DISASTER RESPONSE AND RECOVERY: A HANDBOOK FOR MENTAL HEALTH PROFESSIONALS by Diane Myers, R.N., M.S.N. Monterey, California Copy Editor Bruce Hiley-Young, M.S.W., L.C.S.W. National Center for Post-Traumatic Stress Disorder Menlo Park, California CHAPTER ONE KEY CONCEPTS OF DISASTER MENTAL HEALTH This first chapter provides a synopsis of the major concepts important to understanding how disaster mental health services must differ from mental health programs in nondisaster times. The knowledge has been acquired through both research and firsthand experience of mental health administrators and practitioners who have provided disaster mental health recovery services. NO ONE WHO SEES A DISASTER IS UNTOUCHED BY IT In any given disaster, loss and trauma will directly affect many people. In addition, there are many other individuals who are emotionally impacted simply by being a part of the affected community. Myers (Hartsough and Myers, 1985) addresses the extensive kind of personal and community upheaval which disaster can cause: A disaster is an awesome event. Simply seeing massive destruction and terrible sights evokes deep feelings. Often, residents of disaster-stricken communities report disturbing feelings of grief, sadness, anxiety, and anger, even when they are not themselves victims. . . . Such strong reactions confuse them when, after all, they were spared any personal loss. These individuals find comfort and reassurance when told that their reactions are normal in every way; everyone who sees a disaster is, in some sense, a victim. Even individuals who experience a disaster "second hand" through exposure to extensive media coverage can be affected. This includes children whose parents may lose track of how much disaster material their children are seeing and hearing. Mental health workers have, in essence, a whole population to educate about common disaster stress reactions, ways to cope with stressors, and available resources (Myers, 1991). Therefore, mental health education about the effects of disaster, self-help interventions, and where to call for additional help must be provided to the community at large. THERE ARE TWO TYPES OF DISASTER TRAUMA In his study of the Buffalo Creek, West Virginia flood of 1972, sociologist Kai Erikson described two types of trauma that occur jointly and continuously in most disasters (1976). Disaster mental health services must take both types of trauma into consideration to address all of the needs of the community. Individual trauma is defined as "a blow to the psyche that breaks through one's defenses so suddenly and with such brutal force that one cannot react to it effectively." Collective trauma is "a blow to the basic tissues of social life that damages the bonds attaching people together and impairs the prevailing sense of communality." Individual trauma manifests itself in the stress and grief reactions which individual survivors experience. Bolin and Bolton (1986) emphasize that collective trauma can sever the social ties of survivors with each other and with the locale. These may be ties that could provide important psychological support in times of stress. Disaster disrupts nearly all activities of daily living and the connections they entail. People may relocate to temporary housing away from their neighbors and other social supports such as church, clinics, childcare, or recreation programs. Work may be disrupted or lost due to business failure, lack of transportation, loss of tools, or a worker's inability to concentrate due to disaster stress. For children, there may be a loss of friends and school relationships due to relocation. Fatigue and irritability can increase family conflict and undermine family relationships and ties. Collective trauma is often less "visible" to mental health clinicians trained to work with individuals. However, it is essential to identify and address collective trauma in disaster mental health programs. People will find it difficult, if not impossible, to heal from the effects of individual trauma while the community around them remains in shreds and a supportive community setting does not exist (Erikson, 1976). Thus, mental health interventions such as outreach, support groups, community organization, and advocacy, which seek to reestablish linkages between individuals and groups, are essential. MOST PEOPLE PULL TOGETHER AND FUNCTION DURING AND AFTER A DISASTER, BUT THEIR EFFECTIVENESS IS DIMINISHED There are multitudes of stressors affecting disaster survivors. In the early "heroic" and "honeymoon" phases there is much energy, optimism, and altruism. However, there is often a high level of activity with a low level of efficiency. As the implications and meaning of losses become more real, grief reactions intensify. As fatigue sets in and frustrations and disillusionment accumulate, more stress symptoms may appear (Farberow and Frederick, 1978). Diminished cognitive functioning (short-term memory loss, confusion, difficulty setting priorities and making decisions, etc.) may occur because of stress and fatigue. This can impair survivors' ability to make sound decisions and take necessary steps toward recovery and reconstruction. DISASTER STRESS AND GRIEF REACTIONS ARE NORMAL RESPONSES TO AN ABNORMAL SITUATION Most disaster survivors are normal persons who function reasonably well under the responsibilities and stresses of everyday life. However, with the added stress of disaster, most individuals will usually show some signs of emotional and psychological strain (Farberow and Frederick, 1978). Reactions include post-traumatic stress and grief responses. These reactions are normal reactions to an extraordinary and abnormal situation, and are to be expected under the circumstances. Survivors, residents of the community, and disaster workers alike may experience them. These responses are usually transitory in nature and rarely imply a serious mental disturbance or mental illness. Contrary to myth, neither post-traumatic stress disorder nor pathological grief reactions are rampant following disaster. Green, Wilson, and Lindy (1985) emphasize that the post-traumatic stress process is a dynamic one, in which the survivor attempts to integrate a traumatic event into his/her self-structure. The process is natural and adaptive. It should not be labeled pathological (i.e., a "disorder") unless it is prolonged, blocked, exceeds a tolerable quality, or interferes with regular functioning to a significant extent. Similarly, Myers, Zunin and Zunin (1990) point out that grief reactions are a normal part of recovery from disaster. Not only may individuals lose loved ones, homes, and treasured possessions, but hopes, dreams, and assumptions about life and its meaning may be shattered. Zunin and Zunin (1991) emphasize that the grief responses to such losses are common and are not pathological (warranting therapy or counseling), unless the grief is an intensification, a prolongation, or an inhibition of normal grief. Relief from stress, the ability to talk about the experience, and the passage of time usually lead to the reestablishment of equilibrium. Public information about normal reactions, education about ways to handle them, and early attention to symptoms that are problematic can speed recovery and prevent long-term problems (Hartsough and Myers, 1985). MANY EMOTIONAL REACTIONS OF DISASTER SURVIVORS STEM FROM PROBLEMS OF LIVING CAUSED BY THE DISASTER Because disaster disrupts so many aspects of daily life, many problems for disaster survivors are immediate and practical in nature (Farberow and Frederick, 1978). People may need help locating missing loved ones; finding temporary housing, clothing, and food; obtaining transportation; applying for financial assistance, unemployment insurance, building permits, income tax assistance; getting medical care, replacement of eyeglasses or medication; obtaining help with demolition, digging out, and cleanup. DISASTER RELIEF PROCEDURES HAVE BEEN CALLED "THE SECOND DISASTER" The process of obtaining temporary housing, replacing belongings, getting permits to rebuild, applying for government assistance, seeking insurance reimbursement, and acquiring help from private or voluntary agencies is often fraught with rules, red tape, hassles, delays, and disappointment. People must often establish ties to bureaucracies to get aid they can get nowhere else. However, the organizational style of the aid-giving bureaucracies is often too impersonal for victims in the emotion-charged aftermath of the disaster (Bolin, 1982). Munnichs (1977) has noted that "bureaucracy means impersonality in social relations, routinization of tasks, centralization of authority, rigid rules and procedures. . . ." To complicate the matter, disasters and their special circumstances often foul up the bureaucratic procedures even of organizations established to handle disaster (Bolin, 1982). Families are forced to deal with organizations that seem or are impersonal, inefficient, and inept. Many individuals are unable to obtain the benefits for which they are eligible in a timely manner from the agencies involved. For individuals who felt competent and effective before the disaster, they may suddenly experience a serious erosion of self-esteem and confidence. Feelings of helplessness and anger are common (Farberow and Frederick, 1978). In response, mental health staff may assist individuals by reassuring them that this "second disaster" is a common phenomenon. They can reassure them that most people have difficulty wending their way through the bureaucracy. Simply hearing the phase "the second disaster" often brings a wave of relief to survivors, often with some welcomed laughter. In addition, mental health personnel may need to help individuals to find constructive channels for their anger and frustration. This may involve helping them not to misdirect it (toward family, for example), nor to sabotage their own efforts by "blowing up" at the agencies trying to help them (Project COPE, 1983). Mental health staff may also help individuals by providing information about how specific agencies work. Survivor support groups are often very helpful in this regard, with individuals offering each other concrete advice and suggestions about how to deal with bureaucratic problems. In addition, mental health may provide consultation or training to disaster relief agencies. The goal of such consultation is to influence programs toward maximum responsiveness to needs of disaster survivors. Mental health may also intervene directly with agencies on behalf of disaster survivors. Such advocacy may be case centered, seeking to benefit an individual client, or may be issue-centered, seeking to benefit a group of clients or the general population (Myers, 1990). MOST PEOPLE DO NOT SEE THEMSELVES AS NEEDING MENTAL HEALTH SERVICES FOLLOWING DISASTER, AND WILL NOT SEEK OUT SUCH SERVICES Many people equate "mental health" services with being "crazy." To offer mental health assistance to a disaster survivor may seem to add insult to injury--"First I have lost everything and now you think I'm mentally unstable." In addition, most disaster survivors are overwhelmed with the time-consuming activities of putting the concrete aspects of their lives back together. Counseling or support groups may seem esoteric in the face of such pragmatic pressures. Very effective mental health assistance can be provided while the worker is helping survivors with concrete tasks. For example, a mental health worker can use skilled but unobtrusive interviewing techniques to help a survivor in sorting out demands and setting priorities while they are sifting through rubble together. SURVIVORS MAY REJECT DISASTER ASSISTANCE OF ALL TYPES People may be too busy with cleaning up and other concrete demands to seek out services and programs that might help them. Initially, people are relieved to be alive and well. They often underestimate the financial impact and implication of their losses, and overestimate their available financial resources. The bottom-line impact of losses is often not evident for many months or, occasionally, for years. The heroism, altruism, and optimism of the early phases of disaster may make it seem that "others are so much worse off than I am." For most people, there is a strong need to feel self-reliant and in control. Some people equate government relief programs as "welfare." For others, especially recent immigrants who have fled their countries of origin because of war or oppression, government is not to be trusted. Pride may be an issue for some people. They may feel ashamed that help is needed, or may not want help from "outsiders" (Farberow and Frederick, 1978). Tact and sensitivity to these issues are important. DISASTER MENTAL HEALTH ASSISTANCE IS OFTEN MORE "PRACTICAL" THAN "PSYCHOLOGICAL" IN NATURE Most disaster survivors are people who are temporarily disrupted by a severe stress, but can function capably under normal circumstances. Much of the mental health work at first will be to give concrete types of help (Farberow and Frederick, 1978). Mental health personnel may assist survivors with problem-solving and decision making. They can help them to identify specific concerns, set priorities, explore alternatives, seek out resources, and choose a plan of action (American Red Cross, 1982). Mental health staff must inform themselves about resources available to survivors, including local organizations and agencies in addition to specialized disaster relief resources. Mental health workers may help directly with some problems, such as providing information, filling out forms, helping with cleanup, locating health care or child care, finding transportation. They may also make referrals to specific resources, such as assistance with loans, housing, employment, permits. In less frequent cases, individuals may experience more serious psychological responses such as severe depression, disorientation, immobilization, or an exacerbation of prior mental disturbance. These situations will likely require referral for more intensive psychological counseling. The role of the disaster mental health worker is not to provide treatment for severely disturbed individuals directly, but to recognize their needs and help link them with an appropriate treatment resource (Farberow and Frederick, 1978). DISASTER MENTAL HEALTH SERVICES MUST BE UNIQUELY TAILORED TO THE COMMUNITIES THEY SERVE The demographics and characteristics of the communities affected by disaster must be considered when designing a mental health program (Myers, 1991). Urban, suburban, and rural areas have different needs, resources, traditions and values about giving and receiving help. It is essential that programs consider the ethnic and cultural groups in the community, and provide services that are culturally relevant and in languages of the people. Disaster recovery services are best accepted and utilized if they are integrated into existing, trusted community agencies and resources. In addition, programs are most effective if workers indigenous to the community and to its various ethnic and cultural groups are integrally involved in service delivery. MENTAL HEALTH STAFF NEED TO SET ASIDE TRADITIONAL METHODS, AVOID THE USE OF MENTAL HEALTH LABELS, AND USE AN ACTIVE OUTREACH APPROACH TO INTERVENE SUCCESSFULLY IN DISASTER The traditional, office-based approach is of little use in disaster. Very few people will come to an office or approach a desk labeled "mental health." Most often, the aim will be to provide human services for problems that are accompanied by emotional strain. It is essential not to use words that imply emotional problems, such as counseling, therapy, psychiatric, psychological, neurotic, or psychotic (Farberow and Frederick, 1978). Mental health staff may identify themselves as human service workers, crisis counselors, or use other terminology that does not imply that their focus is on pathology. Workers seem less threatening when they refer to their services as "assistance," "support," or "talking" rather than labeling themselves as "mental health counselors" (DeWolfe, 1992). Mental health staff need to use an active outreach approach. They must go out to community sites where survivors are involved in the activities of their daily lives. Such places include impacted neighborhoods, schools, disaster shelters, Disaster Application Centers (DACs), meal sites, hospitals, churches, community centers, and the like. SURVIVORS RESPOND TO ACTIVE INTEREST AND CONCERN They will usually be eager to talk about what happened to them when approached with warmth and genuine interest. Mental health outreach workers should not hold back from talking with survivors out of fear of "intruding" or invading their privacy. INTERVENTIONS MUST BE APPROPRIATE TO THE PHASE OF DISASTER It is important that disaster mental health workers recognize the different phases of disaster and the varying psychological and emotional reactions of each phase. For example, it will be counterproductive to probe for feelings when shock and denial are shielding the survivor from intense emotions. Once the individual has mobilized internal and external coping resources, they are better able to deal with their feelings about the situation. During the "heroic" and "honeymoon" phases, people who have not lost loved ones may be feeling euphoric, altruistic, and optimistic rather than bereaved. During the "inventory" phase, people are seeking and discussing the facts about the disaster, trying to piece reality together and understand what has happened. They may be more invested in discussing their thoughts than talking about feelings. In the "disillusionment" phase, people will likely be expressing feelings of frustration and anger. It is not usually a good time to ask if they can find something "good" that has happened to them through their experience. Most people are willing and even eager to talk about their experiences in a disaster. However, it is important to respect the times when an individual may not want to talk about how things are going. Talking with a person in crisis does not mean always talking about the crisis (Zunin and Zunin, 1991). People usually "titrate their dosage" when dealing with pain and sorrow, and periods of normalcy and respite are also important. Talking about ordinary events and laughing at humorous points is also healing. If in doubt, ask the person whether they are in the mood to talk. SUPPORT SYSTEMS ARE CRUCIAL TO RECOVERY The most important support group for individuals is the family. Workers should attempt to keep the family together (in shelters and temporary housing, for example). Family members should be involved as much as possible in each others' recovery. Disaster relocation and the intense activity involved in disaster recovery can disrupt people's interactions with their support systems. Encouraging people to make time for family and friends is important. Emphasizing the importance of "rebuilding relationships" in addition to rebuilding structures can be a helpful analogy. For people with limited support systems, disaster support groups can be helpful. Scanlon-Schlipp and Levesque (1981) point out that support groups help to counter isolation. People who have been through the same kind of situation feel they can truly understand one another. Groups help to counter the myths of uniqueness and pathology. People find reassurance that they are not alone or "weird" in their reactions. The groups not only provide emotional support, but survivors can share concrete information and recovery tips. They benefit from the guidance of other experienced survivors. Besides the catharsis of sharing experiences, they can identify with others who are recovering, and can begin to feel hope for their own situation. Mental health staff may involve themselves in setting up self-help support groups for survivors, or may facilitate support groups. In addition, mental health workers may involve themselves in community organization activities. Community organization brings community members together to deal with concrete issues of concern to them. Such issues may include social policy in disaster reconstruction, or disaster preparedness at the neighborhood level. The process can assist survivors with disaster recovery by not only helping with concrete problems, but by reestablishing feelings of control, competence, self-confidence, and effectiveness. Perhaps most important, it can help to reestablish social bonds and support networks that have been fractured by the disaster. SUMMARY The above concepts illustrate some main differences between disaster mental health services and mental health programs in nondisaster times. Mental health administrators and service providers have found these concepts essential to planning and implementing successful disaster mental health recovery programs. REFERENCES AND RECOMMENDED READING American Red Cross. Providing Red Cross Disaster Health Services (ARC 3076-A). December, 1982. Bolin, R.C. Long-term Family Recovery from Disaster. Program on Environment and Behavior, Monograph #36. Boulder, Colorado: University of Colorado, 1982. Bolin, R.C. Families in Natural Disaster: The Vernon and Wichita Falls Tornadoes. Family Recovery Project Interim Report. Las Cruces: New Mexico State University, Department of Sociology and Anthropology, 1980. Bolin, R. and Bolton, P. Race, Religion, and Ethnicity in Disaster Recovery. Program on Environment and Behavior, Monograph #42. Boulder, Colorado: University of Colorado, 1986. DeWolfe, D. "A Guide to Door-to-Door Outreach." In Final Report: Regular Services Grant, Western Washington Floods. State of Washington Mental Health Division, 1992. Erikson, K.T. Everything in Its Path: Destruction of Community in the Buffalo Creek Flood. New York: Simon and Schuster, 1976. Farberow, N.L. and Frederick, C.J. Training Manual for Human Service Workers in Major Disasters. Rockville, Maryland: National Institute of Mental Health, 1978. Green, B.L., Wilson, J.P., and Lindy, J.D. Conceptualizing Post-traumatic Stress Disorder: A Psychosocial Framework. In Figley, C.R. (Ed.), Trauma and its Wake, Volume I: The Study and Treatment of Post-traumatic Stress Disorder. New York: Brunner/Mazel, Inc., 1985. Hartsough, D.M. and Myers, D.G. Disaster Work and Mental Health: Prevention and Control of Stress Among Workers. Rockville, Maryland: National Institute of Mental Health, 1985. Janoff-Bulman, R. The Aftermath of Victimization: Rebuilding Shattered Assumptions. In Figley, C.R. (Ed.), Trauma and its Wake, Volume I: The Study and Treatment of Post-traumatic Stress Disorder. New York: Brunner/Mazel, Inc., 1985. Munnichs, J. Linkages of Old People with their Families and Bureaucracy in a Welfare State, the Netherlands. In Shanas, E. and Sussman, M. (Eds.), Family, Bureaucracy, and the Elderly. Durham, NC: Duke University Press, 1977. Myers, D. "Emotional Recovery from the Loma Prieta Earthquake." Networks: Earthquake Preparedness News, 6(1):6-7, 1991. Myers, D., Zunin, H.S., and Zunin, L.M. "Grief: The Art of Coping with Tragedy." Today's Supervisor, 6(11):14-15, 1990. Project COPE: A Community-based Mental Health Response toDisaster. Final Report: FEMA Crisis Counseling Project. County of Santa Cruz Community Mental Health Services, 1983. Scanlon-Schlipp, A.M., and Levesque, J. "Helping the Patient Cope with the Sequelae of Trauma through the Self-help Group Approach." The Journal of Trauma, 21: 135-139, February, 1981. Zunin, L.M., and Zunin, H.S. The Art of Condolence: What to Write, What to Say, What to Do at a Time of Loss. New York: HarperCollins Publishers, 1991. CHAPTER TWO SELECTION AND TRAINING OF DISASTER MENTAL HEALTH STAFF The skills and competencies required of disaster mental health workers are sufficiently different from typical inpatient/outpatient clinical practice to demand specialized selection and training. When a disaster strikes a community, it is ideal to have a cadre of mental health professionals with special training who can be quickly mobilized, oriented and deployed. If the impacted area does not have this capacity, then mutual aid agreements with communities having trained and experienced disaster mental health workers will be helpful in the chaotic times immediately following impact. The purpose of this chapter is to assist mental health planners and administrators in selecting mental health staff for disaster assignments, and in establishing appropriate training programs to enable them to do their work effectively. Items for consideration in selecting disaster mental health staff are presented. The chapter then offers an overview of training issues, including practical aspects of rapid training and deployment, objectives of comprehensive disaster mental health training, and selection of appropriate trainers. This chapter is not intended as a training manual per se. Many manuals and models for disaster mental health training already exist (Farberow and Frederick, 1978; Hartsough and Myers, 1985; Myers, 1990; American Red Cross, 1991). Similarly, the chapter does not seek to "train the trainer" in principles of adult education and methods of instruction. Many books and workshops are available on those topics. PREDISASTER PLANNING Much of the confusion and stress at the time of disaster impact can be eliminated when a mental health agency has a core of staff predesignated and trained as a disaster response team. Regular in-service training and participation in disaster exercises in the local jurisdiction can help to maintain and fine-tune skills. If resources allow, the team can respond to smaller crises that occur in the jurisdiction, so that staff will have some firsthand experience behind them if a large disaster strikes. With the diminishing budgets of many community mental health programs, funds for training have become almost nonexistent. Training is considered a necessary and appropriate aspect of the Federal Emergency Management Agency (FEMA) Crisis Counseling programs, both in the Immediate Services and Regular Programs. Mental health planners and administrators should include realistic training budgets in their grant applications. SELECTION OF DISASTER MENTAL HEALTH STAFF Disaster mental health work is not for everyone. This challenging and rewarding work requires that mental health professionals be flexible and socially extroverted. Despite altruism and a sincere desire to help, not all individuals are well-suited for disaster work. Whether designating and training disaster staff before or during a disaster, the mental health manager must consider several selection issues. Ideally, selection of professional or paraprofessional staff should consider demographics of the disaster-affected population, including ethnicity and language; the personality characteristics and social skills of the staff member; the phase of disaster; and the roles the worker may play in disaster response and recovery efforts. Workers selected for disaster response and recovery work should not be so severely personally impacted by the disaster that their responsibilities at home or their emotional reactions will interfere with participation in the program, or vice versa. Many points that follow may seem obvious, but they are crucial in establishing effective response teams. Demographics of the population Managers should choose staff with special skills to match needs of the population. For example, staff with special expertise in working with children and the local schools should be included. If there are many elderly persons in the community, the team should include persons skilled in working with older adults. Ethnicity and language Survivors will react to and recover from disaster within the context of their ethnic background, cultural viewpoint, life experiences and values. Survivors with limited English-speaking skills may have difficulty communicating needs and feelings except in their native language. All aspects of disaster operations must be sensitive to cultural issues, and services must be provided in ways that are culturally appropriate. For these reasons, it is essential that mental health staff be both familiar and comfortable with the culture of the groups affected by the disaster. It is highly desirable that they be fluent in the languages of non-English speaking groups affected. Ideally, mental health staff should include individuals indigenous to specific cultural groups affected by the disaster. If such staff are not immediately available, coordinators can recruit mutual aid staff with the required ethnic backgrounds and language skills from other community agencies or mental health jurisdictions for the immediate postdisaster phase. Indigenous personnel can be recruited and trained for the longer-term recovery work later. Personality of staff members A necessary quality for individuals participating directly in disaster is the ability to remain focused and able to respond appropriately. Disaster mental health staff must be able to function well in confused, often chaotic environments. Workers must be able to "think on their feet," and have a common-sense, practical, flexible and often improvisational approach to problem-solving. They must be comfortable with changing situations, and able to function with role ambiguity, unclear lines of authority, and a minimum of structure. Many of the most successful disaster mental health workers perceive these factors as challenges rather than burdens. Initiative and stamina are required, as well as self-awareness and an ability to monitor and manage their own stress. Workers must be able work cooperatively in a liaison capacity. They should be aware of and comfortable with value systems and life experiences other than their own. An eagerness to reach out and explore the community to find people needing help, instead of a "wait and treat" attitude, is essential (Farberow and Frederick, 1978). Workers must enjoy people and not appear lacking in confidence. If the worker is shy or afraid, it will interfere with establishing a connection (DeWolfe, 1992). Staff must be comfortable initiating a conversation in any community setting. Additionally, workers must be willing and able to "be with" survivors who may be suffering tragedy and enormous loss without being compelled to try to "fix" the situation. The phase of disaster In the immediate response phase of disaster, an "action orientation" is important. Workers who do well with the pace of crisis intervention do well in this phase. Personnel who have worked in emergency services in a local mental health center or a hospital emergency room are frequently well-suited to this phase of disaster work. Some people cannot tolerate and do not function well when exposed to the sights and sounds of physical trauma. These staff should obviously not be asked to provide mental health services at the scene of injuries, in first aid stations, hospital emergency rooms, or morgues. This does not mean that they cannot be on the disaster response team, as there are many other roles they can play. However, involved personnel should openly discuss such issues during initial formation of the team, so individuals best suited to these roles can be predesignated. Long-term mental health recovery programs, covering the period from about one month to one year postdisaster, are different in nature and pace from the immediate response phase. Mass care shelters and disaster application centers (DACs) are closed or closing, and locating disaster survivors is more difficult. Mental health workers need to be adept and creative with outreach in the community. The results of outreach and education efforts are often hard to measure, as survivors traditionally do not seek out mental health services and there are few "clients" to treat and count. Clinically oriented staff accustomed to an office-based practice often question their usefulness and effectiveness. "Action-oriented" staff who thrived in the immediate response phase may not enjoy or function well in the longer-term recovery phase where patience, perseverance, and an ability to function without seeing immediate results are assets. Roles and responsibilities of disaster mental health workers Disaster mental health roles and responsibilities are diverse. Thoughtful matching of worker skills and personalities to the specific assignment can help ensure success of mental health efforts. 1. Outreach: Working in neighborhoods, mass care shelters, disaster application centers or other community settings requires workers who are adept at such nontraditional mental health approaches as "aggressive hanging out" and "over a cup of coffee" assessments and interventions. 2. Public education: Public education efforts require staff who are interested and effective in public speaking and working with the media. Development of fliers and brochures requires good writing skills. 3. Community liaison: Establishing and maintaining liaison with community leaders requires someone who understands and is effective in dealing with organizational dynamics and the political process. Working successfully in the "grass roots" community requires someone who understands the local culture, social network, formal and informal leadership, and is effective in establishing relationships at the neighborhood level. Liaison activities might include everything from attending grange or church gatherings, participating in neighborhood meetings, or providing disaster mental health consultation to government officials. 4. Crisis counseling: For most disaster survivors, prolonged psychotherapy is not necessary or appropriate. Crisis intervention, brief treatment, support groups and practical assistance are most effective. Mental health staff must have knowledge and skills in these modalities. Qualifications of professional disaster mental health workers Ideally, the disaster mental health team should be multidisciplinary and multiskilled. Staff should be experienced in psychiatric triage, first aid, crisis intervention, and brief treatment. They should have knowledge of crisis, post-traumatic stress and grief reactions, and disaster psychology. Survivors are often reluctant to come to mental health centers for services, so staff must be able to provide their services in nontraditional community-based settings. Prior disaster mental health training and experience are highly recommended. In situations of mutual aid where licensed professionals cross state lines to provide assistance in disaster, licensing in the impacted state may be waived under the Good Samaritan law. This issue should be investigated in instances of cross-state mutual aid. Staff should be well-acquainted with the functions and dynamics of the community's human service organizations and agencies (Farberow and Frederick, 1978). They should have experience in consultation and community education. Excellent communication, problem-solving, conflict resolution, and group process skills are needed, in addition to an ability to establish rapport quickly with people from diverse backgrounds. Managers should pay careful attention to the state's scope of practice laws for various mental health professional disciplines. Individuals provide formal assessment and counseling which fall into the definition of psychotherapy should be appropriately licensed and insured for professional liability. Qualifications of paraprofessional disaster mental health workers Paraprofessionals can be excellent choices for outreach and community workers, especially if they are familiar with the community and trusted by its residents. They may be already employed by a mental health, social service, health, or other community-based agency, or they may be recruited from among community residents. Characteristics and qualifications should include the following (Collins and Pancoast, 1976; Farberow and Frederick, 1978; Tierney and Baisden, 1979): 1. Possess at least some high school education (to master information and concepts to be taught). 2. Are indigenous to the area, if possible. 3. Represent a cross section of the community/neighborhood members with regard to age, sex, ethnicity, occupation, length of residence in the community, etc. 4. Are motivated to help other people, like people, and have sensitivity and empathy for others. 5. Are functioning in a stable, mature, and logical manner. 6. Possess sufficient emotional and physical resources and receive sufficient personal rewards to be truly capable of helping. 7. Can work cooperatively with others. 8. Are able to work with people of other value systems without inflicting their own value system on others. 9. Are able to accept instructions and do not have ready-made, simplistic answers. 10. Have an optimistic, yet realistic, view of life, i.e., a "health engendering personality." 11. Have a high level of energy to remain active and resourceful in the face of stress. 12. Are committed to respect the confidentiality of survivors and are not inclined to gossip. 13. Have special skills related to unique populations (e.g., children or older adults, particular ethnic groups) or useful to disaster recovery (e.g., understanding of insurance, building requirements, etc.). 14. Are able to set personal limits and not become too involved with survivor recovery (e.g., understand the difference between facilitating and empowering survivors as opposed to "taking over" for the survivor). WHY TRAINING? Mental health professionals frequently assume that their clinical training and experience are more than sufficient to enable them to respond adequately in disaster. Unfortunately, traditional mental health training does not address many issues found in disaster-affected populations (FEMA, 1988). While clinical expertise, especially in the field of crisis intervention, is valuable, it is not enough. Mental health personnel need to adopt new procedures and methods for delivering a highly specialized service in disaster. Training must be designed to prepare staff for the uniqueness of disaster mental health approaches. Though disasters profoundly affect individuals, people rarely disintegrate and become incapable of coping with the situation. Nor does mental illness suddenly manifest in a full-blown florid state. Problems do appear and vary in nature and intensity (Farberow, 1978). However, most of the problems and postdisaster symptomatology are normal reactions of normal people to abnormal events. Few require traditional psychotherapy. Very few people seek out mental health assistance following disaster, and mental health staff who simply open the doors of their clinics to clients or patients will have little to do. Because of this, outreach to the community is essential. Outreach is more than simply setting up decentralized clinical services in impacted areas, or sending out brochures advertising mental health services. Outreach also means mingling with survivors in shelters and DACs and meal sites and devastated neighborhoods. The key to effective outreach is the mental health worker's ability to establish rapport and to have therapeutic intervention with individuals in an informal, social context in which there is not a psychotherapeutic "contract." In addition to the impact on individuals, a disaster is a political and bureaucratic event. Disasters profoundly affect the community and its social systems. Everyday resources for basic human needs may be destroyed or damaged. Transportation and communication may be disrupted. In a large-scale disaster, specialized emergency response and recovery agencies move into action and exert a significant influence on the postdisaster environment. Resources, structures, and individuals change as specialized response groups finish their jobs and move on and as new, grass-roots groups spring up. Mental health staff need to understand and be able to function effectively in a complex and fluid political and bureaucratic network. Disaster mental health training will help staff to understand the impact of disaster on individuals and the community. It will provide information about the complex systems and resources in the postdisaster environment. It will also help staff to fine-tune clinical skills that are relevant and useful in disaster, and will aid them in learning effective community-based approaches. Through videotapes, role play, and other exercises, training allows staff to experience vicariously the emotional climate of disaster recovery work. Sometimes, staff may decide they are not well suited to this type of work. Usually, the experiential aspects of the training will provide workers with some measure of "emotional inoculation" that will help them to anticipate the emotional aspects of the work. Training must also provide staff with awareness of the personal impact of disaster work, and with strategies for stress management and self-care. BEFORE THE TRAINING It is essential that disaster mental health workers begin to process their own emotions about the disaster before attempting to help survivors. While workers may talk about their own reactions during the training, training is not designed to be a debriefing. If workers come to the training with unmet needs related to their own feelings, the training will not be able to proceed effectively. A debriefing or other group format for discussion of workers' reactions to the disaster should be conducted for workers before training. A trained facilitator who has not been directly involved in service delivery, yet thoroughly understands the demands of disaster work, should provide the debriefing. LOGISTICS OF TRAINING IN THE MIDDLE OF A DISASTER Immediately postimpact, mental health administrators may feel pressured to deploy their staff without delay. The urgency of disaster underscores the value of having a core team of staff trained in disaster response before a disaster occurs. If such a team is not in place, training must be conducted during the disaster response and recovery activities. This can require some juggling of schedules and personnel, but it has been done and remains essential to the success of the mental health response. Administrators and staff will need to shift from the pace of a regular work week to "disaster time" which often involves working 12 hour days and weekends. In the urgency of immediate response, the timeframe required for a comprehensive disaster mental health training (2-5 days) is probably unrealistic. In addition, skilled trainers may not be instantly available. Such a comprehensive training may need to be postponed for a few days or weeks. In the short-run, the following suggestions will be helpful. If possible, select disaster response staff with good crisis intervention and community relations skills, as these are the skills most transferable to the disaster situation. A trainer should ideally have disaster experience, but if one is not immediately available, an experienced crisis intervention worker can use materials from this book or other training materials to provide staff with basic training. The checklists at the end of most chapters will help staff in applying the information in the chapters. Initially, the chapters entitled "Key Concepts of Disaster Mental Health," "Providing Mental Health Services in a Disaster Shelter," and "Outreach Services Following Disaster" will be helpful for field-based staff. When Disaster Application Centers (DACs) open, the chapter on DACs will be helpful. The National Institute of Mental Health Training Manual for Human Service Workers in Major Disasters (Farberow and Frederick, 1978) provides essential information on phases of disaster, common stress reactions of adults and children, and suggested interventions. In an urgent timeframe, staff can read the materials and take them with them into the field. The National Institute of Mental Health Field Guide for Human Service Workers in Major Disasters is a reference guide for use by workers in the field. Video training tapes may also be used until an experienced trainer can be engaged for comprehensive training. Appendix A lists training materials and videotapes. Time allotted to this "basic" training may vary according to local circumstances, but if possible, at least a half-day should be devoted to training and orientation. In addition, at least one and a half to two hours should be set aside for debriefing of staff before the training. Training may need to be repeated one or more times, so that staff can attend in "shifts" while other workers provide services. The training may also need to be repeated as new personnel such as volunteers, mutual aid, or extra-hire personnel come on board. On the job training can be provided by linking inexperienced disaster mental health workers with those who have had prior disaster experience. Experienced workers may be part of a core team that was trained predisaster, or they may be mutual aid staff who have come from another jurisdiction to assist. An experienced worker assigned to a team of new workers can provide on-scene consultation, direction, and role modeling. ORIENTATION OF DISASTER STAFF TO FIELD ASSIGNMENTS Besides training, managers should be sure that an orientation to the disaster is provided to mental health staff before deployment. The following topics should be covered: 1. Status of the disaster: nature of damages and losses, statistics, predicted weather or condition reports, boundaries of impacted area, hazards, response agencies involved. 2. Orientation to the impacted community: demographics, ethnicity, socioeconomic makeup, pertinent politics, etc. 3. Community and disaster-related resources: handouts with brief descriptions and phone numbers of human service and disaster-related resources. FEMA or the state Office of Emergency Services (OES) usually provides written fliers describing state and federal disaster resources once Disaster Application Centers (DACs) are opened. If available, provide them to all staff. Provide workers with a supply of mental health brochures or fliers to give to survivors, outlining normal reactions of adults and children, ways to cope, and where to call for help. For volunteers or mutual aid personnel, provide a brief description of the sponsoring mental health agency. 4. Logistics: arrangements for workers' food, housing, obtaining messages, medical care, etc. 5. Communications: how, when, and what to report through mental health chain of command; orientation to use of cellular phones, two-way radios, or amateur radio volunteers, if being used. 6. Transportation: clarify mode of transportation to field assignment; if workers are using personal vehicles, provide maps, delineate open and closed routes, indicate hazard areas. 7. Health and safety in a disaster area: outline potential hazards and safety strategies (e.g., protective action in earthquake aftershocks, flooded areas, etc.). Discuss possible sources of injury and injury prevention. Discuss pertinent health issues such as safety of food and drinking water, personal hygiene, communicable disease control, disposal of waste, and exposure to the elements. Inform of first aid/medical resources in the field. 8. Field assignments: outline sites where workers will be deployed (shelters, meal sites, etc.). Provide brief description of the setup and organization of the site and name of the person to report to. Provide brief review of appropriate interventions at the site. 9. Policies and procedures: briefly outline policies regarding length of shifts, breaks, staff meetings, required reporting of statistics, logs of contacts, etc. Give staff necessary forms. 10. Self-care and stress management: encourage the use of a "buddy system" to monitor each other's stress and needs. Remind of the importance of regular breaks, good nutrition, adequate sleep, exercise, deep breathing, positive self-talk, appropriate use of humor, "defusing" or talking about the experience after the shift is over. Inform workers regarding debriefing to be provided at the end of the tour of duty. OBJECTIVES OF COMPREHENSIVE DISASTER MENTAL HEALTH TRAINING Comprehensive training on disaster mental health should be provided for all staff and volunteers who will be involved in disaster response and recovery, including management and administrative personnel who will be closely involved. Training should be mandatory. Effective disaster mental health training will provide participants with certain knowledge, skills, and attitudes that will enhance their effectiveness in the disaster setting. Because involvement with disaster mental health work requires a perceptual shift from traditional mental health service delivery, the acquisition of new skills and information is essential. The objectives of a comprehensive disaster mental health training are to provide participants with the knowledge, skills, and attitudes that will enable them to: 1. Understand human behavior in disaster, including factors affecting individuals' response to disaster, phases of disaster, "at risk" groups, concepts of loss and grief, postdisaster stress, and the disaster recovery process. 2. Intervene effectively with special populations in disaster, including children, older adults, people with disabilities, ethnic and cultural groups indigenous to the area, and the disenfranchised or people living in poverty with few resources. 3. Understand the organizational aspects of disaster response and recovery, including key roles, responsibilities, and resources; local, state, and federal and voluntary agency programs; and how to link disaster survivors with appropriate resources and services. 4. Understand the key concepts and principles of disaster mental health, including how disaster mental health services differ from traditional psychotherapy; the spectrum and design of mental health programs needed in disaster; and appropriate sites for delivery of mental health services. 5. Provide appropriate mental health assistance to survivors and workers in community settings, with emphasis on crisis intervention, brief treatment, post-traumatic stress strategies, age-appropriate child interventions, debriefing, group counseling, support groups, and stress management techniques. 6. Provide mental health services at the community level, with emphasis on casefinding, outreach, mental health education, public education, consultation, community organization, advocacy, and use of the media. 7. Understand the stress inherent in disaster work and recognize and manage that stress for themselves and with other workers. SELECTION OF TRAINER The person or persons chosen to provide disaster mental health training should have knowledge, skills, and experience that will enable them to meet the above training objectives. Ideally, this should be someone who has worked in at least one actual disaster (preferably more). In addition, the individual should have a good understanding of principles of adult learning, and must have excellent training skills to promote learning of knowledge, skills, and attitudes. Teaching disaster mental health involves working in the domain of emotions. Students often find that the material about disaster triggers deep feelings in themselves, and the trainer must be comfortable and skilled in group process and appropriate classroom discussion of emotions. If a large group of people is being trained (over about 60), it is advisable to have more than one trainer to facilitate group discussion and skills practice. It is also possible to use trainers with different areas of expertise to teach various aspects of the material. Training about ethnic groups affected by the disaster should ideally be done by individuals indigenous to the specific groups and familiar with conducting ethnic diversity training for majority culture groups. Representatives of state, federal and voluntary agencies should provide training about their resources and programs. The intent is to familiarize mental health staff with programs to help them make effective referrals. At no time should mental health staff attempt to make determinations about individuals' eligibility for state or federal programs. Involving state and federal representatives in the training will also enhance the linkage and communication between mental health and the various programs. This part of the training can be arranged by contacting the Individual Assistance Officer (IAO) for the state Office of Emergency Services, the FEMA IAO at the Disaster Field Office, and the Voluntary Agencies (VOLAG) coordinator at the Disaster Field Office. If a trainer is coming from outside the impacted area and is not familiar with the community, the mental health agency can help the trainer by providing him or her with background on the community and on the disaster. Census tract information, newspaper clippings or videotapes of the disaster will help the trainer to tailor the training to local characteristics and needs. The trainer should read the FEMA Crisis Counseling grant application if one has been written. TRAINING TOPICS The following topics are recommended for inclusion in a comprehensive disaster mental health training program: 1. Understanding Disaster and Disaster-related Behavior a. Definition of disaster b. Myths and realities of human behavior in disaster c. Factors affecting the psychological response of individuals to disaster (factors related to the disaster, the individual, and the social situation) d. "At risk" groups following disaster e. Phases of disaster f. Psychological, cognitive, behavioral, and affective responses to disaster g. Differential assessment of normal responses vs. those requiring intervention 2. Special Populations in Disaster: Issues and Interventions a. Children b. Older adults c. People with disabilities d. The mentally ill e. Ethnicity and disaster f. People with previous traumatic experiences 3. Roles, Responsibilities, and Resources in Disaster a. The disaster declaration process b. Chain of command among local, state, and federal authorities c. Local, state, and federal mental health programs d. Purpose and objectives of the FEMA crisis counseling programs (if appropriate) e. Government and voluntary agency resources and services for disaster survivors 4. The Disaster Recovery Process a. Loss and Grief b. Post-traumatic stress c. Interplay of individual recovery and community recovery processes 5. Key Concepts of Disaster Mental Health a. Survivors' perception of needs b. Scope of community needs c. Milieu and time factors d. How effective disaster mental health interventions differ from traditional psychotherapy e. Spectrum and design of mental health services in disaster f. Sites for disaster mental health service delivery 6. Effective Interventions with Disaster Survivors a. Disaster preparedness b.Crisis intervention c. Brief treatment d. Post-traumatic stress strategies e. Age-appropriate child interventions and school programs f. Debriefing g. Group counseling and support groups h. Stress management techniques 7. Effective Interventions at the Community Level a. Casefinding b. Outreach c. Mental health training d. Public education, including effective use of media e. Consultation f. Community organization g. Advocacy 8. Disaster Work and Mental Health: Prevention and Control of Stress Among Workers a. Sources of stress for workers (including mental health workers) b. Stress management for workers before, during, and after the disaster Special consideration: Paraprofessional staff without prior human service experience will need training in communications and peer counseling skills before attending the comprehensive disaster mental health training. Topics should include the following: *Basics of crisis intervention *Establishing rapport *Active listening and responding skills *Attending to feelings *Interviewing techniques *Paraphrasing and interpretation *Cognitive reframing techniques *Nonverbal communication *Group dynamics *Helpful and unhelpful styles of assistance *When and how to refer to mental health *How to link clients with resources *Ethics (confidentiality, boundaries of relationship with the client, etc.) *Legalities (duty to report to child protective services,etc.) *Risk factors for suicide *Handling difficult situations Close clinical supervision should be part of the organizational structure. Training should provide peer counselors with information regarding how and when to consult with their supervisors and how and when to refer individuals. They should be provided with specific indicators of when they are becoming overinvolved with a client, and how to overcome this professional vulnerability. TRAINING FORMAT Under ideal circumstances, a comprehensive disaster mental health training will take from two to five days. The length of the training will vary according to the disaster, the location, prior experience of the staff, and the trainer. To transmit the knowledge, skills, and attitudes encompassed in the comprehensive objectives, a variety of instructional methods should be used. Interactive teaching methods are important. Skills practice that approximates the true disaster scene is crucial. Exposure to scenarios and case studies that will challenge participants to examine their own emotional responses to disaster is also essential. A mix of methods such as didactic presentations, reading, videotapes, self-awareness exercises, discussion sessions, demonstrations, skills practice and supervised field experience will help to achieve the training objectives. TRAINING DURING LONG-TERM RECOVERY As disaster response efforts are completed and longer-term recovery efforts begin, there continue to be training needs for disaster mental health workers. If a FEMA Regular Program grant is sought and awarded for crisis counseling services, new or additional staff may be hired for the program. If they have not had a comprehensive disaster mental health training program, such a program should be given or repeated when staff are hired. Besides the comprehensive training program, inservice training and/or consultation should be provided at regular intervals. Staff and supervisors working on long-term recovery efforts must be attuned to training needs that may arise during the work. Some needs are unique to a given disaster or locale. Such training, if tailored to specific needs as they arise, can help staff to overcome service-delivery barriers that they may encounter along the way. Training always provides a welcome infusion of ideas and gives a boost to staff morale. The Crisis Counseling grant application should include funding for appropriate levels of inservice training and consultation. Staff may need in-depth training on a subject covered briefly in the comprehensive training, or they may find that topics not covered in the training are needed. Some common training needs and interests seem to occur regularly in long-term recovery programs. Examples include the following: * treatment of post-traumatic stress disorder * treatment of post-traumatic stress disorder and alcohol abuse/dependence * interventions with complicated bereavement * advanced group dynamics * expressive therapies (art, music, writing) for use with adults and children * advanced peer counseling for paraprofessionals * disaster and family issues * stress management interventions for survivors and workers * long-term recovery issues and interventions * outreach techniques for long-term recovery * the first anniversary: individual reactions and community recovery events * community organizing at the neighborhood level * specialized topics important to understanding and helping survivors, e.g., insurance issues, the city or county permit process, working with architects and contractors, and the like * specialized topics pertinent to the local disaster (e.g., floodplain management, seismic safety, hurricane warning systems, etc.) * preparing for termination of the project: termination of relationships with clients, referral of clients to appropriate resources, notification of community regarding ending of services It is recommended that staff complete written evaluations of training sessions as they occur. Evaluations provide useful feedback to the trainer. They also provide information to managers about the perceived usefulness of training. At the end of the disaster recovery program, a critique of the training component of the program is also useful. The FEMA crisis counseling program final report can include the results of the critique as a way to help other projects with their training components. It should also be kept with the local disaster mental health plan as documentation of what was done for use in future disasters. SUMMARY Because the knowledge and skills required of mental health workers in disaster differ from those needed in nondisaster times, special attention should be given to selecting and training a disaster mental health team. The guidelines provided in this chapter can help mental health planners and administrators in selecting disaster team members and preparing them to be effective in this challenging and rewarding work. CHECKLIST SELECTION AND TRAINING OF DISASTER MENTAL HEALTH STAFF PREDISASTER _____ Select core group of disaster mental health staff _____ Provide comprehensive disaster mental health training based on objectives and topics listed in chapter on "Selection and Training of Disaster Mental Health Staff" _____ Provide regular in-service training and participate in disaster exercises at local level DISASTER RESPONSE _____ Provide disaster mental health training for all staff and volunteers who have not received prior training; initial training may be abbreviated until more comprehensive training can be arranged _____ Orient staff to: _____ Status of disaster situation _____ Profile of the impacted community _____ Community and disaster-related resources _____ Logistics (food, housing, medical care) _____ Communications _____ Transportation/travel in disaster area _____ Health and safety in disaster area _____ Field assignment sites _____ Policies and procedures _____ Self-care and stress management _____ As soon as possible, provide comprehensive disaster mental health training based on objectives and topics listed in training chapter for all staff who will be working on response and recovery who have not had prior training DISASTER RECOVERY _____ Develop training plan for staff who will be working on long-term recovery program _____ Include phase-appropriate topics such as those suggested in training chapter _____ Allow for consultation or training in response to specific needs that may arise _____ Provide expert consultation, technical assistance, and regular debriefing sessions for staff involved in long-term recovery program POSTDISASTER _____ Include staff in a critique of pre- and postdisaster training. _____ Keep written evaluation of training and recommendations for the future; include in FEMA Crisis Counseling program final report (if appropriate) REFERENCES AND RECOMMENDED READING American Red Cross. Disaster Mental Health Provider's Course (ARC 3076A). April, 1991. California Department of Mental Health, Center for Mental Health Training. Conference on How to Train Professionals for Psychosocial Intervention in a Community Disaster. February 18-19, 1981. Collins, A.H. and Pancoast, D.L. Natural Helping Networks: A strategy for Prevention. Washington, D.C.: National Association of Social Workers, 1976. DeWolfe, D. Final Report: Regular Services Grant, Western Washington Floods. State of Washington Mental Health Division, 1992. Farberow, N.L. and Frederick, C.J. Training Manual for Human Service Workers in Major Disasters. Rockville, Maryland: National Institute of Mental Health, 1978. Federal Emergency Management Agency. Disaster Assistance Programs: Crisis Counseling Program: A Handbook for Grant Applicants. DAP-9. Washington, DC: 1988. Hartsough, D.M. and Myers, D.G. Disaster Work and Mental Health: Prevention and Control of Stress Among Workers. Rockville, Maryland: National Institute of Mental Health, 1985. Myers, D. Loma Prieta Earthquake Training Manual. Unpublished Training Manual compiled for California Department of Mental Health, 1990. Tierney, K.J. and Baisden, B. Crisis Intervention Programs for Disaster Victims: A Source Book and Manual for Smaller Communities. Rockville, Maryland: National Institute of Mental Health, 1979. CHAPTER THREE ORGANIZATIONAL ASPECTS OF DISASTER INTRODUCTION A disaster is a complex human, bureaucratic, and political event. Routine procedures and resources are not enough to manage the changes caused by a disaster. The number and type of responding groups, agencies, and jurisdictions increase monumentally, and relationships among organizations change. Alterations in traditional divisions of labor and resources increase the need for multi-organizational and multi-disciplinary coordination among all of the various responding participants. Without this coordination, resources may not be shared or distributed according to need. There may be insufficient communication and control, and a resulting duplication of effort, omission of essential tasks, and even counterproductive activity. This chapter describes the roles, responsibilities, resources, and interrelationships of key private and governmental organizations involved in disaster management. To function effectively, it is essential that mental health agencies understand this complex organizational environment and system of resources. Clinical skills alone will not enable mental health to reach and serve the community of survivors in an effective way. The chapter also describes the federal funding available to local mental health agencies in a presidentially declared disaster through Section 416 of the Robert T. Stafford Disaster Relief and Emergency Assistance Act. This funding can help mental health agencies in providing immediate response as well as longterm recovery services to survivors. MANAGEMENT OF ROUTINE EMERGENCIES In the United States, the management of day-to-day non-catastrophic emergencies is influenced by a national preference for local control. As a result, tasks are divided among a multitude of community organizations (public and private) and individuals, with roles and responsibilities determined by tradition, laws, contracts, and charters (Auf der Heide, 1989; Drabek, 1985; Drabek, 1987; Quarantelli, 1981). The allocation of tasks and of resources is fairly standardized and there is relatively little confusion (Auf der Heide, 1989). Community mental health agencies routinely interact in well-defined and understood relationships with other agencies such as social services, the schools, law enforcement, probation, and the like. In disaster, things change. MANAGEMENT OF DISASTERS The Federal Emergency Management Agency defines disaster as: "An occurrence of a severity and magnitude that normally results in deaths, injuries, and property damage and that cannot be managed through the routine procedures and resources of government. It . . . requires immediate, coordinated, and effective response by multiple government and private sector organizations to meet human needs and speed recovery" (FEMA, 1984). A disaster differs from routine emergencies in that it cannot be adequately managed merely by mobilizing more personnel, equipment, and supplies. Disasters often create demands that exceed the capacities of single organizations, requiring them to share tasks and resources with other organizations that use unfamiliar procedures. As Auf der Heide (1989) has reported, disasters may cross jurisdictional boundaries. They change the number and structure of responding organizations, and may result in the creation of new organizations. They create new tasks, and engage participants who are not ordinarily disaster responders. Disasters also disable the routine equipment and facilities needed for emergency response. The complexity of government in the United States compounds the difficulty of understanding "who does what" in disaster response. The 1982 Census of Governments found over 82,000 separate governments operating in this country. Such decentralization results in a lack of standardization in disaster planning and response, and complicates coordination in time of disaster (Auf der Heide, 1989). In addition, organizations inexperienced in disaster often respond by continuing their independent roles, failing to see how their function fits into the complex, total response effort. Auf der Heide (1989) describes this as the "Robinson Crusoe syndrome" ("We're the only ones on the island"). This isolation occurs not just in response, but in planning as well. Too often, private sector groups and different levels of government may not have plans that realistically consider the roles and resources of other groups. Because of the complexities and challenges of the disaster environment, key factors in an organization's effectiveness are flexibility and the ability to improvise. However, it is crucial for responding agencies to educate themselves about the roles and responsibilities of other local, state, and federal agencies in time of disaster. They must plan for disaster response based on a solid knowledge of the organizational environment. PLANNING FOR MENTAL HEALTH'S ROLE IN EMERGENCY RESPONSE AND RECOVERY A mental health disaster plan is essential to coordinating the mental health emergency response efforts with other emergency response organizations in time of disaster. It is strongly recommended that each state department of mental health have a mental health disaster plan which is a component of the state emergency management plan. In many states, the governor mandates a mental health disaster plan by executive order. Similarly, each department of mental health, whether municipal, county, or regional, should have a mental health disaster plan. The plan should be a well-integrated component of the comprehensive emergency management plan of the jurisdiction. Some states have mandated this by legislation. The purpose of the mental health plan is to ensure an efficient, coordinated, effective response to the mental health needs of the affected population in time of disaster. It will enable mental health to maximize the use of structural facilities, personnel, and other resources in providing mental health assistance to disaster survivors, emergency response personnel, and the community (California Department of Mental Health, 1989; New Jersey Department of Human Services, 1991). The mental health disaster plan will specify the roles, responsibilities, and relationships of the agency to federal, state, and local entities with responsibility for disaster planning, response, and recovery. A mental health plan must also specify roles, responsibilities, and relationships within the agency in responding to disasters (South Carolina Department of Mental Health, 1991). The plan needs to be organized so that it reaches each level and each component of the agency. It must also identify the respective individuals (by position) who are responsible for carrying out the functions. Individuals should all have back-ups, preferably three deep. Mental health services to disaster survivors must be provided in community locations where survivors congregate, such as shelters and meal sites. These sites are often operated by the Red Cross in cooperation with social services or other organizations. In long-term recovery, mental health efforts need to be integrated with other human services to survivors. Because close collaboration is necessary with these agencies, the mental health disaster plan is often a component of, or an attachment to, the social services/shelter plan. In some areas, mental health agencies have found it beneficial to include in their plan a Memorandum of Understanding (MOU) with the Red Cross, delineating roles and responsibilities of the two agencies. Mental health services to survivors may also be provided at hospitals, first aid sites, and the coroner's office. Consequently, the mental health plan requires coordination and integration with the emergency medical plan, the public health plan, and the coroner's plan. GOVERNMENT ROLES AND RESPONSIBILITIES IN EMERGENCY MANAGEMENT Local government The local level of emergency management consists of staff of cities and counties. County staff are responsible for unincorporated areas within counties, and may also function in a coordinating role in a local emergency or state of emergency. Local ordinances and resolutions establish local responsibilities for emergency management, with each local program fitting into the state emergency management organization. Local government has the primary responsibility for emergency response, even when the event overwhelms local government's capacity for effective response and the state is called upon for assistance (Drabek and Hoetmer, 1991). There is wide diversity in how local government carries out its emergency management functions. In most small cities, emergency management is the responsibility of an individual who performs the function as part of another job, such as city manager or fire chief. In counties, the responsibility is usually given to a full- or part-time emergency manager. Larger cities or counties are more likely to have a dedicated emergency management department with a small staff. The department may be an independent unit, or may be embedded in another unit, such as the fire department. Given the wide variation in political and organizational realities among local governments, there is not any standard design for local emergency management structure. However, Figure 1 provides a simplified organization chart of how many local emergency management units fit within local government. It is the responsibility of the local emergency management unit to: 1. Identify all hazards that may pose a major threat to the jurisdiction, and develop hazard mitigation plans and programs to eliminate or reduce potential hazards. 2. Develop maps of areas within the jurisdiction that may be subject to disasters, for example, geologic hazards, flood plains, dam failure inundation areas, etc. 3. Work cooperatively with government and community organizations to develop and maintain up-to-date emergency plans that are consistent with the state plan and mutual aid agreements. 4. Coordinate with industry to develop industrial emergency plans and capabilities in support of local government plans. 5. Develop a training program for emergency response personnel, and an exercise program to test response capabilities. 6. Develop a public education program. 7. Develop and maintain emergency communication systems, including a system to alert key public officials and warn the public in the event of an emergency. Establish an emergency public information system. 8. Develop plans for meeting all conditions that could constitute a local emergency. Inventory personnel and material resources from government and private sector sources that would be available in an emergency. Identify and work with local officials to correct resource deficiencies. 9. Develop and supply an Emergency Operations Center (EOC) as a site for direction and control operations during an emergency. 10. Establish and maintain a shelter and reception and care system. 11. Develop continuity of government procedures and systems. 12. Assist in the establishment of mutual aid or cooperative assistance agreements to provide needed services, equipment, or other resources in case of an emergency. 13. Provide the county or state Office of Emergency Services (OES) with estimates of the severity and extent of damage resulting from a disaster, including dollar value of both public and private damage sustained as well as estimates of resource costs required to alleviate the situation. 14. Secure technical and financial assistance available to local jurisdiction through state and federal programs. State government State government plays a pivotal role in emergency management. It is in a position to determine the emergency needs and capabilities of its political subdivisions. In addition, it channels state and federal resources to local government, including training, technical assistance, and operational support in an emergency. The authority and responsibility for emergency management at the state level belong to the governor or his/her designee. While state laws vary, the governor is typically given the powers or options to do the following (Drabek and Hoetmer, 1991): 1. Suspend state statutes, rules and regulations. 2. Procure materials and facilities without regard to limitations of existing law. 3. Direct evacuations. 4. Control entrance to and exit from disaster area. 5. Authorize release of emergency funds. 6. Activate emergency contingency funds and reallocate state agency budgets for emergency work. 7. Issue state or area emergency declarations and invoke appropriate state response actions. 8. Apply for and monitor federal disaster and emergency assistance. Day-to-day emergency management responsibilities are generally delegated by the governor to a lead agency in the state, usually called the Office of Emergency Services. Various other state agencies are mandated to carry out assigned activities related to mitigating the effects of an emergency and to cooperate with each other and other political subdivisions in providing assistance. Figure 2 illustrates state emergency management functions under the governor, and show state agencies with emergency management responsibilities. Drabek and Hoetmer (1991) list the responsibilities of the state Office of Emergency Services as follows: 1. Prepare and maintain a comprehensive state emergency plan and emergency management program. 2. Assign emergency functions to various state agencies, and coordinate the activities of the agencies in developing the state emergency plan. 3. Ensure that all personnel assigned specific responsibilities in support of the state plan are adequately trained and prepared to assume those responsibilities. 4. Support and facilitate local government preparedness efforts, to ensure that disasters are handled at the lowest government level; write standards and requirements for county and municipal plans; and review and maintain a file of current plans that are developed or updated under those standards. 5. Oversee the damage assessment process following emergencies. 6. Administer and coordinate state resources providing assistance requested by the county or affected area, and request federal disaster assistance, if warranted. 7. Administer the state mutual aid system, with regional or state staff assisting local emergency operations at the request of local coordinators. 8. Maintain mutual aid agreements with adjoining states. When a disaster exceeds the local government's ability to respond effectively, the state Office of Emergency Services activates functions that are essential to a coordinated response in support of the local jurisdiction (Drabek and Hoetmer, 1991). The specific emergency support functions provided by the state in support of local government may include the following (California Basic Emergency Plan, 1989): 1. Management of emergency operations: coordination, direction, and control of emergency operations, usually at a State Operations Center (SOC) managed by the state Office of Emergency Services (OES) director or designee; communications; alert, warning, notification of people in threatened areas; and situation reporting and damage analysis. 2. Fire and rescue operations: fire suppression, fire safety, and search and rescue. 3. Law enforcement and traffic control: enforcement of laws regarding evacuation, traffic control, access control. 4. Emergency medical services: care and treatment for the ill and injured. 5. Public health services: public health and sanitation. 6. Coroner operations: collection, identification, and protection of the remains of deceased persons. 7. Care and shelter operations: care for the basic needs of evacuees and disaster service workers; registration of all homeless, displaced, injured, and sick people; and shelter and care to displaced survivors and disaster service workers through emergency congregate care centers. 8. Movement operations: movement of people from threatened or hazardous areas. 9. Rescue operations: search and rescue. 10. Construction and engineering operations: maintenance or repair of roads, structures, or other public areas. 11. Resources and support operations: provision of personnel, equipment, food, fuel, transportation, and utilities to support operations. 12. Emergency public information: rapid distribution of emergency instruction and accurate information to the public during emergencies. 13. Technological services response: technological response to hazardous material incidents; advice to the public of protective measures. 14. Radiological protection: radiological response, including monitoring radiation levels in the environment, determining measures to minimize personal exposure, and identification and management of fallout shelters. Federal government The basic role of the federal government in emergency management is to protect life and property in a disaster and to assist state and local governments in the recovery process. By executive order, the president has assigned emergency preparedness and operating responsibilities to certain federal agencies, with overall responsibility assigned to the Federal Emergency Management Agency (FEMA). Assignments are based on each agency's regular functions and capabilities. Federal emergency management includes the administration of natural disaster relief programs and civil defense plans and programs. In 1988, Public Law 93-288 was amended by Public Law 100-707 and retitled as the Robert T. Stafford Disaster Relief and Emergency Assistance Act. The Stafford Act provides the authority for the Federal government to provide assistance to save lives and to protect public health and safety and property as the result of natural disasters and other incidents for which federal response assistance is required. Crisis counseling for victims of presidentially declared disasters is one of the assistance programs authorized under the Stafford Act. The crisis counseling program is discussed in more detail in a subsequent section of this chapter. The federal government recognizes local and state governments as being in charge of emergency response operations. Federal assistance under the provisions of the Stafford Act is supplemental to state efforts. The president is authorized under the Stafford Act to declare a "major disaster" or "emergency" for an area affected by a disaster. This is done in response to a request by the governor of the affected state, when state and local resources are inadequate to respond effectively and to undertake recovery. Once a presidential declaration has been made, FEMA may direct any federal agency to help state and local governments directly. Figure 3 illustrates the specific emergency support functions (ESFs) of federal agencies. AMERICAN RED CROSS ROLES AND RESPONSIBILITIES IN DISASTER The American Red Cross was mandated by Congressional charter in 1905 to help meet the human needs created by disaster. This mandate was reaffirmed by Congress in the Disaster Relief Acts of 1970 and 1974 (as amended, 1988) and in the published regulations of the Federal Emergency Management Agency (FEMA) and a statement of understanding between FEMA and the American Red Cross in 1982. Thus, the Red Cross role in disaster is a legal mandate that it has neither the authority nor the right to surrender ( American Red Cross, 1982). Nonetheless, the Red Cross receives no government funding for its services, and relies solely upon voluntary contributions. In addition, local governmental responsibilities and mandates are not superseded by Red Cross authority. The Red Cross is responsible for providing emergency congregate and individual care in coordination with local government and private agencies. Figures 4 and 5 illustrate the responsibilities of local government and the American Red Cross in disaster. VOLUNTARY AGENCY RESPONSE IN DISASTER Many volunteer organizations provide a response to disaster. These responses are not mandated by law, but many individual organizations include disaster response in their charters. Many voluntary groups are members of the National Voluntary Organizations Active in Disaster (NVOAD). In addition, existing local groups, such as volunteer centers, may take on specific responses to a local disaster. Spontaneous "grass roots" groups also sometimes emerge to tackle unique situations for which no organization has responsibility. Mental health should be alert to and familiar with voluntary groups' response in disaster, as these groups often provide human services that are not otherwise available to survivors. Figure 6 illustrates the response of many of the formal voluntary agencies. The following list illustrates other voluntary groups and private sector organizations who may be involved in disaster response: Private hospitals Physicians, nurses, pharmacists, other health professionals Mental health professionals and agencies Professional associations Suicide prevention hotlines Private ambulance companies American Hospital Association Private vendors of health supplies National Association of Funeral Directors Poison control centers Veterinarians American Humane Association Volunteer search and rescue teams Explorer Search and Rescue Manufacturing plant fire departments National Ski Patrol Rescue Dog Association Civil Air Patrol Amateur radio organizations Commercial radio and television stations Private hazardous spill cleanup companies Chemical Manufacturers' Association Railroad, airline, maritime, trucking, pipeline, petroleum, mining, or chemical firms American Society of Civil Engineers National Association of Independent Fee Appraisers National Association of Home Builders Private building contractors Heavy equipment owners and operators Labor unions AFL-CIO Department of Community Services Private utility companies Private colleges and universities Childcare providers National Restaurant Association Private restaurants and food vendors Veterans of Foreign Wars of the United States American Legion Service clubs League of United Latin American Citizens National Association for the Advancement of Colored People THE DISASTER DECLARATION PROCESS When disaster-caused needs exceed the resources of a jurisdiction to respond, a declaration of increasing level of emergency may be made. The following are the definitions of levels of emergency as abstracted from several state emergency plans: Local emergency The declaration of a local emergency is made by the governing body of a city or county when conditions of disaster or extreme peril to the safety of persons and property exist within the jurisdiction. A declaration is made when conditions are or are likely to be beyond the control of the services, personnel, equipment, and facilities of local government. Declaration of a local emergency assumes that effective response will likely require the combined forces of other jurisdictions. The declaration enables the jurisdiction to use emergency funds, resources, and powers, and to divert funds from other programs to cover emergency costs. It is normally a prerequisite to requesting a gubernatorial proclamation of a state of emergency. State of emergency The proclamation of a state of emergency is made by the governor when conditions of extreme peril to the safety of persons and property exist within the state. The governor makes the declaration when conditions are or are likely to be beyond the control of any single county, city and county, or city. A declaration assumes that conditions may require the combined forces of a mutual aid region or regions. The proclamation does the following: * Makes mutual aid assistance mandatory from other cities, counties, and state agencies. * Enables the state to use emergency powers (suspend hindering regulations, make emergency purchases, redirect monies allocated for different purposes). * In some states, allows for state reimbursement of local jurisdiction response, repair, and restoration costs connected with the emergency and property tax relief for damaged/destroyed private property. * In some states, may make state housing loans available to owners of damaged private residences. * Is a prerequisite for requesting federal recovery assistance. If damage assessments find that the extent of damage merits a presidential declaration, the governor submits a letter to the FEMA regional director. If the FEMA regional director confirms the governor's findings, a recommendation is submitted to the FEMA director in Washington, D.C. The FEMA director then submits a recommendation to the president. Major disaster The declaration of a major disaster is made by the president when damage exceeds resources of state and local government and private relief organizations. Under a major disaster declaration, two types of federal assistance may be provided, as authorized under The Stafford Act. Not all disasters include approval for both types of assistance. A jurisdiction must be approved for individual assistance to be eligible for a Section 416 Crisis Counseling grant for mental health. Individual assistance to individuals and businesses may include: * Temporary housing assistance * Low interest loans (individuals, businesses, and farmers/ranchers) * Individual and family grants * Crisis counseling program Public assistance to state and local governments, special districts and certain private nonprofit agencies may include: * Debris clearance * Repair/replacement of public property (roads, streets, bridges, buildings) * Emergency protective measures (search and rescue, demolition of unsafe structures) * Repair/replacement of water control facilities (dikes, levees) Emergency The declaration of an emergency is made by the president and authorizes specialized assistance to state and local governments to meet specific needs. Assistance may include: * Emergency mass care * Search and rescue * Emergency transportation Figure 7 illustrates the steps in the disaster declaration process. Once a presidential declaration has been made, the FEMA director or designee appoints a federal coordinating officer (FCO) as the senior federal official who coordinates the administration of relief activities in the affected area. The FEMA regional director appoints a disaster recovery manager (DRM) to carry out the responsibilities of the regional director in administering relief programs. The governor appoints a state coordinating officer (SCO) to coordinate state and local response efforts with those of the federal government. The governor also appoints a governor's authorized representative (GAR) to execute for the state all necessary documents for disaster assistance, including certification of applications for public assistance. The FCO, DRM, and where possible, SCO and GAR work together in the disaster field office (DFO). The DFO is a temporary office established in or near the affected area for coordination and control of state and federal response and recovery operations. Figure 8 illustrates the federal programs represented in the DFO. CRISIS COUNSELING PROGRAMS FOR VICTIMS OF PRESIDENTIALLY DECLARED DISASTERS This section of the chapter is adapted from the FEMA/NIMH description of Crisis Counseling Programs for Victims of Presidentially Declared Disasters (FEMA/CMHS, 1992). Section 416 of the Stafford Act authorizes funding for mental health services following a presidentially declared disaster: Sec. 416. The President is authorized to provide professional counseling services, including financial assistance to state or local agencies or private mental health organizations to provide such services or training of disaster workers, to victims of major disasters in order to relieve mental health problems caused or aggravated by such major disaster or its aftermath. Purpose and objectives This crisis counseling program for survivors of major disasters provides support for direct services to disaster survivors. A training component in disaster crisis counseling for direct services staff of the project and for training of other disaster services workers may be included. This program has been developed in cooperation with FEMA and the Center for Mental Health Services (CMHS) within the Substance Abuse and Mental Health Services Administration (SAMHSA). The law was enacted and the program developed in response to the recognition that disasters produce a variety of emotional and mental disturbances that, if untreated, may become long term and debilitating. Such problems as phobias, sleep disturbances, depression, irritability, and family discord occur following a disaster. Programs funded under Section 416 are designed to provide timely relief and to prevent long-term problems from developing. Assistance under this program is limited to presidentially declared major disasters. Moreover, the program is designed to supplement the available resources and services of states and local governments. Thus support for crisis counseling services to disaster victims may be granted if these services cannot be provided by existing agency programs. The support is not automatically provided. Terms and conditions of support For any assistance an assessment of the need for crisis counseling must be initiated by a state within 10 days of the date of the presidential disaster declaration. There are two types of support: Immediate Services Grants and Regular Services Grants. Monies for both types of support come from FEMA. Support for Immediate Services must be requested within 14 days of the date of disaster declaration. Support may be provided for up to 60 days after the date of the major disaster declaration. This decision is made by the regional director of FEMA or his/her on-site designee, the disaster recovery manager (DRM), after consultation with the Emergency Services and Disaster Relief Branch, Center for Mental Health Services (CMHS) within the Substance Abuse and Mental Health Services Administration (SAMHSA). Regular Services funding must be requested within 60 days of the date of the disaster declaration. Support may be provided by the assistant associate director of FEMA through SAMHSA, based upon the recommendations of the FEMA regional director and the CMHS Emergency Services and Disaster Relief Branch. The Regular Program is limited to nine months except in extenuating circumstances when an extension of up to three months may be requested. Eligibility requirements The law provides that financial assistance may be provided to state, local, or private mental health organizations. A state agency official is appointed by the governor to make all requests for federal disaster assistance (i.e., the state is the official applicant). This official is the governor's authorized representative (GAR). Requests for funds under both the Immediate and Regular Program must be made by the GAR. The recipient of support may be a state agency or its designee. Areas of special concern In the development of a request for assistance, the applicant should be aware of special concerns, such as: -Specific attention should be given to high-risk groupssuch as children, the frail elderly, and the disadvantaged; -Prolonged psychotherapy measures are inappropriate for this program; -Maximum use should be made of available local resources and personnel; and -Programs should be adapted to local needs, includingspecial cultural, geographic, or politicalconstraints. Disaster survivors are eligible for crisis counseling services if they are residents of the designated major disaster area or were located in the area at the time of the disaster. In addition, they must (1) have a mental health problem which was caused or aggravated by the disaster or its aftermath; or (2) they may benefit from preventive care techniques (Federal Register, 1989). Crisis counseling project staff or consultants to the project are eligible for training that may be required to enable them to provide professional disaster mental health services to eligible individuals. In addition, all federal, state, and local disaster workers responsible for assisting disaster victims are eligible for training designed to enable them to deal effectively and humanely with disaster survivors (Federal Register, 1989). Application for Immediate Services For Immediate Services, an application for funding in the form of a letter of request should be submitted not later than 14 days following the disaster declaration by the GAR to the FEMA disaster recovery manager (DRM). An additional copy will be submitted to the Emergency Services and Disaster Relief Branch, CMHS, by FEMA for consultation in evaluating the need for Immediate Services and the state's capability for providing the services. The application for Immediate Services must include the state's assessment of need, initiated within 10 days of the disaster declaration. An estimate of the size and cost of the proposed program is required. Specifically the state mental health authority should address each of the following issues, for each jurisdiction that is requesting funds: Extent of Need: To justify initiation of a special mental health program, the state must demonstrate that disaster-precipitated mental health needs exist. One approach to doing so is presented in Figure 9. State Resources: A description of current capabilities and additional disaster needs is required. Program Plan: Plans for outreach, crisis counseling, referral, consultation, and education should be outlined briefly. Staff qualifications and training needs should also be included. While the Immediate Services application is expected to address the above issues, it is anticipated that requests will be brief, only a few pages. A more comprehensive statement is expected of applications for the Regular Services. Attachment 10 illustrates the Immediate Services Program grant request and approval paperflow. Application for Regular Services For Regular Services, a grant application must be submitted with Public Health Service Form 424 not later than 60 days following the disaster declaration. The GAR must submit the application to the FEMA assistant associate director, through the FEMA regional director, and simultaneously to the Emergency Services and Disaster Relief Branch, CMHS. The application for Regular Services must include: (1) Public Health Service Grant Application Form 424. (2) The disaster description including the type of disaster, and its time, place, and duration. (3) Needs Assessment: Estimates of the total number of individuals in need of direct services and the total number of individuals in need of outreach and consultation and education, for each service provider group. Population demographics. (4) Program Plan: Description of the manner in which the needs of the affected populations will be met, types of services to be offered and a rationale for each. The plan must reflect attention to cultural, ethnic, or geographic needs or other special factors indigenous to the area. (5) Staffing and Training: Delineation of the number and kinds of staff required as well as specific training programs for staff. (6) Resource Needs and Budget: Explanation of the extent to which existing resources are unable to meet the needs of the disaster affected population. The budget must be clearly tied to the program narrative and contain both dollars requested and a justification for individual budget items. Figure 11 illustrates the Regular Program grant application and approval paperflow. A Workbook for Development of a Grant Application for the Regular Program, other technical assistance materials, and information and guidance on either of the two types of applications may be obtained by contacting: Emergency Services and Disaster Relief Branch Division of Program Development, Special Populations and Projects Center for Mental Health Services 5600 Fishers Lane, Room 18-101 Rockville, Maryland 20857 Telephone: (301) 443-3728 SUMMARY This chapter has outlined the major roles, responsibilities, and resources of the private and public organizations and agencies involved in disaster response. It is essential for mental health agencies to have an understanding of the basic roles of these groups in order to function effectively in the complex organizational environment of a disaster. In addition, the chapter has described the funding available through Section 416 of the Stafford Act to assist local mental health agencies in helping disaster survivors with their emotional and psychological recovery. GLOSSARY ADAMHA Alcohol, Drug and Mental Health Administration ARC American Red Cross ASCS Agricultural Stabilization and Conservation Service CDRG Catastrophic Disaster Response Group CMHC Community Mental Health Center CMHS Center for Mental Health Services COE Corps of Engineers (U.S. Army) DAC Disaster Application Center DFO Disaster Field Office DHHS Department of Health and Human Services DOC Department of Commerce DOD Department of Defense DOE Department of Energy DOEd Department of Education DOI Department of the Interior DOJ Department of Justice DOT Department of Transportation DRM Disaster Recovery Manager EEO Equal Employment Opportunity EOC Emergency Operations Center EPA Environmental Protection Agency ESF Emergency Support Function FCC Federal Communications Commission FCO Federal Coordinating Officer FDIC Federal Deposit Insurance Corporation FEMA Federal Emergency Management Agency FHLBB Federal Home Loan Bank Board FmHA Farmers Home Administration FRS Federal Reserve Systems GAR Governor's Authorized Representative GSA General Services Administration HQ Headquarters IAO Individual Assistance Officer ICC Interstate Commerce Commission IFG Individual and Family Grants IRS Internal Revenue Service MHA Mental Health Agency MOU Memorandum of Understanding NASA National Aeronautics and Space Administration NCS National Communications System NRC Nuclear Regulatory Commission NVOAD National Voluntary Organizations Active in Disaster OES Office of Emergency Services OFA Other Federal Agencies OPM Office of Personnel Management SAMHSA Substance Abuse and Mental Health Services Administration SBA Small Business Administration SCO State Coordinating Officer SOC State Operations Center SSA Social Security Administration THA Temporary Housing Assistance USDA United States Department of Agriculture USPS United States Postal Service VA Department of Veterans Affairs VOLAGS Voluntary Agencies REFERENCES AND RECOMMENDED READING American Red Cross. Your Community Could Have a Disaster (ARC 1570). December, 1977. Auf der Heide, E. Disaster Response: Principles of Preparation and Coordination. St. Louis, MO: C.V. Mosby Co., 1989. Bush, J.C. Disaster Response: A Handbook for Church Action. Scottdale, PA: Herald Press, 1979. California Department of Mental Health. Mental Health Disaster Plan. Sacramento, CA: 1989. California Basic Emergency Plan. Sacramento, CA: 1989. Drabek, T.E. Managing the Emergency Response. In Petak, W.J., "Emergency Management: A Challenge for Public Administration" (special issue). Public Administration Review 45:85, 1985. Drabek, T.E. The Professional Emergency Manager: Structures and Strategy for Success. Institute of Behavioral Science, Monograph #44. Boulder, Colorado: University of Colorado, 1987. Drabek, T.E. and Hoetmer, G.J. (Eds.). Emergency Management: Principles and Practice for Local Government. Washington, DC: International City Management Association, 1991. Federal Emergency Management Agency. Objectives for LocalEmergency Management. Washington, DC: 1984. Federal Emergency Management Agency. National Plan for Federal Response to a Catastrophic Earthquake: Basic Plan (Draft 4). Washington, DC: 1985. Federal Emergency Management Agency and National Institute of Mental Health. Student Manual: Crisis Counseling in Emergency Management. Washington, DC: 1987. Federal Emergency Management Agency. Disaster Assistance Programs: Crisis Counseling Program: A Handbook for Grant Applicants. DAP-9. Washington, DC: 1988. Federal Emergency Management Agency and California Office of Emergency Services. Fact Sheet: Disaster Assistance Program Information. Loma Prieta Earthquake Disaster Field Office, Mountain View, CA: 1989. Federal Emergency Management Agency and Center for Mental Health Services. Crisis Counseling Programs for Victims of Presidentially Declared Disasters. Washington, DC: 1992. Federal Register, 54(53):11629, March 21, 1989. Hoetmer, G.J. "Emergency Management: Individual and County Data." Baseline Data Report 15. Washington, DC: International City Management Association, August, 1983. Kilijanek, T.S. There She Blows: The Search and Rescue Response to the Mount St. Helens Volcano. Technical Report No. 11, SAR Project. Department of Sociology, University of Denver, CO, 1981. National Governors' Association. Management Notes: Emergency Management. Washington, DC: National Governors' Association, Office of State Services, 1986. New Jersey Department of Human Services, Division of Mental Health and Hospitals. Mental Health/Emergency Disaster Plan. Newark, NJ: 1991. New Jersey Office of Emergency Management. Responsibilities and Programs Manual. Newark, NJ: December, 1991. Parr, A.R. "Organizational Response to Community Crises and Group Emergence." American Behavioral Scientist, 13(3):423, January/February, 1970. Quarantelli, E.L. Sociobehavioral Responses to Chemical Hazards: Preparations for and Responses to Acute Chemical Emergencies at the Local Community Level. Newark, Delaware: Disaster Research Center, University of Delaware, 1981. South Carolina Department of Mental Health. State Mental Health Disaster Plan. Columbia, SC: 1991. Wenger, D., Quarantelli, E.L., and Dynes, R. Disaster Analysis: Emergency Management Offices and Arrangements. Final Project Report No. 34. Newark, Delaware: Disaster Research Center, University of Delaware, 1986. CHAPTER FOUR THE ROLE OF MENTAL HEALTH IN EMERGENCY MANAGEMENT AND THE EMERGENCY OPERATIONS CENTER COMPREHENSIVE EMERGENCY MANAGEMENT In order to manage disasters predictably and efficiently, a concept called Comprehensive Emergency Management (CEM) has been developed. It applies mitigation, preparedness, response, and recovery activities to all types of hazards in a municipal/county/state/federal partnership. Mitigation is any activity aimed at reducing or eliminating the probability of a disaster. Zoning, land use management, and public education are examples of mitigation activities. Inspection and proper maintenance of mental health facilities are fire mitigation activities. Preparedness includes endeavors that seek to prevent casualties, expedite response activities, and minimize property damage in the event of an emergency. Pre-disaster training of a specialized mental health disaster response team is an example of preparedness activities. Response activities occur immediately before, during and after an emergency or disaster. Examples include search and rescue or implementation of shelter plans. Mental health response activities include providing mental health staff at shelters, first aid stations, meal sites, morgues, or command centers. Recovery includes short and long-term activities. Short-term activities attempt initially to compensate for damage to a community's infrastructure and quickly return its vital life-support systems to operation. Short-term recovery assistance includes providing temporary housing, welfare, and unemployment assistance. Psychological first-aid, crisis intervention, and shift-change defusing (mini-debriefings) are short-term mental health recovery activities. Long-term recovery activities are designed to return life to normal or improved levels. Repair of buildings, roads, bridges, and activities to reestablish business are examples. Long-term mental health recovery activities include outreach, consultation and education, individual and group counseling, support groups and referral/information services. Both short and long-term mental health programs may be funded by a grant from the Federal Emergency Management Agency (FEMA) in a presidentially-declared disaster. The program is authorized by Section 416 of the Disaster Relief Act, Public Law 100-707 (FEMA, 1988). THE INTEGRATED EMERGENCY MANAGEMENT SYSTEM The second concept that currently helps to define roles and responsibilities of emergency management is the integrated emergency management system (IEMS). Drabek and Hoetmer (1991) point out that comprehensive emergency management (CEM) provides an inclusive framework that encompasses all hazards and all levels of government. It includes the four phases of mitigation, preparedness, response, and recovery. IEMS shows how the framework can be operationalized. It spells out the details of CEM. IEMS requires that a community carry out a hazard and risk analysis. The community then must assess its capabilities in the areas of mitigation, preparedness, response, and recovery. The shortfall between existing and required levels of capability leads to the development of a multiyear development plan. The plan usually covers a five-year period so that projects can be properly scheduled and funded, with annual work increments. Thus, IEMS supports the development of emergency management capabilities based on functions that are required for all hazards (e.g., warning, shelter, public safety, evacuation, etc.) (FEMA, 1983). PLANNING FOR MENTAL HEALTH'S ROLE IN EMERGENCY RESPONSE AND RECOVERY Emergency management is a complex process. Organizations such as police, fire, emergency medical, health, welfare, public works, public utilities, and other government and volunteer groups all have specific duties and responsibilities. During an emergency, these organizations must pool their resources and work together as a well-coordinated team to protect life and property. The success of emergency management efforts depends upon smooth, effective interaction and communication among the many members of the emergency team. Organizations and individuals must clearly understand their roles for the process to function efficiently. This is achieved by clearly specifying and describing the functions, duties, and responsibilities of each organization. Interrelationships among organizations must be spelled out, and roles and responsibilities must be regularly tested through drills and exercises. In this way, possible problems can be addressed prior to emergencies (New Jersey Office of Emergency Management, Dec., 1991). To ensure the coordination of mental health emergency response efforts with activities of other response organizations in disaster, a mental health disaster plan is essential. A mental health disaster plan should be incorporated into each state's general state emergency plan. In many states, a mental health disaster plan is mandated by an executive order of the Governor. Similarly, each municipal, county, or regional department of mental health should have a disaster plan which is a component of the comprehensive emergency management plan of the jurisdiction. Some states have mandated this by legislation. The purpose of the mental health plan is to ensure an efficient, coordinated, and effective response to the mental health needs of the population in time of disaster. It will enable mental health to maximize the use of structural facilities, personnel, and other resources in providing mental health assistance to disaster survivors, emergency response personnel, and the community (California Department of Mental Health, 1989; New Jersey Department of Human Services, 1991). The mental health disaster plan will specify the roles, responsibilities, and relationships of the agency to federal, state, and local entities with responsibility for disaster planning, response, and recovery. In addition, it will specify roles, responsibilities, and relationships within the agency in responding to disasters (South Carolina Department of Mental Health, 1991). The mental health disaster plan needs to be organized so that it addresses each level and component of the department. It must also identify the respective individuals (by position) who are responsible to implement the plan. Individuals should all have backups, preferably three deep. Mental health services to disaster survivors are provided in community locations where survivors congregate, such as shelters and meal sites. These sites are usually operated by the Red Cross in cooperation with social services or other organizations. In long-term recovery, mental health efforts need to be community-based and integrated with other human services to survivors. Because close collaboration is necessary with these agencies, the mental health disaster plan should be coordinated with or attached to the social services/shelter plan. In some areas, mental health agencies have found it beneficial to have as part of their plan a Memorandum of Understanding (MOU) with the Red Cross delineating the roles and responsibilities of the two agencies. Mental health services to survivors may also be provided at hospitals, first aid sites, schools and the coroner's office. Therefore, the mental health plan should be closely coordinated with the health plan, the schools' plan and the coroner's plan. EXERCISES The mental health disaster team should participate in the regular, official disaster drills of the jurisdiction. The role of mental health response in disaster is very new in some areas. Working side-by-side with more traditional disaster response agencies will increase the knowledge of mental health personnel regarding roles of other disaster responders. In addition, it will increase the knowledge of other disaster agencies regarding the roles and capabilities of mental health in disaster. It will help to establish mental health as a regular and essential part of the response team. In addition, if mental health has disaster responsibilities agreed upon with specific agencies, such as the schools, special exercises of the conjoint disaster response will be important. If mental health has agreed to respond to incidents such as a school suicide or other tragedy, mental health response to those scenarios should be practiced before the event occurs. THE EMERGENCY OPERATIONS CENTER Serious emergencies or disasters require organizational coordination and communication beyond that needed in more routine situations. The Emergency Operations Center, or EOC, facilitates this communication. The EOC is usually under the jurisdiction of local government, with the jurisdiction's emergency management office responsible for its maintenance and operation. If disaster needs escalate beyond the capacity of local resources, the Governor may be requested to declare a state level of emergency, at which point state resources are made available to the local jurisdiction. In this situation, a state EOC may be activated. An EOC is activated, operated, and closed according to a preplanned set of policies and procedures (Herman, 1982). The EOC is usually a predesignated site or facility, equipped and supplied before the need for its operation. It is located away from the disaster scene, usually in or near governmental offices, in order to have access to needed records and resources. Many older EOCs are located underground, with construction designed to protect the facility against radioactive as well as natural and technological hazards. This is no longer perceived to be a need, however, and most newer EOCs are built above ground. EOCs are usually designed to be self-sufficient for a reasonable amount of time, with provisions for electricity, water, sewage disposal, ventilation, and security. Food storage, preparation, and serving facilities are desirable, as well as a bunk room or cots for tired personnel. The EOC may have different rooms and areas for different functions. Figure 1 illustrates the EOC of the Pennsylvania Emergency Management Agency. Ideally, each organization has a clearly designated worksite with communication equipment and status boards for recording information pertinent to the organization's area of responsibility. For example, social service/shelter operations will maintain a status board listing sites of open shelters and numbers of occupants and staff. The EOC differs from a command post in two respects. First, the EOC is not usually at the site of the event. A command post is a facility at the scene of an emergency or disaster where site operations are directed. There may be multiple sites of impact and multiple command posts, with each command post having direct communications with the EOC. Second, the EOC facilitates overall, system-wide coordination of response among many disaster organizations. It does not focus on detailed operations at specific sites. Functions of the EOC The functions of the EOC include information management, situation assessment, and resource allocation. More specifically, these functions include the following: 1. Providing a common location of operation for individuals having top management responsibilities during the response and early recovery phase; providing centralized direction and control. 2. Ensuring clear delegation of responsibility and authority and establishing a clear chain of command. 3. Serving as the single point for collection, evaluation, display and dissemination of information; ensuring that decision makers in the EOC and in the field have adequate and accurate information. 4. Coordinating personnel, supply, and equipment on a priority basis. 5. Communication and direction to external response agencies. 6. Assessing the need for additional assistance such as mutual aid or requests to the governor for state and/or federal assistance. 7. Ensuring that affected populations are evacuated and sheltered. 8. Monitoring the situation and relaying warnings to local officials and the public. 9. Providing accurate public information and rumor control. The Incident Command System in the EOC EOCs must have a system in place for carrying out their diverse responsibilities and activities. The strategy most commonly used is the Incident Command System (ICS). ICS is an on-scene emergency response system developed by the fire service and increasingly being integrated into other emergency organizations and private industry. It provides for basic direction and control, including decision making and coordination among multiple agencies (Drabek and Hoetmer, 1991). It provides a chain of command that adapts to emergency events both large and small. In addition, it provides a common management terminology during times of stress (Russell, 1991). It is an organizational structure divided into four sections: operations, planning, logistics, and finance. Planning involves acquiring information on current and future situations. Operations directs activities to reduce the immediate hazard and to maintain and/or restore essential functions. Providing for all support needs such as food, communications, medical supplies, and the like is the responsibility of logistics. Finance tracks all costs. The functions can be performed by separate individuals simultaneously, or one individual can perform two or more functions (Russell, 1991). Staffing of the EOC A community's characteristics, the size and scope of the emergency, and the phase of response will determine which individuals will need to be in the EOC at any point in time. Those individuals who are needed in the EOC in the early stages of the emergency might not be the same people who will be needed during later stages. In the early phases, the EOC will likely be operating 24 hours a day, which requires coverage for multiple shifts. Although local government has overall responsibility for disaster response, a variety of other public, private, and voluntary agencies might be represented. Groups commonly represented include the following: 1. Elected officials and top appointed officials 2. Office of Emergency Services personnel 3. Public safety (local and state police, county sheriff, fire, emergency medical services, 911 communications) 4. Public works 5. Public health 6. Mental health 7. Social service/shelter operations (including public social services, American Red Cross, Salvation Army, etc.) 8. Coroner 9. Schools 10. Public utilities 11. Public information officer 12. Amateur radio volunteers 13. Resource procurement personnel 14. Finance personnel 15.Support staff (food, janitorial, clerical, stress management) EOC representatives may be of two types: those with emergency decision-making responsibilities and those who serve a liaison function with other agencies and jurisdictions. It is vital that EOC representatives responsible for decision-making come from the top levels of management, representing the top person or second-in-command in their organization