 2018; Halpern & Tramontin, 2007; Watson, 2017). Mental health professionals have multiple roles to play in planning at every step. Educating responders and the public on likely psychological reactions to various situations and useful steps in addressing them will help promote coping during and after an incident. Printed and online materials can be prepared and disseminated. Integrating mental health considerations and psychoeducation into all components of response will result in more efficient overall management. It can be crucial for emergency managers to consider human factors that often affect what may seem to make sense structurally. A recent example at a county planning meeting was a discussion that parents will quickly become aware from social media of any incident at a school and will flock to see if their children are OK. This must be anticipated to avoid interference with the response by police, firefighters, and emergency medical services.
This is also the stage of trying to ensure that adequate psychological services will be available and effectively allocated when needed. Local health and mental health agencies and providers can collaborate to arrange for training and to create a plan for cooperation in a response. Representatives from relief (p. 60) organizations can assist with this and establish relationships that can be very valuable in the event of a disaster. Tabletop exercises and actual simulation drills are vital components. The ARC sponsors drills in anticipating incidents at airports, schools, public events, and a nuclear facility and general environmental events such as earthquakes and hurricanes. These experiences are realistic and quite helpful when responding to a real disaster.
As has been noted, particularly without more extensive disaster mental health interventions, a significant minority of survivors are likely to experience psychological disorders in the weeks and months (and years) following disaster experiences. These include ASD, PTSD, depression, complicated grief, and substance use disorders. While it is beyond the scope of this chapter to discuss these in depth, research has supported a number of effective treatments for these disorders, primarily including cognitive behavioral and interpersonal approaches. Prolonged exposure therapy, cognitive processing therapy, and eye movement desensitization and reprocessing considered evidence-based treatments for ASD and PTSD, as are some medications (particularly serotonin and serotonin/norepinephrine reuptake inhibitors) (Benedek & Wynn, 2017; Foa et al., 2005, 2009; SAMHSA, 2014).
Mind–body techniques (Gordon, 2013; SAMHSA, 2014) have shown utility in treating trauma and may be briefly used in DMH for stress reduction. Group therapy (Dembert & Simmer, 2000; Sloan & Beck, 2016) also has support in treating trauma if particular attention is paid to the composition of the groups, the timing, and the structure of the group process. Critical incident stress debriefing, which was designed to be delivered in the short term following a disaster, remains controversial, as evidence for its efficacy is limited and possible negative effects have been noted (Bisson et al., 2009). At this point, critical incident stress debriefing is generally not recommended in disaster response and is specifically prohibited in ARC interventions. Yet some broader principles of critical incident stress management, employed over a longer term, seem to have more adherents, particularly to work with preexisting or spontaneous groups that have closely shared exposure and experiences (Everly & Mitchell, 2008, Foa et al., 2009; Halpern & Vermeulen, 2017).
Again, these formal treatments are not the province of DMH, as they require multiple and more structured sessions and ongoing relationships with clinicians; however, some elements of these interventions may be helpful in the response phase for people at significant risk of developing disorders. For the most part, cognitive behavioral techniques have empirical support in treating trauma, yet these therapies require more time, and appropriately trained clinicians are in limited supply. Use of cognitive behavioral therapy in acute disaster situations (p. 61) has not been well studied, although some aspects of it are commonly utilized in PFA and DMH, such as psychoeducation, problem solving, and stress reduction. Monitoring people affected by trauma incidents to identify those who may be most in need of more extended follow-up treatment can be an important service (Brymer et al., 2009; Litz & Bryant, 2009).
Grief and mourning may be significant following disasters, especially those involving mass casualties, and those survivors may benefit from more ongoing intervention. Not only have people lost loved ones, but their social support systems and physical environments may also be disrupted. What is usually more private mourning becomes very public. This can all impede some of the typical rituals around death and loss. DMH responders may assist by bearing witness and listening to the stories of the bereaved. They attend vigils and memorials that often arise spontaneously as well as being organized by local community groups and are so important for collective healing. This may also include assistance in planning such events so they may be more healing and inclusive and to increase awareness and attention over the long term, such as anniversary reactions. Clinicians may visit those in mourning and even attend funerals, if invited. Simply being present and providing information and sometimes guidance are much appreciated (ARC, 2017b; Dass-Brailsford, 2010; Halpern & Vermeulen, 2017).
Self-Care for the DMH Responder
As noted earlier, disaster work can take a significant toll on the provider. The ability to assist others is largely based on one’s own well-being, so taking care of oneself is a priority stressed by relief organizations. In addition to being potentially subject to some of the same effects of trauma as survivors, DMH workers are at risk of secondary trauma, compassion fatigue, and burnout (Figley, 2005; New York State Office of Mental Health, 2017). Yet they are often not so good at taking their own advice. The desire to be of service to others and the situational pressures on a response, unrealistic beliefs about one’s own ability to resist or cope with the stress, concern about how one may be seen by colleagues, and the powerful feeling of being a part of something much larger than oneself may all lead to ignoring or “postponing” sufficient attention to the very human needs of the DMH professional.
Living and working conditions on a response may make it difficult to exercise, eat well, find private space, or engage in recreation. Spending some time with colleagues, away from clients, and having a sense of humor even amidst the difficult circumstances can be helpful. Keeping in touch with friends and family is important to remain grounded and not let the disaster take over one’s (p. 62) own life. Some of the same traits important in working with others may be applicable to taking good care of oneself. These include being flexible and genuine, as opposed to rigidly maintaining a “professional” barrier, finding some enjoyment in the work, and being creative about exercise (running laps around a motel parking lot, for example). Many find comfort from the therapy dogs that may be brought by some groups after disasters and also from local spiritual care providers. I believe that relief organizations should pay more active attention to these issues during and after a response. Designating DMH personnel specifically to attend to staff can improve the functioning and well-being of many responders.
Sadly, as both natural and human-caused disasters become more frequent and affect more people, responding to the psychological and social effects on survivors is becoming an ever more important component for the mental health professions. Based on early efforts at research and the accumulation of significant experience at this point, evidence has led to a considerable degree of consensus on what may be helpful. Yet much more remains to be done. The unpredictability and chaotic nature of disasters make well-designed research difficult. Yet, providing advanced training and preparation to arrange for studies and interventions will make them more likely (Brymer et al., 2009). More efforts are underway to do this and to enhance the resilience and recovery of individuals and communities (Birkhead & Vermeulen, 2018). Mental health professionals have much to offer and are committed to assisting others. With greater efforts to make them aware of the opportunities and need related to disaster preparedness and response, and if more training were provided, more would step up to meet the challenge.
The first step is serious and extensive planning and outreach, to include as many potential resources as possible that will agree to play a role and collaborate before, during, and after an incident. Anticipating human factors, maintaining clear lines of communication, educating the public about plans, and disseminating useful, accurate information are also important aspects of preparation as well as in the response and recovery phases of a disaster. Tabletop exercises and practice drills are vital components of effective preparation. This is also the period to offer training in PFA to all those who may respond, as well as to implement training in DMH and in evidence-based, trauma-focused psychotherapies to local mental health professionals.
When a disaster strikes, and in the immediate warning period if there is one, having DMH responders available will allow for quickly assisting the public in (p. 63) anticipating and coping with likely reactions and in marshaling their individual and collective resources and for providing crisis intervention and connections to other services when indicated. Along with addressing physical safety and basic needs, this can be crucial in improving their capacity to manage and to recover. Advocacy on behalf of survivors may also be an important service when needed.
In the longer term, continuing to provide information and access to services in the community remains important, particularly for those who suffered the most significant losses. In addition, having local mental health resources prepared to offer affordable psychotherapy for trauma-related conditions is needed to address those who are experiencing the greatest impairment in recovery. Greater funding is required so more communities have greater access to mental health services in general.
Public education as primary prevention, along with PFA and psychoeducation to survivors, combined with cultural awareness and competence in delivery of all services, can help reduce client barriers to obtaining assistance. The overall reduction of stigma regarding psychological difficulties and the promotion of greater socioeconomic equity are tall orders for society, yet we can each do our part as mental health professionals and as citizens. Disaster response agencies can also do more to promote the importance of DMH services and, not incidentally, to make sure that their DMH responders take care of themselves and one another.
Finally, it is hoped that this chapter may play a small role in promoting the involvement of more mental health providers in this type of work. Acknowledging the sacrifices and challenges, and recognizing that it is not for everyone, this can be a remarkably enriching path.
American Red Cross. (2017a). Psychological first aid instructor manual. Washington, DC: American Red Cross.Find this resource:
American Red Cross. (2017b). Reference guide—Supplemental information for the disaster mental health program. Washington, DC: American Red Cross.Find this resource:
American Red Cross. (2018). Disaster mental health fundamentals—Part I instructor manual. Washington, DC: American Red Cross.Find this resource:
Applebome, P., & Stelter, B. (2012, December 16). Media spotlight seen as a blessing, or a curse, in a grieving town. New York Times. Retrieved from www.nytimes.com/2012/12/17/business/media/newtown-has-mixed-feelings-about-the-media-horde-in-its-midst.html
Benedek, D. M., & Wynn, G. H. (2017). Acute stress disorder and posttraumatic stress disorder. In R. J. Ursano, C. S. Fullerton, L. Weisaeth, & B. Raphael (Eds.), Textbook of disaster psychiatry (2nd ed., pp. 101–123). New York, NY: Cambridge University Press.Find this resource:
(p. 64) Birkhead, G. S., & Vermeulen, K. (2018). Sustainability of psychological first aid training for the disaster workforce. American Journal of Public Health, 108(S5), S381–S382.Find this resource:
Bisson, J. I., McFarlane, A. C., Rose, S., Ruzek, J. I., & Watson, P. J. (2009). Psychological debriefing for adults. In E. Foa, E. M. Keane, M. J. Friedman, & J. A. Cohen (Eds.), Effective treatments for PTSD (pp. 83–105). New York, NY: Guilford Press.Find this resource:
Bonanno, G. A. (2004). Loss, trauma, and human resilience. American Psychologist, 59(1), 20–28.Find this resource:
Boyd-Franklin, N. (2010). Families affected by Hurricane Katrina and other disasters: Learning from the experiences of African American survivors. In P. Dass-Brailsford (Ed.), Crisis and disaster counseling: Lessons learned from Hurricane Katrina and other disasters (pp. 67–82). Los Angeles, CA: Sage.Find this resource:
Brymer, M. J., Steinberg, A. M., Vernberg, E. M., Layne, C. M., Watson, P. J., Jacobs, A., . . . Pynoos, R. S. (2009). Acute interventions for children and adolescents. In E. Foa, E. M. Keane, M. J. Friedman, & J. A. Cohen (Eds.), Effective treatments for PTSD (pp. 106–116). New York, NY: Guilford Press.Find this resource:
Center for Research on the Epidemiology of Disasters. (2018). Natural disasters 2017. Brussels: CRED.Find this resource:
Center for Research on the Epidemiology of Disasters. (2018). Economic losses, poverty and disasters 1998–2017. Brussels: CRED.Find this resource:
Dass-Brailsford, P. (Ed.). (2010). Crisis and disaster counseling: Lessons learned from Hurricane Katrina and other disasters. Los Angeles, CA: Sage.Find this resource:
Dembert, M. L., & Simmer, E. D. (2000). When trauma affects a community: Group interventions and support after a disaster. In R. H. Klein & V. L. Schermer (Eds.), Group psychotherapy for psychological trauma (pp. 239–264). New York, NY: Guilford Press.Find this resource:
Everly, G. S., & Lating, J. M. (2017). The Johns Hopkins guide to psychological first aid. Baltimore, MD: Johns Hopkins University Press.Find this resource:
Everly, G. S., McCabe, O. L., Semon, N. L., Thompson, C. B., & Links, J. M. (2014). The development of a model of psychological first aid for non-mental health trained public health personnel: The Johns Hopkins RAPID-PFA. Journal of Public Health Management Practice, 20(5), S24–S29.Find this resource:
Everly, G. S., & Mitchell, J. T. (2008). Integrative crisis intervention and disaster mental health. Ellicott City, MD: Chevron Publishing Corporation.Find this resource:
Figley, C. R. (2005, Oct. 17). Compassion fatigue: An expert interview with Charles R. Figley. Medscape. Retrieved from https://www.medscape.com/viewarticle/513615
Foa, E. B., Cahill, S. P., Boscarino, J. A., Hobfoll, S. E., Lahad, M., McNally, R. J., & Solomon, Z. (2005). Social, psychological, and psychiatric interventions following terrorist attacks: Recommendations for practice and research. Neuropsychopharmacology, 30, 1806–1817.Find this resource:
Foa, E., Keane, T. M., Friedman, M. J., & Cohen, J. A. (2009). Effective treatments for PTSD. New York, NY: Guilford Press.Find this resource:
Fox, J. H., Burkle Jr, F. M., Bass, J., Pia, F. A., Epstein, J. L., & Markenson, D. (2012). The effectiveness of psychological first aid as a disaster intervention tool: Research analysis of peer-reviewed literature from 1990-2010. Disaster Medicine and Public Health Preparedness, 6(3), 247–253.Find this resource:
Gordon, J. (2013, April 25). Center for Mind Body Medicine. Presentation at Albert Einstein College of Medicine, New York, NY.Find this resource:
(p. 65) Halpern, J., & Tramontin, M. (2007). Disaster mental health: Theory and practice. Belmont, CA: Thompson Brooks/Cole.Find this resource:
Halpern, J., & Vermeulen, K. (2017). Disaster mental health interventions: Core principles and practices. New York, NY: Routledge.Find this resource:
Hobfoll, S., Watson, P., Bell, C., Bryant, R., Brymer, M., Friedman, M., . . . Ursano, R. J. (2007). Five essential elements of immediate and mid-term mass trauma intervention: Empirical evidence. Psychiatry, 70(4), 283–315.Find this resource:
Inter-Agency Standing Committee. (2007). IASC guidelines on mental health and psychosocial support in emergency settings. Geneva: IASC.Find this resource:
Joshi, S., & Cerda, M. (2017). Trajectories of health, resilience, and illness. In R. J. Ursano, C. S. Fullerton, L. Weisaeth, & B. Raphael (Eds.), Textbook of disaster psychiatry (2nd ed., pp. 76–86). New York, NY: Cambridge University Press.Find this resource:
Knapp, K. C. (2010). Children and crises. In P. Das-Brailsford (Ed.), Crisis and disaster counseling: Lessons learned from Hurricane Katrina and other disasters (pp. 83–98). Los Angeles, CA: Sage.Find this resource:
Litz, B. T., & Bryant, R. A. (2009). Early cognitive-behavioral interventions for adults. In E. Foa, E. M. Keane, M. J. Friedman, & J. A. Cohen (Eds.), Effective treatments for PTSD (pp. 117–135). New York, NY: Guilford Press.Find this resource:
Miller, J. L. (2012). Psychosocial capacity building in response to disasters. New York, NY: Columbia University Press.Find this resource:
National Institute for Environmental Health Services. (2015). Care provider’s role: Disaster workers behavioral health care. Washington, DC: HIEHS.Find this resource:
New York State Office of Mental Health. (2017). Long-term impact of disaster response on counselors. NY DMH Responder, 22(3), 8–9.Find this resource:
North, C. S. (2017). Epidemiology of disaster mental health: The foundation for disaster mental health response. In R. J. Ursano, C. S. Fullerton, L. Weisaeth, & B. Raphael (Eds.), Textbook of disaster psychiatry (2nd ed., pp. 27–43). New York, NY: Cambridge University Press.Find this resource:
Substance Abuse and Mental Health Services Administration. (2014). Trauma-informed care in behavioral health services. Treatment improvement protocol (TIP) Series 57. HHS Publication No. (SMA) 13-4801. Rockville, MD: Author.Find this resource:
SAMHSA/ARC. (2015, June 18). A mental health response to disaster. Presentation. Retrieved from https://www.mentalhealthamerica.net/sites/default/files/MHA%20Disaster%20MH%20All.pdf
Sloan, D. M., & Beck, J. G. (2016) Group treatment for PTSD. PTSD Research Quarterly, 27(2), 1–4.Find this resource:
University of Albany Center for Public Preparedness & State University of New York, New Paltz, Institute for Disaster Mental Health. (2017). Psychological first aid training coordinator guide. Albany, NY: University of Albany.Find this resource:
Watson, P. J. (2017). Early interventions for trauma-related problems. In R. J. Ursano, C. S. Fullerton, L. Weisaeth, & B. Raphael. Textbook of disaster psychiatry (2nd ed., pp. 87–100). New York, NY: Cambridge University Press.Find this resource:
Weine, S., Danieli, Y., Silove, D., Van Ommeren, M., Fairbank, J. A., & Saul, J. (2002). Guidelines for international training in mental health and psychosocial interventions for trauma-exposed populations in clinical and community settings. Psychiatry, 65(2), 156–164.Find this resource:
World Health Organization. (2011). Psychological first aid: Guide for field workers. Geneva: WHO.Find this resource:
Websites with Information and Training Materials on DMH
American Psychiatric Association— www.psychiatry.org
American Psychological Association— www.apa.org
American Red Cross— www.redcross.org
Center for the Study of Traumatic Stress (part of Uniformed Services University)— https://www.cstsonline.org/
International Society for Traumatic Stress Studies— https://www.istss.org/
National Child Traumatic Stress Network— https://www.nctsn.org/
Office of Homeland Security— www.ready.gov
Substance Abuse and Mental Health Services Administration— https://www.samhsa.gov/
U.S. Department of Veterans Affairs— www.ptsd.va.gov
World Health Organization, Interagency Standing Committee— http://www.who.int/mental_health/emergencies/guidelines_iasc_mental_health_psychosocial_june_2007.pdf