Mental Health Services in Large Scale Disasters: An Overview Of The Crisis Counseling Program
By Brian W. Flynn, Ed.D.
NCP Clinical Quarterly 4(2): Spring 1994
To meet the psychological needs of victims following Presidentally-declared disasters, the Federal Emergency Management Agency (FEMA) provides funding for crisis counseling, training, and public information and education services through provisions of the Robert T. Stafford Disaster Relief and Emergency Assistance Act (P.L. 100-707). The program is implemented using the Interagency Agreement mechanism with the Center for Mental Health Services (CMHS), within the Substance Abuse and Mental Health Service Administration (SAMHSA). These crisis counseling programs are awarded through State Mental Health Authorities, or their designees, and provide services without charge for approximately one year following a disaster declaration to anyone residing or working in the declared disaster area.
The crisis counseling program is relatively unique in the speed and flexibility with which funding and services can be initiated and delivered. Funding can be in the hands of the State within two weeks of a Presidential declaration and the approved program can be modified throughout the grant period to accommodate changing needs. The following principles are among those guiding the design and operation of crisis counseling programs:
1. The program assumes competency and normalcy in survivors unless and until there is reason to believe otherwise. The "mantra" of these programs is that, in general, services are directed toward "normal people, responding normally, to very abnormal situations." As a result, much of the intervention and education is oriented toward normalizing individual experience and reestablishing previously successful support and coping mechanisms.
2. Crisis counseling is not treatment or psychotherapy and does not require the full armamentarium of a mental health professional in the majority of cases. Special efforts are made to assure adequate and appropriate training, supervision by mental health professionals, and ease of referral.
3. Most people served are not, and have never been, recipients of mental health services. Special effort is made to reach out to individuals and groups in their natural settings, to assure that people receive counseling and education without being inappropriately diagnosed, and do not enter the treatment system unless it is clearly indicated.
4. Special populations require special emphasis as a result of either their vulnerability to disaster related stress, or their difficulties in obtaining assess to services. These groups include, but are not limited to, children, the frail elderly, emergency and disaster workers, racial and ethnic minorities, handicapped, and those who have been injured or who have diminished health status.
5. Following a disaster, people seek help from their natural and historical sources of assistance. As a result, training and close program coordination with groups and individuals such as schools, primary health care providers, and clergy are strongly encouraged.
Under the administration and supervision of mental health professionals, the majority of services are provided by nonprofessionals who receive specialized and ongoing training. The programs rely heavily on outreach and, when necessary, refer disaster survivors who require treatment or evaluation beyond the scope or intent of the program to appropriate resources.
The first enabling legislation for the crisis counseling program was enacted in 1974. Since that time, the program has steadily grown in size, duration, and complexity. In recent years, funding in the range of $30 million annually is spent on this program. It is rare that, at any given time, fewer than eight to twelve programs are active across the country. Staff of the CHMS Emergency Services and Disaster Relief Branch (ESDRB), frequently travel to the site of major disasters and assist in needs assessment, training, and program design and development activities. Throughout the period of funding, ESDRB staff provide ongoing program consultation and monitoring.
The remainder of this report highlights some of the challenges facing the crisis counseling program.
Research
The difficulties in conducting credible disaster research have been thoroughly described by Solomon and Green (1). Although the crisis counseling program has benefited significantly from it's many years of experience, there continues to be an inadequate research base to meaningfully inform service planners, administrators, and providers. Significant research gaps and inconclusive findings characterize the disaster trauma literature. Sound research on the efficacy of various interventions is virtually non-existent.
The flow of information between researchers and service providers is problematic. In general, research findings have been difficult to apply and service providers have not found a vehicle to address programmatic research. The lower priority given to service delivery within the National Institute of Mental Health (NIMH) during the several years prior to it's reorganization in October, 1992 also impede this information flow. The organizational separation of mental health research and services into different agencies following that date has also exacerbated this problem.
Training
Few mental health professionals are appropriately trained to deliver effective mental health service following disasters. Training which serves clinicians well in more traditional service settings often impedes their function in the disaster environment. For example, disaster mental health often requires providers to initiate contact rather than waiting for the consumer to seek services. Clinicians appear to help most when they are proactive and directive in their care giving rather that relying on more indirect and insight oriented techniques. Moreover, the post-traumatic stress syndrome is a normal reaction to an abnormal event and diagnosis is inappropriate when given prematurely (e.g., diagnosing PTSD shortly after a disaster).
Practitioners in disasters are often called upon to serve in non-conventional roles and settings where they are not in control of the environment. It may be necessary to assist in cleanup or help serve or deliver food in order to have access to, and credibility with the individuals they serve. This mode of functioning is often perceived to be alien by traditionally trained clinicians.
Many clinical skills are extremely valuable in the disaster setting and its aftermath. A major training task in crisis counseling programs is to help mental health professionals differentiate between models of disaster mental health intervention and those used in conventional mental health settings.
Reviewing the experience of the past twenty years of the crisis counseling program, one cannot help but be struck with how our training and services systems tend to be pathology oriented. Disappointingly, little is known about mental health -- what makes and keeps people healthy.
Trends In Public Mental Health Services
Comprehensive Community Mental Health Centers, the cornerstone of the Federal mental health services initiative during the 1960's and 70's, are increasingly scarce. The public mental health system today, in most areas of the country, are almost exclusively oriented to serving people with severe and persistent mental illness. Consultation and education programs, children's and school programs, broad based outpatient services, and specialized programs to serve the elderly, all of which resonated to the crisis counseling program model, are nearly nonexistent. Frequently, the organizational mission, the political will, the programmatic base, and the staff interest and skills upon which to build a crisis counseling program no longer exist.
Public community mental health agencies, which continue to remain the primary sponsors of crisis counseling programs, find themselves in the midst of a mission conflict as they again sponsor broad based services. Ironically, while the organizational mission often appears to be antithetical to the mission of crisis counseling programs, the relatively recent case management function, which is now an integral part of most provider agencies, has much in common with the activities of disaster crisis counselors.
Many executive directors and boards of directors of community based mental health agencies find themselves in the very uncomfortable situation of having gone through many years of redefining agency focus within their communities only to find, following a disaster, that their communities (and governmental funding sources) continue to expect them to respond rapidly and appropriately within a markedly different organizational orientation.
Preparedness
States and mental health service provider agencies that place a priority on planning and preparing for disasters seem to respond more rapidly and appropriately when disaster strikes. However, with the exception of those States and agencies that are in areas that experience disasters frequently, planning and preparedness nearly always take a back seat to more exigent service and planning demands. ESDRB staff continue to promote disaster planning with all State mental health authorities and attempt to interest local agencies in planning for smaller scale disasters (such as a school bus accident, a mass shooting, etc.). Although the scope of a major disaster is quite different, many of the programmatic principles clearly apply in many disasters of smaller scope.
Catastrophic Disasters
The United States has been extremely fortunate, when compared to many other countries, in our relative lack of experience with truly catastrophic disasters - those which cause widespread massive destruction, destroy major portions of the community infrastructure (pervasive acute medical and public health problems, disruption in sheltering, food, and water, school destruction, etc.). Hurricanes Andrew and Iniki, the recent Northridge Earthquake, and last year's flooding in the Mississippi river states fall within this category.
From the perspective of mental health, the impact of catastrophic disasters appear more complex than originally expected. First, "secondary disasters" (e.g., unemployment, chronic economic decline, domestic violence, changes in community structure and composition, etc.) intersect with post-recovery issues and create hardships that are not easily or quickly resolved. Second, it is an enormous challenge for mental health provider organizations to resume pre-disaster services while implementing a disaster program, particularly when staff have been victimized. Taking these problems into consideration, an effort to adapt the crisis counseling program is underway with a re-examination of objectives, including grant duration and scope.
Reference
Solomon, S.D. & Green, B.L. (1992). Mental health effectrs of natural and human-made disasters. National Center for Post-Traumatic Stress Disorder PTSD Research Quarterly, 3, (1), 1-8.
For additional information regarding the crisis counseling program, or to order publications, please contact:
Emergency Services and Disaster Relief Branch
Center for Mental Health Services
Room 13-103
5600 Fishers Lane
Rockville, Maryland 20857
Brian Flynn is Chief, Emergency Services and Disaster Relief Branch, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration.
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